005-2011 Nurse's Drug Handbook, 10th Edition-Jones & Bartlett Learning-0763792381-Jones & Bartlet

2011Nurse’sDrugHandbook

The Drug ReferenceThat Gives You More!Take drug information with you wherever you go!Powered by Skyscape, this software offers instant access toall of the content found in the 2011 Nurse’s Drug Handbook.Accurate index of all generic, trade, andalternate drug names for quick referencewith timely facts on hundreds of drugs fromabacavir sulfate to ZyvoxNo-nonsense writing style that speaks yourlanguage in terms you use every dayMechanism-of-action illustrations showhow drugs work at the cellular, tissue,or organ levelsDownload it to your mobile device!www.skyscape.com/jbrndrug

Jones & Bartlett Learning2011Nurse’sDrugHandbookTenth Edition

World HeadquartersJones & Bartlett Learning40 Tall Pine DriveSudbury, MA 01776978-443-5000info@jblearning.comwww.jblearning.comJones & Bartlett LearningCanada6339 Ormindale WayMississauga, Ontario L5V 1J2CanadaJones & Bartlett LearningInternationalBarb House, Barb MewsLondon W6 7PAUnited KingdomJones & Bartlett Learning books and products are available through most bookstores and online booksellers.To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit ourwebsite, www.jblearning.com.Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available tocorporations, professional associations, and other qualified organizations. For details and specificdiscount information, contact the special sales department at Jones & Bartlett Learning via the abovecontact information or send an email to specialsales@jblearning.com.Copyright © 2011 by Jones & Bartlett Learning, LLCISBN: 978-0-7637-9238-1All rights reserved. No part of the material protected by this copyright may be reproduced or utilizedin any form, electronic or mechanical, including photocopying, recording, or by any information storageand retrieval system, without written permission from the copyright owner.The authors, editors, and publisher have made every effort to provide accurate information. However,they are not responsible for errors, omissions, or any outcomes related to the use of the contents ofthis book and take no responsibility for the use of the products and procedures described. Treatmentsand side effects described in this book may not be applicable to all people; likewise, some people mayrequire a dose or experience a side effect that is not described herein. Drugs and medical devices arediscussed that may have limited availability controlled by the Food and Drug Administration (FDA)for use only in a research study or clinical trial. Research, clinical practice, and government regulationsoften change the accepted standard in this field. When consideration is being given to use of any drugin the clinical setting, the health care provider or reader is responsible for determining FDA status ofthe drug, reading the package insert, and reviewing prescribing information for the most up-to-daterecommendations on dose, precautions, and contraindications, and determining the appropriate usagefor the product. This is especially important in the case of drugs that are new or seldom used.Production CreditsPublisher: Kevin SullivanAcquisitions Editor: Amy SibleyAssociate Editor: Patricia DonnellyEditorial Assistant: Rachel ShusterSenior Production Editor: Carolyn F. RogersSenior Marketing Manager: Rebecca WasleyV. P., Manufacturing and InventoryControl: Therese ConnellClinical Reviewer: Marlene Ciranowicz-Steenburg, RN, MSN, CDEComposition: Catherine E. HaroldInterior Illustrations: Rolin Graphics, Inc.Cover Design: Kristin E. ParkerCover Image: © ajt/ShutterStock, Inc.Printing and Binding: Malloy, Inc.Cover Printing: Malloy, Inc.6048Printed in the United States of America14 13 12 11 10 10 9 8 7 6 5 4 3 2 1

ContentsAdvisors, Reviewers, and Clinical ConsultantsixHow to Use This BookxivForewordxixOverview of Pharmacology 1Principles of Drug Administration 8Drug Therapy and the Nursing Process 12Individual Drugs (organized alphabetically)A 17B 123C 163D 281E F 363G H I 475J K L 557M 613N O 707P 785Q R S 885T 975U V W 1069X Y Z 1093AppendicesInsulin Preparations 1111Selected Ophthalmic Drugs 1114Antihistamines 1124Selected Topical Drugs 1126Selected Antivirals 1142Selected Antineoplastic Drugs 1149Selected Antihypertensive Combinations 1166Vitamins 1174Interferons 1186Compatible Drugs in a Syringe 1192Drug Formulas and Calculations 1194Weights and Equivalents 1199Equianalgesic Doses for Opioid Agonists 1201Abbreviations 1202Index 1205vii

AdvisorsJack E. Fincham, RPh, PhDDean and Professor of PharmacyPracticeSchool of PharmacyUniversity of KansasLawrence, KSMartha Mitchell Funnell, RN, MS, CDEAssociate Director for AdministrationDiabetes Research and Training CenterUniversity of MichiganAnn Arbor, MIMary E. MacCara, PharmDAssociate ProfessorCollege of PharmacyAssistant ProfessorDepartment of Family MedicineDalhousie UniversityHalifax, NS, CanadaS. Edet Ohia, PhDProfessor of Pharmaceutical SciencesAssociate Dean for AdministrationSchool of Pharmacy and Allied HealthProfessionsCreighton UniversityOmaha, NERuth Stanley, PharmD, FASHPConsultantBirmingham, ALJoseph P. Zbilut, RN,C, DNSc, PhD,ANPProfessorAdult Health NursingRush University College of NursingProfessorMolecular Biophysics and PhysiologyRush Medical CollegeChicago, ILPatti Rager Zuzelo, RN,CS, MSN, EdDAssociate ProfessorSchool of NursingLa Salle UniversityPhiladelphia, PAAssociate Director of Nursing forResearchAlbert Einstein Medical CenterPhiladelphia, PACasual Pool Registered NurseEmergency Trauma CareAbington Memorial HospitalAbington, PAKristine A. Quart, PharmDMedical Education ConsultantOlivenhain, CAix

ReviewersPeter J. Ambrose, PharmDAssociate Clinical Professor, Step IIIDirectorLos Angeles-Orange County AreaClerkshipsUniversity of California, San FranciscoSan Francisco, CADonna Barto, RN, MA, CCRNNurse EducatorHelene Fuld School of NursingBlackwood, NJStaff NurseVirtua Memorial HospitalMount Holly, NJEdward M. Bednarczyk, PharmDClinical Assistant ProfessorPharmacy Practice and NuclearMedicineState University of New York at BuffaloBuffalo, NYCristina E. Bello, PharmDAssistant Professor of PharmacyPracticeCollege of PharmacyNova Southeastern UniversityFort Lauderdale, FLScott M. Bonnema, PharmDConsultant PharmacistEmissary Pharmacy and InfusionCasper, WYFelesia R. Bowen, RN, MS, PNP,CClinical Nurse SpecialistChildren’s Hospital at Robert WoodJohnson University HospitalNew Brunswick, NJCynthia Burman, PharmDClinical Assistant ProfessorSchool of PharmacyTemple UniversityPhiladelphia, PAxReviewers and Clinical ConsultantsJason M. Cota, PharmD, MS, BCPSAssistant Professor, Department ofPharmacy PracticeUniversity of the Incarnate WordFeik School of PharmacyInfectious Diseases Clinical PharmacistBrooke Army Medical Center (BAMC)San Antonio, TXKimberly A. Couch, PharmDClinical Pharmacy Specialist, InfectiousDiseasesDepartment of PharmacyChristiana Care Health SystemNewark, DEBrenda S. Frymoyer, RN, MSNClinical Nurse SpecialistBerks Cardiologists, Inc.Reading, PAKimberly A. Galt, PharmD, FASHPAssociate Professor of PharmacyPracticeDirectorDrug Information ServicesCo-DirectorCenter for Practice Improvement andOutcomes ResearchCreighton UniversityOmaha, NEJohn Gatto, RPhClinical PharmacistEckerd PharmacyOwego, NYDeborah L. Green, RN, MSNDirectorMedical Telemetry-CHF ProgramMoses H. Cone Health SystemGreensboro, NCRonald L. Greenberg, PharmD, BCPSClinical Pharmacy CoordinatorFairview Ridges HospitalBurnsville, MN

Jan K. Hastings, PharmDAssistant ProfessorCollege of PharmacyUniversity of Arkansas for MedicalScienceLittle Rock, ARMichael D. Hogue, PharmDAssistant Professor of PharmacyPracticeMcWhorter School of PharmacySamford UniversityClinical CoordinatorWalgreen Drug StoreBirmingham, ALKimberly A. Hunter, PharmDAssistant Professor of PharmacyPracticeAlbany College of PharmacyAlbany, NYWilliam A. Kehoe, Jr., PharmD, BCPS,FCCPProfessor of Clinical Pharmacy andPsychologySchool of Pharmacy and HealthSciencesUniversity of the PacificStockton, CAJulienne K. Kirk, PharmD, BCPS, CDEAssistant ProfessorDepartment of Family MedicineSchool of MedicineWake Forest UniversityWinston-Salem, NCPeter G. Koval, PharmD, BCPSClinical PharmacistMoses H. Cone Family PracticeGreensboro, NCLisa M. Krupa, RN,C, CEN, FNPNurse PractitionerMedical SpecialistsMunster, INAmista A. Lone, PharmDClinical Assistant ProfessorCollege of PharmacyUniversity of ArizonaTucson, AZJennifer L. Lutz, PharmDPharmacy ResidentSamuel S. Stratton Veterans AffairsMedical CenterAlbany, NYT. Donald Marsh, PharmD, FASCP,FASHPDirectorDepartment of PharmacotherapyMountain Area Health EducationCenterAsheville, NCPatrick McDonnell, PharmDAssistant Professor of ClinicalPharmacySchool of PharmacyTemple UniversityPhiladelphia, PAKenyetta N. Nesbitt, PharmDAssistant ProfessorWayne State UniversityDetroit, MICatherine M. Oliphant, PharmDAssistant Professor of PharmacyPracticeSchool of PharmacyUniversity of WyomingLaramie, WYMichael A. Oszko, PharmD, BCPSAssociate ProfessorDept. of PharmacyUniversity of KansasKansas City, KSxi

Reviewers and Clinical Consultants (cont’d)Reviewers (cont’d)Vinita B. Pai, PharmDAssistant Professor of PharmacyPracticeCollege of PharmacyIdaho State UniversityPocatello, IDMelissa L. Sanders, PharmDAssistant Professor of ClinicalPharmacySchool of PharmacyTemple UniversityPhiladelphia, PADavid J. Quan, PharmDClinical PharmacistUniversity of California, San FranciscoSan Francisco, CASusan M. Rao, RN, MSNStaff NurseIntensive Care UnitSaint Luke EastFort Thomas, KYSusan L. Ravnan, PharmDAssistant Professor of PharmacyPracticeSchool of Pharmacy and HealthSciencesUniversity of the PacificStockton, CABrenda M. Reap-Thompson, RN, MSNNurse EducatorCommunity College of PhiladelphiaPhiladelphia, PANurse ConsultantChauncey International, ETSPrinceton, NJNancy Jex Sabin, RN, MSN, CFNPInstructorHahn School of Nursing and HealthScienceFamily Nurse PractitionerStudent Health CenterUniversity of San DiegoSan Diego, CARegina E. Silk, PharmD, RPh, BCPSAssistant Clinical ProfessorUniversity of Connecticut HealthCenterFarmington, CTElizabeth Sloand, RN, MSN, CPNPAssistant ProfessorSchool of NursingJohns Hopkins UniversityBaltimore, MDThomas F. Turco, PharmDClinical PharmacistAssistant Director of PharmacyOur Lady of Lourdes Medical CenterCamden, NJLili Wang, PhDAssistant ProfessorSchool of PharmacyMemorial University of NewfoundlandSt. Johns, NF, CanadaCraig Williams, PharmDClinical SpecialistWishard Memorial HospitalAssistant Professor of ClinicalPharmacySchool of PharmacyPurdue UniversityIndianapolis, INxii

Clinical ConsultantsMadeline Albanese, RN, MSNNurse EducatorHospital of the University ofPennsylvaniaPhiladelphia, PASheree M. Fitzgerald, RN,C, MSN,CNAProgram CoordinatorAncora Psychiatric HospitalHammonton, NJMaryann Foley, RN, BSNIndependent ConsultantFlourtown, PAGrace Hukushi, RN, BSN, LNCCritical Care NurseNursing Enterprises, Inc.Brick, NJSammie Justesen, RN, BSNIndependent Nurse ConsultantProvidence, UTCatherine T. Kelly, RN, PhD, CCRN,CEN, ANPFacultySchool of NursingMount Saint Mary CollegeNewburgh, NYSharon Kumm, RN, MN, CCRNAssistant ProfessorSchool of NursingUniversity of KansasKansas City, KSLeanne McQuade, RN, BSN, CENStaff NurseEmergency DepartmentDoylestown HospitalCase ManagerCAB Medical ConsultantDoylestown, PAPamela S. Ronning, RN, MPAProgram CoordinatorKirkhof School of NursingGrand Valley State UniversityAllendale, MIMaureen Ryan, RN,CS, MSN, FNPAssistant ProfessorGrand Valley State UniversityAllendale, MINurse PractitionerEmergency Dept.St. Mary’s HospitalGrand Rapids, MIJulie M. Smith, RN, BAStaff NurseRadiology-Heart StationRancocas HospitalWillingboro, NJAaron J. Strehlow, RN,CS, FNP-C,NPNPAdministrator and Director of ClinicalServicesUCLA School of NursingHealth Center at the Rescue MissionLos Angeles, CAMaria Wilson, RN, MSN, CCRNStaff NurseEmergency DepartmentChestnut Hill HospitalPhiladelphia, PAxiii

How to Use This BookJones & Bartlett Learning 2011 Nurse’sDrug Handbook gives you what today’snurses and nursing students need: accurate,concise, and reliable drug facts. Thisbook emphasizes the vital informationyou need to know before, during, andafter drug administration. The informationis presented in easy-to-understandlanguage and organized alphabetically, soyou can find what you need quickly.What’s SpecialIn addition to the drug information youexpect to find in each entry (see “DrugEntries” for details), the 2011 Nurse’sDrug Handbook boasts these special features:• A new design makes it easy to find themost need-to-know drug information,such as indications, dosages, dosageadjustments, and warnings.• A new size makes the 2011 Nurse’s DrugHandbook easier and more convenientto carry and use. But even though thebook is now smaller and more convenient,this new edition contains moredrug information than ever. We madethe book smaller and better withouttaking anything out.• Practical trim size allows the book toopen flat so you can find the informationyou need without wrestling with abook that wants to close. You can holdthe book in one hand, see completepages at a glance, and use your otherhand to document or perform otheractivities.• Introductory material reviews essentialgeneral information you need to knowto administer drugs safely and effectively,including an overview of pharmacologyand the principles of drug administration.In addition, the five steps of thenursing process are explained and relatedspecifically to drug therapy.• Highly useful illustrations throughoutthe text help you visualize selectedmechanisms of action by showing howdrugs work at the cellular, tissue, andxivorgan levels. In addition, the insidefront cover features a table listing all thedrugs whose mechanisms of action areillustrated as well as other drugs withthe same mechanisms of action.• No-nonsense writing style speakseveryday language and uses the termsand abbreviations you typicallyencounter in your practice and yourstudies. To avoid sexist language, wealternate between male and female pronounsthroughout the book.• Up-to-date drug information includesthe latest FDA-approved drugs, new andchanged indications, new warnings, andnewly reported adverse reactions.• Dosage adjustment, headlined in color,alerts you to expected dosage changesfor a patient with a specific condition ordisorder, such as advanced age or renalimpairment.• Warning, displayed in color, calls attentionto important facts that you need toknow before, during, and after drugadministration. For example, in the alatrofloxacinentry, this feature informsyou that the drug usually is reserved forhospitalized patients and is given for nomore than 2 weeks because of the highrisk of severe liver damage.• Easy-to-use tables showing route, onset,peak, and duration (see page xv formore details) and other tables in theappendices provide a timesaving way totrack and check information. Theappendices give you an overview of themost important facts and nursing considerationsfor important drug groups,including insulin preparations andselected antihistamines, topical drugs,antivirals, antineoplastic drugs, interferons,and antihypertensive combinationdrugs. You’ll also find handy instructionsfor calculating drug dosages andI.V. flow rates.Drug EntriesThe 2011 Nurse’s Drug Handbook clearlyand concisely presents all the vital facts

on the drugs that you’ll typically administer.To help you find the informationyou need quickly, drug entries are organizedalphabetically by generic drugname—from abatacept to zonisamide.For ease of use, every drug entry followsa consistent format. However, if specificdetails are unknown or don’t apply, theheading isn’t included so you can goright to the next section.GENERIC AND TRADE NAMESFirst, each entry identifies the drug’smain generic name as well as alternategeneric names. (For drugs prescribed bytrade name, you can quickly check thecomprehensive index, which refers you tothe appropriate generic name and page.)Next, the entry lists the most commonU.S. trade names for each drug. It alsoincludes common trade names availableonly in Canada, marked (CAN).CLASS, CATEGORY, AND SCHEDULEEach entry lists the drug’s chemical andtherapeutic classes. With this information,you can compare drugs in the samechemical class but in different therapeuticclasses and vice versa.The entry also lists the FDA’s pregnancyrisk category, which categorizes drugsbased on their potential to cause birthdefects. (For details, see FDA pregnancyrisk categories.)Where appropriate, the entry alsoincludes the drug’s controlled substanceschedule. (For details, see Controlled substanceschedules, page xvi.)INDICATIONS AND DOSAGESThis section lists FDA-approved therapeuticindications. For each indication,you’ll find the applicable drug form orroute, age-group (adults, adolescents, orchildren), and dosage (which includesamount per dose, timing, and duration,when known and appropriate).ROUTE, ONSET, PEAK, AND DURATIONQuick-reference tables show the drug’sonset, peak, and duration (when known)FDA pregnancy riskcategoriesEach drug may be placed in a pregnancyrisk category based on the FDA’s estimateof risk to the fetus. If the FDA hasn’tprovided a category, the DrugHandbook notes that the drug is “Notrated.”The categories range from A to X,signifying least to greatest fetal risk.A Controlled studies show no riskAdequate, well-controlled studies withpregnant women have failed to demonstratea risk to the fetus in any trimesterof pregnancy.BNo evidence of risk in humansAdequate, well-controlled studies withpregnant women haven’t shownincreased risk of fetal abnormalitiesdespite adverse findings in animals, or, inthe absence of adequate human studies,animal studies show no fetal risk. Thechance of fetal harm is remote, butremains possible.C Risk can’t be ruled outAdequate, well-controlled human studiesare lacking, and animal studies haveshown a risk to the fetus or are lacking aswell. A chance of fetal harm exists if thedrug is given during pregnancy, but thepotential benefits may outweigh the risk.D Positive evidence of riskStudies in humans, or investigational orpost-marketing data, have shown fetalrisk. Nevertheless, potential benefits fromthe drug’s use may outweigh risks. Forexample, the drug may be acceptable ifneeded in a life-threatening situation orserious disease for which safer drugscan’t be used or are ineffective.X Contraindicated in pregnancyStudies in animals or humans, or investigationalor post-marketing reports, haveshown positive evidence of fetal abnormalitiesor risks that clearly outweigh anypossible benefit to the patient.xv

Controlled substanceschedulesThe Controlled Substances Act of 1970mandated that certain prescription drugsbe categorized in schedules based ontheir potential for abuse. The greatertheir abuse potential, the greater therestrictions on their prescription. Thecontrolled substance schedules rangefrom I to V, signifying highest to lowestabuse potential.I High potential for abuseNo accepted medical use exists forSchedule I drugs, which include heroinand lysergic acid diethylamide (LSD).II High potential for abuseUse may lead to severe physical or psychologicaldependence. Prescriptionsmust be written in ink or typewrittenand must be signed by the prescriber.Oral prescriptions must be confirmedin writing within 72 hours and may begiven only in a genuine emergency.Norenewals are permitted.III Some potential for abuseUse may lead to low-to-moderate physicaldependence or high psychologicaldependence. Prescriptions may be oralor written. Up to five renewals are permittedwithin 6 months.IV Low potential for abuseUse may lead to limited physical or psychologicaldependence. Prescriptionsmay be oral or written. Up to fiverenewals are allowed within 6 months.V Subject to state and local regulationAbuse potential is low; a prescriptionmay not be required.for each administration route. The onsetof action is the time a drug takes to beabsorbed, reach a therapeutic blood level,and elicit an initial therapeutic response.The peak therapeutic effect occurs whena drug reaches its highest blood concentrationand the greatest amount of drugreaches the site of action to produce themaximum therapeutic response. Theduration of action is the amount of timethe drug remains at a blood level thatproduces a therapeutic response.MECHANISM OF ACTIONThis section concisely describes how adrug achieves its therapeutic effects atcellular, tissue, and organ levels, as appropriate.Illustrations of selected mechanismsof action lend exceptional clarityto sometimes complex processes.INCOMPATIBILITIESIn this section, you’ll be alerted to drugsor solutions that are incompatible withthe topic drug when mixed in a syringeor solution or infused through the sameI.V. line.CONTRAINDICATIONSAn alphabetical list details the conditionsand disorders that preclude administrationof the topic drug.INTERACTIONSThis section includes drugs, foods, andactivities (such as alcohol use and smoking)that can cause important, problematic,or life-threatening interactions withthe topic drug. For each interacting drug,food, or activity, you’ll learn the effects ofthe interaction.ADVERSE REACTIONSOrganized by body system, this sectionhighlights common, serious, and lifethreateningadverse reactions.NURSING CONSIDERATIONSWarnings, general precautions, and keyinformation that you must know before,during, and after drug administration aredetailed in this section. Examples includewhether a pill can be crushed and how toproperly reconstitute, dilute, store, handle,or dispose of a drug.Patient teaching information is alsoincluded here. You’ll find importantguidelines for patients, such as how andwhen to take each prescribed drug, howto spot and manage adverse reactions,which cautions to observe, when to callthe prescriber, and more. To save youxvi

Teaching your patient about drug therapyYour teaching about drug therapy will vary with your patient’s needs and your practicesetting. To help guide your teaching, each drug entry provides key information that youmust teach your patient about that drug. For all patients, however, you also should: Teach the generic and trade name foreach prescribed drug that he’ll takeafter discharge—even if he took thedrug before admission. Clearly explain why each drug was prescribed,how it works, and what it’s supposedto do. To help your patientunderstand the drug’s therapeuticeffects, relate its action to her disorderor condition. Review the drug form, dosage, androute with the patient. Tell him whetherthe drug is a tablet, suppository, spray,aerosol, or other form, and explain howto take it correctly. Also, tell him howoften to take the drug and for whatlength of time. Emphasize that heshould take the drug exactly as prescribed. Describe the drug’s appearance, andexplain that scored tablets can be brokenin half for safe, accurate dosing.Warn the patient not to break unscoredtablets because doing so may alter thedrug dosage. If your patient has troubleswallowing capsules, explain that shecan open ones that contain sprinklesand take them with food or a drink butthat she shouldn’t do this with capsulesthat contain powder. Also, warn her notto crush or chew enteric-coated,extended-release, sustained-release, orsimilar drug forms. Teach the patient about commonadverse reactions that may occur.Advise him to notify the prescriber atonce if a dangerous adverse reaction,such as syncope, occurs. Warn her not to suddenly stop taking adrug if she’s bothered by unpleasantadverse reactions, such as a rash andmild itching. Instead, encourage her todiscuss the reactions with her prescriber,who may adjust the dosage orsubstitute a drug that causes feweradverse reactions. Because drugs may cause adverse reactions,such as dizziness and drowsiness,that can impair the patient’s ability toperform activities that require alertness,help him develop a dosing schedulethat prevents these adverse reactions. Inform the patient which adverse reactionsresolve with time. Teach the patient how to store the drugproperly. Let him know if the drug issensitive to light or temperature andhow to protect it from these elements. Instruct the patient to store the drug inits original container, if possible, withthe drug’s name and dosage clearlyprinted on the label. Inform the patient which devices touse—and which to avoid—for drugstorage or administration. For example,warn him not to take liquid cyclosporinewith a plastic cup or utensils. Teach the patient what to do if shemisses a dose. Generally, she shouldtake a once-daily drug as soon as sheremembers—provided that she rememberswithin the first 24 hours. If 24 hourshave elapsed, she should take the nextscheduled dose, but not double thedose. If she has questions or concernsabout missed doses, tell her to contactthe prescriber. Provide information specific to the prescribeddrug. For example, if a patienttakes a diuretic to manage heart failure,instruct him to weigh himself daily atthe same time of day, using the samescale, and wearing the same amount ofclothing. Or if the patient takes digoxinor an antihypertensive drug, teach himhow to measure his pulse and bloodpressure and how to record the measurements.Then instruct him to bringthe diary to his regular appointmentsso the prescriber can monitor hisresponse to the drug. Advise the patient to refill prescriptionspromptly, unless she no longer needsthe drug. Also instruct her to discardexpired drugs because they maybecome ineffective or even dangerousover time. Warn the patient to keep all drugs outof the reach of children at all times.xvii

time, however, this section doesn’t repeatbasic patient-teaching points. (For asummary of those, see Teaching yourpatient about drug therapy, page xvii, andFederal guidelines for drug disposal, pagexviii.)In short, Jones & Bartlett Learning2011 Nurse’s Drug Handbook is designedexpressly to give you more of what youneed. It puts vital drug information atyour fingertips and helps you stay ALWAYSCURRENT in this critical part of your practiceor studies.Federal guidelines fordrug disposalGive patients these important instructionsfor properly disposing of theirunwanted presciption drugs: Take unused, unneeded, or outdatedprescription drugs out of their originalcontainers and throw them in thetrash. Consider mixing discarded prescriptiondrugs with a substance like coffeegrounds or used cat litter andputting them in impermeable, nondescriptcontainers, such as emptycans or sealable bags. Flush prescription drugs down thetoilet only if the label or accompanyingpatient information specificallytells you to do so. See if your community has a pharmaceuticaltake-back program thatallows citizens to bring unuseddrugs to a central location for properdisposal.xviii

ForewordSafe, effective drug therapy is one of yourmost important responsibilities. Notinfrequently, a patient’s life will dependon your ability to give drugs accuratelyand safely. In addition, you must keep upwith the latest drug information, includingnewly approved drugs and recentlyreported life-threatening adverse reactions,as well as those drugs withdrawnfrom the market after widespread use.Despite all the drug information available,medication errors remain one of thegreatest threats to patients’ well-beingand a leading cause of lawsuits againstnurses, physicians, and hospitals.Your Responsibilities in Drug TherapyYour basic responsibilities in drug therapyinclude:• administering the right drug in the rightdose by the right route at the right timeto the right patient• knowing the therapeutic use, dosage,interactions, adverse reactions, andwarnings of each administered drug• being aware of newly approved drugsthat may be prescribed• knowing about changes to existingdrugs, such as new indications anddosages and recently discovered adversereactions and interactions• concentrating fully when preparing andadministering drugs• responding promptly and appropriatelyto serious or life-threatening adversereactions, interactions, and complications• instructing each patient about the drug,how it’s administered, which effects itcauses or may cause, and which reactionsto watch for and report.Several factors may reduce your abilityto meet these basic responsibilities—andcontribute to medication errors. First,hospitals and other health care facilitieshave budget constraints that may resultin the elimination of professional nursingpositions or the hiring of less qualifiedtechnicians to fill them. This forces theremaining nurses to care for morepatients. Second, hospital patients areolder and more acutely ill, and they typicallyreceive more complex drug therapythan ever. Together, these factors placegreater demands on you—increasingyour stress level, reducing the time youhave to concentrate on drug administration,and increasing your risk of makingmedication errors or overlooking seriousadverse reactions or interactions.The same factors reduce your timeand energy for learning the latest drugfacts—which you need to have at yourcommand. You must have this informationat your fingertips because your nextpatient may need a recently approveddrug or a complex and unfamiliar drugregimen.How can you balance your limitedtime, on the one hand, with your need toknow the latest developments, on theother?Meeting Your NeedsNurses and students need a reliable,accurate, easy-to-use, quick-referencedrug book. They need a book clearlywritten by and for nurses that has beenreviewed by experts in nursing and pharmacology.You hold such a book in yourhands: Jones & Bartlett Learning 2011Nurse’s Drug Handbook, with its ALWAYSCURRENT features.The content of 2011 Nurse’s DrugHandbook was developed, written, andedited by experienced practicing nurses.Expert consultants, reviewers, and advisors—bothnurses and pharmacists—help ensure the accuracy and reliability ofthe information covered in each entryand help target that information to yourneeds. What’s more, every drug fact ischecked against the most prominent drugreferences today, including the AmericanHospital Formulary Service DrugInformation, Drug Facts and Comparisons,xix

The Physicians’ Desk Reference, the FDA’swebsite of new drug approvals, and theUSP DI’s Drug Information for the HealthCare Professional.In addition, to help you quickly accessmuch-needed information, the book isorganized alphabetically by generic drugname, follows a consistent format, and isconcise.To ensure that you’re always current,Jones & Bartlett Learning Nurse’s DrugHandbook is updated every year. Thisnewest edition contains:• important new drug entries in the mainpart of the book and in the appendices• new drug facts on hundreds of existingentries, including updated informationon new indications and dosages, newincompatibilities and interactions, newadverse reactions, and new nursing considerations• hundreds of patient-teaching guidelinesand suggestions• thoroughly updated appendices oninsulin preparations, antiviral drugs,topical drugs, antihistamines, combinationantihypertensive drugs, interferons,ophthalmic drugs, and antineoplasticdrugs• a comprehensive new index.And as always, you’ll find the samecolor-coded, highly readable type thatreduces eyestrain as you speed to theinformation you need.Getting More from Your DrugReferenceWhether you work in or are preparing towork in acute care, home care, long-termcare, or another health care setting, you’llwant your own copy of the 2011 Nurse’sDrug Handbook. That’s because this bookcan help you:• reduce your risk of medication errorsbecause you’ll have easy access to accurate,reliable drug information that’s relevantto your practice• stay current on the most up-to-datedrug developments of the year• improve your drug administration skillsand patient care before, during, andafter drug therapy• quickly detect and manage serious orlife-threatening adverse reactions andcomplications or prevent them fromoccurring• save time because you won’t have tosift through volumes of information tofind what you need, search for a bookthat’s up-to-date, or look through severaldrug handbooks to get enough information• increase your confidence about drugadministration and enhance your professionalinteractions with other healthcare team members• ensure the delivery of safe, effective care• improve the depth and quality of yourpatient teaching.Reaping the RewardsYour patients deserve the best and safestcare possible—and you deserve to havethe tools to deliver that care. Whetheryou’re a student or an experienced clinician,Jones & Bartlett Learning 2011Nurse’s Drug Handbook will help youprovide safe, effective drug therapybecause of its practical, easy-to-understand,accurate, and reliable informationon virtually all the drugs you’re likely toadminister.This handbook has aided thousandsof nurses in their patient care. Take itwith you to the clinical setting, share itwith your peers, and use it to enhanceyour present and future position in thenursing profession.Kathleen Dracup, RN, FNP, DNSc, FAANDean and ProfessorSchool of NursingUniversity of California, San FranciscoSan Francisco, CAxx

Overview of PharmacologyUnderstanding the basics of pharmacologyis an essential nursing responsibility.Pharmacology is the science that dealswith the physical and chemical properties,and biochemical and physiologiceffects, of drugs. It includes the areas ofpharmacokinetics, pharmacodynamics,pharmacotherapeutics, pharmacognosy,and toxicodynamics.The 2011 Nurse’s Drug Handbookdeals primarily with pharmacokinetics,pharmacodynamics, and pharmacotherapeutics—theinformation you need toadminister safe and effective drug therapy(discussed below). Pharmacognosy isthe branch of pharmacology that dealswith the biological, biochemical, and economicfeatures of naturally occurringdrugs. Toxicodynamics is the study of theharmful effects that excessive amounts ofa drug produce in the body; in a drugoverdose or drug poisoning, large drugdoses may saturate or overwhelm normalmechanisms that control absorption, distribution,metabolism, and excretion.Drug NomenclatureMost drugs are known by severalnames—chemical, generic, trade, andofficial—each of which serves a specificfunction. (See How drugs are named.)However, multiple drug names can alsocontribute to medication errors. You mayfind a familiar drug packaged with anunfamiliar name if your institutionchanges suppliers or if a familiar drug isnewly approved in a different dose or fora new indication.Drug ClassificationDrugs can be classified in various ways.Most pharmacology textbooks groupdrugs by their functional classification,such as psychotherapeutics, which isbased on common characteristics. Drugscan also be classified according to theirtherapeutic use, such as antipanic orantiobsessional drugs. Drugs within acertain therapeutic class may be furtherdivided into subgroups based on theirmechanisms of action. For example, thetherapeutic class antineoplastics can befurther classified as alkylating agents,antibiotic antineoplastics, antimetabolites,antimitotics, biological responseHow drugs are namedA drug’s chemical, generic, trade, and officialnames are determined at differentphases of the drug development processand serve different functions. For example,the various names of the commonlyprescribed anticonvulsant divalproexsodium are:• Chemical name: Pentanoic acid,2-propyl-, sodium salt (2:1) or(C 16 H 31 O 4 Na)• Generic name: divalproex sodium• Trade name: Depakote• Official name: Divalproex SodiumDelayed-Release Tablets, USPA drug’s chemical name describes itsatomic and molecular structure. Thechemical name of divalproex sodium—pentanoic acid, 2-propyl-, sodium salt(2:1), or C 16 H 31 O 4 Na (pronounced valproatesemisodium)—indicates that thedrug is a combination of two valproicacid compounds with a sodium moleculeattached to only one side.Once a drug successfully completesseveral clinical trials, it receives a genericname, also known as the nonproprietaryname. The generic name is usuallyderived from but shorter than the chemicalname. The United States AdoptedNames Council is responsible for selectinggeneric names, which are intendedfor unrestricted public use.Before submitting the drug for FDAapproval, the manufacturer creates andregisters a trade name (or brand name)when the drug appears ready to be marketed.Trade names are copyrighted andfollowed by the symbol ® to indicatethat they’re registered and that their useis restricted to the drug manufacturer.Once the original patent on a drug hasexpired, any manufacturer may producethe drug under its own trade name.A drug’s official name is the nameunder which it’s listed in the UnitedStates Pharmacopoeia (USP) and theNational Formulary (NF).

2Overview of Parmacologymodifiers, antineoplastic enzymes, andhormonal antineoplastics.PharmacokineticsPharmacokinetics is the study of a drug’sactions—or fate—as it passes throughthe body during absorption, distribution,metabolism, and excretion.ABSORPTIONBefore a drug can begin working, it mustbe transformed from its pharmaceuticaldosage form to a biologically available(bioavailable) substance that can passthrough various biological cell membranesto reach its site of action. Thisprocess is known as absorption. A drug’sabsorption rate depends on its route ofadministration, its circulation throughthe tissue into which it’s administered,and its solubility—that is, whether it’smore water-soluble (hydrophilic) or fatsoluble(lipophilic).Although drugs may penetrate cellularmembranes either actively or passively,most drugs do so by passive diffusion,moving inertly from an area of higherconcentration to an area of lower concentration.Passive diffusion may occurthrough water or fat. Passive diffusionthrough water—aqueous diffusion—occurs within large water-filled compartments,such as interstitial spaces, andacross epithelial membrane tight junctionsand pores in the epithelial lining ofblood vessels. Aqueous diffusion is drivenby concentration gradients. Drug moleculesthat are bound to large plasma proteins,such as albumin, are too large topass through aqueous pores in this way.Passive diffusion through fat—lipid diffusion—playsan important role in drugmetabolism because of the large numberof lipid barriers that separate the aqueouscompartments of the body. The tendencyof a drug to move through lipid layersbetween aqueous compartments oftendepends on the pH of the medium—thatis, the ability of the water-soluble or fatsolubledrug to form weak acid or weakbase.Drugs with molecules that are toolarge to readily diffuse may rely on activediffusion, in which special carriers onmolecules, including peptides, aminoacids, and glucose, transport the drugthrough the membranes. However, somemolecules with selective membrane carrierscan expel foreign drug molecules; thisis why many drugs can’t cross the bloodbrainbarrier.Drug absorption begins at the administrationroute. The three main administrationroute categories are enteral, parenteral,and transcutaneous. Dependingon its nature or chemical makeup, a drugmay be better absorbed from one sitethan from another.Enteral AdministrationEnteral administration consists of theoral, nasogastric, and rectal routes.Oral: Drugs administered orally areabsorbed in the GI tract and then proceedby the hepatic portal vein to theliver and into the systemic circulation.Although generally considered the preferredroute, oral drug administrationhas a number of disadvantages:• The oral route doesn’t always yield sufficientlyhigh blood concentrations to beeffective.• Bioavailability may be less than optimalbecause of incomplete absorption andfirst-pass elimination (the part ofmetabolism that occurs during transitthrough the liver before the drug reachesthe general circulation).• Drug absorption may be incomplete ifthe drug is degraded by digestiveenzymes or the acidic pH in the stomachor if it’s excreted from the liver intothe bile.• Food in the GI tract, gastric emptyingtime, and intestinal motility may alsoimpede drug absorption.Nasogastric: Drugs administeredthrough a nasogastric tube enter thestomach directly and are absorbed in theGI tract.Rectal: Rectal drugs and suppositoriesalso enter the GI tract directly after beinginserted in the rectum and absorbedthrough the rectal mucosa. After being

Overview of Pharmacology 3absorbed into the lower GI tract, rectaldrugs enter the circulation through theinferior vena cava, bypassing the liver andthus avoiding first-pass metabolism.Suppositories, however, tend to travelupward into the rectum, where veins,such as the superior hemorrhoidal vein,lead to the liver. As a result, drug absorptionby this route is often unreliable anddifficult to predict.Parenteral AdministrationParenteral routes may be used wheneverenteral routes are contraindicated orinadequate. These routes include intramuscular(I.M.), intravenous (I.V.), subcutaneous(SubQ) and intradermal (I.D.)administration. Drug absorption is muchfaster and more predictable after parenteraladministration than after enteraladministration.I.M.: Drugs administered by the I.M.route are injected deep into the muscle,where they’re absorbed relatively quickly.The rate of drug absorption depends onthe vascularity of the injection site, thephysiochemical properties of the drug,and the solution in which the drug iscontained.I.V.: I.V. drug administration involvesinjecting or infusing the drug directlyinto the blood circulation, allowing forrapid distribution throughout the body.This route usually provides the greatestbioavailability.SubQ: Drugs administered by the subcutaneousroute are injected into thealveolar connective tissue just below theskin and are absorbed by simple diffusionfrom the injection site. The factors thataffect I.M. absorption also affect subcutaneousabsorption. Absorption by the subcutaneousroute may be slower than bythe I.M. route.I.D.: Drugs administered intradermally,such as purified protein derivative (PPD),are injected into the dermis, from whichthey diffuse slowly into the local microcapillarysystem.Transcutaneous AdministrationTranscutaneous drug administrationallows drug absorption through the skinor soft-tissue surface. Drugs may beinhaled, inserted sublingually, appliedtopically, or administered by the eyes,ears, nose, or vagina.Inhalation: Inhaled drugs may be givenas a powder and aerosolized or mixed insolution and nebulized directly into therespiratory tract, where they’re absorbedthrough the alveoli. Inhaled drugs areusually absorbed quickly because of theabundant blood flow in the lungs.Sublingual: Sublingual drug administrationinvolves placing a tablet, troche,or lozenge under the tongue. The drug isabsorbed across the epithelial lining ofthe mouth, usually quickly. This routeavoids first-pass metabolism.Topical: Topical drugs—creams, ointments,lotions, and patches—are placedon the skin and then cross the epidermisinto the capillary circulation. They mayalso be absorbed through sweat glands,hair follicles, and other skin structures.Absorption by the skin is enhanced if thedrug is in a solution.Ophthalmic: Ophthalmic drugs includesolutions and ointments that are instilledor applied directly to the cornea or conjunctivaas well as small, elliptical disksthat are placed directly on the eyeballbehind the lower eyelid. The movementsof the eyeball promote distribution ofthese drugs over the surface of the eye.Although ophthalmic drugs produce alocal effect on the conjunctiva or anteriorchamber, some preparations may beabsorbed systemically and therefore producesystemic effects.Otic: Drops administered into theexternal auditory canal, otic drugs areused to treat infection or inflammationand to soften and remove ear wax. Oticsolutions exert a local effect and mayresult in minimal systemic absorptionwith no adverse effects.Nasal: Nasal solutions and suspensionsare applied directly to the nasal mucosaby instillation or inhalation to producelocal effects, such as vasoconstriction toreduce nasal congestion. Some nasal

4Overview of Pharmacologysolutions, such as vasopressin, are administeredby this route specifically to producesystemic effects.Vaginal: Vaginal drugs include creams,suppositories, and troches that are insertedinto the vagina, sometimes using aspecial applicator. These drugs areabsorbed locally to treat such conditionsas bacterial and fungal infections.DISTRIBUTIONDistribution is the process by which adrug is transported by the circulating fluidsto various sites, including its sites ofaction. To ensure maximum therapeuticeffectiveness, the drug must permeate allmembranes that separate it from itsintended site of action. Drug distributionis influenced by blood flow, tissue availability,and protein binding.METABOLISMDrug metabolism is the enzymatic conversionof a drug’s structure into substratemolecules or polar compoundsthat are either less active or inactive andare readily excreted. Drugs can also besynthesized to larger molecules.Metabolism may also convert a drug to amore toxic compound. Because the primarysite of drug metabolism is the liver,children, the elderly, and patients withimpaired hepatic function are at risk foraltered therapeutic effects.Biotransformation is the process ofchanging a drug into its active metabolite.Compounds that require metabolicbiotransformation for activation areknown as prodrugs. During phase I ofbiotransformation, the parent drug isconverted into an inactive or partiallyactive metabolite. Much of the originaldrug may be eliminated during thisphase. During phase II, the inactive orpartially active metabolite binds withavailable substrates, such as acetic acid,glucuronic acid, sulfuric acid, or water, toform its active metabolite. When biotransformationleads to synthesis, largermolecules are produced to create a pharmacologiceffect.EXCRETIONThe body eliminates drugs by bothmetabolism and excretion. Drug metabolites—and,in some cases, the active drugitself—are eventually excreted from thebody, usually through bile, feces, andurine. The primary organ for drug eliminationis the kidney. Impaired renal functionmay alter drug elimination, therebyaltering the drug’s therapeutic effect.Other excretion routes include evaporationthrough the skin, exhalation fromthe lungs, and secretion into saliva andbreast milk.A drug’s elimination half-life is theamount of time required for half of thedrug to be eliminated from the body. Thehalf-life roughly correlates with thedrug’s duration of action and is based onnormal renal and hepatic function.Typically, the longer the half-life, the lessoften the drug has to be given and thelonger it remains in the body.PharmacodynamicsPharmacodynamics is the study of thebiochemical and physiologic effects ofdrugs and their mechanisms of action. Adrug’s actions may be structurally specificor nonspecific. Structurally specific drugscombine with cell receptors, such as proteinsor glycoproteins, to enhance orinhibit cellular enzyme actions. Drugreceptors are the cellular componentsaffected at the site of action. Many drugsform chemical bonds with drug receptors,but a drug can bond with a receptoronly if it has a similar shape—much thesame way that a key fits into a lock.When a drug combines with a receptor,channels are either opened or closed andcellular biochemical messengers, such ascyclic adenosine monophosphate or calciumions, are activated. Once activated,cellular functions can be turned either onor off by these messengers.Structurally nonspecific drugs, such asbiological response modifiers, don’t combinewith cell receptors; rather, they producechanges within the cell membraneor interior.The mechanisms by which drugs interactwith the body are not always known.Drugs may work by physical action (such

Overview of Pharmacology 5as the protective effects of a topical ointment)or chemical reaction (such as anantacid’s effect on the gastric mucosa), orby modifying the metabolic activity ofinvading pathogens (such as an antibiotic)or replacing a missing biochemicalsubstance (such as insulin).AGONISTSAgonists are drugs that interact with areceptor to stimulate a response. Theyalter cell physiology by binding to plasmamembranes or intracellular structures.Partial agonists can’t achieve maximaleffects even though they may occupy allavailable receptor sites on a cell. Strongagonists can cause maximal effects whileoccupying only a small number of receptorsites on a cell. Weak agonists mustoccupy many more receptor sites thanstrong agonists to produce the sameeffect.ANTAGONISTSAntagonists are drugs that attach to areceptor but don’t stimulate a response;instead, they inhibit or block responsesthat would normally be caused by agonists.Competitive antagonists bind toreceptor sites that are also compatiblewith an agonist, thus preventing the agonistfrom binding to the site. Noncompetitiveantagonists bind to receptor sitesthat aren’t occupied by an agonist; thischanges the receptor site so that it’s nolonger recognized by the agonist. Irreversibleantagonists work in much the sameway that noncompetitive ones do, exceptthat they permanently bind with thereceptor.Antagonism plays an important role indrug interactions. When two agoniststhat cause opposite therapeutic effects,such as a vasodilator and a vasoconstrictor,are combined, the effects cancel eachother out. When two antagonists, such asmorphine and naloxone, are combined,both drugs may become inactive.PharmacotherapeuticsPharmacotherapeutics is the study ofhow drugs are used to prevent or treatdisease. Understanding why a drug is prescribedfor a certain disease can assist youin prioritizing drug administration withother patient care activities. Knowing adrug’s desired and unwanted effects mayhelp you uncover problems not readilyapparent from the admitting diagnosis.This information may also help you preventsuch problems as adverse reactionsand drug interactions.A drug’s desired effect is the intended orexpected clinical response to the drug.This is the response you start to evaluateas soon as a drug is given. Dosage adjustmentsand the continuation of therapyoften depend on your accurate evaluationand documentation of the patient’sresponse.An adverse reaction is any noxious andunintended response to a drug thatoccurs at therapeutic doses used for prophylaxis,diagnosis, or therapy. Adversereactions associated with excessiveamounts of a drug are considered drugoverdoses. Be prepared to follow yourinstitution’s policy for reporting adversedrug reactions.An idiosyncratic response is a geneticallydetermined abnormal or excessiveresponse to a drug that occurs in a particularpatient. The unusual responsemay indicate that the drug has saturatedor overwhelmed mechanisms that normallycontrol absorption, distribution,metabolism, or excretion, thus alteringthe expected response. You may beunsure whether a reaction is adverse oridiosyncratic. Once you report the reaction,the pharmacist usually determinesthe appropriate course of action.An allergic reaction is an adverseresponse that results from previous exposureto the same drug or to one that’schemically similar to it. The patient’simmune system reacts to the drug as if itwere a foreign invader and may producea mild hypersensitivity reaction, characterizedby localized dermatitis, urticaria,angioedema, or photosensitivity. Allergicreactions should be reported to the prescriberimmediately and the drug shouldbe discontinued. Follow-up care may

6Overview of Parmacologyinclude giving drugs, including antihistaminesand corticosteroids, to counteractthe allergic response.An anaphylactic reaction involves animmediate hypersensitivity responsecharacterized by urticaria, pruritus, andangioedema. Left untreated, an anaphylacticreaction can lead to systemicinvolvement, resulting in shock. It’s oftenassociated with life-threatening hypotensionand respiratory distress. Be preparedto assist with emergency life supportmeasures, especially if the reaction occursin response to I.V. drugs, which have thefastest rate of absorption.A drug interaction occurs when onedrug alters the pharmacokinetics ofanother drug—for example, when two ormore drugs are given concurrently. Suchconcurrent administration can increaseor decrease the therapeutic or adverseeffects of either drug. Some drug interactionsare beneficial. For example, whentaken with penicillin, probeneciddecreases the excretion rate of penicillin,resulting in higher blood levels of penicillin.Drug interactions also may occurwhen a drug’s metabolism is altered,often owing to the induction of or competitionfor metabolizing enzymes. Forexample, H 2 -receptor agonists, whichreduce secretion of the enzyme gastrin,may alter the breakdown of enteric coatingson other drugs. Drug interactionsdue to carrier protein competition typicallyoccur when a drug inhibits the kidneys’ability to reduce excretion of otherdrugs. For example, probenecid is completelyreabsorbed by the renal tubulesand is metabolized very slowly. It competeswith the same carrier protein assulfonamides for active tubular secretionand so decreases the renal excretion ofsulfonamides. This particular competitioncan lead to an increased risk of sulfonamidetoxicity.Special ConsiderationsAlthough every drug has a usual dosagerange, certain factors—such as a patient’sage, weight, culture and ethnicity, gender,pregnancy status, and renal and hepaticfunction—may contribute to the need fordosage adjustments. When you encounterspecial considerations such as these, beprepared to reassess the prescribeddosage to make sure that it’s safe andeffective for your patient.CULTURE AND ETHNICITYCertain drugs are more effective or morelikely to produce adverse effects in particularethnic groups or races. For example,blacks with hypertension respond betterto thiazide diuretics than do patients ofother races; on the other hand, blacksalso have an increased risk of developingangioedema with angiotensin-convertingenzyme (ACE) inhibitors. A patient’s religiousor cultural background also maycall for special consideration. For example,a drug made from porcine productsmay be unacceptable to a Jewish orMuslim patient.ELDERLY PATIENTSBecause aging produces certain changesin body composition and organ function,elderly patients present unique therapeuticand dosing problems that require specialattention. For example, the weight ofthe liver, the number of functioninghepatic cells, and hepatic blood flow alldecrease as a person ages, resulting inslower drug metabolism. Renal functionmay also decrease with aging. Theseprocesses can lead to the accumulation ofactive drugs and metabolites as well asincreased sensitivity to the effects ofsome drugs in elderly patients. Becausethey’re also more likely to have multiplechronic illnesses, many elderly patientstake multiple prescription drugs eachday, thus increasing the risk of druginteractions.CHILDRENBecause their bodily functions aren’t fullydeveloped, children—particularly thoseunder age 12—may metabolize drugs differentlythan adults. In infants, immaturerenal and hepatic function delay metabolismand excretion of drugs. As a result,pediatric drug dosages are very different

Overview of Pharmacology 7from adult dosages.The FDA has provided drug manufacturerswith guidelines that define pediatricage categories. Unless the manufacturerprovides a specific age range, usethese categories as a guide when administeringdrugs:• neonates—birth up to age 1 month• infants—ages 1 month to 2 years• children—ages 2 to 12• adolescents—ages 12 to 16.PREGNANCYThe many physiologic changes that takeplace in the body during pregnancy mayaffect a drug’s pharmacokinetics and alterits effectiveness. Additionally, exposure todrugs may pose risks for the developingfetus. Before administering a drug to apregnant patient, be sure to check itsassigned FDA pregnancy risk categoryand intervene appropriately.

Principles of Drug AdministrationBecause there are thousands of drugs andhundreds of facts about each one, takingresponsibility for drug administrationcan seem overwhelming. One way thatyou can enhance your understanding ofthe principles of drug administration isto associate, ask, and predict during thecritical thinking process. For example,associate each drug with general informationyou may already know about thedrug or drug class. Ask yourself why adrug is administered by a certain routeand why it’s given multiple timesthroughout the day rather than onlyonce. Learn to predict a drug’s actions,uses, adverse effects, and possible druginteractions based on your knowledge ofthe drug’s mechanism of action. As youapply these principles to drug administration,you’ll begin to intuitively knowwhich facts you need to make rationalclinical decisions.Prescriptions for patients in hospitalsand other institutions typically are writtenby a physician on a form called thephysician’s order sheet or they’re directlyinput into a computerized system with anelectronic signature. Drugs are prescribedbased not only on their specific mechanismsof action but also on the patient’sprofile, which commonly includes age,ethnicity, gender, pregnancy status,smoking and drinking habits, and use ofother drugs.“Rights” of Drug AdministrationAlways keep in mind the following“rights” of drug administration: the rightdrug, right time, right dose, right patient,right route, and right preparation andadministration.RIGHT DRUGMany drugs have similar spellings, differentconcentrations, and several genericforms. Before administering any drug,compare the exact spelling and concentrationof the prescribed drug thatappears on the label with the informationcontained in the medication administrationrecord or drug profile. Regardless ofwhich drug distribution system yourfacility uses, you should read the druglabel and compare it to the medicationadministration record at least threetimes:• before removing the drug from the dispensingunit or unit dose cart• before preparing or measuring the prescribeddose• before opening a unit dose package (justbefore administering the drug to thepatient).RIGHT TIMEVarious factors can affect the time that adrug is administered, such as the timingof meals and other drugs, scheduleddiagnostic tests, standardized times usedby the institution, and factors that mayalter the consistency of blood levels anddrug absorption. Before administeringany p.r.n. drug, check the patient’s chartto ensure that no one else has alreadyadministered it and that the specifiedtime interval has passed. Also, documentadministration of a p.r.n. drug immediately.RIGHT DOSEWhenever you’re dispensing an unfamiliardrug or in doubt about a dosage,check the prescribed dose against therange specified in a reliable reference. Besure to consider any reasons for a dosageadjustment that may apply to your particularpatient. Also, make sure you’refamiliar with the standard abbreviationsyour institution uses for writing prescriptions.RIGHT PATIENTAlways compare the name of the patienton the medication record with the nameon the patient’s identification bracelet.When using a unit dose system, comparethe name on the drug profile with thaton the identification bracelet.RIGHT ROUTEEach drug prescription should specify theadministration route. If the administra-

Principles of Drug Administration 9tion route is missing from the prescription,consult the prescriber before givingthe drug. Never substitute one route foranother unless you obtain a prescriptionfor the change.RIGHT PREPARATION AND ADMINISTRATIONFor drugs that need to be mixed, poured,or measured, be sure to maintain aseptictechnique. Follow any specific directionsincluded by the manufacturer regardingdiluent type and amount and the use offilters, if needed. Clearly label any drugthat you’ve reconstituted with thepatient’s name, the strength or dose, thedate and time that you prepared thedrug, the amount and type of diluentthat you used, the expiration date, andyour initials.Administration RoutesDrugs may be administered by a varietyof routes and dosage forms. A particularroute may be chosen for convenience orto maximize drug concentration at thesite of action, to minimize drug absorptionelsewhere, to prolong drug absorption,or to avoid first-pass metabolism.Different dosage forms of the samedrug may have different drug absorptionrates, times of onset, and durations ofaction. For example, nitroglycerin is acoronary vasodilator that may be administeredby the I.V., sublingual, oral, orbuccal route, or as a topical ointment ordisk. The I.V., sublingual, and buccalforms of nitroglycerin provide a rapidonset of action, whereas the oral, ointment,and disk forms have a slower onsetand a prolonged duration of action.Drug administration routes include theenteral, parenteral, and transcutaneousroutes.ENTERALThe enteral route consists of oral, nasogastric,and rectal administration. Drugsadministered enterally enter the bloodcirculation by way of the GI tract. Thisroute is considered the most natural andconvenient route as well as the safest. As aresult, most drugs are taken enterally,usually to provide systemic effects.Oral• Tablets: Tablets, the most commonlyused dosage form, come in a variety ofcolors, sizes, and shapes. Some tabletsare specially coated for various purposes.Enteric coatings permit safe passageof a tablet through the stomach, wheresome drugs may be degraded or mayproduce unwanted effects, to the environmentof the intestine. Some coatingsprotect the drug from the destructiveinfluences of moisture, light, or air duringstorage; some coatings actually containthe drug, such as procainamide; stillothers conceal a bad taste. Coatings arealso used to ensure appropriate drugrelease and absorption. Some tabletsshouldn’t be crushed or broken becausedoing so may alter drug release.• Capsules: Capsules are solid dosageforms in which the drug and otheringredients are enclosed in a hard orsoft shell of varying size and shape.Drugs typically are released faster fromcapsules than from tablets.• Solutions: Drugs administered in solutionare absorbed more rapidly thanthose administered in solid form; however,they don’t always produce predictabledrug levels in the blood. Somedrugs in solution should be administeredwith meals or snacks to minimizetheir irritating effect on the gastricmucosa.• Suspensions: Suspensions are preparationsconsisting of finely divided drugsin a suitable vehicle, usually water.Suspensions should be shaken beforeadministration to ensure the uniformityof the preparation and administrationof the proper dosage.NasogastricDrugs administered through a nasogastricor gastrostomy tube enter the stomachdirectly, bypassing the mouth andesophagus. They’re usually administeredin liquid form because an intact tablet orcapsule could cause an obstruction in agastric tube. Sometimes a tablet may becrushed or a capsule opened for nasograsticadministration; however, doing so

10Principles of Drug Administrationwill affect the drug’s release. You mayneed to consult a pharmacist to determinewhich tablets can be crushed orcapsules opened.RectalSome enteral drugs are administered rectally—assuppositories, solutions, or ointments—toprovide either local or systemiceffects. When inserted into the rectum,suppositories soften, melt, or dissolve,releasing the drug contained insidethem. The rectal route may be preferredfor drugs that are destroyed or inactivatedby the gastric or intestinal environmentor that irritate the stomach. It alsomay be indicated when the oral route iscontraindicated because of vomiting ordifficulty swallowing. The drawbacks ofrectal administration include inconvenience,noncompliance, and incomplete orirregular drug absorption.PARENTERALIn parenteral drug administration, a drugenters the circulatory system through aninjection rather than through GI absorption.This administration route is chosenwhen rapid drug action is desired; whenthe patient is uncooperative, unconscious,or unable to accept medication bythe oral route; or when a drug is ineffectiveby other routes. Drugs may be injectedinto the joints, spinal column, arteries,veins, and muscles. However, the mostcommon parenteral routes are the intramuscular(I.M.), intravenous (I.V.), subcutaneous(SubQ), and intradermal(I.D.) routes. Drugs administered parenterallymay be mixed in either a solutionor a suspension; those mixed in asolution typically act more rapidly thanthose mixed in a suspension. Parenteraladministration has several disadvantages:The drug can’t be removed or the dosagereduced once it has been injected, andinjections typically are more expensive toadminister than other dosage formsbecause they require strict sterility.IntramuscularI.M. injections are administered deepinto the anterolateral aspect of the thigh(vastis lateralis), the dorsogluteal muscle(gluteus maximus), the upper arm (deltoid),or the ventrogluteal muscle (gluteusmedius). I.M. injections typicallyprovide sustained drug action. This routeis commonly chosen for drugs that irritatethe subcutaneous tissue. The drugshould be injected as far as possible frommajor nerves and blood vessels.IntravenousIn I.V. drug administration, an aqueoussolution is injected directly into thevein—typically of the forearm. Drugsmay be administered as a single, smallvolumeinjection or as a slow, large-volumeinfusion. Because drugs injected I.V.don’t encounter absorption barriers, thisroute produces the most rapid drugaction, making it vital in emergency situations.Except for I.V. fat emulsions usedas nutritional supplements, oleaginouspreparations aren’t usually administeredby this route because of the risk of fatembolism.SubcutaneousThe subcutaneous route may be used toinject small volumes of medication, usually1 ml or less. Subcutaneous injectionstypically are given below the skin in theabdominal area, lateral area of the anteriorthigh, posterior surface of the upperarm, or lateral lumbar area. Injectionsites should be rotated to minimize tissueirritation if the patient receives frequentsubcutaneous injections—as, for example,in a patient who takes insulin.IntradermalCommon sites for I.D. injection are thearm and the back. Because only about0.1 ml may be administered intradermally,this route is rarely used except in diagnosticand test procedures, such asscreening for allergic reactions.TRANSCUTANEOUSIn transcutaneous administration, a drugcrosses the skin layers from either theoutside (dermal) or the inside (mucocutaneous).This route includes sublingual(S.L.), inhalation, ophthalmic, otic, nasal,topical, and vaginal administration.

Principles of Drug Administration 11SublingualIn S.L. administration, tablets are placedunder the tongue and allowed to dissolve.Nitroglycerin is commonly administeredby this route, which allows rapid drugabsorption and action. The S.L. routealso avoids first-pass metabolism.InhalationSome drugs may be inhaled orally ornasally to produce a local effect on therespiratory tract or a systemic effect.Although drugs given by inhalation avoidfirst-pass hepatic metabolism, the lungscan also serve as an area of first-passmetabolism by providing respiratoryconversion to more water-soluble compounds.OphthalmicOphthalmic solutions and ointments areapplied directly to the cornea or conjunctivafor enhanced local penetrationand decreased systemic absorption. Thesedrugs usually are used in eye examinationsand to treat glaucoma. Ophthalmicsolutions pose a greater risk of drug lossthrough the nasolacrimal duct into thenasopharynx than ophthalmic ointmentsdo.OticOtic solutions are instilled directly intothe external auditory canal for local penetrationand decreased systemic absorption.These drugs, which include anesthetics,antibiotics, and anti-inflammatorydrugs, usually require occlusion of theear canal with cotton after instillation.NasalNasal solutions and suspensions areapplied directly to the nasal mucosa forenhanced local penetration anddecreased systemic absorption. Thesedrugs are usually used to reduce theinflammation typically associated withseasonal or perennial rhinitis.TopicalTopical drugs—including creams, ointments,lotions, and pastes—are applieddirectly to the skin. Transdermal deliverysystems, usually in the form of an adhesivepatch or a disk, are among the latestdevelopments in topical drug administration.Because they provide slow drugrelease, these systems are typically used toavoid first-pass metabolism and ensureprolonged duration of action.VaginalVaginal troches, suppositories, andcreams are inserted into the vagina forslow, localized absorption. Body pH thatdiffers from blood pH causes drug trappingor reabsorption, which delays drugexcretion through the renal tubules.Vaginal secretions are alkaline, with a pHof 3.4 to 4.2, whereas blood has a pH of7.35 to 7.45.

Drug Therapy and the Nursing ProcessA systematic approach to nursing care,the nursing process helps guide you asyou develop, implement, and evaluateyour care and ensures that you’ll deliversafe, consistent, and effective drug therapyto your patients. The nursing processconsists of five steps, including assessment,nursing diagnosis, planning,implementation, and evaluation. Eventhough documentation is not a step inthe nursing process, you’re legally andprofessionally responsible for documentingall aspects of your care before, during,and after drug administration.AssessmentThe first step in the nursing process,assessment involves gathering informationthat’s essential to guide yourpatient’s drug therapy. This informationincludes the patient’s drug history, presentdrug use, allergies, medical history,and physical examination findings.Assessment is an ongoing process thatserves as a baseline against which to compareany changes in your patient’s condition;it’s also the basis for developing andindividualizing your patient’s plan ofcare.DRUG HISTORYThe patient’s drug history is critical inyour planning of drug-related care. Askabout his previous use of over-the-counterand prescription drugs as well asherbal remedies. For each drug, determine:• the reason the patient took it• the prescribed dosage• the administration route• the frequency of administration• the duration of the drug therapy• any adverse reactions the patient mayhave experienced and how he handledthem.Also determine if the patient has a historyof drug abuse or addiction.Depending on his physical and emotionalstate, you may need to obtain the drughistory from other sources, such as familymembers, friends, other caregivers, andthe medical record.PRESENT DRUG USEAsk about the patient’s current use ofover-the-counter and prescription drugsas well as herbal remedies. As you did inthe drug history, find out the specificdetails for each drug (dosage, route, frequency,and reason for taking). Also askthe patient if he thinks the drug has beeneffective and when he took the last dose.If the patient uses herbal remedies,similarly explore the use of these productsbecause herbs may interact with certaindrugs. Also ask about the patient’suse of recreational drugs, such as alcoholand tobacco, as well as illegal drugs, suchas marijuana and heroin. If the patientacknowledges use of these drugs, be alertfor possible drug interactions. This informationalso may provide you with insightabout the patient’s response—or lack ofresponse—to his current drug treatmentplan.Try to find out if the patient has anyother problems that might affect hiscompliance with the drug treatment plan,and intervene appropriately. For instance,a patient who is unemployed and has nohealth insurance may fail to fill a neededprescription. In such a case, contact anappropriate individual in your facilitywho may be able to help the patientobtain financial assistance.Be sure to ask the patient if his drugtreatment plan requires special monitoringor follow-up laboratory tests. Forexample, patients who take antihypertensivesneed to have their blood pressurechecked routinely, and those who takewarfarin must have their prothrombintime tested regularly. Other patients mustundergo periodic blood tests to assesstheir hepatic and renal function.Determine whether the patient has compliedwith this part of his treatment plan,

Drug Therapy and the Nursing Process 13and ask him if he knows the results of thelatest monitoring or laboratory tests.ALLERGIESFind out if the patient is allergic to anydrugs or foods. If he has an allergy,explore it further by determining thetype of drug or food that triggers a reaction,the first time he experienced a reaction,the characteristics of the reaction,and other related information. Keep inmind that some patients consider annoyingsymptoms, such as indigestion, anallergic reaction. However, be sure todocument a true allergy according toyour facility’s policy to ensure that thepatient doesn’t receive that drug or anyrelated drug that may cause a similarreaction. Also, document allergies tofoods because they may lead to druginteractions or adverse drug reactions.For example, sulfite is a food additive aswell as a drug additive, so a patient with aknown allergy to sulfite-containing foodsis likely to react to sulfite-containingdrugs.MEDICAL HISTORYWhile reviewing your patient’s medicalhistory, determine if he has any acute orchronic conditions that may interferewith his drug therapy. Certain disordersinvolving major body systems, such asthe cardiovascular, GI, hepatic, and renalsystems, may affect a drug’s absorption,transport, metabolism, or excretion andinterfere with its action; they also mayincrease the incidence of adverse reactionsand lead to toxicity. For each disorderidentified, try to determine when thecondition was diagnosed, what drugswere prescribed, and who prescribedthem. This information can help youdetermine whether the patient is receivingincompatible drugs and whethermore than one prescriber is managing hisdrug therapy.Ask a female patient if she is or may bepregnant or if she’s breast-feeding. Manydrugs are safe to use during pregnancy,but others may harm the fetus. Also,some drugs are distributed into breastmilk. If your patient is or might be pregnant,check the FDA’s pregnancy risk categoryfor the prescribed drug and notifythe prescriber if the drug may pose a riskto the fetus. If the patient is breast-feeding,find out if the drug is distributed inbreast milk and intervene appropriately.PHYSICAL EXAMINATION FINDINGSAs part of the physical examination, notethe patient’s age and weight. Be awarethat age determines the dosage of certaindrugs, such as sedatives and hypnotics,whereas weight determines the dosage ofothers, including some I.V. antibioticsand anticoagulants. As you perform thephysical examination, note any abnormalfindings that may point to body organ orsystem dysfunction. For example, if youdetect liver enlargement and ascites, thepatient may have impaired hepatic function,which can affect the metabolism ofa drug he’s taking and lead to harmfuladverse or toxic effects. Also notewhether a body organ or system appearsto be responding to drug treatment. Forexample, if a patient has been taking anantibiotic to treat chronic bronchitis,thoroughly evaluate his respiratory statusto measure his progress. And be sure toassess the patient for possible adversereactions to the drugs he’s taking.Assess the patient’s neurologic functionto make sure that he can understand hisdrug regimen and carry out requiredtasks, such as performing a fingerstick toobtain blood for glucose measurement. Ifthe patient can’t understand essentialdrug information, you’ll need to identifya family member or another person whois willing to become involved in theteaching process.Nursing DiagnosisBased on information derived from theassessment and physical examinationfindings, the nursing diagnoses are statementsof actual or potential problemsthat a nurse is licensed to treat or managealone or in collaboration with othermembers of the health care team. They’reworded according to guidelines estab-

14Drug Therapy and the Nursing Processlished by the North American NursingDiagnosis Association (NANDA).One of the most common nursingdiagnoses related to drug therapy isknowledge deficit, which indicates that thepatient doesn’t have sufficient understandingof his drug regimen. However,adverse reactions are the basis for mostnursing diagnoses related to drug administration.For example, a patient receivingan opioid analgesic might have a nursingdiagnosis of constipation related todecreased intestinal motility or ineffectivebreathing pattern related to respiratorydepression. A patient receiving longterm,high-dose corticosteroids may havea risk for impaired skin integrity related tocortisone acetate or self-concept disturbancerelated to physical changes fromprednisone therapy. Many antiarrhythmicscause orthostatic hypotension andthus may place an elderly patient at highrisk for injury related to possible syncope.Broad-spectrum antibiotics, especiallypenicillin, may lead to the overgrowth ofClostridium difficile, a bacterium thatnormally is present in the intestine. Thisovergrowth in turn may lead topseudomembranous colitis, characterizedby abdominal pain and severe diarrhea.The nursing diagnoses in such a casemight include potential for infection relatedto bacterial overgrowth, alteration incomfort related to abdominal pain, andfluid balance deficit related to diarrhea.PlanningDuring the planning phase, you’ll establishexpected outcomes—or goals—forthe patient and then develop specificnursing interventions to achieve them.Expected outcomes are observable ormeasurable goals that should occur as aresult of nursing interventions and sometimesin conjunction with medical interventions.Developed in collaborationwith the patient, the outcomes should berealistic and objective and should clearlycommunicate the direction of the plan ofcare to other nurses. They should bewritten as behaviors or responses for thepatient, not the nurse, to achieve andshould include a time frame for measuringthe patient’s progress. An example ofa typical expected outcome is, The patientwill accurately demonstrate self-administrationof insulin before discharge. Basedon each outcome statement you establish,you’d then develop appropriate nursinginterventions, which might include drugadministration techniques, patient teaching,monitoring of vital signs, calculationof drug dosages based on weight, andrecording of intake and output.ImplementationAs you implement the nursing interventions,be sure to stringently follow theclassic rule of drug administration:administer the right dose of the rightdrug by the right route to the rightpatient at the right time. Also, keep inmind that you have a legal and professionalresponsibility to follow institutionalpolicy regarding standing orders, prescriptionrenewal, and the use of nursingjudgment. During the implementationphase, you’ll also begin to evaluate thepatient’s expected outcomes and nursinginterventions and make necessarychanges to the plan of care.EvaluationEvaluation is an ongoing process ratherthan a single step in the nursing process.During this phase, you evaluate eachexpected outcome to determine whetheror not it has been achieved and whetherthe original plan of care is working orneeds to be modified. In evaluating apatient’s drug treatment plan, you shoulddetermine whether or not the drug iscontrolling the signs and symptoms forwhich it was prescribed. You also shouldevaluate the patient for psychological orphysiologic responses to the drug, especiallyadverse reactions. This constantmonitoring allows you to make appropriateand timely suggestions for changes tothe plan of care, such as dosage adjustmentsor changes in delivery routes, untileach expected outcome has beenachieved.

DocumentationYou’re responsible for documenting allyour actions related to the patient’s drugtherapy, from the assessment phase toevaluation. Each time you administer adrug, document the drug name, dose,time given, and your evaluation of itseffect. When you administer drugs thatrequire additional nursing judgment,such as those prescribed on an as-neededbasis, document the rationale for administeringthe drug and follow-up assessmentor interventions for each doseadministered.If you decide to withhold a prescribeddrug based on your nursing judgment,document your action and the rationalefor it, and notify the prescriber of youraction in a timely manner. Whenever younotify a prescriber about a significantfinding related to drug therapy, such asan adverse reaction, document the dateand time, the person you contacted, whatyou discussed, and how you intervened.Drug Therapy and the Nursing Process 15

abataceptOrenciaAClass and CategoryChemical class: Soluble fusion protein,human recombinant fusion proteinTherapeutic class: AntirheumaticPregnancy category: CIndications and Dosages To reduce signs and symptoms, inducemajor clinical response, inhibit progressionof structural damage, and improvephysical function in patients with moderateto severe active rheumatoid arthritisand an inadequate response tomethotrexate or a tumor necrosis factorantagonistI.V. INFUSIONAdults weighing more than 100 kg(220 lb). Initial: 1,000 mg infused over30 min, repeated in 2 to 4 wk. Maintenance:1,000 mg infused over 30 min every 4 wkstarting at wk 8.Adults weighing 60 to 100 kg (132 to220 lb). Initial: 750 mg infused over30 min, repeated in 2 to 4 wk. Maintenance:750 mg infused over 30 min every 4 wkstarting at wk 8.Adults weighing less than 60 kg. Initial:500 mg infused over 30 min, repeated in 2to 4 wk. Maintenance: 500 mg infused over30 min every 4 wk starting at wk 8. To reduce signs and symptoms of moderateto severe active polyarticular juvenileidiopathic arthritisI.V. INFUSIONChildren ages 6 to 17 weighing more than100 kg. Initial: 1,000 mg infused over30 min, repeated in 2 to 4 wk. Maintenance:1,000 mg infused over 30 min every 4 wkstarting at wk 8.Children ages 6 to 17 weighing 75 to100 kg. Initial: 750 mg infused over 30 min,repeated in 2 to 4 wk. Maintenance: 750 mginfused over 30 min every 4 wk starting atwk 8.Children ages 6 to 17 weighing less thanabatacept 1775 kg. Initial: 10 mg/kg infused over30 min, repeated in 2 to 4 wk. Maintenance:10 mg/kg infused over 30 min every 4 wkstarting at wk 8.Mechanism of ActionInhibits T-cell activation by binding toCD80 and CD86 to block interaction withCD28. CD28 is part of the co-stimulatorysignal needed for full activation of T cells.Activated T cells have been implicated inthe pathogenesis of rheumatoid arthritis.With decreased proliferation of T cells,inflammation and other evidence ofrheumatoid arthritis decrease.IncompatiblitiesDon’t infuse abatacept solution with otherdrugs in the same intravenous line concurrentlybecause it isn’t known if the drugsmay interact.ContraindicationsHypersensitivity to abatacept or its componentsInteractionsDRUGSimmunosuppressants: Possibly increased riskof serious infectionlive-virus vaccines: Possibly decreasedresponse to vaccine, and risk of infectionwith live virustumor necrosis factor antagonists: Increasedrisk of serious infectionAdverse ReactionsCNS: Dizziness, fever, headacheCV: Hypertension, hypotensionEENT: Nasopharyngitis, rhinitis, sinusitisGI: Abdominal pain, diarrhea, diverticulitis,dyspepsia, nauseaGU: Acute pyelonephritis, UTIMS: Back or limb painRESP: Bronchitis, COPD worsening, cough,dyspnea, pneumonia, upper respiratorytract infection, wheezingSKIN: Cellulitis, flushing, pruritus, rash,urticariaOther: Anaphylaxis, antibody formation,herpes simplex, herpes zoster infection,influenza, malignancies, varicella infectionNursing Considerations• Screen patient for latent tuberculosis witha tuberculin skin test before starting abatacept.If test is positive, expect to provideA

18abciximabtreatment, as ordered, before starting abatacept.Also screen patient for hepatitis B. Ifpresent, expect abatacept to be withdrawnbecause anti-rheumatic therapies such asabatacept may reactivate hepatitis B.• Review patient’s immunization record,and make sure all immunizations are currentbefore therapy starts. Drug may blunteffectiveness of some vaccines and increasethe risk of infection with live viruses.• Use cautiously in patients with a history ofrecurrent infections, underlying conditionsthat may predispose them to infection,or existing chronic, latent, or localizedinfection. They have an increased riskof infection with abatacept therapy.• Use cautiously in patients with COPD andmonitor respiratory status closely becauseabatacept may worsen COPD and increasethe risk of adverse respiratory reactions.• Tumor necrosis factor antagonists shouldn’tbe given with abatacept because of anincreased of serious infection.• Reconsititue each vial with 10 ml of sterilewater for injection. Use only the siliconefreedisposable syringe provided with eachvial because a siliconized syringe maycause translucent particles to form in solution.After injecting sterile water into vial,gently swirl vial until contents are completelydissolved. To minimize foaming,don’t shake. Vent the vial with a needle todissipate any foam that may be present.• Further dilute reconstituted solution with0.9% sodium chloride injection to achievea final solution of 100 ml. Slowly addsolution into infusion bag or bottle usingthe same silicone-free disposable syringeprovided with each vial. Mix gently. Donot shake the bag or bottle.• Give entire dose of fully diluted drug over30 minutes using an infusion set and asterile, nonpyrogenic, low protein-bindingfilter with a pore size of 0.2 µm.• Once fully diluted, solution may be keptfor 24 hours at room temperature orrefrigerated. If reconstituted solution isn’tused within 24 hours, discard.• After giving abatacept, monitor patientclosely for evidence of hypersensitivityreaction such as rash, pruritus, urticaria,dyspnea, or wheezing. If present, stop drugimmediately, notify prescriber, and provideemergency care, as ordered.• Monitor patient closely for evidence ofinfection or malignancy because abataceptinhibits T-cell activation, increasing therisk of these disorders.PATIENT TEACHING• Instruct patient not to receive immunizationswith live vaccines during abatacepttherapy and for 3 months afterward.• Stress need to report any evidence ofinfection or hypersensitivity to prescriber.• Alert patient that abatacept may increasethe risk of maligancy.• Warn patient to avoid crowds and peoplewith infections.abciximabReoProClass and CategoryChemical class: Fab fragment of chimeric7E3 antibodyTherapeutic class: Platelet aggregationinhibitorPregnancy category: CIndications and Dosages To prevent acute myocardial ischemiccomplications after percutaneous transluminalcoronary angioplasty (PTCA)in patients at high risk for abrupt closureof treated coronary arteryI.V. INFUSION OR INJECTIONAdults. 250-mcg/kg bolus 10 to 60 minbefore PTCA. Maintenance: 0.125 mcg/kg/min by continuous infusion for 12 hr.Maximum: 10 mcg/min. To treat unstable angina in patients whohaven’t responded to conventional therapyand are scheduled for PTCA within24 hrI.V. INFUSION OR INJECTIONAdults. 250-mcg/kg by bolus; then 10 mcg/min by continuous infusion over 18 to24 hr, concluding 1 hr after PTCA.Route Onset Peak DurationI.V. Unknown Unknown 48 hrMechanism of ActionBinds to glycoprotein IIb/IIIa receptor siteson the surface of activated platelets.Circulating fibrinogen can bind to thesereceptor sites and link platelets together,

forming a clot that eventually blocks acoronary artery. By binding to receptorsites, abciximab prevents normal binding offibrinogen and other factors and inhibitsplatelet aggregation.IncompatibilitiesDon’t mix abciximab with other drugs. Givethrough separate I.V. line when possible.ContraindicationsActive internal bleeding, arteriovenous malformationor aneurysm, bleeding disorders,stroke in past 2 years or that caused significantneurologic deficit at any time, GI orGU bleeding in past 6 weeks, hypersensitivityto abciximab, intracranial neoplasm, I.V.dextran use before or during PTCA, oralanticoagulant therapy in past 7 days unlessPT is less than 1.2 times control, severeuncontrolled hypertension, surgery in past6 weeks, thrombocytopenia, vasculitisInteractionsDRUGSdipyridamole, heparin, NSAIDs, oral anticoagulants,thrombolytic drugs, ticlopidine:Increased risk of bleedingAdverse ReactionsCNS: Confusion, dizziness, hyperesthesiaCV: Atrial fibrillation or flutter, bradycardia,embolism, hypotension, peripheraledema, pseudoaneurysm, supraventriculartachycardia, third-degree AV block, thrombophlebitis,weak pulseGI: Dysphagia, hematemesis, nausea, vomitingGU: Dysuria, hematuria, renal dysfunction,urinary frequency, urinary incontinence,urine retentionHEME: Anemia, bleeding, leukocytosis,thrombocytopeniaRESP: Bronchitis, bronchospasm, crackles,dyspnea, pleural effusion, pneumonia, pulmonaryedema, pulmonary embolism,wheezingSKIN: Pruritus, rash, urticariaOther: Development of human antichimericantibodiesNursing Considerations• Know that abciximab may be used withheparin and aspirin therapy.• Inspect abciximab for particles; don’t useif opaque particles are present.• For continuous I.V. infusion, withdraw4.5 ml from 2-mg/ml solution and injectprescribed amount into 250-ml bag ofnormal saline solution or D 5 W using anin-line sterile, nonpyrogenic, low–proteinbinding0.2- to 0.22-micron filter. Discardunused portion.• Give I.V. bolus with sterile, nonpyrogenic,low–protein-binding 0.2- to 0.22-micronfilter.• Avoid I.M. injections, venipunctures, anduse of indwelling urinary catheters, NGtubes, and automatic blood pressure cuffsduring therapy to prevent bleeding. Ifappropriate, insert an intermittent I.V.access device to obtain blood samples.• Watch for GI, GU, and retroperitonealbleeding and bleeding at puncture sites.WARNING If hemorrhage occurs, prepare tostop infusion immediately. Expect to treatsevere thrombocytopenia with platelettransfusions if needed.• Monitor patient for hypersensitivity reactions,such as rash, pruritus, wheezing, anddysphagia from laryngeal edema. If suchreactions occur, stop infusion and notifyprescriber immediately. If anaphylaxisoccurs, give epinephrine, antihistamines,and corticosteroids, as prescribed.• Obtain platelet count 2 to 4 hours afterinitial bolus and every 24 hours duringtherapy as ordered. Expect platelet functionto return to normal within 48 hoursafter therapy ends.• Monitor vital signs and continuous ECGtracings during treatment.PATIENT TEACHING• Teach about possible adverse reactions,including bleeding and hypersensitivityreactions, which may cause rash, urticaria,and dyspnea.• Tell patient to prevent injury from falls bymaintaining bed rest and from bleeding bykeeping limb immobile while cathetersheath is in place.acamprosatecalciumCampralClass and CategoryChemical class: Synthetic endogenousamino acid homotaurine, gammaacamprosatecalcium 19A

20acamprosate calciumaminobutyric acid (GABA) analogueTherapeutic class: AntialcoholicPregnancy category: CIndications and Dosages To maintain abstinence from alcohol foralcohol-dependent patients who areabstinent at the start of treatmentE.R. TABLETSAdults. 666 mg t.i.d.DOSAGE ADJUSTMENT For patients withmoderate renal impairment (creatinineclearance of 30 to 50 ml/min), 333 mg t.i.d.Route Onset Peak DurationP.O. Unknown 3–8 hr UnknownContraindicationsHypersensitivity to acamprosate or its com-Mechanism of ActionChronic alcoholism may alter the balancebetween excitation and inhibition in neuronsin the brain; acamprosate restores it.When the neurotransmitter gammaaminobutyricacid (GABA) binds to itsreceptors in the CNS, it opens the chlorideion channel and releases chloride(Cl-) into the cell (below left), therebyreducing neuronal excitability by inhibitingdepolarization. By interacting withGABA receptor sites, acamprosate preventsGABA from binding (below right).Cell exteriorCell exteriorGABAGABAGABAAcamprosateGABAAcamprosateGABAReceptorReceptorCell exteriorReceptorReceptorGABAReceptorReceptorCl Cl – –ReceptorReceptorCell exteriorCl Cl – –GABAGABAReceptorReceptorAcamprosateAcamprosateCl Cl – –ReceptorReceptorReceptorReceptorCl Cl – –ReceptorReceptorCell membraneCell interiorReceptorReceptorReceptorReceptorCl Cl – –Cell membraneCl Cl – – Cl Cl – – Cl Cl – –ReceptorReceptorCell interiorReceptorReceptorCell membraneCl – Cl – Cell membraneCl – Cl – Cl Cl – –Cl Cl – –Cell exteriorCell exteriorCell interiorGlutamate Cell interiorGlutamateGlutamate binding (below right).AcamprosateGlutamateAcamprosateGlutamateReceptorReceptorCell exteriorReceptorReceptorGlutamateReceptorReceptorWhen glutamate binds to its receptors, itcloses the chloride ion channel, increasingneuronal excitability by promotingdepolarization (below left). This imbalancefosters a craving for alcohol. Byinteracting with glutamate receptor sites,acamprosate prevents glutamate fromCell exterior Cl Cl – –GlutamateGlutamateAcamprosateAcamprosateReceptorReceptorReceptorReceptorCl Cl – –ReceptorReceptorCl Cl – – Cl – Cl –Cl – Cl –Cl Cl – – Cl – Cl –Cl – Cl –ReceptorReceptorCell membraneCell interiorReceptorReceptorReceptorReceptorCl Cl – – Cl Cl – – Cl Cl – – Cl Cl – –Cl Cl – – Cl Cl – – Cl Cl – – Cl Cl – –ReceptorReceptorCell membraneCell interiorReceptorReceptorReceptorReceptorCell membraneCell interiorCell membraneCell interior

ponents, severe hepatic (Child-Pugh classC) or renal impairmentInteractionsDRUGSantidepressants: Increased weight gaintetracyclines: Decreased absorption of tetracyclinesAdverse ReactionsCNS: Abnormal thinking, amnesia, anxiety,asthenia, chills, depression, dizziness,headache, insomnia, paresthesia, somnolence,suicidal ideation, syncope, tremorCV: Chest pain, hypertension, palpitations,peripheral edema, vasodilationEENT: Abnormal vision, dry mouth,pharyngitis, rhinitis, taste perversionGI: Abdominal pain, anorexia, constipation,diarrhea, flatulence, increased appetite,indigestion, nausea, vomitingGU: Acute renal failure, decreased libido,impotenceHEME: Leukopenia, lymphocytosis, thrombocytopeniaMS: Arthralgia, back pain, myalgiaRESP: Bronchitis, cough, dyspneaSKIN: Diaphoresis, pruritus, rashOther: Flulike symptoms, infection, weightgainNursing Considerations• Acamprosate should start as soon as possibleafter patient has undergone alcoholwithdrawal and achieved abstinence.• Continue to give acamprosate even duringperiods of alcohol relapse.PATIENT TEACHING• Instruct patient to take acamprosate exactlyas prescribed, even if a relapse occurs,and to seek help for a relapse.• Warn patient that acamprosate won’treduce symptoms of alcohol withdrawal ifrelapse occurs followed by cessation.• Urge caregivers to monitor patient for evidenceof depression (lack of appetite orinterest in life, fatigue, excessive sleeping,difficulty concentrating) or suicidal tendenciesbecause a small number ofpatients taking acamprosate have attemptedsuicide.• Advise patient to use caution when performinghazardous activities until adverseCNS effects of drug are known.• Tell female patient to notify prescriber ifshe is or intends to become pregnant whiletaking acamprosate; the drug may need tobe stopped because fetal risks areunknown.acarbosePrecoseInteractionsDRUGScalcium channel blockers, digestive enzymes(such as pancreatin), diuretics, estrogen,intestinal adsorbents (such as activated charcoal),isoniazid, nicotinic acid, oral contraacarbose21Class and CategoryChemical class: Alpha-glucosidase inhibitor,oligosaccharideTherapeutic class: Antidiabetic drugPregnancy category: BIndications and Dosages To control blood glucose level in patientswith type 2 (non–insulin-dependent)diabetes mellitus when the level can’t becontrolled by diet aloneTABLETSAdults. Initial: 25 mg t.i.d. with first bite ofeach meal. Maintenance: Increased to maximumat 4- to 8-wk intervals p.r.n.Maximum: 50 mg t.i.d. for patients weighing65 kg (143 lb) or less; 100 mg t.i.d. forpatients weighing more than 65 kg.Mechanism of ActionInhibits action of alpha-amylase and alphaglucosideenzymes. Normally, alphaamylasehydrolyzes complex starches tooligosaccharides in the small intestine andalpha-glucoside hydrolyzes oligosaccharides,trisaccharides, and di-saccharides toglucose and other monosaccharides in thebrush border of the small intestine. In diabeticpatients, acarbose inhibits theseactions and delays glucose absorption,reducing blood glucose level after meals.ContraindicationsChronic intestinal disease, cirrhosis, coloniculceration, conditions that may deterioratebecause of increased gas formation in intestines,diabetic ketoacidosis, digestive orabsorption disorders, history of bowelobstruction, hypersensitivity to acarbose,inflammatory bowel diseaseA

22Mechanism of ActionInhibits stimulation of beta 1 receptors inthe heart, decreasing cardiac excitability,heart rate, cardiac output, and myocardialoxygen demand. Acebutolol also decreaseskidneys’ release of renin, which helpsreduce blood pressure. Drug suppresses SAnode automaticity and AV node conductivity,which suppresses atrial and ventricularectopy. By decreasing myocardial oxygendemand, acebutolol decreases myocardialischemia. At high doses, it inhibits stimulaacebutololhydrochlorideceptives, phenothiazines, phenytoin, sympathomimetics,thyroid hormones: Possiblydecreased therapeutic effects of acarbosedigoxin: Decreased serum level and therapeuticeffects of digoxininsulin, sulfonylureas: Decreased insulinaction, possibly increased risk of hypoglycemiaAdverse ReactionsCV: EdemaGI: Abdominal distention and pain, diarrhea,flatulence, hepatitis, hepatotoxicity,ileus, jaundiceSKIN: Erythema, exanthema, rash, urticariaNursing ConsiderationsWARNING Be aware that acarbose isn’t recommendedfor patients with significantrenal dysfunction and a serum creatininelevel above 2 mg/dl.• If patient is receiving acarbose and a sulfonylureaor insulin to enhance glucose control,check blood glucose level often, asappropriate.• Store drug in sealed container in coolenvironment.• Expect to decrease dosage to control GIupset.• Monitor glycosylated hemoglobin level asordered every 3 months for first year toevaluate glucose control and patient compliance.• Monitor hematocrit and serum AST levelevery 3 months during first year of therapyand periodically thereafter, as ordered,because acarbose may decrease hematocritand increase serum AST level.PATIENT TEACHING• Explain importance of self-monitoringglucose level during acarbose therapy.• Teach patient to recognize hypoglycemiaand hyperglycemia.• Warn patient that noncompliance withtreatment can increase risk of diabeticcomplications, including neuropathy,retinopathy, and renal insufficiency.• Explain that temporary insulin therapymay be needed if fever, trauma, infection,illness, surgery, or other stress alters bloodglucose control.• Warn patient not to take other drugs within2 hours of acarbose unless specificallyinstructed by prescriber.• Tell him to consult prescriber before takingOTC drugs during acarbose therapy.• Advise patient who also takes anotherantidiabetic to carry glucose with him atall times in case hypoglycemia occurs.acebutololhydrochlorideMonitan (CAN), SectralClass and CategoryChemical class: Beta 1 -selective (cardioselective)adrenergic receptor blockerTherapeutic class: Antihypertensive, class IIantiarrhythmicPregnancy category: BIndications and Dosages To treat hypertensionTABLETSAdults. Initial: 400 mg daily or 200 mgb.i.d. Usual: 200 to 800 mg daily. Increasedto 1,200 mg daily in divided doses b.i.d. forsevere hypertension or hypertension thatisn’t well controlled with usual dosage. To treat premature ventricular arrhythmiasTABLETSAdults. Initial: 200 mg b.i.d. Usual: 600 to1,200 mg daily.DOSAGE ADJUSTMENT Maximum of 800 mgdaily for elderly patients. Dosage reducedby 50% for patients with creatinine clearanceless than 50 ml/min/1.73 m 2 . Dosagereduced by 75% for patients with creatinineclearance less than 25 ml/min/1.73 m 2 .Route Onset Peak DurationP.O. 1–1.5 hr 2–8 hr 24 hr orlonger

tion of beta 2 receptors in the lungs and maycause bronchoconstriction.ContraindicationsCardiogenic shock, heart failure unlessfrom tachyarrhythmia, hypersensitivity toacebutolol, overt heart failure, second- andthird-degree heart block, severe bradycardiaInteractionsDRUGSalpha agonists, nasal decongestants:Increased risk of hypertensionaluminum salts, barbiturates, calcium salts,cholestyramine, colestipol, indomethacin,NSAIDs, penicillins, rifampin, salicylates,sulfinpyrazone: Decreased antihypertensiveeffectsanticholinergics, hydralazine, methyldopa,prazosin, reserpine: Increased risk of bradycardiaand hypotensionbeta 2 agonists, theophylline: Decreased bronchodilationepinephrine: Increased risk of blocked sympathomimeticeffectsergot alkaloids: Increased risk of peripheralischemia and gangreneflecainide: Possibly increased effects of bothdrugslidocaine: Possibly increased serum lidocainelevel, causing toxicityoral contraceptives, quinidine: Possiblyincreased serum acebutolol levelsulfonylureas: Possibly decreased hypoglycemiceffectsverapamil: Increased cardiac effects, leadingto bradycardia and hypotensionAdverse ReactionsCNS: Abnormal dreams, anxiety, confusion,depression, dizziness, fatigue, fever, headache,insomniaCV: Bradycardia, chest pain, edema, heartblock, heart failure, hypotensionEENT: Abnormal vision, conjunctivitis, dryeyes, eye pain, pharyngitis, rhinitisGI: Constipation, diarrhea, flatulence,hepatotoxicity, indigestion, nauseaGU: Dysuria, impotence, polyuriaMS: Arthralgia, myalgiaRESP: Bronchospasm, cough, dyspnea,wheezingSKIN: RashNursing Considerations• Before therapy begins, obtain baselineacetaminophen 23renal function tests, as ordered.• Check apical and radial pulses before givingacebutolol. Also, frequently monitorblood pressure and pulse rate, rhythm,and quality during treatment.• Give drug with food to prevent GI upset.• Acebutolol may elevate uric acid, potassium,triglyceride, lipoprotein, and antinuclearantibody levels; it also may interferewith accuracy of glucose tolerance tests.• Monitor diabetic patient’s blood glucoselevel to spot alterations.• Notify prescriber if you detect a heart ratebelow 50 beats/min or signs of heart failure,such as dyspnea, crackles, unexplainedweight gain, and jugular vein distention.• Monitor patient for peripheral edema, andevaluate fluid intake and output.PATIENT TEACHING• Tell patient that tablets may be crushed orswallowed whole.• Warn against stopping acebutolol abruptlybecause doing so could cause angina ordangerously high blood pressure.• Instruct patient to take a missed dose assoon as possible up to 6 hours before nextscheduled dose but not to double the nextdose.• Advise patient to consult prescriber beforetaking OTC drugs that contain alpha agonists,such as nasal decongestants and coldpreparations.• Instruct patient to report dizziness, confusion,and fever immediately.• Urge patient to maintain diet and lifestylechanges to help control blood pressure.acetaminophenAbenol (CAN), Acephen, Aceta Elixir,Acetaminophen Uniserts, Aceta Tablets,Apacet Capsules, Apacet Elixir, ApacetExtra Strength Tablets, Apacet RegularStrength Tablets, Aspirin Free PainRelief, Exdol (CAN), Feverall, FeverallSprinkle Caps, Genapap Infants’ Drops,Genebs Extra Strength, HalenolChildren’s Junior Strength, LiquiprinElixir, Liquiprin Infants’ Drops, MedaCap, Neopap, Oraphen-PD, Panadol,Panadol Infants’ Drops, Pediaphen,Redutemp, Robigesic (CAN), St. JosephAspirin-Free Infant Drops, TapanolA

24acetaminophenExtra Strength, Tempra, Tempra Drops,Tylenol, Tylenol Caplets, TylenolChildren’s Chewable Tablets, TylenolExtra Strength, Tylenol Gelcaps,Tylenol Infants’ DropsClass and CategoryChemical class: Nonsalicylate, paraaminophenolderivativeTherapeutic class: Antipyretic, nonopioidanalgesicPregnancy category: BIndications and Dosages To relieve mild to moderate pain fromheadache, muscle ache, backache, minorarthritis, common cold, toothache, ormenstrual cramps; to reduce feverCAPLETS, CAPSULES, CHEWABLE TABLETS, ELIXIR,E.R. CAPLETS, GELCAPS, LIQUID, SOLUTION,SPRINKLES, SUSPENSION, TABLETSAdults. 325 to 650 mg every 4 to 6 hr, or1,000 mg t.i.d. or q.i.d., or 2 E.R. capletsevery 8 hr. Maximum: 4,000 mg daily.Children over age 14. 650 mg every 4 hr.Maximum: 5 doses in 24 hr.Children ages 12 to 14. 640 mg every 4 hr.Maximum: 5 doses in 24 hr.Children age 11. 480 mg every 4 hr.Maximum: 5 doses in 24 hr.Children ages 9 to 10. 400 mg every 4 hr.Maximum: 5 doses in 24 hr.Children ages 6 to 8. 320 mg every 4 hr.Maximum: 5 doses in 24 hr.Children ages 4 to 5. 240 mg every 4 hr.Maximum: 5 doses in 24 hr.Children ages 2 to 3. 160 mg every 4 hr.Maximum: 5 doses in 24 hr.Children age 1. 120 mg every 4 hr.Maximum: 5 doses in 24 hr.Children ages 4 to 11 months. 80 mg every4hr.Maximum: 5 doses in 24 hr.Children ages 0 to 3 months. 40 mg every4hr.Maximum: 5 doses in 24 hr.SUPPOSITORIESAdults and adolescents. 650 mg every 4 to6 hr. Maximum: 4,000 mg daily.Children ages 6 to 12. 325 mg every 4 to 6hr. Maximum: 2,600 mg daily.Children ages 3 to 6. 120 to 125 mg every4 to 6 hr. Maximum: 720 mg daily.Children ages 1 to 3. 80 mg every 4 hr.Children ages 3 months to 11 months.80 mg every 6 hr.Mechanism of ActionInhibits the enzyme cyclooxygenase, blockingprostaglandin production and interferingwith pain impulse generation in theperipheral nervous system. Acetaminophenalso acts directly on temperature-regulatingcenter in the hypothalamus by inhibitingsynthesis of prostaglandin E 2 .Route Onset Peak DurationP.O., P.R. Varies 1–3 hr 3–4 hrContraindicationsHypersensitivity to acetaminophen or itscomponentsInteractionsDRUGSanticholinergics: Decreased onset of acetaminophenactionbarbiturates, carbamazepine, hydantoins, isoniazid,rifampin, sulfinpyrazone: Decreasedtherapeutic effects and increased hepatotoxiceffects of acetaminophenlamotrigine, loop diuretics: Possiblydecreased therapeutic effects of these drugsoral contraceptives: Decreased effectivenessof acetaminophenprobenecid: Possibly increased therapeuticeffects of acetaminophenpropranolol: Possibly increased action ofacetaminophenzidovudine: Possibly decreased zidovudineeffectsACTIVITIESalcohol use: Increased risk of hepatotoxicityAdverse ReactionsGI: Abdominal pain, hepatotoxicity, nausea,vomitingHEME: Hemolytic anemia (with long-termuse), leukopenia, neutropenia, pancytopenia,thrombocytopeniaSKIN: Jaundice, rash, urticariaOther: Angioedema, hypoglycemic comaNursing Considerations• Before and during long-term therapy,monitor liver function test results, includingAST, ALT, bilirubin, and creatinine levels,as ordered.• Monitor renal function in patient on longtermtherapy. Keep in mind that blood oralbumin in urine may indicate nephritis;decreased urine output may indicate renal

failure; and dark brown urine may indicatepresence of the metabolitephenacetin.• Expect to reduce dosage for patients withrenal dysfunction.• Store suppositories under 80° F (26.6° C).WARNING Be aware that Pediaphen is a concentratedform of acetaminophen containing80 mg/0.8 ml (standard liquid formscontain 32 mg/ml). Make sure to use correctconcentration and dosage of liquidacetaminophen because serious adversereactions can result from confusing concentratedform with regular liquid form.PATIENT TEACHING• Tell patient that tablets may be crushed orswallowed whole.• Instruct patient to read manufacturer’slabel and follow dosage guidelines precisely.Explain that infants’ and children’s acetaminophenliquid aren’t equal in drugconcentration and aren’t interchangeable.• Advise patient to use manufacturer’s dropperor dosage cup for measuring liquidacetaminophen.• Advise him to contact prescriber beforetaking other prescription or OTC productsbecause they may contain acetaminophen.• Teach patient to recognize signs of hepatotoxicity,such as bleeding, easy bruising,and malaise, which commonly occurs withchronic overdose.acetazolamideAcetazolam (CAN), Ak-Zol, Apo-Acetazolamide (CAN), Dazamide,Diamox, Diamox Sequels,StorzolamideClass and CategoryChemical class: Sulfonamide derivativeTherapeutic class: Anticonvulsant, antiglaucoma,diureticPregnancy category: CIndications and Dosages To treat chronic simple (open-angle)glaucomaS.R. CAPSULES, TABLETS, I.V. OR I.M. INJECTIONAdults. 250 to 1,000 mg daily (divided fordoses exceeding 250 mg). As short-term therapy to treat secondaryglaucoma and preoperatively to treatacetazolamide 25acute congestive (closed-angle) glaucomaS.R. CAPSULES, TABLETS, I.V. OR I.M. INJECTIONAdults. 250 mg b.i.d. or every 4 hr; or 1S.R. capsule (500 mg) b.i.d.; or 500 mg initially,followed by 125 to 250 mg every 4 to6 hr for severe acute glaucoma. To initiallylower intraocular pressure rapidly, 500 mgI.V.; may repeat in 2 to 4 hr in acute cases,depending on patient response. Oral therapyusually started after initial I.V. dose.S.R. CAPSULES, TABLETSChildren. 10 to 15 mg/kg daily in divideddoses every 6 to 8 hr.I.V. OR I.M. INJECTIONChildren. 5 to 10 mg/kg/dose every 6 hr. To induce diuresis in heart failureTABLETS, I.V. OR I.M. INJECTIONAdults. Initial: 250 to 375 mg or 5 mg/kgdaily in morning. Maintenance: 250 to375 mg or 5 mg/kg on alternate days or for2 days followed by a drug-free day. To treat drug-induced edemaTABLETS, I.V. OR I.M. INJECTIONAdults. 250 to 375 mg daily for 1 to 2 days.TABLETS, I.V. INJECTIONChildren. 5 mg/kg/dose daily in morning. To treat seizures, including generalizedtonic-clonic, absence, and mixedseizures, and myoclonic jerk patternsTABLETS, I.V. OR I.M. INJECTIONAdults and children. 8 to 30 mg/kg daily individed doses. Optimal: 375 to 1,000 mgdaily. When used with other anticonvulsants,250 mg daily. To prevent or relieve symptoms of acutemountain sicknessS.R. CAPSULES, TABLETSAdults. 500 to 1,000 mg daily in divideddoses, given 24 to 48 hr before ascent andcontinued for 48 hr or longer while at highaltitude p.r.n. to control symptoms.Route Onset Peak DurationP.O. 1–1.5 hr 2–4 hr 8–12 hrP.O. (S.R.) 2 hr 8–12 hr 18–24 hrI.V. 2 min 15 min 4–5 hrMechanism of ActionInhibits the enyzme carbonic anhydrase,which normally appears in the eyes’ ciliaryprocesses, brain’s choroid plexes, and kidneys’proximal tubule cells. In the eyes,enzyme inhibition decreases aqueoushumor secretion, which lowers intraocularA

26acetohexamidepressure. In the brain, inhibition may delayabnormal, intermittent, and excessive dischargefrom neurons that cause seizures. Inthe kidneys, it increases bicarbonate excretion,which carries out water, potassium,and sodium, thus inducing diuresis andmetabolic acidosis. This acidosis counteractsrespiratory alkalosis and reduces symptomsof mountain sickness, includingheadache, dizziness, nausea, and dyspnea.ContraindicationsChronic noncongestive closed-angle glaucoma;cirrhosis; hyperchloremic acidosis;hypersensitivity to acetazolamide;hypokalemia; hyponatremia; severe pulmonaryobstruction; severe renal, hepatic,or adrenocortical impairmentInteractionsDRUGSamphetamines, methenamine, phenobarbital,procainamide, quinidine: Decreased excretionand possibly toxicity of these drugscorticosteroids: Increased risk ofhypokalemiacyclosporine: Increased cyclosporine level,possibly nephrotoxicity or neurotoxicitydiflunisal: Possibly significantly decreasedintraocular pressurelithium: Increased excretion and decreasedeffectiveness of lithiumprimidone: Decreased serum and urineprimidone levelssalicylates: Increased risk of salicylate toxicityAdverse ReactionsCNS: Ataxia, confusion, depression, disorientation,dizziness, drowsiness, fatigue,fever, flaccid paralysis, headache, lassitude,malaise, nervousness, paresthesia, seizures,tremor, weaknessEENT: Altered taste, tinnitus, transientmyopiaGI: Anorexia, constipation, diarrhea, hepaticdysfunction, melena, nausea, vomitingGU: Crystalluria, decreased libido, glycosuria,hematuria, impotence, nephrotoxicity,phosphaturia, polyuria, renal calculi,renal colic, urinary frequencyHEME: Agranulocytosis, hemolytic anemia,leukopenia, pancytopenia, thrombocytopenia,thrombocytopenic purpuraSKIN: Photosensitivity, pruritus, rash,Stevens-Johnson syndrome, urticariaOther: Acidosis, hyperuricemia, hypokalemia,weight lossNursing Considerations• Use acetazolamide cautiously in patientswith calcium-based renal calculi, diabetesmellitus, gout, or respiratory impairment.• Know that acetazolamide may increaserisk of hepatic encephalopathy in patientswith hepatic cirrhosis.• To avoid painful I.M. injections (caused byalkaline solution), give acetazolamide bymouth or I.V. injection if possible.• Reconstitute each 500-mg vial with at least5 ml sterile water for injection. Use within24 hours because drug has no preservative.• Monitor blood tests during acetazolamidetherapy to detect electrolyte imbalances.• Monitor fluid intake and output every8 hours and body weight daily to detectexcessive fluid and weight loss.PATIENT TEACHING• Inform patient that acetazolamide tabletsmay be crushed and suspended in chocolateor another sweet syrup. Or, one tabletmay be dissolved in 10 ml hot water andadded to 10 ml honey or syrup.• Advise patient to avoid hazardous activitiesif dizziness or drowsiness occurs.• Instruct patient who takes high doses ofsalicylates to notify prescriber immediatelyabout evidence of salicylate toxicity, suchas anorexia, tachypnea, and lethargy.• If patient plans to mountain climb, urgeher to descend mountain gradually and toseek immediate medical care if symptomsof mountain sickness occur.acetohexamideDimelor (CAN), DymelorClass and CategoryChemical class: SulfonylureaTherapeutic class: AntidiabeticPregnancy category: CIndications and Dosages To treat stable type 2 (non–insulindependent)diabetes mellitusTABLETSAdults. Initial: 250 to 1,500 mg daily.Dosages of 1,000 mg or more daily may bedivided and given b.i.d. before morning and

evening meals.DOSAGE ADJUSTMENT For patient beingswitched from another antidiabetic, acetohexamidedosage reduced to half the usualtolbutamide dosage or twice the usualchlorpropamide dosage. For patient beingswitched from insulin to acetohexamidemonotherapy, dosages adjusted as follows:if insulin dosage is less than 20 units daily,acetohexamide starts at 250 mg daily andinsulin is discontinued; if insulin dosageexceeds 20 units daily, acetohexamide startsat 250 mg daily and insulin is tapered by25% to 30% before being reduced furtheraccording to patient response.Route Onset Peak DurationP.O. 1 hr Unknown 12–24 hrMechanism of ActionStimulates insulin release from active betacells in the pancreas, resulting in decreasedblood glucose level. Improves insulin bindingto insulin receptors. Increases the numberof insulin receptors (with long-termadministration). May reduce basal hepaticglucose secretion.ContraindicationsDiabetes mellitus complicated by ketoacidosisor pregnancy, hypersensitivity toaceto-hexamide, renal failure, sole therapyfor type 1 (insulin-dependent) diabetesmellitusInteractionsDRUGSactivated charcoal: Possibly reduced absorptionand effectiveness of acetohexamideandrogens, anticoagulants, azole antifungals,chloramphenicol, clofibrate, fluconazole, gemfibrozil,H 2 -receptor antagonists, magnesiumsalts, MAO inhibitors, methyldopa,probenecid, salicylates, sulfinpyrazone, sulfonamides,tricyclic antidepressants, urinaryacidifiers: Enhanced hypoglycemic effect ofacetohexamidebeta blockers, calcium channel blockers,cholestyramine, corticosteroids, diazoxide,estrogens, hydantoins, isoniazid, nicotinicacid, oral contraceptives, phenothiazines,rifampin, sympathomimetics, thiazide diuretics,thyroid drugs, urinary alkalizers:Decreased hypoglycemic effectdigitalis glycosides: Possibly increased serumdigitalis levelacetohexamide 27Adverse ReactionsCNS: Anxiety, chills, confusion, depression,dizziness, drowsiness, fatigue, headache,hyperesthesia, insomnia, malaise, nervousness,paresthesia, somnolence, syncope,tremor, vertigo, weaknessCV: Arrhythmias, edema, hypertension,vasculitisEENT: Blurred vision, conjunctivitis, eyepain, pharyngitis, retinal hemorrhage,rhinitis, tinnitusENDO: HypoglycemiaGI: Abdominal pain, anorexia, constipation,diarrhea, epigastric fullness, flatulence,heartburn, hepatitis, hepatotoxicity, indigestion,nausea, proctocolitis, vomitingGU: Decreased libido, dysuria, polyuriaHEME: Agranulocytosis, aplastic anemia,eosinophilia, hemolytic anemia, leukopenia,pancytopenia, thrombocytopeniaMS: Abnormal gait, arthralgia, hypertonia,leg crampsRESP: DyspneaSKIN: Diaphoresis, eczema, erythema multiforme,exfoliative dermatitis, flushing,jaundice, lichenoid reaction (skin thickening,accentuated lesions), maculopapularrash, photosensitivity, pruritus, rash,urticariaOther: Disulfiram-like reaction (flushing,head throbbing, hypotension, nausea,tachycardia, vomiting), hyponatremiaNursing Considerations• Use acetohexamide cautiously in elderlypatients and in those with cardiac, hepatic,or renal disease or thyroid dysfunction.Drug’s duration of action is prolonged inpatients with renal disease.• Give acetohexamide 30 minutes beforemeals, crushing tablets if desired. If GIupset occurs, give in divided doses, as prescribed.• Watch for evidence of hypoglycemia andhyperglycemia, especially after meals.• Check blood glucose level often, as ordered.Provide additional insulin if needed duringstressful periods, as prescribed.• Monitor liver enzyme levels during therapy;acetohexamide may increase AST, ALT,and alkaline phosphatase levels.• Store acetohexamide in tightly sealed containerin a cool environment.A

28acetohydroxamic acidPATIENT TEACHING• Stress need to adhere to prescribed drugregimen, diet, and exercise program.• Advise patient to take acetohexamide withfood to avoid GI upset.• Teach patient how to self-monitor bloodglucose level and check urine for glucoseand ketones, as appropriate.• Teach patient to recognize and reportsigns of hypoglycemia and hyperglycemia.acetohydroxamicacidLithostatClass and CategoryChemical class: Synthetic hydroxylamineand ethylacetate derivativeTherapeutic class: Urease inhibitorPregnancy category: XIndications and Dosages As an adjunct to antimicrobial therapyto treat chronic UTI caused by ureasplittingbacteriaTABLETSAdults. Initial: 12 mg/kg daily in divideddoses every 6 to 8 hr. Usual: 250 mg t.i.d. orq.i.d. for a total of 10 to 15 mg/kg daily.Maximum: 1,500 mg daily.Children. 10 mg/kg daily.DOSAGE ADJUSTMENT Maximum dosagereduced to 1,000 mg daily or 500 mg every12 hr for patients with serum creatininelevel that exceeds 1.8 mg/dl.Mechanism of ActionInhibits urease, the enzyme that catalyzesurea’s hydrolysis to carbon dioxide andammonia in urine infected with ureasplittingbacteria. This action reduces theurine ammonia level and pH, enhancingantimicrobial drug effectiveness.ContraindicationsContributing disorder that’s treatable bysurgery or appropriate antimicrobial therapy,hypersensitivity to acetohydroxamicacid, inadequate renal function (serum creatininelevel above 2.5 mg/dl or creatinineclearance below 20 ml/min/1.73 m 2 ), risk ofpregnancy, UTI caused by non–ureaseproducingorganisms, UTI that could becontrolled by appropriate antimicrobialtherapyInteractionsDRUGSiron: Decreased intestinal absorption ofiron, decreased effects of iron and acetohydroxamicacidACTIVITIESalcohol use: Increased risk of severe rash30 to 45 minutes after drinking alcoholAdverse ReactionsCNS: Anxiety, depression, fever, lack ofcoordination, malaise, headache, nervousness,slurred speech, tiredness, tremorCV: Calf pain (deep vein blood clot), palpitations,sudden chest painEENT: Pharyngitis, sudden change in visionGI: Anorexia, nausea, vomitingHEME: Reticulocytosis, unusual bleedingRESP: DyspneaSKIN: Ecchymosis, hair loss, nonpruriticmacular rashNursing Considerations• Use acetohydroxamic acid cautiously inpatients with severe chronic renal diseaseor anemia and those who’ve had phlebitisor thrombophlebitis.• Be aware that risk of adverse psychomotoreffects increases if patient drinks alcoholor takes drugs that affect alertness andreflexes, such as antihistamines, tranquilizers,sedatives, analgesics, and narcotics.• Administer tablets with food or liquid,crushing them if needed.WARNING Acetohydroxamic acid chelateswith dietary iron. If patient has iron deficiencyanemia, expect to administer I.M.iron as needed during acetohydroxamicacid therapy.• Monitor follow-up laboratory tests tocheck renal and hepatic function andurine pH, as ordered.PATIENT TEACHING• Instruct patient to take drug at same timeeach day, as prescribed.• Tell patient to take a missed dose up to2 hours after scheduled time. If more than2 hours have passed, he should wait fornext scheduled dose and shouldn’t doublethat dose.• Warn patient not to take drug with alcoholor iron and to consult prescriberbefore taking it with any other drug.

• Instruct patient to avoid hazardous activitiesduring therapy.acetylcysteineAcetadote, Mucomyst, MucosilClass and CategoryChemical class: N-acetyl derivative ofcysteineTherapeutic class: Antidote (for acetaminophenoverdose), mucolyticPregnancy category: BIndications and Dosages To liquefy abnormal, viscid, or thickenedmucus secretions in chronic pulmonarydisorders (including emphysema, bronchitis,tuberculosis, bronchiectasis, andcystic fibrosis) and in pneumonia, pulmonarycomplications of thoracic or cardiovascularsurgery, and tracheostomycareSOLUTION BY DIRECT INSTILLATION INTOTRACHEOSTOMY (MUCOMYST, MUCOSIL)Adults and children. 1 to 2 ml of 10% or20% solution instilled every 1 to 4 hr, p.r.n.SOLUTION BY INHALATIONAdults and children. 1 to 10 ml of 20%solution or 2 to 20 ml of 10% solution nebulizedthrough face mask, mouthpiece, ortracheostomy every 2 to 6 hr. Usual: 3 to5 ml of 20% solution or 6 to 10 ml of 10%solution t.i.d. or q.i.d. To treat acetaminophen overdoseSOLUTION P.O.(MUCOMYST, MUCOSIL)Adults and children. Loading dose: 140 mg/kg. Maintenance: 70 mg/kg 4 hr after loadingdose and then every 4 hr to a total of17 doses.I.V. INFUSION (ACETADOTE)Adults and children weighing 40 kg (88 lb)or more. 150 mg/kg in 200 ml of diluentinfused over 60 min, followed by 50 mg/kgin 500 ml of diluent infused over 4 hr, followedby 100 mg/kg in 1,000 ml of diluentinfused over 16 hr.Adults and children weighing more than20 kg (44 lb) but less than 40 kg. 150 mg/kg in 100 ml of diluent infused over 60 min,followed by 50 mg/kg in 250 ml of diluentinfused over 4 hr, followed by 100 mg/kg in500 ml of diluent infused over 16 hr.Children weighing 20 kg or less. 150 mg/acetylcysteine 29kg in 3 ml/kg of diluent infused over 60 min,followed by 50 mg/kg in 7 ml/kg of diluentinfused over 4 hr, followed by 100 mg/kg in14 ml/kg of diluent infused over 16 hr.Mechanism of ActionDecreases viscosity of pulmonary secretionsby breaking disulfide links that bind glycoproteinsin mucus. Reduces liver damagefrom acetaminophen overdose. Usually,acetaminophen’s toxic metabolites bindwith glutathione in the liver, which detoxifiesthem. When acetaminophen overdosedepletes glutathione stores, toxic metabolitesbind with protein in liver cells, killingthem. Acetylcysteine maintains or restoreslevels of glutathione or acts as its substitute,which reduces liver damage from acetaminophenoverdose.IncompatibilitiesDon’t give acetylcysteine with nebulizationequipment if drug can contact iron, copper,or rubber. Don’t give drug with amphotericinB, ampicillin sodium, chlortetracycline,chymotrypsin, erythromycin, hydrogenperoxide, iodized oil, oxytetracycline,tetracycline, or trypsin.ContraindicationsHypersensitivity to acetylcysteine, nocontraindications when used as antidoteInteractionsDRUGSactivated charcoal: Possibly adsorption anddecreased effectiveness of oral acetylcysteinenitroglycerin: Increased effects of nitroglycerinand possibly significant hypotensionand headacheAdverse ReactionsCNS: Chills, dizziness, drowsiness, fever,headacheCV: Edema, hypertension, hypotension,tachycardiaEENT: Rhinorrhea, stomatitis, tooth damageGI: Anorexia, constipation, hepatotoxicity,nausea, vomitingRESP: Bronchospasm, chest tightness,cough, hemoptysis, respiratory distress,shortness of breath, stridor, wheezingSKIN: Clammy skin, facial flushing, pruritus,rash, urticariaOther: Anaphylaxis, angioedemaA

30acitretinNursing Considerations• Acetylcysteine should be used cautiouslyin patients with asthma or a history ofbronchospasm because drug may adverselyaffect respiratory function.WARNING To avoid fluid overload and possiblyfatal hyponatremia or seizures, adjusttotal administered volume, as ordered, forpatients weighing less than 40 kg (88 lb)and for those who need fluid restriction.• If needed, dilute 20% instillation orinhalation solution with normal salinesolution or sterile water. The 10% solutionmay be used undiluted.• When treating acetaminophen overdose,dilute 20% oral solution with cola or othersoft drink to a concentration of 5%, anduse within 1 hour. Dilute parenteral solutionwith D 5 W or half-normal saline(0.45% sodium chloride) solution forinjection following manufacturer guidelinesbecause dilution is based on dosage.Acetadote may turn from colorless toslight pink or purple once the stopper ispunctured, but color change has no effecton product quality.• Acetylcysteine is most effective if givenwithin 24 hours of acetaminophen ingestion.For specific instructions, contact aregional poison center at 1-800-222-1222or a special health professional assistancehotline at 1-800-525-6115.• If patient vomits loading dose or anymaintenance dose within 1 hour ofadministration, repeat dose as prescribed.• Keep in mind that suicidal patient maynot provide reliable information aboutvomiting. Watch such a patient to ensurethat he ingests all of prescribed dosage.• During treatment for acetaminophenoverdose, watch for signs of hepatotoxicity,such as prolonged bleeding time,altered coagulation, and easy bruising.• Be aware that acetylcysteine may have adisagreeable odor, which disappears astreatment progresses.• Because nebulization causes sticky residueon face and in mouth, have patient washhis face and rinse his mouth at the end ofeach treatment.• Be aware that an open vial of solution mayturn light purple but that this doesn’t alterits effectiveness.• Refrigerate opened vials and discard after96 hours.• Assess type, frequency, and characteristicsof patient’s cough. Particularly note sputum.If cough doesn’t clear secretions, prepareto perform mechanical suctioning.• Monitor patient for tachycardia.PATIENT TEACHING• Instruct patient to notify prescriber immediatelyabout nausea, rash, or vomiting.• Warn patient about acetylcysteine’sunpleasant smell; reassure him that it subsidesas treatment progresses.• To decrease mucus viscosity, urge patientto consume 2 to 3 L of fluid daily unlesscontraindicated by another condition.acitretinSoriataneClass and CategoryChemical class: Synthetic retinoidTherapeutic class: AntipsoriaticPregnancy category: XIndications and Dosages To treat severe psoriasisCAPSULESAdults. 25 to 50 mg once daily with a meal.Route Onset Peak DurationP.O. Unknown 2–5 hr UnknownMechanism of ActionBinds to several retinoid receptors to regulategene transcription. Exactly how theaction of this second-generation retinoidallows normal growth and development ofskin is unknown.ContraindicationsAlcohol consumption; blood donation;breast-feeding; chronic hyperlipidemia;concurrent use of etretinate, methotrexate,or tetracycline; hypersensitivity to acitretin,other retinoids, or their components; pregnancy;severe hepatic or renal impairmentInteractionsDRUGSmethotrexate: Increased risk of hepatitisoral contraceptives containing only progestin:Possibly decreased effectiveness of oral contraceptive

phenytoin: Possibly decreased protein bindingof phenytoinsulfonylureas: Possibly increased risk ofhypoglycemiatetracyclines: Increased intracranial pressurevitamin A and other oral retinoids: Increasedrisk of hypervitaminosis AACTIVITIESalcohol use: Increased risk of adverse reactionsand acitretin toxicityAdverse ReactionsCNS: Aggression, depression, fatigue,headache, hyperesthesia, hypotonia, insomnia,intracranial hypertension, paresthesia,peripheral neuropathy, rigors, somnolence,stroke, suicidal ideation, thirstCV: Chest pain, decreased high-densitylipoproteins, edema, elevated cholesterol ortriglyceride levels, MI, thromboembolismEENT: Abnormal or blurred vision, blepharitis,conjunctivitis, corneal epithelialabnormality, decreased night vision, deafness,dry eyes or mouth, earache, epistaxis,eye pain, gingival bleeding, gingivitis,increased saliva, photophobia, sinusitis,stomatitis, taste perversion, tinnitus, ulcerativestomatititsENDO: Hot flashes, hyperglycemiaGI: Anorexia, abdominal pain, diarrhea,elevated liver enzymes, hepatitis, hepatotoxicity,nausea, pancreatitisGU: VulvovaginitisHEME: Hemorrhage, increased bleedingtimeMS: Arthralgia, arthrosis, back pain, hyperostosis,myalgia, myopathySKIN: Abnormal skin or hair texture,alopecia, bullous eruption, cold or clammyskin, dermatitis, diaphoresis, dry or peelingskin, erythematous rash, flushing, fragilityor thinning of skin, photosensitivity, pruritus,purpura, pyogenic granuloma, rash,scaling, seborrhea, skin fissure or ulcerationOther: Hypervitaminosis A, increasedappetiteNursing ConsiderationsWARNING Don’t give acitretin to a pregnantwoman, a woman contemplating pregnancy,or a woman who may not use reliablecontraception during drug therapy and forat least 3 years afterward because acitretincauses major fetal abnormalities.• Make sure patient has had two negativeacitretin 31urine or serum pregnancy tests with a sensitivityof at least 25 mIU/ml beforereceiving acitretin. First test should beobtained when decision is made to useacitretin and second test during first5 days of the menstrual period just beforeacitretin therapy starts. For patients withamenorrhea, second test should be done atleast 11 days after the last act of unprotectedsexual intercourse (which meanswithout using two effective forms of contraceptionsimultaneously).• Check to make sure female patient ofchildbearing age has signed the patientagreement and informed consent formbefore starting acitretin therapy.• Obtain a lipid profile, as ordered, beforeacitretin therapy starts and every 1 to2 weeks for up to 8 weeks or until lipideffects are known. In high-risk patients,such as those with diabetes, obesity, or ahistory of alcohol abuse and those takingacitretin long-term, check lipid profileperiodically throughout therapy.• Monitor liver function test results, asordered. If hepatotoxicity is suspected,expect to stop drug and investigate cause.• If patient takes acitretin long-term or shedevelops a skeletal disorder, prepare herfor periodic bone radiography becauseossification abnormalities can occur, especiallyof the vertebral column, knees, andankles.• Monitor patient’s eyes for abnormalitiesthroughout therapy. Expect patient to stopdrug and have an ophthalmologic examinationif eye abnormalities occur.• Monitor patient for evidence of increasedintracranial pressure, such as papilledema,headache, nausea, vomiting, and visualdisturbances. If papilledema occurs, stopdrug therapy immediately and obtain aneurologic evaluation, as ordered. Patientshould never receive a tetracycline whiletaking acitretin because combined use canincrease intracranial pressure.• Assess patient for suidical ideation becausedepression and other psychiatric symptoms,including thoughts of self-harm,may occur with acitretin use. Expect drugto be discontinued if psychiatric symptomsdevelop.• Significantly lower doses of phototherapyare needed during acitretin therapyA

32adalimumabbecause drug increases the risk of erythema.PATIENT TEACHINGWARNING Warn women of childbearing agethat acitretin causes major fetal abnormalities.• Inform woman of childbearing age thatshe must have a pregnancy test beforeacitretin therapy starts, every month duringacitretin therapy, and every 3 monthsfor 3 years after therapy stops.• Stress to woman of childbearing age thatshe must use two effective forms of contraceptionsimultaneously unless she haschosen absolute abstinence or has had ahysterectomy. This must begin at least 1month before acitretin therapy starts andcontinue throughout therapy and for atleast 3 years after therapy ends.• Caution women taking oral contraceptivesthat some prescribed and OTC drugs,including herbal supplements such as St.John’s wort, may interfere with oral contraceptives.Urge her to tell prescriberabout all drugs she takes.• Caution patient not to consume alcohol orproducts that contain alcohol duringacitretin therapy and for 2 months aftertherapy ends.• Warn patient, male or female of any age,not to donate blood during acitretin therapyand for at least 3 years after it ends.• Review acitretin medication guide withpatient, and answer the patient’s questions.• Inform patient that psoriasis may worsenduring initial treatment and that fulleffects of drug may not be seen for up to3 months.• Caution patient to avoid hazardous activitiesuntil drug’s CNS and ophthalmiceffects are known.• Inform patient that tolerance to contactlenses may decrease during acitretin therapyand for a period of time after treatmentends.• Advise patient not to take more than theminimum recommended daily allowanceof vitamin A during acitretin therapybecause of the risk of vitamin A toxicity.• Caution patient not to use sun lamps andto avoid excessive exposure to sunlightbecause the effects of UV light areenhanced by retinoids such as acitretin.adalimumabHUMIRAClass and CategoryChemical class: Recombinant human IgG1monoclonal antibodyTherapeutic class: Disease-modifyingantirheumaticPregnancy category: BIndications and Dosages To reduce signs and symptoms, inducemajor clinical response, inhibit progressionof structural damage, and improvephysical function in patients with moderatelyto severely active rheumatoidarthritis; to reduce signs and symptoms,inhibit progression of structural damage,and improve physical function inpatients with psoriatic arthritis; toreduce signs and symptoms in patientswith active ankylosing spondylitisSUBCUTANEOUS INJECTIONAdults. 40 mg every other wk.DOSAGE ADJUSTMENT Dosage may beadjusted to 40 mg every wk, as needed andprescribed, for patients not takingmethotrexate. To reduce signs and symptoms andinduce and maintain clinical remissionin patients with moderately to severelyactive Crohn’s disease who have had aninadequate response to conventionaltherapy or who have stopped respondingto or have become intolerant of infliximabSUBCUTANEOUS INJECTIONAdults. Initial: 40 mg q.i.d. for 1 day or40 mg b.i.d. for 2 consecutive days, followedby 80 mg 2 wk later. Maintenance: 40 mgevery other wk starting at week 4. To reduce signs and symptoms of moderatelyto severely active polyarticularjuvenile idiopathic arthritisSUBCUTANEOUS INJECTIONChildren age 4 and over who weigh 30 kg(66 lb) or more. 40 mg every other wk.Children age 4 and over who weigh lessthan 30 kg but at least 15 kg (33 lb). 20 mgevery other wk. To treat moderate to severe chronicplaque psoriasis in patients who are

candidates for systemic therapy or phototherapy,and when other systemic therapiesare less appropriateSUBCUTANEOUS INJECTIONAdults. Initial: 80 mg followed 1 wk laterwith 40 mg. Maintenance: 40 mg everyother wk.Mechanism of ActionBinds to tumor necrosis factor (TNF) toblock interaction with p55 and p75 cellsurfaceTNF receptors, and lyses surfaceTNF-expressing cells in the presence ofcomplement. TNF may be a major componentof rheumatoid arthritis inflammationand joint destruction. Reduced TNFlevel in synovial fluid improves signs andsymptoms and prevents further structuraldamage in rheumatoid arthritis.ContraindicationsActive infection, breast-feeding, hypersensitivityto adalimumab or its componentsInteractionsDRUGSanakinra: Possibly increased risk of seriousinfection and neutropenialive vaccines: Increased risk of adverse vaccineeffectsAdverse ReactionsCNS: Confusion, fever, headache, hypertensiveencephalopathy, multiple sclerosis,paresthesia, subdural hematoma, syncope,tremorCV: Arrhythmias, atrial fibrillation, cardiacarrest, chest pain, coronary artery disease,congestive heart failure, hypercholesterolemia,hyperlipidemia, hypertension, MI,palpitations, pericardial effusion, pericarditis,peripheral edema, tachycardiaEENT: Cataracts, sinusitisENDO: Ketosis, parathyroid disorderGI: Abdominal pain, cholecystitis,cholelithiasis, diverticulitis, elevated alkalinephosphatase level, elevated liver enzyme levels,esophagitis, gastroenteritis, hemorrhage,hepatic necrosis, nausea, vomitingGU: Hematuria, paraproteinemia,pyelonephritis, UTIHEME: Agranulocytosis, aplastic anemia,granulocytopenia, leukopenia, lymphocytosis,pancytopenia, polycythemia, thrombocytopeniaMS: Arthritis (including pyogenic or septicadalimumab 33arthritis); back, extremity, pelvic, or thoraxpain; bone disorder, fracture, or necrosis;muscle spasms; myasthenia; prostheticinfections; synovitisRESP: Asthma, bronchitis, bronchospasm,decreased pulmonary function, dyspnea,pleural effusion, pneumonia, pulmonarytuberculosis, upper respiratory tract infectionSKIN: Cellulitis, erysipelas, erythema multiforme,herpes zoster, new or worseningpsoriasis, rash, urticariaOther: Anaphylaxis; antibody formationagainst adalimumab; dehydration; flare-upof disease process; flulike symptoms; healingabnormalities; injection site erythema,hemorrhage, itching, pain, or swelling;invasive fungal infection; lupus-like symptoms;lymphomas; malignancies; opportunisticinfection; postsurgical infection;sepsis; tuberculosis (miliary, lymphatic, orperitoneal)Nursing Considerations• Use adalimumab cautiously in patientswith recurrent infection or increased riskof infection, patients who live in regionswhere tuberculosis and mycoses areendemic, and patients with a history ofCNS demyelinating disorders because theyoccur, rarely, during adalimumab therapy.WARNING If patient has evidence of anactive infection when drug is prescribed,therapy shouldn’t start until infection hasbeen treated. Monitor all patients forinfection during therapy, especially thosereceiving immunosuppressants. If a seriousinfection develops, expect prescriberto stop drug.• Make sure patient has a tuberculin skintest before therapy starts. If skin test ispositive, treatment of latent tuberculosiswill start before adalimumab, as prescribed.• Be aware that the needle cover of thesyringe contains dry rubber. Don’t handleif you’re allergic to latex.• To activate the protection device on needlesof prefilled syringes delivered to institutions,hold the syringe in one hand and,with the other hand, slide outer protectiveshield over exposed needle until it locksinto place.WARNING Stop adalimumab immediatelyA

34adenosineand tell prescriber if patient has an allergicreaction. Expect to provide supportivecare.• Watch closely for evidence of congestiveheart failure (sudden, unexplained weightgain; dyspnea; crackles; anxiety), and notifyprescriber if they occur.• Monitor patient’s CBC, as ordered,because adalimumab may have adversehematologic effects. Notify prescriberabout persistent fever, bruising, bleeding,or pallor.• Be aware that adalimumab belongs to agroup of drugs called tumor necrosis factor(TNF) blockers. Although rare, malignancies,especially lymphomas andleukemias, have occurred in patients receivingTNF blockers, including children.Patients with rheumatoid arthritis, especiallythose with very active disease, are atgreatest risk. Monitor patients closely.PATIENT TEACHINGvInform patient that the first injection ofadalimumab must take place with a healthcare professional present.• Teach patient or caregiver how to giveadalimumab as a subcutaneous injectionat home, if applicable. Emphasize importanceof injecting the full amount in thesyringe (0.8 ml) to obtain the correct doseof 40 mg.• If patient is allergic to latex, explain thatthe needle cover contains rubber.• Caution patient against reusing needlesand syringes. Provide patient or caregiverwith a puncture resistant container fordisposal of needles and syringes at home.• Instruct patient or caregiver to rotateinjection sites and to avoid injecting in anyarea that’s tender, bruised, red, or hard.• Inform patient that prefilled syringes mustbe refrigerated (not frozen), protectedfrom light, and stored in the original container.• Urge patient to check expiration dates andnot to use outdated drug.• Review signs and symptoms of an allergicreaction (rash, swollen face, difficultybreathing), and tell patient to seek emergencycare immediately if these occur.• Inform patient that injection site reactions(such as redness, rash, swelling, itching,and bruising) may occur but are usuallymild and transient. Instruct him to apply atowel soaked with cold water on the injectionsite if it hurts or remains swollen. Ifreaction does not disappear or seems toworsen, tell patient to call prescriberimmediately.• Inform patient that tuberculosis mayoccur during adalimumab therapy.Instruct him to report persistent cough,wasting or weight loss, and low-gradefever to prescriber.• Teach patient to recognize evidence ofinfection and bleeding disorders and totell prescriber if they occur; drug mayneed to be stopped. Advise patient toavoid people with infections and to haveall prescribed laboratory tests.• Inform patient that the risk of certainkinds of cancer, especially lymphomas, ishigher in patients taking adalimumab butstill rare. Emphasize the importance offollow-up visits and reporting an unusualor sudden onset of signs or symptoms.• Caution patient against receiving livevirusvaccines while taking adalimumabbecause doing so may adversely effect theimmune system.• Inform patient that blood samples may beneeded periodically, but especially aroundweek 24 of therapy, to check for autoantibodydevelopment. Explain that adalimumabtherapy will need to be stopped ifthey’re detected.• Instruct patient to report lupus-like signsand symptoms that, although rare, mayoccur during therapy, such as chest painthat doesn’t go away, shortness of breath,joint pain, or a rash on cheeks or armsthat’s sensitive to the sun. Explain thatdrug may be stopped if these occur.• Advise patient to inform all health careproviders about adalimumab use and toinform prescriber about any OTC medicationsbeing taken, including herbal remediesand vitamin and mineral supplements.adenosineAdenocard, AdenoscanClass and CategoryChemical class: Monophosphorylatedadenine riboside

Therapeutic class: AntiarrhythmicPregnancy category: CIndications and Dosages To convert paroxysmal supraventriculartachycardia (PSVT) to normal sinusrhythmI.V. INJECTIONAdults and children weighing 50 kg (110lb) or more. Initial: 6 mg by rapid peripheralI.V. bolus over 1 to 2 sec. If PSVT continuesafter 1 to 2 min, 12 mg given as rapidbolus and repeated in 1 to 2 min if needed.Don’t give single doses of more than 12 mg.Children weighing less than 50 kg. Initial:0.05 to 0.1 mg/kg as rapid central orperipheral I.V. bolus followed by salineflush. If PSVT continues after 1 to 2 min,additional bolus injections are given, incrementallyincreasing dose by 0.05 to 0.1 mg/kg. Follow each bolus with saline flush.Injections continue until PSVT converts tonormal sinus rhythm or until patient reachesmaximum single dose of 0.3 mg/kg.Route Onset Peak DurationI.V. Immediate Immediate UnknownMechanism of ActionSlows conduction time through the AVnode and can interrupt AV node reentrypathways to restore normal sinus rhythm.IncompatibilitiesDon’t mix adenosine with other drugs.ContraindicationsAtrial fibrillation or flutter; hypersensitivityto adenosine; second- or third-degree heartblock or sick sinus syndrome, except inpatients with a functioning artificial pacemaker;ventricular tachycardiaInteractionsDRUGScarbamazepine: Increased heart blockdigoxin, verapamil: Possibly increaseddepressant effect on SA or AV nodedipyridamole: Increased adenosine effectsmethylxanthines, such as theophylline:Antagonized adenosine effectsFOODScaffeine: Antagonized adenosine effectsAdverse ReactionsCNS: Apprehension, dizziness, headache,adenosine 35heaviness in arms, light-headedness, nervousness,paresthesia, seizuresCV: Atrial fibrillation, bradycardia, chestpain or pressure, heart block, hypertension,hypotension, MI, palpitations, prolongedasystole, sinus exit block or pause, torsadesde pointes, transient hypertension, ventricularfibrillation, ventricular tachycardiaEENT: Blurred vision, metallic taste, throattightnessGI: Nausea, vomitingMS: Jaw, neck, and back painRESP: Bronchoconstriction, bronchospasm,dyspnea, hyperventilation, respiratory arrestSKIN: Diaphoresis, facial flushingOther: Injection site reactionNursing Considerations• Before use, inspect adenosine for crystals.If solution isn’t clear, don’t give it.• Give adenosine by rapid I.V. bolus over 1to 2 seconds. Slower delivery can causesystemic vasodilation and reflex tachycardia.• Expect prescriber to inject adenosinedirectly into a vein to make sure drugreaches systemic circulation. If given intoan I.V. line, give drug as close to insertionsite as possible and follow with rapidsaline flush.WARNING Don’t give single doses of morethan 12 mg.• Monitor heart rate and rhythm, bloodpressure, and respiratory status often duringadenosine therapy.• Be aware that at the time of conversion tonormal sinus rhythm, arrhythmias (suchas PVCs, premature atrial contractions,sinus bradycardia, sinus tachycardia, andAV block) may occur for a few seconds,but they don’t usually require intervention.WARNING Stop drug use and notify prescriberimmediately if severe respiratorydifficulties develop.• Store adenosine at room temperature.Discard unused portion.PATIENT TEACHING• Instruct patient to report chest pain, palpitations,difficulty breathing, or severeheadache during adenosine therapy.• Warn patient that mild, temporary reactionsmay occur, such as flushing, nausea,and dizziness.A

36alatrofloxacin mesylatealatrofloxacinmesylateTrovan I.V.trovafloxacinmesylateTrovanClass and CategoryChemical class: FluoroquinoloneTherapeutic class: AntibacterialPregnancy category: CIndications and Dosages To treat life-threatening nosocomialpneumoniaTABLETS, I.V. INFUSIONAdults. 300 mg I.V. every 24 hr followed by200 mg P.O. every 24 hr when patient is stabilizedfor total of 10 to 14 days. To treat life-threatening communityacquiredpneumoniaTABLETS, I.V. INFUSIONAdults. 200 mg I.V. every 24 hr followed by200 mg P.O. every 24 hr when patient is stabilizedfor total of 7 to 14 days; or 200 mgP.O. every 24 hr for total of 7 to 14 days. To treat complicated, life-threateningintra-abdominal infections, includingpostsurgical, gynecologic, and pelvicinfectionsTABLETS, I.V. INFUSIONAdults. 300 mg I.V. every 24 hr followed by200 mg P.O. every 24 hr when patient is stabilizedfor total of 7 to 14 days. To treat complicated, life-threatening orlimb-threatening skin and soft-tissueinfections, including diabetic foot infectionsTABLETS, I.V. INFUSIONAdults. 200 mg P.O. every 24 hr—or 200mg I.V. every 24 hr followed by 200 mg P.O.every 24 hr when patient is stabilized—fortotal of 10 to 14 days.DOSAGE ADJUSTMENT For patients withmild to moderate cirrhosis, 300-mg I.V.dosage reduced to 200 mg and 200-mg I.V.and P.O. dosage reduced to 100 mg.Mechanism of ActionInterferes with DNA gyrase, the enzymeneeded for DNA replication in aerobic andanaerobic bacteria. May be active againstpathogens resistant to such antibiotics aspenicillins, cephalosporins, aminoglycosides,macrolides, and tetracyclines.IncompatibilitiesDon’t mix alatrofloxacin with or infuse itsimultaneously through same I.V. line asother drugs. Don’t dilute it with normalsaline solution or lactated Ringer’s solution.ContraindicationsHypersensitivity to alatrofloxacin, quinoloneantimicrobials, trovafloxacin, or theircomponentsInteractionsDRUGSantacids that contain aluminum, citric acid,magnesium, or sodium citrate; iron; morphinesulfate; sucralfate: Reduced absorptionof trovafloxacinAdverse ReactionsCNS: Dizziness, headache, light-headedness,seizuresCV: HypotensionEENT: Hoarseness, throat tightnessGI: Abdominal pain, acute hepatic failure(anorexia, dark urine, dysphagia, fatigue,jaundice, pale stool, and vomiting)GU: VaginitisRESP: DyspneaSKIN: Photosensitivity, rash, urticaria orother skin reactionsOther: AngioedemaNursing Considerations• Infuse alatrofloxacin over 60 minutes;rapid or bolus I.V. delivery may causehypotension.• Periodically assess patient’s liver functiontest results. Results may be elevated for upto 21 days after alatrofloxacin use.WARNING Be aware that alatrofloxacin maycause severe liver damage, requiring livertransplantation or leading to death. Expecttherapy to last no longer than 2 weeks toreduce risk of liver damage. Alatrofloxacinis reserved for hospitalized patients withlife- or limb-threatening infections.PATIENT TEACHING• Instruct patient to report rash; urticaria;trouble swallowing; swelling of the lips,face, or tongue; hoarseness; or throattightness.

38alefaceptMechanism of ActionAlbuterol attaches to beta 2 receptors onbronchial cell membranes, which stimulatesthe intracellular enzyme adenylatecyclase to convert adenosine triphosphate(ATP) to cyclic adenosine monophosphate(cAMP). This reaction decreasesintracellular calcium levels. It alsoincreases intracellular levels of cAMP, asshown. Together, these effects relaxbronchial smooth-muscle cells and inhibithistamine release.ATPAlbuterolBeta 2 receptorAdenylatecyclaseBronchial cellmembranecAMPpotassium-lowering drugs: Possibly hypokalemiapotassium-wasting diuretics: Possiblyincreased hypokalemiaAdverse ReactionsCNS: Anxiety, dizziness, drowsiness, headache,hyperkinesia, insomnia, irritability,nervousness, tremor, vertigo, weaknessCV: Angina; arrhythmias, including atrialfibrillation, extrasystoles, supraventriculartachycardia, and tachycardia; chest pain;hypertension; hypotension; palpitationsEENT: Altered taste, dry mouth and throat,ear pain, glossitis, hoarseness, oropharyngealedema, pharyngitis, rhinitis, taste perversionENDO: HyperglycemiaGI: Anorexia, diarrhea, dysphagia, heartburn,nausea, vomitingGU: UTIMS: Muscle crampsRESP: Bronchospasm, cough, dyspnea, paradoxicalbronchospasm, pulmonary edemaSKIN: Diaphoresis, flushing, pallor, pruritus,rash, urticariaOther: Angioedema, hypokalemia, infection,metabolic acidosisNursing Considerations• Administer pressurized inhalations ofalbuterol during second half of inspiration,when airways are open wider andaerosol distribution is more effective.WARNING Use cautiously in patients withcardiac disorders, diabetes mellitus, digitalisintoxication, hypertension, hyperthyroidism,or history of seizures. Albuterolcan worsen these conditions.• Monitor serum potassium level becausealbuterol may cause transient hypokalemia.• Be aware that drug tolerance can developwith prolonged use.PATIENT TEACHING• Teach patient to use inhaler. Tell him toshake canister before use and to check thata new canister is working by spraying itthe appropriate number of times (once tofour times based on manufacturer instructions)into the air while looking for a finemist.• Instruct patient to wash mouthpiece withwater once a week and let it air-dry.• Advise patient to wait at least 1 minutebetween inhalations.• Tell patient to check with his prescriberbefore using other inhaled drugs.• Warn patient not to exceed prescribeddose or frequency. If doses become lesseffective, tell patient to contact his prescriber.• Tell patient to immediately report signsand symptoms of allergic reaction, such asdifficulty swallowing, itching, and rash.alefaceptAmeviveClass and CategoryChemical class: Recombinant leukocytefunction-associated antigen-3immunoglobulin GI fusion proteinTherapeutic class: ImmunosuppresantPregnancy category: B

Indications and Dosages To treat moderate to severe chronicplaque psoriasis in patients who arecandidates for systemic therapy or phototherapyI.V. INJECTIONAdults. Initial: 7.5 mg every wk for 12 wk.After at least 12 wk in which drug isn’tgiven, a second 12-wk course may be given,if needed and if patient’s CD4 and T-lymphocytecounts are within normal ranges.I.M. INJECTIONAdults. 15 mg every week for 12 wk. Afterat least 12 wk in which drug isn’t given, asecond 12-wk course may be given, if neededand if patient’s CD4 and T-lymphocytecounts are within normal ranges.Mechanism of ActionInterferes with T-lymphocyte activation bybinding to lymphocyte antigen and CD2,inhibiting LFA-3/CD2 interaction, andreducing the subsets of CD2+ T lymphocytes.This interference helps prevent plaqueformation in chronic plaque psoriasis.IncompatibilitiesDon’t add other drugs to solutions containingalefacept.ContraindicationsBreast-feeding, hypersensitivity to alefaceptor its componentsAdverse ReactionsCNS: Chills, dizziness, headacheCV: Coronary artery disease, MIEENT: PharyngitisGI: NauseaHEME: LymphopeniaMS: MyalgiaRESP: Increased coughSKIN: Pruritus, urticariaOther: Angioedema, injection site pain orinflammation, infection, malignanciesNursing Considerations• Use alefacept cautiously in patients at highrisk for malignancy because the drugincreases risk of malignancy development.Know that drug isn’t recommended foruse in patients with a history of a systemicmalignancy.• Also use alefacept cautiously in patientswith chronic infections or history ofrecurrent infection. Drug may increasealefacept 39risk of infection because of its immunosuppressiveaction.• Obtain a CD4+ and T-lymphocyte countbefore starting alefacept therapy, asordered. If counts are below normal, beaware that therapy shouldn’t be started.After therapy starts, monitor patient’sCD4+ and T-lymphocyte counts weeklythroughout therapy. If levels drop below250 cells/microliter, notify prescriberbecause drug will need to be withheld. Ifcounts remain below 250 cells/microliterfor 1 month, expect that drug will be discontinued.• Reconstitute drug with 0.6 ml using onlythe supplied diluent (sterile water forinjection) before administration. With theneedle pointed at sidewall of vial, slowlyinject diluent into vial of alefacept. Beaware that some foaming will occur. Toprevent excessive foaming, don’t shake orvigorously agitate vial. Instead, gently swirlvial during dissolution, which usuallytakes less than 2 minutes.• Administer drug as soon as possible afterreconstitution. Discard solution if notused within 4 hours.• Don’t filter reconstituted solution duringpreparation or administration.• For I.M. administration, inject the full0.5 ml of solution. Use a different injectionsite for each subsequent injection,injecting at least 1 inch away from previoussites. Never inject the drug into tender,bruised, red, or hard areas.• For I.V. administration, prepare twosyringes with 3 ml normal saline solutionfor preadministration and postadministrationflush. Then prime thewinged infusion set with 3 ml normalsaline solution and insert into vein. Attachfilled syringe to infusion set, and administersolution over no more than 5 seconds.Finish by flushing set with 3 ml of normalsaline solution.• Be aware that drug shouldn’t be started ina patient with a concurrent serious infection.Monitor patient closely during andafter therapy for signs and symptoms ofinfection. If these occur, report them tothe prescriber immediately and begintreatment, as prescribed, to reduce risk ofserious infection. If infection becomesserious, expect drug to be discontinued.A

40Adverse ReactionsCNS: Asthenia, dizziness, headache, vertigoCV: Peripheral edemaGI: Abdominal distention and pain, constialendronatesodium• Monitor patient for allergic reactions. Ifthese occur, discontinue drug and notifyprescriber immediately.PATIENT TEACHING• Advise patient that weekly blood tests willbe required to monitor his WBC countduring alefacept therapy.• Teach patient signs and symptoms ofinfection and common warning signs ofmalignancy. Emphasize importance ofcomplying with follow-up visits andpromptly reporting any unusual or suddensigns or symptoms suggesting malignancyor infection.• Instruct female patient to notify prescriberif she becomes pregnant while taking alefaceptor within 8 weeks after stopping it.alendronate sodiumFosamaxClass and CategoryChemical class: AminobisphosphonateTherapeutic class: Bone resorption inhibitorPregnancy category: CIndications and Dosages To prevent postmenopausal osteoporosisTABLETSAdults. 5 mg daily or 35 mg once/wk in themorning with a full glass of water at least30 min before first food, drink, or drug. To treat postmenopausal osteoporosisTABLETSAdults. 10 mg daily or 70 mg once/wk inthe morning with a full glass of water atleast 30 min before first food, drink, ordrug. To treat Paget’s disease of the bone inpatients whose alkaline phosphataselevel is twice the upper limit of normalor higher and who are symptomatic andat risk for further complicationsTABLETSAdults. 40 mg daily with a full glass ofwater for 6 mo.DOSAGE ADJUSTMENT Dosage increased to10 mg daily for postmenopausal womennot receiving estrogen. To increase bone mass in men with osteoporosisTABLETSAdults. 10 mg daily or 70 mg once/wk inthe morning with a full glass of water atleast 30 min before first food, drink, ordrug. To treat glucocorticoid-induced osteoporosisin men and women who receivea daily glucocorticoid dosage of 7.5 mgof greater of prednisone and who havelow bone mineral densityTABLETSAdults. 5 mg daily in the morning with afull glass of water at least 30 min beforefirst food, drink, or drug.Route Onset Peak DurationP.O. Unknown Unknown 6 wk*Mechanism of ActionReduces activity of cells that cause boneloss, slows rate of bone loss after menopause,and increases amount of bone mass.May act by inhibiting osteoclast activity onnewly formed bone resorption surfaces,which reduces the number of sites wherebone is remodeled. Bone formation thenexceeds bone resorption at these remodelingsites, which gradually increases bonemass. May also inhibit bone dissolution bybinding to hydroxyapatite crystals, whichare composed of calcium, phosphate, andhydroxide and give bone its rigid structure.ContraindicationsEsophageal abnormalities that delay esophagealemptying, such as stricture or achalasia;hypersensitivity to alendronate;hypocalcemia; inability to stand or situpright for at least 30 minutesInteractionsDRUGSantacids, calcium, iron, multivalent cations:Decreased absorption of alendronateaspirin: Increased risk of GI distressFOODSany food: Delayed absorption and decreasedserum level of alendronate* After single 5-mg dose for osteoporosis;6 mo after single 5-mg dose for Paget’sdisease.

pation, diarrhea, dysphagia, esophageal perforationor ulceration, esophagitis, flatulence,gastritis, gastroesophageal reflux disease,heartburn, indigestion, melena, nausea,vomitingMS: Arthralgia, bone pain, focal osteomalacia,joint swelling, muscle spasms, myalgiaSKIN: Photosensitivity, pruritus, rash,Stevens-Johnson syndrome, toxic epidermalnecrolysisOther: HypocalcemiaNursing Considerations• Monitor patient’s serum calcium levelbefore, during, and after treatment. Expecthypocalcemia to be treated before alendronatetherapy. If hypocalcemia occursduring therapy, expect prescriber to ordera calcium supplement.• Ensure adequate dietary intake of calciumand vitamin D before, during, and aftertreatment.WARNING Alendronate may irritate upperGI mucosa, causing adverse reactions suchas esophageal ulceration. To help minimizethese reactions, have patient takedrug with a full glass of water and remainupright for at least 30 minutes.PATIENT TEACHING• Advise patient to take alendronate in themorning with a full glass of water. Explainthat beverages such as orange juice, coffee,and mineral water reduce alendronate’seffects.• To help reduce esophageal irritation, tellpatient not to chew or suck on tablet.• Instruct patient to wait at least 30 minutesafter taking alendronate before eating,drinking, or taking other drugs. Teachpatient to remain upright for 30 minutesafter taking alendronate and until she haseaten the first food of the day.• Encourage patient to consume adequatedaily amounts of calcium and vitamin D.alfuzosinhydrochlorideUroxatralClass and CategoryChemical class: Tetrahydro-2-furancarboxamide hydrochloridealfuzosin hydrochloride 41Therapeutic class: Selective alpha 1 -adrenergic antagonistPregnancy category: BIndications and Dosages To treat signs and symptoms of benignprostatic hyperplasiaE.R. TABLETSAdults. 10 mg daily taken immediately aftersame meal each day.Mechanism of ActionSelectively blocks alpha 1 -adrenergic receptorsin smooth muscle of the bladder neckand prostate, causing relaxation, and blockspostsynaptic alpha 1 adrenoreceptors in thebladder base and neck, prostate, prostaticcapsule, and urethra, preventing furtheraction at these sites. These actions improveurine flow and bladder emptying andreduce urinary hesitancy, frequency, andnocturia.ContraindicationsHypersensitivity to alfuzosin or its components,moderate or severe hepatic insufficiency,use with CYP3A4 inhibitors, such asitraconazole, ketoconazole, and ritonavirInteractionsDRUGSalpha blockers: May potentiate alfuzosinactionantihypertensives, nitrates: Possibly synergisticlowering of blood pressure and syncopeCYP3A4 inhibitors (such as itraconazole,ketoconazole, ritonavir): Increased alfuzosineffectsAdverse ReactionsCNS: Dizziness, fatigue, headacheCV: Angina, chest pain, edema, orthostatichypotension, QT-interval prolongation,tachycardiaEENT: Intraoperative floppy iris syndrome,pharyngitis, rhinitis, sinusitisGI: Abdominal pain, constipation, diarrhea,indigestion, jaundice, hepatotoxicity, nauseaGU: Impotence, priapismRESP: Bronchitis, upper respiratory tractinfectionSKIN: Flushing, pruritus, rash, urticariaOther: Angioedema, generalized painNursing Considerations• Use alfuzosin cautiously in patients whohave symptomatic hypotension or whoA

42alglucerasehave had a hypotensive response to otherdrugs. Orthostatic hypotension (with orwithout symptoms such as dizziness) mayoccur within hours after alfuzosin administration.• Use cautiously in patients with severerenal insufficiency; decreased drug clearancemay increase risk of adverse reactions.• Be aware that alfuzosin shouldn’t be usedto treat bladder symptoms in women.• Know that alpha 1 blockers such as alfuzosinmay predispose patients to intraoperativefloppy iris syndrome duringcataract surgery that may require surgicalrepair.• Monitor patient for chest pain. If symptomsof angina pectoris occur or worsen,notify prescriber immediately and expectdrug to be discontinued.PATIENT TEACHING• Stress need to take alfuzosin immediatelyafter a meal because absorption isdecreased by 50% if taken on an emptystomach.• Tell patient not to crush or chew tabletsbut to swallow them whole.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are knownand also for several hours after takingdose; blood pressure may drop suddenlyafter use.algluceraseCeredaseClass and CategoryChemical class: Glucocerebrosidase betaglucosidaseTherapeutic class: Enzyme replacementPregnancy category: CIndications and Dosages To treat chronic nonneuropathicGaucher’s disease in patients with moderateto severe anemia, thrombocytopeniawith bleeding tendencies, bone disease,or significant hepatomegaly orsplenomegalyI.V. INFUSIONAdults and children age 2 and over.Individualized. 2.5 units/kg to 60 units/kginfused over 1 to 2 hr, usually every 2 wk.DOSAGE ADJUSTMENT Highly individualizedbased on body size and disease severity.Some patients may need infusion onceevery other day; others may need it onceevery 4 wk. Maintenance dosage progressivelyreduced every 3 to 6 mo to as low as1 unit/kg.Route Onset Peak DurationI.V. Up to Unknown Variable60 minMechanism of ActionCatalyzes hydrolysis of glucocerebroside toglucose and ceramide in membrane lipids.Gaucher’s disease results from deficiency ofthe enzyme beta-glucocerebrosidase andcauses the lipid glucocerebroside to accumulatein tissue macrophages.ContraindicationsHypersensitivity to algluceraseAdverse ReactionsCNS: Chills, dizziness, fatigue, fever, headacheCV: Transient peripheral edema, vasomotorirritabilityEENT: Oral ulcerationsGI: Abdominal discomfort, diarrhea, nausea,vomitingMS: BackacheOther: I.V. site burning, itching, or swellingNursing Considerations• Before starting alglucerase therapy, expectto give antihistamines if patient is hypersensitiveto drug.• On day of dose, use aseptic technique todilute alglucerase with normal saline solutionto final volume of no more than200 ml.• Don’t shake drug because doing so couldinactivate it.• Don’t use alglucerase if it’s discolored orcontains precipitate.• Be aware that drug doesn’t contain preservatives.Discard unused portion.• Infuse drug with in-line I.V. particle filter.PATIENT TEACHING• Tell patient that he may experience flulikesymptoms with each dose of alglucerase.• Instruct patient to report headache, hotflashes, nausea, and other adverse reactions.

• Inform patient that alglucerase is derivedfrom pooled human placental tissue andposes a slight risk of viral contamination.• Advise patient to keep appointments forscheduled doses of alglucerase.aliskirenTekturnaClass and CategoryChemical class: Hemifumarate saltTherapeutic class: Antihypertensive (directrenin inhibitor)Pregnancy category: C (first trimester), D(second and third trimester)Indications and Dosages To treat hypertensionTABLETSAdults. 150 mg once daily, increased to300 mg once daily, as needed.Route Onset Peak DurationP.O. Unknown 1–3 hr UnknownMechanism of ActionInhibits renin secreted by the kidneys inresponse to decreased blood volume andrenal perfusion. Renin cleaves angiotensinogento form angiotensin I, which isconverted to angiotensin II by ACE andnon-ACE pathways. Angiotension II is apowerful vasoconstrictor that inducesrelease of catecholamines from the adrenalmedulla and prejunctional nerve endings. Italso promotes aldosterone secretion andsodium reabsorption. Together, theseactions increase blood pressure. By inhibitingrenin release, aliskiren impairs therenin-angiotensin-aldosterone system.Without the vasoconstrictive effect ofangiotension II, blood pressure decreases.ContraindicationsHypersensitivity to aliskiren or its components;pregnancy; renal impairment, disease,or failureInteractionsDRUGSACE inhibitors (diabetics): Increased risk ofhyperkalemiaatorvastatin, cyclosporin, ketoconazole:aliskiren 43Increased aliskiren blood levelfurosemide: Decreased blood furosemidelevelsirbesartan: Decreased blood aliskiren levelAdverse ReactionsCNS: Dizziness, fatigue, headache, seizuresCV: HypotensionEENT: NasopharyngitisGI: Abdominal pain, diarrhea, dyspepsia,gastroesophageal refluxGU: Renal calculiHEME: Decreased hemoglobin and hematocritMS: Back painRESP: Increased cough, upper respiratorytract infectionSKIN: RashOther: Angioedema of head and neck, elevatedcreatine kinase or uric acid level,gout, hyperkalemiaNursing Considerations• Use cautiously in patients with a history ofdialysis or who have moderate to severerenal dysfunction; it isn’t known whethernephritic syndrome and renovascularhypertension are adverse effects ofaliskiren.• To prevent hypotension, take measures tocorrect volume or salt depletion fromhigh-dose diuretic therapy before startingaliskiren. If hypotension occurs duringaliskiren therapy, place patient in a supineposition and give normal saline solutionintravenously, as needed and prescribed.WARNING Watch closely for angioedema ofthe head or neck. If angioedema occurs,discontinue aliskiren, notify prescriber,and provide supportive therapy untilswelling has ceased. If swelling of thetongue, glottis, or larynx is involved, beprepared to give epinephrine solution1:1,000 (0.3 ml to 0.5 ml), as prescribed,and provide measures to ensure a patentairway. Be aware that patient shouldn’treceive aliskiren again.• Monitor serum potassium level as orderedin patients who are diabetic and alsoreceiving ACE inhibitor therapy becausehyperkalemia may occur. Also monitorserum electrolytes, as ordered, especially inpatients wth severe renal impairment.PATIENT TEACHING• Advise patient to avoid high-fat mealsA

46almotriptan malateIndications and Dosages To treat acute migraineTABLETSAdults and adolescents ages 12 to 17.Initial: 6.25 to 12.5 mg as a single dose,repeated in 2 hr p.r.n. Maximum: 2 doses/24 hr or 4 migraine treatments/mo.DOSAGE ADJUSTMENT For patient withimpaired renal or hepatic function, initialdose reduced to 6.25 mg with maximumdaily dose of 12.5 mg.Mechanism of ActionMay stimulate 5-HT 1 receptors on intracranialblood vessels and sensory nerves intrigeminal vascular system. By activatingthese receptors, almotriptan selectively constrictsinflamed and dilated cranial bloodvessels and inhibits production of proinflammatoryneuropeptides. It also interruptstransmission of pain signals to the brain.ContraindicationsBasilar or hemiplegic migraine; cerebrovascular,peripheral vascular, or ischemic orvasospastic coronary artery disease (CAD);hypersensitivity to almotriptan or its components;hypertension (uncontrolled); usewithin 24 hours of other serotonin-receptoragonists or ergotamine-containing or ergottypedrugsInteractionsDRUGSergotamine-containing drugs: Prolongedvasospastic reactionserythromycin, itraconazole, ketoconazole,ritonavir: Possibly increased blood almotriptanlevelMAO inhibitors, verapamil: Increased bloodalmotriptan levelselective serotonin reuptake inhibitors, suchas citalopram, escitalopram, fluoxetine, fluvoxamine,paroxetine, sertraline: Increasedrisk of serotonin syndromeserotonin norepinephrine reuptake inhibitors,such as duloxetine, venlafaxine: Increasedrisk of serotonin syndromeAdverse ReactionsCNS: Dizziness, headache, paresthesia,seizures, somnolence, syncopeCV: Coronary artery vasospasm, hypertension,ischemia, MI, palpitations, vasodilation,ventricular fibrillation, ventriculartachycardiaEENT: Dry mouthGI: NauseaOther: Serotonin syndromeNursing ConsiderationsWARNING Because almotriptan can causecoronary artery vasospasm, monitorpatient with CAD for angina. Because itmay cause peripheral vasospastic reactions,such as ischemic bowel disease, watch forabdominal pain and bloody diarrhea.• For patient with risk factors for CAD butno known cardiovascular abnormalities,expect to give first dose of almotriptan ina medical facility.• In patient with risk factors for CAD,obtain an ECG immediately after first doseof almotriptan, as ordered, because cardiacischemia can occur without causing clinicalsymptoms.• Expect to give a lower dosage to patientswith hepatic or renal dysfunction becauseof impaired drug metabolism or excretion.• Monitor blood pressure regularly duringtherapy in patients with hypertension becausealmotriptan may produce a transientincrease in blood pressure.WARNING Monitor patient for evidence ofserotonin syndrome, such as agitation,chills, confusion, diaphoresis, diarrhea,fever, hyperactive reflexes, poor coordination,restlessness, shaking, talking or actingwith uncontrolled excitement, tremor, andtwitching. In its most severe form, serotoninsyndrome can resemble neurolepticmalignant syndrome, which includes ahigh fever, muscle rigidity, autonomicinstability with possible fluctuations invital signs, and mental status changes.• Monitor patients hypersensitive to sulfonamidesfor hypersensitivity to almotriptanbecause cross-sensitivity may occur.PATIENT TEACHING• Inform patient that almotriptan is used totreat acute migraine and that he shouldn’ttake it to treat nonmigraine headaches.• Advise patient to consult prescriber beforetaking any OTC or prescription drugs.• Advise patient not to take more than maximumprescribed.• Caution patient that drug may cause adverseCNS reactions, and advise him toavoid hazardous activities until he knowshow drug affects him.• Instruct patient to seek emergency care

immediately for cardiac symptoms (suchas heaviness, pain, pressure, or tightness inchest, jaw, neck, or throat) or if multiplenew symptoms develop (such as mentalchanges, high fever, incoordination, nausea,vomiting, diarrhea) after taking drug.alosetronhydrochlorideLotronexClass and CategoryChemical class: Selective serotonin 5-HT 3receptor antagonistTherapeutic class: AntidiarrhealPregnancy category: BIndications and Dosages To treat women with severe diarrheapredominantirritable bowel syndrome(IBS) who haven’t responded to conventionaltherapyTABLETSAdults. Initial: 1 mg daily for 4 wk,increased to 1 mg b.i.d. if needed. Discontinuedif no response in first 4 wk oftherapy or if drug doesn’t adequately controlsymptoms after 4 wk of b.i.d. regimen.Mechanism of ActionInhibits activation of 5-HT 3 nonselectivecation channels found in enteric neurons inthe GI tract, thereby decreasing visceralsensations, colonic transit, and secretions inthe GI tract. These changes reduce GI painand hyperactivity, symptoms that areprominent in diarrhea-predominant IBS.ContraindicationsAdministration with fluvoxamine, historyof chronic or severe constipation or sequelaefrom constipation, Crohn’s disease,diverticulitis, GI perforation or adhesions,hypercoagulable state, impaired intestinalcirculation, intestinal obstruction or stricture,ischemic colitis, thrombophlebitis,toxic megacolon, or ulcerative colitis;hypersensitivity to alosetron or its components;severe hepatic impairmentInteractionsDRUGSfluvoxamine, ketoconazole: Increased bloodalosetron levelalosetron hydrochloride 47cimetidine, clarithromycin, itraconazole, proteaseinhibitors, quinolones, telithromycin,voriconazole: Possibly increased alosetronlevelAdverse ReactionsCNS: Anxiety, fatigue, headache, hypnagogiceffects, malaise, temperature regulationdisturbancesCV: TachyarrhythmiasGI: Abdominal or GI discomfort and pain,abdominal distention, constipation (may besevere), diarrhea, dyspepsia, flatulence, GIspasms or lesions, hemorrhoids, hemorrhoidalhemorrhage, hyposalivation, ileus,impaction, ischemic colitis, nausea,obstruction, perforation, regurgitation andreflux, small-bowel mesenteric ischemia,ulcerationGU: Urinary frequencyRESP: Breathing disordersSKIN: Diaphoresis, rash, urticariaOther: Nonspecific cramps or painNursing Considerations• Be aware that only physicians enrolled inGlaxoSmithKline’s prescribing programfor alosetron should prescribe the drugand only patients who have read andsigned the patient-physician agreementcan receive the drug. Confirm that theagreement has been signed before therapystarts.• Use alosetron cautiously in patients withmild to moderate liver dysfunctionbecause alosetron is extensively metabolizedin the liver.• Report all adverse reactions to alosetronto the prescriber and to Prometheus at1-888-423-5227.WARNING Monitor patient for constipation,especially if she’s elderly or debilitated ortakes drugs that decrease GI motility. Alsowatch for evidence of ischemic colitis,such as rectal bleeding, bloody diarrhea, ornew or worsening abdominal pain. Seriousadverse GI reactions may occur withoutwarning. If they do, be prepared to stopalosetron therapy immediately. If discontinuedfor ischemic colitis, drug shouldn’tbe resumed later; however, a patient whono longer has constipation can resume it,if needed.• Make sure program stickers required bydrug maker are affixed to all prescriptions,A

48alpha 1 -proteinase inhibitor (human)including refills, before giving to patient.PATIENT TEACHING• Explain that alosetron therapy can’t beginuntil patient has read the medicationguide that outlines drug’s risks and benefitsand has signed the permission form.• Instruct patient not to start alosetron ifconstipated and to notify prescriber.• Advise patient that serious adverse GIeffects may occur without warning. Tellher to stop taking alosetron immediatelyand to notify prescriber if evidence ofischemic colitis or constipation arises. Tellher to notify prescriber if constipationdoesn’t resolve after stopping drug.• Inform patient that alosetron will bestopped after 4 weeks of 1 mg b.i.d. if itdosen’t control IBS symptoms.alpha 1 -proteinaseinhibitor (human)Prolastin, Prolastin-C, ZemairaClass and CategoryChemical class: Plasma proteinTherapeutic class: Enzyme replacementPregnancy category: CIndications and Dosages To treat congenital alpha 1 -antitrypsindeficiency in patients with signs ofpanacinar emphysema (Prolastin); toaugment and maintain patients withemphysema who are deficient in alpha 1 -proteinase inhibitorI.V. INFUSIONAdults. 60 mg/kg infused over 30 min(Prolastin) or 15 min (Prolastin-C,Zemaira) at a rate of at least 0.08 ml/kg/min once weekly.Mechanism of ActionReplaces the enzyme alpha 1 -antitrypsin,which normally inhibits the proteolyticenzyme elastase in patients with alpha 1 -antitrypsin deficiency. Without alpha 1 -proteinase inhibitor, elastase attacks anddestroys alveolar membranes and causesemphysema.ContraindicationsHypersensitivity to alpha 1 -proteinaseinhibitor, its components, or other alpha 1 -proteinase products; selective immunoglobulinA (IgA) deficiency in patients withanti-IgA antibodiesInteractionsACTIVITIESsmoking: Inactivation of alpha 1 -proteinaseinhibitorAdverse ReactionsCNS: Asthenia, chills, dizziness, fever,headache, light-headedness, malaise, paresthesiaEENT: SinusitisENDO: Hot flashesHEME: Mild, transient leukocytosisRESP: Upper respiratory tract infection,worsening of existing COPDSKIN: Pruritus, rashOther: Flulike symptoms, infusion site painNursing Considerations• Use alpha 1 -proteinase inhibitor cautiouslyin patients at risk for circulatory overloadbecause drug is a colloid solution thatincreases plasma volume.• Before reconstituting, remove drug anddiluent from refrigerator and let it warmto room temperature.• To reconstitute, remove caps from vialsand clean rubber stoppers with antiseptic.After stoppers are dry, remove protectivecover from diluent end of transfer deviceand insert into center of upright diluentvial. Then remove protective cover fromdrug end of transfer device, invert diluentvial with attached transfer device, andusing minimal force, insert drug end oftransfer device into center of rubber stopperof upright drug vial. Make sure flangeof transfer device rests on stopper surfaceso that diluent flows into drug vial.• During diluent transfer, wet lyophilizedcake completely by gently tilting drug vial.Don’t let air inlet filter face downward.(Take care not to lose the vacuum becausethis will prolong drug reconstitution.)Once diluent transfer is complete, pulltransfer device along with attached diluentvial out of drug vial and discard. Gentlyswirl drug vial until powder is completelydissolved. Avoid shaking because this maycause drug to foam and degrade.• If more than one vial of alpha 1 -proteinaseinhibitor is required, use aseptic techniqueto transfer reconstituted solution from

each vial into a sterile I.V. administrationcontainer.• Administer at room temperature within3 hours of reconstitution as an I.V. infusion,using the large-volume 5-micronconical filter provided. Place filter betweendistal end of I.V. administration set andinfusion set, and infuse at 0.08 ml/kg/minor as determined by patient response andcomfort.WARNING Alpha 1 -proteinase inhibitor ismade from human plasma and may containinfectious agents, such as viruses.Make sure patient is immunized againsthepatitis B before giving drug. If timedoesn’t allow for antibody formation, givea single dose of hepatitis B immune globulinwith hepatitis B vaccine, as prescribed.• Monitor patient for delayed fever, whichmay occur up to 12 hours after therapy.Fever usually resolves within 24 hours.PATIENT TEACHING• Tell patient to report immediately earlyevidence of allergic reaction, such as chesttightness, trouble breathing, faintness,hives, wheezing, and any other unusualsymptoms.• Advise patient to notify prescriber aboutsigns or symptoms of viral infection(chills, drowsiness, fever, and runny nose,followed 2 weeks later by joint pain and arash) after receiving drug.• Stress importance of receiving weeklydoses to maintain an adequate antielastasebarrier in the lungs. Explain that treatmentmust continue for life.• Warn patient not to smoke.alprazolamApo-Alpraz (CAN), Novo-Alprazol(CAN), Nu-Alpraz, Xanax, Xanax XRClass, Category, and ScheduleChemical class: BenzodiazepineTherapeutic class: Antianxiety drugPregnancy category: DControlled substance schedule: IVIndications and Dosages To control anxiety disorders, relieve anxiety(short-term therapy), or treat anxietyassociated with depressionInteractionsDRUGSantacids: Altered alprazolam absorption ratecimetidine, disulfiram, fluoxetine, isoniazid,metoprolol, oral contraceptives, propoxyphene,propranolol, valproic acid: Decreased alprazolamelimination and increased effectsCNS depressants: Possibly increased CNSeffects of both drugsdigoxin: Possibly increased serum digoxinlevel, causing digitalis toxicityitraconazole, ketoconazole: Possibly profoundlyinhibited alprazolam metabolismlevodopa: Decreased effects of levodopaneuromuscular blockers: Possibly potentiatedor antagonized effects of these drugsphenytoin: Possibly increased serum phenyalprazolam49TABLETSAdults. Initial: 0.25 to 0.5 mg t.i.d., adjustedto patient’s needs. Maximum: 4 mg dailyin divided doses.DOSAGE ADJUSTMENT In elderly or debilitatedpatients or patients with advancedhepatic disease, initial dosage 0.25 mg b.i.d.or t.i.d. and increased gradually, as neededand tolerated. To treat panic attackORALLY DISINTEGRATING TABLETS, TABLETSAdults. Initial: 0.5 mg t.i.d., increased every3 to 4 days by no more than 1 mg daily,based on patient response. Maximum:10 mg daily in divided doses.E.R. TABLETSAdults. Initial: 0.5 to 1 mg daily in morning,increased every 3 to 4 days by no morethan 1 mg daily, based on patient response.Maximum: 10 mg daily as single dose inmorning.Mechanism of ActionMay increase effects of gamma-aminobutyricacid (GABA) and other inhibitoryneurotransmitters by binding to specificbenzodiazepine receptors in limbic and corticalareas of the CNS. GABA inhibits excitatorystimulation, which helps controlemotional behavior. The limbic system containsmany benzodiazepine receptors, whichmay help explain drug’s antianxiety effects.ContraindicationsAcute angle-closure glaucoma; hypersensitivityto alprazolam, its components, orother benzodiazepines; itraconazole orketoconazole therapyA

50alprostadiltoin level, causing phenytoin toxicityprobenecid: Possibly faster onset or prolongedeffects of alprazolamranitidine: Possibly reduced absorption ofalprazolamACTIVITIESalcohol use: Enhanced adverse CNS effectsof alprazolamAdverse ReactionsCNS: Agitation, akathisia, confusion,depression, dizziness, drowsiness, fatigue,hallucinations, headache, insomnia, irritability,lack of coordination, lightheadedness,memory loss, nervousness,paresthesia, rigidity, speech problems, syncope,tremor, weaknessCV: Chest pain, edema, hypotension, nonspecificECG changes, palpitations, tachycardiaEENT: Blurred vision, altered salivation, drymouth, nasal congestion, tinnitusENDO: Galactorrhea, gynecomastia, hyperprolactinemiaGI: Abdominal discomfort, anorexia, constipation,diarrhea, elevated liver functiontest results, hepatitis, hepatic failure, nausea,vomitingGU: Altered libido, urinary hesitancyMS: Dysarthria, muscle rigidity and spasmsRESP: Hyperventilation, upper respiratorytract infectionSKIN: Dermatitis, diaphoresis, pruritus,rash, Stevens-Johnson syndromeOther: Weight gain or lossNursing Considerations• Expect to give a higher dosage if patient’spanic attacks occur unexpectedly or duringsuch activities as driving.• Because use can lead to dependency,expect to reduce dosage gradually whenstopping drug. To prevent withdrawalsymptoms, don’t stop drug abruptly.PATIENT TEACHING• Warn against stopping drug abruptlybecause withdrawal symptoms may occur.• Instruct patient never to increase prescribeddose because of risk of dependency.• Urge patient to avoid drinking alcoholduring alprazolam therapy.• Advise patient to avoid driving and activitiesthat require alertness until alprazolam’seffects are known.• Instruct female patient of childbearing ageto notify prescriber immediately if shebecomes or might be pregnant. Drug isn’trecommended during pregnancy.alprostadilCaverject, Edex, MuseClass and CategoryChemical class: Prostaglandin E 1Therapeutic class: Anti-impotence drugPregnancy category: CIndications and Dosages To treat erectile dysfunction caused byvascular or psychogenic causes or bothINTRACAVERNOUS INJECTION (CAVERJECT, EDEX)Adults. Initial: 2.5 mcg. Increased to 5 mcgif partial response or 7.5 mcg if noresponse, followed by incremental increasesof 5 to 10 mcg until erection suitable forintercourse (not exceeding 1-hr duration) isachieved. No more than 2 doses, separatedby 1 hr, should be given on a single dayduring initial titration phase. Maximum:3 doses/wk, separated by 24 hr.URETHRAL SUPPOSITORY (MUSE)Adults. Initial: 125 to 250 mcg. If noresponse, dosage increased in increments to500 or 1,000 mcg until erection suitable forintercourse (not exceeding 1-hr duration) isachieved. Maximum: 2 doses/24 hr. To treat erectile dysfunction caused byspinal cord injuryINTRACAVERNOUS INJECTION (CAVERJECT, EDEX)Adults. Initial: 1.25 mcg. Increased to2.5 mcg if partial response, then to 5 mcg,and increased in 5-mcg increments untilerection suitable for intercourse (notexceeding 1-hr duration) is achieved. Nomore than 2 doses, separated by 1 hr,should be given on a single day during initialtitration phase. Maximum: 3 doses/week, separated by 24 hr.Route Onset Peak DurationIntra- 5–20 min Unknown 60 mincavernousIntra- 5–10 min Unknown 30–60 minurethralContraindicationsAnuria, balanitis (inflammation of head of

alprostadil 51Mechanism of ActionAlprostadil causes penile erection byincreasing blood flow to the penisthrough relaxation of trabecular smoothmuscles and dilation of cavernosal arteries(upper right). A naturally occurringprostaglandin, alprostadil interacts withspecific membrane-bound receptors inthe corpora cavernosa cells of the penis.This action activates intracellular adenylcyclase (lower right), which in turn convertsadenosine triphosphate (ATP) intocyclic adenosine monophosphate(cAMP). Increased intracellular levels ofcAMP activate Dorsal protein veins kinase, Dorsal an artery enzymethat activates other enzymes to initiate acascade Trabecular of chemical reactions.smoothThese chemical reactions cause themusclestrabecular smooth muscles to relax andthe cavernosal arteries to dilate. Bloodflow to the penis is then increased, whichdistends the penile lacunar spaces andCorpuscavernosumcompresses the veins, trapping blood inthe penis Lacunar and space causing it Urethra to becomeenlarged and rigid.Transverse section of penisTrabecularsmoothmusclesDorsal veinsLacunar spaceOutside corpuscavernosum cellDorsal arteryUrethraTransverse section of penisAdenylcyclaseProteinkinaseATP cAMPInside corpus cavernosum cellCorpuscavernosumAlprostadilReceptorAOutsidecavernosAInside copenis), cavernosal fibrosis, hypersensitivityto alprostadil or its components, hyperviscositysyndrome, indwelling urethralcatheter, leukemia, men for whom sexualactivity is contraindicated, multiple myeloma,penile angulation, penile implants,Peyronie’s disease, polycythemia, severehypospadius (urethral opening on undersideof penis), sickle cell anemia or trait,tendency to develop venous thrombosis,thrombocythemia, urethral obstruction orstricture, urethritisInteractionsDRUGSanticoagulants: Possibly increased risk ofbleedingcyclosporine: Possibly decreased bloodcyclosporine levelAdverse ReactionsCNS: Dizziness, headache, syncopeCV: Hypertension, hypotension, tachycardia,vasodilationEENT: Nasal congestion, sinusitisGU: Pelvic pain; penile disorders, includingedema, fibrosis, pain, and rash; priapism;prolonged erection; prostatic pain orenlargement; urethral abrasions; urethralbleedingMS: Back painRESP: Cough, upper respiratory tract infectionOther: Flulike symptoms, injection sitebruising or hematoma, needle breakageNursing Considerations• Reconstitute solution with 1 ml diluent,for a concentration of 5, 10, 20, or 40 mcg/ml, depending on vial strength. Gentlyswirl contents of reconstituted vial. Usereconstituted solution within 24 hourswhen stored at room temperature. Don’tuse vials that contain precipitate or discoloredsolution. Discard unused reconstitutedsolution.• Using a 1 ⁄2-inch 27G to 30G needle, injectdrug at a 90-degree angle into proximalthird of spongy tissue that runs the lengthof the dorsolateral aspect of penis, avoidingany visible veins. Rotate injection sitesby alternating sides of the penis.

52alteplase• Carefully examine penis for evidence ofpenile fibrosis. Expect to discontinuetreatment if patient develops cavernosalfibrosis, penile angulation, or Peyronie’sdisease (hardening of the corpora cavernosa,which causes penis to become distortedwhen erect) during therapy.WARNING Watch for prolonged erectionafter giving drug. Notify prescriber, and beprepared to treat patient for priapism iferection lasts longer than 4 hours.• If patient is receiving an anticoagulant,such as warfarin or heparin, watch forbleeding at injection site because drugmay inhibit platelet aggregation.PATIENT TEACHING• Inform patient that initial therapy must beperformed in the office setting. Teach himhow to correctly administer intracavernousinjections or urethral suppositories.Inform him that the goal of treatmentis to produce an erection that lasts nolonger than 1 hour.• Advise patient to use alprostadil for injectionno more than three times/week andto separate doses by 24 hours. Informpatient using urethral suppositories not toexceed two doses in a 24-hour period.• Tell patient to inform prescriber immediatelyabout nodules or hard tissue in thepenis; an erection that persists for morethan 4 hours; new or worsened penilepain; or persistent curvature, redness,swelling, or tenderness of the erect penis.• Inform patient that common adverse reactionsinclude mild to moderate painimmediately after injection and burningafter suppository insertion. Also, needlemay break. Advise patient to avoid it byfollowing prescriber’s instructions exactlyand by handling injection device properly.If needle breaks during injection and hecan see and grasp broken end, he shouldremove it and contact prescriber. If hecan’t see or grasp broken end, he shouldseek medical care.• Instruct patient using suppository form tourinate just before inserting suppositoryand to insert it with applicator suppliedwith drug. Tell patient to hold penisupright after insertion and to roll it firmlybetween his hands to distribute drug.• Tell patient to sit, stand, or walk for 10minutes after inserting suppository toincrease blood flow and enhance erection.• Tell patient to expect an erection 5 to20 minutes after injecting drug or about10 minutes after inserting suppository.• Advise patient not to change dosage withoutconsulting prescriber and to keepscheduled follow-up appointments.• Warn patient that alprostadil offers noprotection from sexually transmitted diseases.Urge him to use a condom todecrease risk of blood-borne disease,because injection can cause minor bleedingat injection site.• Instruct patient not to reuse or share needlesor syringes. Inform him of properprocedure for sharps disposal.• Warn patient using suppository form notto have sexual intercourse with a pregnantwoman unless a condom is used becausedrug’s effect on pregnancy is unknown.• Advise patient who plans to travel not tocheck drug with airline baggage or store itin a closed car.alteplase(tissue plasminogenactivator, recombinant)Activase, Activase rt-PA (CAN)Class and CategoryChemical class: Purified glycoproteinTherapeutic class: ThrombolyticPregnancy category: CIndications and Dosages To treat acute MIACCELERATED I.V. INFUSIONAdults weighing more than 67 kg (148 lb).15-mg bolus followed by 50 mg infusedover next 30 min and then by 35 mginfused over next 60 min.Adults weighing 67 kg or less. 15-mg bolusfollowed by 0.75 mg/kg (up to 50 mg)infused over next 30 min and then 0.5 mg/kg (up to 35 mg) infused over next 60 min.I.V. INFUSIONAdults weighing more than 65 kg (143 lb).100 mg infused over 3 hr as follows: 6 to10 mg by bolus over first 1 to 2 min, 50 to54 mg over remainder of first hr, 20 mgover second hr, and 20 mg over third hr.Adults weighing 65 kg or less. 1.25 mg/kg

infused over 3 hr on similar schedule asthose weighing more than 65 kg. To treat acute ischemic strokeTo avoid acute bleeding complications,treatment for acute ischemic stroke mustbegin within 3 hr after onset of strokesymptoms and only after computed tomographyor other diagnostic imaging methodexcludes intracranial hemorrhage.I.V. INFUSIONAdults. 0.9 mg/kg infused over 60 min,with 10% of total dose given as bolus overfirst min. Maximum: 90 mg. To treat pulmonary embolismI.V. INFUSIONAdults. 100 mg infused over 2 hr.Route Onset Peak DurationI.V. Immediate 20–120 min 4 hrMechanism of ActionBinds to fibrin in a thrombus and convertstrapped plasminogen to plasmin. Plasminbreaks down fibrin, fibrinogen, and otherclotting factors, which dissolves the thrombus.IncompatibilitiesDon’t add other drugs to solution that containsalteplase.ContraindicationsFor all indications: Active internal bleeding,arteriovenous malformation or aneurysm,bleeding diathesis, intracranial neoplasm,severe uncontrolled hypertensionFor acute MI and pulmonary embolism only:History of stroke, intracranial or intraspinalsurgery or trauma in past 2 monthsFor acute ischemic stroke only: Recent headtrauma, recent intracranial surgery, recentstroke, seizure activity at onset of stroke,subarachnoid hemorrhage, suspicion orhistory of intracranial hemorrhageInteractionsDRUGSdrugs that alter platelet function, such asabciximab, acetylsalicylic acid, and dipyridamole;heparin; vitamin K antagonists:Increased risk of bleedingAdverse ReactionsCNS: Cerebral edema, cerebral herniation,fever, seizure, strokealteplase 53CV: Arrhythmias (including bradycardiaand electromechanical dissociation), cardiacarrest, cardiac tamponade, cardiogenicshock, cholesterol embolism, coronarythrombolysis, heart failure, hypotension,mitral insufficiency, myocardial reinfarctionor rupture, pericardial effusion, pericarditis,venous thrombosis and embolismEENT: Epistaxis, gingival bleeding, laryngealedemaGI: GI bleeding, nausea, retroperitonealbleeding, vomitingGU: GU bleedingRESP: Pleural effusion, pulmonary edema,pulmonary reembolizationSKIN: Bleeding at puncture sites, ecchymosis,rash, urticariaOther: AnaphylaxisNursing ConsiderationsWARNING To avoid acute bleeding complications,treatment for acute ischemicstroke must begin within 3 hr after onsetof stroke symptoms and only after computedtomography or other diagnosticimaging method excludes intracranialhemorrhage.• Immediately before use, reconstitute alteplasewith sterile water for injection only.Swirl gently to dissolve powder; don’tshake.• Monitor patient for bleeding, especially atarterial puncture sites.• Monitor blood pressure and heart rate andrhythm frequently during and after therapy.WARNING Alteplase therapy may causearrhythmias from sudden reperfusion ofthe myocardium. Monitor continuousECG for arrhythmias during drug therapy.• Minimize bleeding from noncompressiblesites by avoiding internal jugular and subclavianvenous puncture sites.• Discontinue alteplase immediately if seriousbleeding occurs.• After administering alteplase, apply pressurefor at least 30 minutes, followed by apressure dressing.• Store reconstituted solution at room temperature(about 86° F [30° C]) or refrigerated(36° to 46° F [2.2° to 7.7° C]).PATIENT TEACHING• Tell patient to immediately report bleeding,including from the nose or gums.A

54aluminum; alvimopan• Advise patient to limit physical activityduring alteplase administration to reducerisk of injury and bleeding.aluminumcarbonateBasaljelaluminumhydroxideAlternaGEL, Alu-Cap, Alugel (CAN),Alu-Tab, Amphojel, DialumeClass and CategoryChemical: Aluminum saltTherapeutic: Antacid, phosphate binderPregnancy category: Not ratedIndications and Dosages To treat hyperacidity associated withgastric hyperacidity, gastritis, hiatal hernia,peptic esophagitis, and peptic ulcers;to prevent phosphate renal calculus formation;to reduce hyperphosphatemia inchronic renal failureALUMINUM CARBONATE CAPSULES, SUSPENSION,TABLETSAdults. 2 capsules or tablets or 10 ml suspensionevery 2 hr up to 12 times daily p.r.n.ALUMINUM HYDROXIDE CAPSULES, SUSPENSION,TABLETSAdults. 500 to 1,500 mg as capsules ortablets in divided doses 3 to 6 times daily,taken between meals and at bedtime; 5 to30 ml as suspension, p.r.n., taken betweenmeals and at bedtime.Route Onset Peak DurationP.O. Varies Unknown 20–40 min*Mechanism of ActionNeutralizes or reduces gastric acidity,increasing stomach and duodenal alkalinity.Protects stomach and duodenum lining byinhibiting pepsin’s proteolytic activity.Binds with phosphate ions in intestine toform insoluble aluminum-phosphate compounds,which lower blood phosphate level.* If fasting; at least 3 hr if given 1 hr aftermeals.ContraindicationsHypersensitivity to aluminumInteractionsDRUGSallopurinol, chloroquine, corticosteroids,diflunisal, digoxin, ethambutol, H 2 -receptorblockers, iron, isoniazid, penicillamine,phenothiazines, ranitidine, tetracyclines, thyroidhormones, ticlopidine: Decreased effectsof these drugsbenzodiazepines: Increased benzodiazepineeffectsAdverse ReactionsCNS: EncephalopathyGI: Constipation, intestinal obstruction,white-speckled stoolMS: Osteomalacia, osteoporosisOther: Aluminum accumulation in serum,bone, and CNS; aluminum intoxication;electrolyte imbalancesNursing Considerations• Don’t give aluminum hydroxide within1 to 2 hours of other oral drugs.• Know that two 0.6-g aluminum hydroxidetablets can neutralize 16 mEq of acid.• Monitor patient’s serum levels of sodium,phosphate, and other electrolytes, asappropriate.PATIENT TEACHING• Instruct patient to chew tablets thoroughlybefore swallowing and then to drink a fullglass of water.• Warn patient not to take maximumdosage for more than 2 weeks unless prescribedbecause doing so may cause stomachto secrete excess hydrochloric acid.• Teach patient to prevent constipation witha high-fiber diet and increased fluid intake(2 to 3 L daily), if appropriate.• If patient takes other prescription drugs,advise him to notify prescriber aboutthembefore taking aluminum because ofrisk of interactions.• Advise patient to notify prescriber ifsymptoms worsen or don’t subside.alvimopanEnteregClass and CategoryChemical class: Single stereoisomer

Therapeutic class: Mu opioid receptorantagonistPregnancy category: BIndications and Dosages To accelerate GI recovery in hospitalizedpatients after partial large- or smallbowelresection with primary anastomosisCAPSULESAdults. Initial: 12 mg started 30 min to 5 hrbefore surgery, followed by 12 mg b.i.d.starting the day after surgery for up to 7days or until discharge. Maximum: 24 mg/day with a maximum of 15 doses total.Route Onset Peak DurationP.O. Unknown 2 hr UnknownMechanism of ActionCompetitively binds to selective mu opioidreceptors in GI tract, antagonizing peripheraleffects of opioids on GI motility andsecretion without reversing the centralanalgesic effects of opioid agonists. Thisaction alleviates postoperative ileus by causingbowel function to return more quicklyafter part of bowel has been removed andan end-to-end anastomosis performed.ContraindicationsHypersensitivity to alvimopan or its components,severe hepatic or renal impairment,use of opiods for more than 7 consecutivedays immediately before alvimopanstartsInteractionsDRUGSopioids given within previous 7 days at therapeuticdoses: Increased sensitivity to alvimopanAdverse ReactionsGI: Abdominal pain, constipation, diarrhea,dyspepsia, flatulenceGU: Urine retentionHEME: AnemiaMS: Back painOther: Hypokalemiaamantadine hydrochloride 55Nursing Considerations• Don’t give alvimopan to patients withsevere hepatic or renal impairment or topatients having surgery to correct a completebowel obstruction.• Alvimopan is prescribed only for shorttermuse with maximum of 15 doses andis only dispensed in hospitals enrolled inEntereg Access Support and Education(E.A.S.E.) program. Closely monitor numberof doses given, and expect to stop drugwhen patient has received 15 doses or isdischarged from hospital.• Monitor patient’s serum potassium levelclosely, as ordered, because drug maycause hypokalemia. Also check patient’shemoglobin level and hematocrit becausedrug has been associated with anemia.• Monitor patient with mild to moderatehepatic or renal failure for evidence ofhigh alvimopan levels, such as abdominalpain or cramping, diarrhea, nausea, andvomiting. If present, alert prescriber.• Monitor Japanese patients closely for possibleadverse effects because alvimopanlevel may be higher in this population.PATIENT TEACHING• Explain the need to accurately describelong-term or intermittent use of opioidpain therapy, including any use of opioidsin the week before receiving alvimopan.Taking almivopan after such use maycause serious adverse GI reactions.• Inform patient that the most commonadverse effects of alvimopan are constipation,dyspepsia, and flatulence.• Tell patient that drug is for in-hospital useonly and will not be taken at home.amantadinehydrochloride(adamantanaminehydrochloride)Endantadine (CAN), Gen-Amantadine(CAN), SymmetrelClass and CategoryChemical class: Adamantane derivativeTherapeutic class: Antidyskinetic, antiviralPregnancy category: CIndications and Dosages To manage symptoms of primaryParkinson’s disease, postencephaliticparkinsonism, arteriosclerotic parkinsonism,and parkinsonism caused byCNS injury from carbon monoxideA

56Adverse ReactionsCNS: Agitation, anxiety, confusion, dizziness,drowsiness, fatigue, fever, hallucinations,insomnia, irritability, light-headedamantadinehydrochlorideintoxicationCAPSULES, SYRUP, TABLETSAdults. Initial: 100 mg b.i.d. Maximum:400 mg daily in divided doses. To treat drug-induced extrapyramidalreactionsCAPSULES, SYRUP, TABLETSAdults. Initial: 100 mg b.i.d. Maximum:300 mg daily in divided doses.DOSAGE ADJUSTMENT For elderly patients,patients taking high doses of other antidyskinetics,and patients who have a seriousmedical condition (such as heart failure,epilepsy, or psychosis), initial dosagereduced to 100 mg daily, with gradual titrationto 100 mg b.i.d. after 1 to several wk.For patients with impaired renal function,dosage adjusted to 200 mg on day 1 andthen to 100 mg daily if creatinine clearanceis 30 to 50 ml/min/1.73 m 2 ; to 200 mg onday 1 and then to 100 mg every other day ifcreatinine clearance is 15 to 29 ml/min/1.73 m 2 ; and to 200 mg every wk if creatinineclearance is less than 15 ml/min/1.73m 2 or if patient is receiving hemodialysis. To prevent and treat respiratory tractinfection caused by influenza ACAPSULES, SYRUP, TABLETSAdults and children age 12 and over.Initial: 200 mg daily or 100 mg b.i.d.Maximum: 200 mg daily.DOSAGE ADJUSTMENT In impaired renalfunction, if creatinine clearance is 30 to50 ml/min/1.73 m 2 , 200 mg on day 1 andthen 100 mg daily. If clearance is 15 to29 ml/min/1.73 m 2 , 200 mg on day 1 andthen 100 mg every other day. If clearance isless than 15 ml/min/1.73 m 2 or patient ishaving hemodialysis, 200 mg every wk.Children ages 9 to 12. 100 mg every 12 hr.Maximum: 200 mg daily.Children ages 1 to 9. 1.5 to 3 mg/kg every8 hr or 2.2 to 4.4 mg/kg every 12 hr.Maximum: 150 mg/day.Route Onset Peak DurationP.O. In 48 hr* Unknown Unknown* Antidyskinetic action; antiviral actionunknown.Mechanism of ActionAffects dopamine, a neurotransmitter thatis synthesized and released by neurons leadingfrom substantia nigra to basal gangliaand is essential for normal motor function.In Parkinson’s disease, progressive degenerationof these neurons reduces intrasynapticdopamine. Amantadine may causedopamine to accumulate in the basal gangliaby increasing dopamine release or byblocking dopamine reuptake into the presynapticneurons of the CNS. Amantadinealso may stimulate dopamine receptors ormake postsynaptic receptors more sensitiveto dopamine. These actions help controlalterations in involuntary muscle movements,such as tremors and rigidity, that areassociated with Parkinson’s disease.Amantadine may inhibit influenza Aviral replication by blocking uncoating ofvirus and release of viral nucleic acid intorespiratory epithelial cells. It also may interferewith early replication of viruses thathave already penetrated cells.ContraindicationsAngle-closure glaucoma, hypersensitivity toamantadine or its componentsInteractionsDRUGSanticholinergics or other drugs with anticholinergicactivity, other antidyskinetics,antihistamines, phenothiazines, tricyclicantidepressants: Possibly increased anticholinergiceffects and risk of paralytic ileuscarbidopa-levodopa, levodopa: Increasedeffectiveness of these drugsCNS stimulants: Excessive CNS stimulation,possibly causing arrhythmias, insomnia,irritability, nervousness, or seizureshydrochlorothiazide, triamterene: Possiblydecreased amantadine clearance andincreased risk of toxicitylive-virus vaccines: Possibly interferencewith vaccine effectivenessquinidine, quinine, trimethoprimsulfamethoxazole:Increased blood amantadinelevelACTIVITIESalcohol use: Possibly increased risk of CNSeffects—including confusion, dizziness, andlight-headedness—and orthostatichypotension

ness, mental impairment, nervousness, neurolepticmalignant syndrome, nightmares,suicidal ideation, syncopeCV: Arrhythmias, cardiac arrest, orthostatichypotension, peripheral edema, tachycardiaEENT: Blurred vision; dry mouth, nose, orthroat; keratitis; mydriasisGI: Constipation, diarrhea, dysphagia,nauseaGU: Dysuria, increased libidoHEME: Agranulocytosis, leukopenia, neutropeniaRESP: Acute respiratory failure, pulmonaryedema, tachypneaSKIN: Diaphoresis, livedo reticularis (purplish,netlike rash), pruritusOther: Anaphylaxis; intense urges to performcertain activities, such as gambling orsexual actsNursing Considerations• Be aware that prophylactic therapy withamantadine should begin as soon as possibleafter exposure to persons infected withinfluenza A virus and should continue for10 days. During an influenza epidemic,expect drug to be given daily throughoutthe epidemic, which typically lasts 6 to 8weeks. If patient has previously receivedinactivated influenza A vaccine, prescribermay discontinue it when sure that patienthas developed active immunity against thevirus. If patient receives inactivatedinfluenza A vaccine at the same timeamantadine therapy starts, expect amantadineto be given for 2 to 3 weeks.• Expect amantadine therapy to start 24 to48 hours after the onset of influenza Asymptoms and to continue 48 hours afterthey resolve.• Monitor patients who have a history ofpsychiatric illness or substance abusebecause amantadine may worsen theseconditions. Some patients taking amantadinehave attempted suicide or had suicidalideation.• If patient has a history of heart failure orperipheral edema, monitor for weight gainand edema because drug may cause redistributionof body fluid.• Amantadine may increase seizure activityin patients with a history of seizures.WARNING Monitor patient for evidence ofneuroleptic malignant syndrome duringamantadine hydrochloride 57dosage reduction or discontinuation oftherapy. These include fever, hypertensionor hypotension, involuntary motor activity,mental changes, muscle rigidity, tachycardia,and tachypnea. Be prepared to providesupportive treatment and additionaldrug therapy, as prescribed.• Be aware that patients receiving more than200 mg daily are more likely to experienceadverse or toxic reactions.• Monitor patient for decreased drug effectivenessover time. If therapeutic responsedeclines, expect to increase dosage or discontinuedrug temporarily, as ordered.• Assess patient regularly for skin changesbecause melanoma risk is higher in thosewith Parkinson’s disease. It isn’t clearwhether the risk is increased by the diseaseor by its treatment.PATIENT TEACHING• Instruct patient to take amantadine exactlyas prescribed and not to stop abruptly.Advise patient to notify prescriber if drugbecomes less effective.• Tell patient to notify prescriber if influenzasymptoms don’t improve after 2 to 3 days.WARNING Advise patient or family memberto notify prescriber immediately if patientreveals thoughts of suicide.• Encourage patient to avoid consumingalcohol during amantadine therapybecause alcohol may increase the risk ofconfusion, dizziness, light-headedness, ororthostatic hypotension.• Advise patient to avoid driving and otheractivities that require a high level of alertnessuntil he knows how the drug affectshim because it may cause blurred visionand mental impairment.• Advise patient to change positions slowlyto minimize effects of orthostatichypotension.• Tell patient to use ice chips or sugarlesscandy or gum to relieve dry mouth.• Caution patient to resume physical activitiesgradually as signs and symptomsimprove.• Urge patient to have regular skin examinationsby a dermatologist or other qualifiedhealth professional.• Instruct patient to notify prescriber aboutintense urges, such as for gambling or sex,because dosage may need to be reduced ordrug discontinued.A

58ambenonium chlorideambenoniumchlorideMytelaseClass and CategoryChemical class: Synthetic quaternaryammonium compoundTherapeutic class: Antimyasthenic, cholinergicPregnancy category: CIndications and Dosages To improve muscle strength in patientswith myasthenia gravis in whom pyridostigmineor neostigmine are contraindicatedTABLETSAdults and adolescents. Initial: 5 mg t.i.d.or q.i.d., increased at 1- to 2-day intervalsto optimum dosage based on patientresponse. Usual: Highly individualized butusually 5 to 50 mg t.i.d. or q.i.d.Children. Initial: 0.3 mg/kg or 10 mg/m 2daily in divided doses t.i.d. or q.i.d.Maintenance: Up to 1.5 mg/kg or 50 mg/m 2daily in divided doses t.i.d. or q.i.d.Route Onset Peak DurationP.O. 20–30 min Unknown 3–8 hrMechanism of ActionAttaches to acetylcholinesterase and blocksits breakdown. This action prolongs andexaggerates acetylcholine’s effects, producingcholinergic responses, such as miosis,increased intestinal and skeletal muscletone, bronchoconstriction, bradycardia, andincreased salivary and sweat gland secretion.ContraindicationsHypersensitivity to ambenonium, its components,or anticholinesterases; mechanicalintestinal or urinary tract obstructionInteractionsDRUGSanesthetics, antiarrhythmics, corticosteroids,magnesium, methocarbamol:Decreased effects of ambenoniumaminoglycosides, anticholinesterase musclestimulants, depolarizing muscle relaxants,ganglionic blockers, mecamylamine:Increased effects of ambenoniumAdverse ReactionsCNS: Dizziness, drowsiness, headache, lossof consciousness, seizures, syncopeCV: AV block, bradycardia, decreased cardiacoutput, hypotensionEENT: Dysphonia, increased salivation,laryngospasmGI: Abdominal cramps, dysphagia, flatulence,increased gastric and intestinal secretions,increased peristalsis, mild diarrhea,nausea, vomitingGU: Incontinence, urinary frequency orurgencyMS: Arthralgia, dysarthria, fasciculations,muscle spasms, muscle weaknessRESP: Bronchoconstriction, bronchospasm,dyspnea, increased tracheobronchial secretions,lung congestion, respiratory arrest ordepression, respiratory muscle paralysisSKIN: Diaphoresis, flushing, rash, urticariaNursing Considerations• Increase dosage gradually as prescribed toavoid ambenonium buildup and overdose.• When increasing dosage to optimum level,note when no further increase in musclestrength is observed. Then expect toreduce dosage to previous effective leveland to use this as maintenance dosage.• Expect prescriber to order ephedrine(25 mg per ambenonium dose) or potassiumchloride (1 to 2 g per ambenoniumdose) to further improve muscle strength.WARNING Drug has a narrow marginbetween effectiveness and overdose. Ifpatient receives more than 200 mg daily,watch closely for overdose (cholinergiccrisis), such as abdominal cramps, diarrhea,nausea, vomiting, increased salivation,diaphoresis, difficulty swallowing,blurred vision, miosis, hypertension, fasciculations,and voluntary muscle paralysis.• Assess neuromuscular status to detect progressiveor recurrent muscle weaknessduring long-term ambenonium therapy.• If patient develops drug resistance in longtermtherapy, expect to restore responsivenessby decreasing dosage or briefly stoppingdrug with close supervision.PATIENT TEACHING• Instruct patient to swallow tablet with liquidor food to minimize GI irritation.• Advise patient to consult prescriber beforediscontinuing drug—even if symptomsdiminish or disappear.

ambrisentanLetairisClass and CategoryChemical class: Autocrine and paracrinepeptideTherapeutic class: Endothelin receptorantagonistPregnancy category: XIndications and Dosages To treat pulmonary arterial hypertension,improve exercise capacity, anddelay worsening in patients with WorldHealth Organization (WHO) class II orIII symptomsTABLETSAdults. Initial: 5 mg once daily, increased to10 mg once daily as needed and tolerated.Route Onset Peak DurationP.O. Unknown 2 hr UnknownMechanism of ActionBlocks the action of endothelin-1 (ET-1), apotent autocrine and paracrine peptide invascular smooth muscle and endotheliumof lung tissue. ET-1 levels increase in pulmonaryarterial hypertension, and ET-1may affect its development and progression.Ambrisentan blocks an ET-1 receptor subtype,ETA, that causes vasoconstriction andcell proliferation, decreasing pulmonaryartery pressure and cell proliferation andpossibly delaying disease progression.ContraindicationsHypersensitivity to ambrisentan or its components,pregnancy, breast-feeding, moderateto severe hepatic diseaseInteractionsDRUGScyclosporine A: Possibly increased exposureto ambrisentanstrong CYP3A inhibitors (such as ketoconazole)and CYP2C19 inhibitors (such asomeprazole): Possibly increased plasmaambrisentan level and increased risk of toxicityFOODSgrapefruit juice: Possibly increased bloodambrisentan levelambrisentan 59Adverse ReactionsCNS: HeadacheCV: Heart failure, palpitations, peripheraledemaEENT: Nasal congestion, nasopharyngitis,sinusitisGI: Abdominal pain, constipation, elevatedliver enzymesHEME: AnemiaRESP: DyspneaSKIN: FlushingOther: AngioedemaNursing Considerations• Ambrisentan isn’t recommended forpatients with moderate to severe hepaticimpairment. Use it cautiously in patientswith mild hepatic impairment.• Ambrisentan is available only through arestricted distribution program. Patientsmust be enrolled, meet all conditions ofthe program, and be re-enrolled annually.• Before giving ambrisentan for the firsttime, make sure patient understands itsrisks, has signed the agreement form, andknows that he’ll need to be re-enrolledafter 6 months of therapy and then yearly.• If patient is a woman of childbearing age,obtain a negative pregnancy test beforegiving ambrisentan and then monthlyduring therapy. A positive result requiresimmediately stopping drug because of therisk of serious birth defects.• Obtain liver enzyme levels, as ordered,before starting ambrisentan therapy andmonthly during therapy because drug maysignificantly increase liver aminotransferase(ALT and AST) levels. If liverenzymes are more than three times theupper limit of normal. expect to not startambrisentan. If they’re somewhat elevated,expect to monitor bilirubin before andmonthly during therapy. If liver enzymesbecome elevated during therapy and evidenceof hepatic dysfunction (abdominalpain, fever, jaundice, nausea, vomiting,unusual lethargy or fatigue) develops orpatient’s bilirubin level exceeds twice theupper limit of normal, notify prescriberand expect to stop ambrisentan therapy.• Monitor patient’s hemoglobin level beforestarting ambrisentan, again after 1 monthof therapy, and periodically thereafter. Iflevel declines significantly, notify prescriberand expect to discontinue drug.A

60amikacin sulfate• Assess patient closely for peripheraledema, especially if elderly. If edemabecomes pronounced, notify prescriber.Further evaluation will reveal whether itresults from ambrisentan or another condition,such as heart failure.• If patient takes ambrisentan for longerthan 12 months, watch for hepatic cirrhosis(abdominal pain, fever, jaundice, nausea,vomiting, or unusual lethargy orfatigue). A similar drug, bosentan, rarelyhas caused unexplained hepatic cirrhosisafter being taken longer than 12 months.PATIENT TEACHING• Caution patient not to split, crush, orchew ambrisentan tablets.• Instruct female patient of childbearing ageto use two reliable forms of birth controlduring therapy unless she has had a tuballigation or a Copper T 380A or LNg 20intrauterine device inserted. Explain thatshe’ll need monthly pregnancy test.• Inform male patient that sperm countshave declined in some men taking drugssimilar to ambrisentan, affecting theirability to father children. If this concernshim, suggest that he consult prescriber.• Stress the need for follow-up visits andtests, such as hemoglobin checks.• Advise patient to promptly report anysigns of liver dysfunction to the prescriber.• Instruct patient to notify prescriber aboutfluid retention.amikacin sulfateAmikinClass and CategoryChemical class: AminoglycosideTherapeutic class: AntibioticPregnancy category: DIndications and Dosages To treat serious gram-negative bacterialinfections (including septicemia; neonatalsepsis; respiratory tract, bone, joint,CNS, skin, soft-tissue, intra-abdominal,burn, and postoperative infections; andserious, complicated, and recurrentUTI) caused by Acinetobacter, Enterobacter,Escherichia coli, Klebsiella,Proteus, Providencia, Pseudomonas,and Serratia; and staphylococcal infectionswhen penicillin is contraindicatedI.V. INFUSION, I.M. INJECTIONAdults and children. 15 mg/kg daily inequal doses at equally spaced intervals (7.5mg/kg every 12 hr or 5 mg/kg every 8 hr)for 7 to 10 days. Maximum: 1,500 mg daily.DOSAGE ADJUSTMENT For patients withimpaired renal function, loading dose of7.5 mg/kg daily; then maintenance dosagebased on creatinine clearance and serumcreatinine level and given every 12 hr. Formorbidly obese patients, dosage not toexceed 1.5 g daily.Neonates. Loading dose: 10 mg/kg.Maintenance: 7.5 mg/kg every 12 hr for 7 to10 days. To treat uncomplicated UTII.V. INFUSION, I.M. INJECTIONAdults. 250 mg b.i.d. for 7 to 10 days.Route Onset Peak DurationI.V. Immediate Unknown UnknownI.M. Rapid Unknown UnknownMechanism of ActionBinds to negatively charged sites on bacteria’souter cell membrane, disrupting cellintegrity. Also binds to bacterial ribosomalsubunits and inhibits protein synthesis.Both actions lead to cell death.IncompatibiltiesDon’t mix or infuse amikacin with otherdrugs.ContraindicationsHypersensitivity to amikacin or otheraminoglycosidesInteractionsDRUGScephalosporins, enflurane, methoxyflurane,vancomycin: Increased nephrotoxic effectsgeneral anesthetics: Increased risk of neuromuscularblockadeloop diuretics: Increased risk of ototoxicityneuromuscular blockers: Possibly increasedneuromuscular blockade and prolongedrespiratory depressionpenicillins: Possibly inactivation of or synergisticeffects with amikacinAdverse ReactionsCNS: Drowsiness, headache, loss of balance,neuromuscular blockade, tremor, vertigoEENT: Hearing loss, ototoxicity, tinnitus

GI: Nausea, vomitingGU: Azotemia, dysuria, nephrotoxicity, oliguriaor polyuria, proteinuriaMS: Acute muscle paralysis; arthralgia;muscle fatigue, spasms, and weaknessRESP: ApneaOther: HyperkalemiaNursing Considerations• Expect to obtain results of culture andsensitivity testing before therapy begins.• Prepare amikacin I.V. solution by addingcontents of 500-mg vial to 100 to 200 mlof sterile diluent. Then infuse drug over30 to 60 minutes.• Give I.M. injection in large muscle mass.• Watch for signs of ototoxicity, such as tinnitusand vertigo, especially during highdosageor prolonged amikacin therapy.WARNING Because amikacin may producenephrotoxic effects, assess renal functionbefore and daily during therapy, asordered. To minimize renal tubule irritation,maintain hydration during therapy.• Be aware that amikacin may exacerbatemuscle weakness in such conditions asmyasthenia gravis and Parkinson’s disease.• Measure serum amikacin concentrationsas ordered, usually 30 to 90 minutes afterinjection (for peak concentration) and justbefore administering next dose (for troughconcentration).PATIENT TEACHING• Tell patient that daily laboratory tests arenecessary during treatment.• Instruct patient to report ringing in ears,hearing changes, headache, nausea, vomiting,and changes in urination.amiloridehydrochlorideMidamorClass and CategoryChemical class: Pyrazine-carbonylguanidineTherapeutic class: Potassium-sparing diureticPregnancy category: BIndications and Dosages As adjunct to thiazide or loop diuretic inamiloride hydrochloride 61patient with heart failure or hypertensionto correct diuretic-induced hypokalemiaor to prevent diuretic-inducedhypokalemia that increases the risk ofarrhythmias or other complicationsTABLETSAdults. 5 to 10 mg daily as single dose; ifhypokalemia persists, increased to 15 mgdaily and then 20 mg daily.Route Onset Peak DurationP.O. 2 hr 6–10 hr 24 hrMechanism of ActionInhibits sodium reabsorption in distal convolutedtubules and cortical collectingducts, causing sodium and water loss andenhancing potassium retention.ContraindicationsHypersensitivity to amiloride; impairedrenal function; serum potassium level above5.5 mEq/L; therapy with another potassiumsparingdiuretic, such as spironolactone ortriamterene, or a potassium supplementInteractionsDRUGSangiotensin II receptor antagonists, captopril,enalapril, lisinopril, potassium products,spironolactone: Increased risk of hyperkalemiadigoxin: Decreased effectiveness of digoxinlithium: Reduced renal clearance of lithiumand increased risk of lithium toxicityNSAIDs: Reduced diuretic effect ofamiloridesympathomimetics: Possibly reduced antihypertensiveeffects of amilorideFOODShigh-potassium food: Increased risk ofhyperkalemiaAdverse ReactionsCNS: Confusion, depression, dizziness,drowsiness, encephalopathy, fatigue,headache, insomnia, nervousness, paresthesia,somnolence, tremor, vertigoCV: Angina, arrhythmias, orthostatichypotension, palpitationsEENT: Dry mouth, increased intraocularpressure, nasal congestion, tinnitus, visiondisturbancesGI: Abdominal pain or fullness, anorexia,appetite changes, constipation, diarrhea, GIA

62aminocaproic acidbleeding, heartburn, indigestion, nausea,thirst, vomitingGU: Bladder spasms, dysuria, impotence,loss of libido, polyuriaHEME: Aplastic anemia, neutropeniaMS: Arthralgia, muscle spasms or weaknessRESP: Cough, dyspneaSKIN: Alopecia, jaundice, pruritus, rashOther: Dehydration, hyperchloremia,hyperkalemia, hypernatremia, metabolicacidosisNursing Considerations• Administer amiloride with food to reduceGI upset and early in the day to minimizesleep interference from polyuria.• Monitor renal function test results, fluidintake and output, and weight. Also monitorserum potassium level to detect hyperkalemia.WARNING Don’t administer amiloride withother potassium-sparing diuretics.PATIENT TEACHING• Warn patient to avoid high-potassiumfood and salt substitutes that containpotassium.• Advise patient to consult prescriber beforetaking other drugs, including OTC remedies,especially sympathomimetics.• Tell patient to report dizziness, trembling,numbness, and muscle weakness orspasms.• Advise patient to increase fluid and fiberintake to prevent constipation.• Warn patient to expect reversible hair lossand impotence.aminocaproic acidAmicarClass and CategoryChemical class: Aminohexanoic acidTherapeutic class: Antifibrinolytic, antihemorrhagicPregnancy category: CIndications and Dosages To treat excessive bleeding caused byfibrinolysisSYRUP, TABLETSAdults. Initial: 5 g in first hour, followed by1 to 1.25 g/hr to sustain drug plasma levelof 0.13 mg/ml. Maximum: 30 g daily.I.V. INJECTIONAdults. 4 to 5 g in 250 ml of diluent over1 hr followed by continuous infusion of1 g/hr in 50 ml of diluent. Continue for8 hr or until bleeding stops.Route Onset Peak DurationP.O. Rapid Unknown UnknownI.V. Immediate Unknown Under 3 hrMechanism of ActionInhibits breakdown of blood clots by interferingwith plasminogen activator substancesand producing antiplasmin activity.ContraindicationsHypersensitivity to aminocaproic acid;signs of active intravascular clotting, as indisseminated intravascular coagulation;upper urinary tract bleedingInteractionsDRUGSactivated prothrombin, prothrombin complexconcentrates: Increased risk of thrombosisestrogens, oral contraceptives: Increased riskof hypercoagulationAdverse ReactionsCNS: Delirium, dizziness, hallucinations,headache, malaise, stroke, weaknessCV: Bradycardia, cardiomyopathy, elevatedserum CK level, hypotension, ischemia,thrombophlebitisEENT: Nasal congestion, tinnitusGI: Abdominal cramps and pain, diarrhea,elevated AST level, nausea, vomitingGU: Elevated BUN level, intrarenal obstruction,renal failureHEME: Agranulocytosis, leukopenia,thrombocytopeniaMS: MyopathyRESP: Dyspnea, pulmonary embolismSKIN: Pruritus, rashOther: Elevated serum aldolase and potassiumlevelsNursing Considerations• Be aware that patients on oral therapy mayneed up to 10 tablets during the first hourof treatment and tablets around the clockduring continued treatment.• Mix aminocaproic acid solution with sterilewater for injection, normal saline solution,D 5 W, or Ringer’s solution.WARNING Avoid rapid I.V. delivery because

it increases risk of hypotension and bradycardia.• Monitor neurologic status for druginducedchanges. Note that increased clottingmay lead to stroke.PATIENT TEACHING• Tell patient that he’ll be closely monitoredduring I.V. therapy and will have blooddrawn for laboratory tests before, during,and after treatment.• Advise patient who takes aminocaproicacid at home to report adverse reactions,take drug exactly as prescribed, and keepfollow-up appointments with prescriber.aminoglutethimideCytadrenClass and CategoryChemical class: HormoneTherapeutic class: Adrenal steroid inhibitorPregnancy category: DIndications and Dosages To suppress adrenal function in patientswith Cushing’s syndrome who are waitingfor surgery or for whom other treatmentcan’t be usedTABLETSAdults. Initial: 250 mg every 6 hr. Increasedas needed by 250 mg daily every 1 to 2 wk.Maximum: 2,000 mg daily.Route Onset Peak DurationP.O. 3–5 days Unknown 72 hrMechanism of ActionInhibits the conversion of cholesterol todelta-5-pregnenolone, which is needed toproduce certain hormones, including adrenalglucocorticoids, mineralocorticoids,estrogens, and androgens.ContraindicationsHypersensitivity to aminoglutethimide orglutethimideInteractionsDRUGSantidiabetics, dexamethasone, digoxin, medroxyprogesterone,synthetic glucocorticoids,theophylline, warfarin and other oral anticoagulants:Decreased effects of these drugsIndications and Dosages To relieve acute bronchospasmI.V. INFUSIONAdults and children not currently receivaminoglutethimide;aminophylline 63Adverse ReactionsCNS: Dizziness, drowsiness, fever, headacheCV: Hypotension, orthostatic hypotension,tachycardiaENDO: Adrenal insufficiency, hypothyroidism,masculinizationGI: Anorexia, nauseaSKIN: Hair growth, morbiliform rash, pruritus,urticariaNursing Considerations• Expect to reduce aminoglutethimidedosage or discontinue treatment ifextreme drowsiness, severe rash, or excessivelylow cortisol level occurs.WARNING Monitor for signs of hypothyroidism,including lethargy, dry skin, andslow pulse. If prescribed, administer thyroidhormone supplement.• Monitor blood pressure for orthostatic orpersistent hypotension.PATIENT TEACHING• Teach patient to recognize orthostatichypotension (dizziness, weakness whenmoving from sitting to standing position)and to minimize it (as by rising slowlyfrom a supine to an upright position).• Tell patient to report dizziness, appetiteloss, nausea, headache, or severe drowsiness.Warn him to avoid driving if drowsy.• Instruct patient to take a missed dose assoon as remembered and to evenly spaceout the day’s remaining doses.• Advise patient that rash, sometimesaccompanied by fever, may appear on day10 of treatment and should subside by day15 or 16. Tell him to report severe rash orone that doesn’t disappear.aminophylline(theophyllineethylenediamine)Phyllocontin, TruphyllineClass and CategoryChemical class: XanthineTherapeutic class: BronchodilatorPregnancy category: CA

64aminophyllineing theophylline products. Initial: 6 mg/kg(equal to 4.7 mg/kg anhydrous theophylline),not to exceed 25 mg/min.Maintenance: For adults (nonsmokers),0.7 mg/kg/hr for first 12 hr, then 0.5 mg/kg/hr. For children ages 9 to 16, 1 mg/kg/hr forfirst 12 hr, then 0.8 mg/kg/hr. For childrenages 6 months to 9 years and young adultsmokers, 1.2 mg/kg/hr for first 12 hr, then1 mg/kg/hr.Adults and children currently receivingtheophylline products. Initial: If possible,determine the time, amount, administrationroute, and form of last dose. Loadingdose is based on the principle that each0.63 mg/kg (0.5 mg/kg anhydrous theophylline)given raises serum theophyllinelevel by 1 mcg/ml. Defer loading dose ifserum theophylline level can be readilyobtained. If this isn’t possible and patienthas no obvious signs of theophylline toxicity,prescriber may order 3.1 mg/kg (2.5 mg/kg anhydrous theophylline), which mayincrease serum theophylline level by about5 mcg/ml. Maintenance: For adults (nonsmokers),0.7 mg/kg/hr for first 12 hr, then0.5 mg/kg/hr. For children ages 9 to 16, 1mg/kg/hr for first 12 hr, then 0.8 mg/kg/hr.For children ages 6 months to 9 years andyoung adult smokers, 1.2 mg/kg/hr for first12 hr, then 1 mg/kg/hr.DOSAGE ADJUSTMENT For elderly patientsand those with cor pulmonale, dosagereduced to 0.6 mg/kg for 12 hr, then0.3 mg/kg. For patients with heart failureand hepatic disease, dosage reduced to0.5 mg/kg for 12 hr, then 0.1 to 0.2 mg/kg. To prevent or treat reversible bronchospasmfrom asthma, chronic bronchitis,and emphysema and to maintainpatent airwaysE.R. TABLETS, ORAL LIQUID, TABLETS, SUPPOSITORIESAdults and children. Initial (rapidlyabsorbed forms): 16 mg/kg daily or 400 mgdaily (whichever is less) in divided dosesevery 6 to 8 hr. Maintenance: Daily dosageincreased in increments of 25% every3 days, as tolerated, until response achievedor maximum dose reached. When maximumdose is reached, dosage adjustedaccording to peak serum theophylline level.Initial (E.R. forms): 12 mg/kg daily or400 mg daily (whichever is less) in divideddoses every 8 to 12 hr. Maintenance: Dailydosage increased in increments of 2 to3 mg/kg every 3 days. When maximumdose is reached, dosage adjusted accordingto peak serum theophylline level.Route Onset Peak DurationP.O. (E.R.) Unknown Unknown 8–12 hrP.O. (tab) Unknown Unknown 6–8 hrI.V. Immediate Unknown 4–8 hrMechanism of ActionInhibits phosphodiesterase enzymes, causingbronchodilation. Normally, theseenzymes inactivate cyclic adenosinemonophosphate (cAMP) and cyclic guanosinemonophosphate (cGMP), which areresponsible for bronchial smooth-musclerelaxation. Other mechanisms of actionmay include translocation of calcium,prostaglandin antagonism, stimulation ofcatecholamines, inhibition of cGMP metabolism,and adenosine receptor antagonism.IncompatibilitiesDon’t add other drugs to prepared bag orbottle of aminophylline. Don’t mix aminophyllinein same syringe with doxapram.Also avoid administering amiodarone,ciprofloxacin, diltiazem, dobutamine,hydralazine, or ondansetron into the Y-portof a continuous infusion of aminophylline.ContraindicationsActive peptic ulcer disease, hypersensitivityto aminophylline, rectal or lower intestineirritation or infection (suppository form),underlying seizure disorderInteractionsDRUGSactivated charcoal, aminoglutethimide, barbiturates,ketoconazole, rifampin, sulfinpyrazone,sympathomimetics: Decreased serumtheophylline levelallopurinol, calcium channel blockers, cimetidine,corticosteroids, disulfiram, ephedrine,influenza virus vaccine, interferon, macrolides,mexiletine, nonselective beta blockers,oral contraceptives, quinolones, thiabendazole:Increased serum theophylline levelbenzodiazepines: Antagonized sedativeeffects of benzodiazepinesbeta agonists: Increased effects of aminophyllineand beta agonistcarbamazepine, isoniazid, loop diuretics:

Altered serum theophylline levelhalothane: Increased risk of cardiotoxicityhydantoins: Decreased hydantoin levelketamine: Increased risk of seizureslithium: Decreased serum lithium levelnondepolarizing muscle relaxants: Reversedneuromuscular blockadepropofol: Antagonized sedative effects ofpropofoltetracyclines: Enhanced adverse effects oftheophyllineFOODSall foods: Altered bioavailability and absorptionof E.R. form, leading to toxicityhigh-carbohydrate, low-protein diet:Decreased theophylline elimination andprolonged aminophylline half-lifelow-carbohydrate, high-protein diet; charbroiledbeef: Increased theophylline eliminationand shortened aminophylline half-lifeACTIVITIESalcohol abuse: Increased aminophylline effectssmoking (1 or more packs daily): Decreasedeffects of aminophyllineAdverse ReactionsCNS: Dizziness, fever, headache, insomnia,irritability, restlessness, seizuresCV: Arrhythmias (including sinus tachycardiaand life-threatening ventricular arrhythmias),hypotension, palpitationsEENT: Bitter aftertasteENDO: Hyperglycemia, syndrome of inappropriateADH secretionGI: Anorexia, diarrhea, epigastric pain,heavy feeling in stomach, hematemesis,indigestion, nausea, rectal bleeding or irritation(suppositories), vomitingGU: Diuresis, proteinuria, urine retentionin men with prostate enlargementMS: Muscle twitchingRESP: Respiratory arrest, tachypneaSKIN: Alopecia, exfoliative dermatitis,flushing, rash, urticariaNursing ConsiderationsWARNING Because aminophylline has a narrowtherapeutic window (10 to 20 mcg/ml), closely monitor serum theophyllinelevel and watch for evidence of toxicity(tachycardia, tachypnea, nausea, vomiting,restlessness, seizures). Keep in mind thatacetaminophen, furosemide, phenylbutazone,probenecid, theobromine, coffee, tea,soft drinks, and chocolate can alter serumaminosalicylate sodium 65theophylline result.• To determine peak serum theophyllinelevel, draw blood sample 15 to 30 minutesafter administering I.V. loading dose.• Give immediate-release and liquid formswith food to reduce GI upset. Give E.R.form 1 hour before or 2 hours after mealsbecause food can alter drug absorption.PATIENT TEACHING• Advise patient to avoid excessive caffeine(in coffee, tea, soft drinks, and chocolate);it can falsely elevate theophylline level.• Explain that blood tests may be needed tomonitor drug’s therapeutic effect.aminosalicylatesodium(para-aminosalicylate,PAS)Nemasol Sodium (CAN), PASClass and CategoryChemical class: Para-aminobenzoic acidanalogueTherapeutic class: AntitubercularPregnancy category: CIndications and Dosages To treat tuberculosis as adjunct to isoniazid,streptomycin, or both and inpatients with multidrug-resistant tuberculosisor when therapy with rifampinand isoniazid isn’t possible because ofresistance or intoleranceTABLETSAdults. 14 to 16 g daily in 2 or 3 divideddoses.Children. 275 to 420 mg/kg daily in 3 or4 divided doses.Mechanism of ActionInhibits incorporation of para-aminobenzoicacid into folic acid and prevents synthesisof folic acid, a compound needed forbacterial growth. Aminosalicylate sodium isbacteriostatic against Mycobacterium tuberculosis,and it delays bacterial resistance tostreptomycin and isoniazid.ContraindicationsHypersensitivity to aminosalicylate sodium,severe renal diseaseA

66amiodarone hydrochlorideInteractionsDRUGSdigoxin: Decreased serum digoxin levelprobenecid: Increased serum aminosalicylatelevelrifampin: Decreased serum rifampin levelAdverse ReactionsCNS: Encephalopathy, feverCV: VasculitisENDO: Goiter with or without myxedemaGI: Abdominal pain, diarrhea, hepatitis,nausea, vomitingHEME: Agranulocytosis, hemolytic anemia,leukopenia, thrombocytopeniaSKIN: Jaundice, various types of eruptionsOther: Infectious mononucleosis-like syndrome,Loeffler’s syndrome (anorexia,breathlessness, fever, and weight loss)Nursing Considerations• Administer aminosalicylate with food toreduce GI upset.WARNING Protect drug from water, heat,and sunlight to prevent rapid deterioration.Don’t give tablets with brown or purplediscoloration—a sign of deterioration.PATIENT TEACHING• Teach patient to discard aminosalicylatethat appears brown or purple.• Instruct patient to take drug with food.amiodaronehydrochlorideCordarone, Nexterone, PaceroneClass and CategoryChemical class: Iodinated benzofuranderivativeTherapeutic class: Class III antiarrhythmicPregnancy category: DIndications and Dosages To treat life-threatening, recurrent ventricularfibrillation and hemodynamicallyunstable ventricular tachycardiawhen these arrhythmias don’t respond toother drugs or when patient can’t tolerateother drugsTABLETSAdults. Loading: 800 to 1,600 mg daily individed doses for 1 to 3 wk. Maintenance:600 to 800 mg daily in divided doses for1 mo; then if cardiac rhythm is stable,400 mg daily in 1 or 2 doses. Use lowestpossible dose.I.V. INFUSIONAdults. Loading: 150 mg over 10 min (15 mg/min) followed by 360 mg infused over 6 hr(1 mg/min). Maintenance: 540 mg infusedover 18 hr (0.5 mg/min); then after the first24 hr, 720 mg infused over 24 hr (0.5 mg/min), continued up to 2 to 3 wk, as needed.Rate may be increased in first 24 hr, ifneeded, but initial infusion rate shouldn’texceed 30 mg/min. Change to oral form assoon as possible. To treat breakthrough episodes of ventricularfibrillation or hemodynamicallyunstable ventricular tachycardiaI.V. INFUSION (NEXTERONE)Adults. 150 mg mixed in 100 ml D 5 W andinfused over 10 min (15 mg/min).Route Onset Peak DurationP.O. 2 days– 1–5 mo Weeks–3 wk monthsI.V. Hours– 1–3 wk Weeks–3 days monthsMechanism of ActionActs on cardiac cell membranes, prolongingrepolarization and the refractory periodand raising ventricular fibrillation threshold.Drug relaxes vascular smooth muscles,mainly in coronary circulation, andimproves myocardial blood flow. It relaxesperipheral vascular smooth muscles,decreasing peripheral vascular resistanceand myocardial oxygen consumption.IncompatibilitiesAmiodarone is incompatible with heparin.To prevent precipitation, don’t add amiodaroneadmixed with D 5 W to aminophylline4 mg/ml, cefamandole nafate, cefazolinsodium, or mezlocillin sodium, anddon’t mix amiodarone 3 mg/ml with sodiumbicarbonate. Also, don’t use evacuatedglass containers for admixing because precipitationmay occur.ContraindicationsBradycardia that causes syncope (unlesspacemaker present), cardiogenic shock,hypersensitivity to amiodarone or its components,hypokalemia, hypomagnesemia,

SA node dysfunction, second- and thirddegreeAV block (unless pacemaker present)InteractionsDRUGSanticoagulants: Increased anticoagulantresponse and possibly serious bleedingazole antifungals, fluoroquinolones, macrolideantibiotics: Increased risk of prolongedQT interval and life-threatening arrhythmiasbeta blockers: Increased serum levels of betablockers with increased risk of AV block,hypotension, and bradycardiacalcium channel blockers: Increased serumlevels of these drugs and increased risk ofAV block, bradycardia, and hypotensioncholestyramine, phenytoin, rifampin, St.John’s wort: Decreased amiodarone levelcimetidine: Increased amiodarone levelclopidogrel: Increased risk of ineffectiveinhibition of platelet aggregationcyclosporine: Increased cyclosporine leveldextromethorphan, methotrexate, phenytoin:Increased serum levels of these drugs andincreased risk of toxicity if amiodarone istaken orally for more than 2 weeksdigoxin: Increased serum digoxin level andrisk of digitalis toxicitydiltiazem, propranolol, verapamil: Increasedrisk of hemodynamic and electrophysiologicabnormalitiesdisopyramide: Increased serum disopyramidelevel with QT prolongation andincreased risk of arrhythmiasfentanyl: Increased serum fentanyl levelwith increased risk of bradycardia,decreased cardiac output, and hypotensionflecainide: Increased serum flecainide levelHMG-CoA reductase inhibitors such as atorvastatinand simvastatin: Increased risk ofmyopathy and rhabdomyolysishydantoins: Increased serum hydantoinlevel with long-term use and reduced serumamiodarone levellidocaine: Increased serum lidocaine leveland risk of seizures and bradycardialoratadine, trazodone: Increased risk of QTintervalprolongation and torsades depointespotassium- and magnesium-depleting drugs:Increased risk of hypokalemia and hypomagnesemiaprocainamide: Increased serum procainamideor N-acetylprocainamide levelamiodarone hydrochloride 67quinidine: Increased serum quinidine levelwith risk of life-threatening arrhythmiasritonavir: Increased serum amiodarone levelwith increased risk of cardiotoxicitytheophylline: Increased serum theophyllinelevel; increased risk of theophylline toxicitywarfarin: Increased PT and risk of bleedingFOODSgrapefruit juice: Increased amiodarone levelAdverse ReactionsCNS: Abnormal gait, ataxia, confusion,delirium, demyelinating polyneuropathy,disorientation, dizziness, fatigue, fever, hallucinations,headache, insomnia, involuntarymotor activity, lack of coordination,malaise, paresthesia, parkinsonian symptoms,peripheral neuropathy, pseudotumorcerebri, sleep disturbances, tremorCV: Arrhythmias (including bradycardia,electromechanical dissociation, torsades depointes, and ventricular tachycardia or fibrillation),cardiac arrest, cardiogenic shock,edema, heart failure, hypotension, vasculitisEENT: Abnormal salivation, abnormal tasteand smell, blurred vision, corneal microdeposits,dry eyes, halo vision, lens opacities,macular degeneration, optic neuritis, opticneuropathy, papilledema, permanent blindness,photophobia, scotomaENDO: Hyperthyroidism, hypothyroidism,syndrome of inappropriate ADH secretion,thyroid cancerGI: Abdominal pain, anorexia, cirrhosis,constipation, diarrhea, elevated liver functiontest results, hepatitis, nausea, pancreatitis,vomitingGU: Acute renal failure, decreased libido,epididymitis, impotenceHEME: Agranulocytosis, aplastic orhemolytic anemia, coagulation abnormalities,neutropenia, pancytopenia, spontaneousbruising, thrombocytopeniaMS: Muscle weakness, myopathy, rhabdomyolysisRESP: Acute respiratory distress syndrome;bronchospasm; eosinophilic pneumonia;infiltrates that lead to dyspnea, cough,hemoptysis, hypoxia, pulmonary fibrosis,pulmonary alveolar hemorrhage, pulmonaryinterstitial pneumonitis, crackles,and wheezing; pleural effusion; pleuritis;pneumonia; respiratory arrest or failureSKIN: Alopecia, bluish gray pigmentation,eczema, erythema multiforme, exfoliativeA

68InteractionsDRUGSanticholinergics, epinephrine, norepinephamitriptylinehydrochloridedermatitis, flushing, photosensitivity, pruritus,rash, skin cancer, Stevens-Johnson syndrome,toxic epidermal necrolysis, urticariaOther: Anaphylactic shock, angioedemaNursing Considerations• If patient has an implantable cardiacdevice, have it checked, as ordered, at thestart of and during amiodarone therapybecause drug may affect pacing or defibrillatingthresholds.• Parenteral amiodarone may be diluted inD 5 W or normal saline solution and givenin polyvinvyl chloride (PVC), polyolefin,or glass containers.• Use an in-line filter during I.V. administrationof amiodarone. Also use a centralvenous catheter whenever possible. A centralvenous catheter is required when infusionrate exceeds 2 mg/ml because drugmay cause peripheral vein phlebitis athigher rates. Cordarone I.V. must be givenby volumetric infusion pump.• Monitor amiodarone I.V. infusion closelybecause loading doses at higher concentrationsand rates may cause hepatocellularnecrosis, acute renal failure, and death.• Although maintenance therapy usually isneeded for only up to 96 hours, infusionof up to 0.5 mg/minute may be continuedfor 2 to 3 weeks regardless of patient’s age,renal function, or left ventricular function.WARNING Amiodarone may cause or worsenpulmonary disorders that may developdays to weeks after therapy and progress torespiratory failure or even death. Expect toobtain chext x-ray and pulmonary functiontests before therapy starts and thenchest x-ray and follow-up exams every3 to 6 months during therapy.• Monitor vital signs and oxygen level oftenduring and after giving amiodarone. Keepemergency equipment and drugs nearby.WARNING Monitor continuous ECG; checkfor increased PR and QRS intervals,arrhythmias, and heart rate below60 beats/min because amiodarone toxicitymay cause or worsen arrhythmias.• Monitor serum amiodarone level, whichnormally ranges from 1.0 to 2.5 mcg/ml.• Assess liver enzyme and thyroid hormonelevels; drug inhibits conversion of T 4 to T 3and may cause drug-induced hyperthyroidism,thyrotoxicosis, and new or worsenedarrhythmias. If new signs of arrhythmiaoccur, notify prescriber at once.PATIENT TEACHING• Explain that patient will need frequentmonitoring and laboratory tests duringtreatment.• Advise patient to report swollen handsand feet, wheezing, dyspnea, cough, nausea,vomiting, dark urine, fatigue, yellowskin or sclerae, stomach pain, light-headedness,fainting, or a rapid, slow, pounding,or irregular heartbeat.• Instruct patient to report abnormal bleedingor bruising.• Advise patient to avoid corneal refractivelaser surgery while taking drug.amitriptylinehydrochlorideApo-amitriptyline (CAN), Endep, Levate(CAN), Novotriptyn (CAN)Class and CategoryChemical class: Tertiary amineTherapeutic class: Tricyclic antidepressantPregnancy category: DIndications and Dosages To relieve depression, especially whenaccompanied by anxiety and insomniaTABLETSAdults and children over age 12. Outpatient:75 mg daily in divided doses,increased to 150 mg daily, if needed. Inpatient:100 mg daily, gradually increased to300 mg daily, if needed. Maintenance: 40 to100 mg daily at bedtime.DOSAGE ADJUSTMENT Maintenance dosagereduced to 10 mg t.i.d. plus 20 mg at bedtimefor adolescent and elderly patients.Route Onset Peak DurationP.O. 14–21 Unknown UnknowndaysContraindicationsAcute recovery phase after MI, hypersensitivityto amitriptyline, MAO inhibitor therapywithin 14 days

amitriptyline hydrochloride 69Mechanism of ActionNormally, when an impulse reachesadrenergic nerves, the nerves release serotoninand norepinephrine from theirstorage sites. Some serotonin and norepinephrinereaches receptor sites on targettissues. Most is taken back into the nervesand stored by the reuptake mechanism, asshown below on the left.Amitriptyline blocks serotonin andnorepinephrine reuptake by adrenergicnerves. By doing so, it raises serotoninand norepinephrine levels at nervesynapses. This action may elevate moodand reduce depression.ANerve impulseAdrenergic nerveSerotoninreuptakeReuptake blockedby amitriptylineNorepinephrinereuptakeSerotoninReceptor sitesNorepinephrinerine: Increased effects of these drugsbarbiturates: Decreased amitriptyline levelcarbamazepine: Decreased serum amitriptylinelevel and increased serum carbamazepinelevel, which increases therapeutic andtoxic effects of carbamazepinecimetidine, disulfiram, fluoxetine, fluvoxamine,haloperidol, H 2 -receptor antagonists,methylphenidate, oral contraceptives, paroxetine,phenothiazines, sertraline: Increasedserum amitriptyline levelcisapride: Possibly prolonged QT intervaland increased risk of arrhythmiasclonidine, guanethidine, and other antihypertensives:Decreased antihypertensive effectsdicumarol: Increased anticoagulant effectlevodopa: Decreased levodopa absorption;sympathetic hyperactivity, sinus tachycardia,hypertension, agitationMAO inhibitors: Possibly seizures and deaththyroid replacement drugs: Arrhythmias andincreased antidepressant effectsACTIVITIESalcohol use: Enhanced CNS depressionsmoking: Decreased amitriptyline effectsAdverse ReactionsCNS: Anxiety, ataxia, coma, chills, delusions,disorientation, drowsiness, extrapyramidalreactions, fatigue, fever, headache,insomnia, nightmares, peripheral neuropathy,suicidal ideation, tremorCV: Arrhythmias (including prolonged AVconduction, heart block, and tachycardia),cardiomyopathy, hypertension, MI, nonspecificECG changes, orthostatic hypotension,palpitationsEENT: Abnormal taste, black tongue,blurred vision, dry mouth, increased salivation,nasal congestion, tinnitusENDO: Gynecomastia, increased ordecreased blood glucose level, increasedprolactin level, syndrome of inappropriateADH secretionGI: Abdominal cramps, constipation, diarrhea,flatulence, ileus, increased appetite,nausea, vomitingGU: Impotence, libido changes, menstrualirregularities, testicular swelling, urinaryhesitancy, urine retentionHEME: Agranulocytosis, bone marrowdepression, eosinophilia, leukopenia,thrombocytopeniaSKIN: Alopecia, flushing, purpuraOther: Weight gainNursing Considerations• Because of amitriptyline’s atropine-likeeffects, use caution if patient has a history

70amlodipine besylateof seizures, urine retention, or angleclosureglaucoma.WARNING Don’t give an MAO inhibitorwithin 14 days of amitriptyline because ofthe risk of seizures and death.• Closely monitor patient with CV disorderbecause amitriptyline may cause arrhythmias,such as sinus tachycardia.• Watch patients closely (especially children,adolescents, and young adults), for suicidaltendencies, particularly when therapystarts and dosage changes. Depression mayworsen temporarily during these times.• Monitor blood pressure for hypotensionor hypertension.• Stay alert for behavior changes, such ashallucinations and decreased interest inpersonal appearance. Be aware that psychosismay develop in schizophrenicpatients, and symptoms may increase inparanoid patients.• Abrupt withdrawal after long use maycause nausea, headache, vertigo, andnightmares.PATIENT TEACHING• Instruct patient to take amitriptyline atbedtime to avoid daytime drowsiness.• Instruct patient to avoid using alcohol orOTC drugs that contain alcohol duringamitriptyline therapy because alcoholenhances CNS depressant effects.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes andparticularly if patient is a child, teenager,or young adult.amlodipine besylateNorvascClass and CategoryChemical class: DihydropyridineTherapeutic class: Antianginal, antihypertensivePregnancy category: CIndications and Dosages To control hypertensionTABLETSAdults. Initial: 5 mg daily, increased graduallyover 10 to 14 days, as needed.Maximum: 10 mg daily.DOSAGE ADJUSTMENT Initially 2.5 mg dailyfor elderly patients or patients withimpaired hepatic function. Increased graduallyover 7 to 14 days based on response. To treat chronic stable angina andPrinzmetal’s (variant) anginaTABLETSAdults. 5 to 10 mg daily.DOSAGE ADJUSTMENT 5 mg daily for elderlypatients and those with impaired hepaticfunction.Route Onset Peak DurationP.O. Unknown 6–12 hr 24 hrMechanism of ActionBinds to dihydropyridine and nondihydropyridinecell membrane receptor sites onmyocardial and vascular smooth-musclecells and inhibits influx of extracellular calciumions across slow calcium channels.This decreases intracellular calcium level,inhibiting smooth-muscle cell contractionsand relaxing coronary and vascular smoothmuscles, decreasing peripheral vascularresistance, and reducing systolic and diastolicblood pressure. Decreased peripheralvascular resistance also decreases myocardialworkload, oxygen demand, and possiblyangina. Also, by inhibiting coronaryartery muscle cell contractions and restoringblood flow, drug may relievePrinzmetal’s angina.ContraindicationsHypersensitivity to amlodipine or its componentsInteractionsDRUGSbeta blockers: Possibly excessive hypotensionfentanyl: Increased risk of severe hypotensionand increased fluid volume requirementsduring surgeryAdverse ReactionsCNS: Anxiety, dizziness, fatigue, headache,lethargy, light-headedness, paresthesia,somnolence, syncope, tremorCV: Arrhythmias, hypotension, palpitations,peripheral edemaEENT: Dry mouth, pharyngitisENDO: Hot flashesGI: Abdominal cramps, abdominal pain,constipation, diarrhea, esophagitis, indigestion,nausea

GU: Decreased libido, impotence, urinaryfrequencyMS: MyalgiaRESP: DyspneaSKIN: Dermatitis, flushing, rashOther: Weight lossNursing Considerations• Use amlodipine cautiously in patients withheart block, heart failure, impaired renalfunction, hepatic disorder, or severe aorticstenosis.• Monitor blood pressure while adjustingdosage, especially in patients with heartfailure or severe aortic stenosis.PATIENT TEACHING• Tell patient to take missed dose as soon asremembered and next dose in 24 hours.• Tell patient to immediately notify prescriberof dizziness, arm or leg swelling,difficulty breathing, hives, or rash.• Suggest taking amlodipine with food toreduce GI upset.• Advise patient to routinely have bloodpressure checked for possible hypotension.ammonium chlorideClass and CategoryChemical class: Ammonium ionTherapeutic class: AcidifierPregnancy category: CIndications and Dosages To treat hypochloremia and metabolicalkalosisI.V. INFUSIONAdults. Individualized based on serumbicarbonate level. Usual: 100 to 200 mEqadded to 500 or 1,000 ml of normal salinesolution, infused at 5 ml/min or less (about3 hr for an infusion of 1,000 ml).Route Onset Peak DurationI.V. 1–3 min 3–6 hr UnknownMechanism of ActionIs converted to urea and hydrochloric acidin the liver. During conversion, drug breaksinto ammonium and chloride ions, andhydrogen ions are released. They enter theblood and extracellular fluid, where hydrogenreacts with bicarbonate ions to formammonium chloride 71water and carbon dioxide. This processdecreases bicarbonate ions and increaseschloride ions in blood and extracellularfluid, which decreases blood and urine pHand corrects alkalosis.IncompatibilitiesDon’t mix I.V. ammonium chloride withcodeine, levorphanol, or methadone.ContraindicationsHypersensitivity to ammonium chloride orits components, markedly impaired renal orhepatic function, metabolic alkalosis causedby vomiting of hydrochloric acid andaccompanied by sodium loss caused bysodium bicarbonate excretion in urineInteractionsDRUGSamphetamines, salicylates, sulfonylureas, tricyclicantidepressants: Decreased therapeuticblood level of ammoniumchlorpropamide: Increased ammonium effectsAdverse ReactionsCNS: Fever, headacheCV: Phlebitis or thrombosis extending frominjection siteGI: Indigestion, nausea, severe hepatic dysfunction,vomitingRESP: HyperventilationSKIN: ExtravasationOther: Injection site infection, irritation, orpain; hypovolemia; severe metabolic acidosis(with large doses)Nursing Considerations• Before use, warm ammonium chloridesolution to room temperature to dissolvecrystals by placing infusion in warm water.• During I.V. use, keep sodium bicarbonateor sodium lactate nearby to treat overdose.• Infuse ammonium chloride slowly toavoid I.V. site pain and irritation.WARNING Monitor patient for ammoniatoxicity (arrhythmias, such as bradycardia;coma; irregular breathing; pallor; retching;seizures; diaphoresis; and twitching).• Watch for signs of metabolic acidosis, suchas increased respirations, increased serumpH, restlessness, and diaphoresis.• Monitor serum bicarbonate level, urinalysisresults, and renal and liver function testresults as appropriate.PATIENT TEACHING• Tell patient to eat potassium-rich foods,A

72amobarbital sodiumsuch as bananas, oranges, cantaloupe,spinach, dried fruit, and potatoes, duringtherapy.amobarbital sodiumAmytal, Novamobarb (CAN)Class, Category, and ScheduleChemical class: BarbiturateTherapeutic class: Anticonvulsant, sedativehypnoticPregnancy category: DControlled substance schedule: IIIndications and Dosages To produce preanesthesia sedationCAPSULES, ELIXIR, TABLETSAdults. 200 mg 1 to 2 hr before surgery.Children. 2 to 6 mg/kg up to a maximumof 100 mg/dose. To produce sedationCAPSULES, ELIXIR, TABLETS, I.V. OR I.M.INJECTIONAdults. 30 to 50 mg (may range from 15 to120 mg) b.i.d. or t.i.d. Maximum I.V.:1,000 mg/dose. Maximum I.M.: 500 mg/dose.Children over age 6. 2 mg/kg daily in fourdivided doses. To treat insomniaCAPSULES, ELIXIR, TABLETSAdults. 65 to 200 mg at bedtime for up to2 wk. To induce a hypnotic stateCAPSULES, ELIXIR, TABLETS, I.V. OR I.M.INJECTIONAdults. 65 to 200 mg/dose. Maximum I.V.:1,000 mg/dose. Maximum I.M.: 500 mg/doseChildren up to age 6. 2 to 3 mg/kg I.M. perdose. To manage seizuresI.V. OR I.M. INJECTIONUse I.V. route only when other routes aren’tappropriate. For I.V. injection, use I.M. doseand inject slowly at 50 mg/min or less toprevent sudden respiratory depression,apnea, laryngospasm, or hypotension.Adults. Usual: 65 to 500 mg to a maximumof 1,000 mg. Dosage for acute seizures isdetermined by response; 200- to 500-mgdoses are typically needed to controlseizures.Children age 6 and over. 65 to 500 mg I.V.Children up to age 6. 3 to 5 mg/kg/dose.Route Onset Peak DurationP.O.* 60 min Unknown 10–12 hrI.V. Unknown Unknown 10–12 hrI.M. Unknown Unknown 10–12 hrMechanism of ActionNonselectively acts on the CNS to depressthe sensory cortex, decrease motor activity,alter cerebellar function, and producedrowsiness, sedation, and hypnosis. Appearsto reduce wakefulness and alertness by actingin the thalamus, where it depresses thereticular activating system and interfereswith impulse transmission from the peripheryto the cortex. Produces CNS depressanteffects ranging from mild sedation and anxietyreduction to anesthesia and coma,depending on the dose, route, and individualpatient’s response.IncompatibilitiesDon’t mix amobarbital in solution withother drugs.ContraindicationsAlcoholism, history of porphyria, history ofsedative or barbiturate addiction, hypersensitivityto barbiturates, renal or hepatic disease,severe respiratory disease, sleep apnea,suicidal tendency, uncontrolled painInteractionsDRUGSacetaminophen: Increased blood acetaminophenlevel and risk of hepatotoxicityantihistamines, CNS depressants, phenothiazines,tranquilizers: Increased CNS depressionbeta blockers, carbamazepine, clonazepam,corticosteroids, digitoxin, doxycycline, estrogens,griseofulvin, metronidazole, oral anticoagulants,oral contraceptives, phenylbutazones,quinidine, theophyllines, tricyclic antidepressants:Decreased blood levels andeffects of these drugschloramphenicol: Inhibited amobarbitalmetabolism; enhanced chloramphenicolmetabolismMAO inhibitors: Increased serum level andsedative effects of amobarbital* For capsules, elixir, and tablets.

methoxyflurane: Increased nephrotoxicityphenytoin: Altered effects of phenytoinrifampin: Decreased serum level and effectsof amobarbitalvalproic acid: Increased amobarbital effectsACTIVITIESalcohol use: Increased serum level of amobarbitaland additive CNS depressant effectsAdverse ReactionsCNS: Agitation, anxiety, ataxia, CNSdepression, confusion, dizziness, hallucinations,hangover, headache, hyperkinesia,insomnia, nightmares, nervousness, paradoxicalstimulation, permanent neurologicdeficit (with injection near nerve), psychiatricdisturbance, somnolence, syncope,vertigoCV: Bradycardia, hypotension, shockEENT: LaryngospasmGI: Constipation, diarrhea, epigastric pain,nausea, vomitingRESP: Apnea, bronchospasm, hypoventilation,respiratory depressionSKIN: Exfoliative dermatitis, rash, Stevens-Johnson syndrome, urticariaOther: Angioedema, gangrene of arm or legfrom accidental injection into artery, injectionsite tissue damage and necrosis, physicaland psychological dependence, potentiallyfatal withdrawal syndrome, toleranceNursing Considerations• Use amobarbital cautiously in patientswith cardiac disease, debilitation, diabetesmellitus, fever, hyperthyroidism, severeanemia, shock, status asthmaticus, or uremia.• Administer by deep I.M. injection, preferablyin large muscle.WARNING To prevent tissue damage andnecrosis at I.M. injection site, don’t givemore than 5 ml of this highly alkalinedrug at any one site. Know that accidentalarterial injection may cause gangrene ofthe arm or leg.• During I.V. administration, closely monitorblood pressure, pulse, and respirations.Keep emergency equipment and drugsnearby in case respiratory depressionoccurs.WARNING Use I.V. route only when otherroutes aren’t appropriate.WARNING Don’t administer solution after30 minutes of exposure to air. Solutionquickly becomes unstable because amobarbitalsodium hydrolyzes in solution.• To prevent withdrawal symptoms, such asdiaphoresis, insomnia, irritability, nightmares,and tremors, expect to taper amobarbitaldosage gradually after long-termuse, especially for epileptic patients.PATIENT TEACHING• Advise patient to use caution when drivingor doing tasks that require alertness.• Instruct patient not to use alcohol or otherCNS depressants (unless prescribed)because they increase amobarbital’seffects.• Warn patient not to stop taking drugabruptly; withdrawal symptoms can occur.• Instruct patient to report severe dizziness,persistent drowsiness, rash, or skin lesions.• Explain that drug effects, such as drowsiness,may be less pronounced after a fewdays and when drug is taken with food.amoxapineAsendinamoxapine 73Class and CategoryChemical class: Dibenzoxazepine derivativeTherapeutic class: Tricyclic antidepressantPregnancy category: CIndications and Dosages To relieve depression, includingendogenous (long-term) depression anddepression associated with anxiety andagitationTABLETSAdults and children age 16 and over.Initial: 50 mg b.i.d. or t.i.d., increased to100 mg b.i.d. or t.i.d. by end of first wk, iftolerated. Maintenance: If 300-mg dailydose is ineffective after 2-wk trial period,dosage increased to a maximum of 400 mgdaily in divided doses. Inpatients mayreceive up to a maximum of 600 mg dailyin divided doses. When effective dose isachieved, a single dose may be given at bedtime,not to exceed 300 mg.DOSAGE ADJUSTMENT For elderly patients.Initial: 25 mg b.i.d. or t.i.d., increased to50 mg b.i.d. or t.i.d. by end of first wk.Maintenance: 100 to 150 mg daily in divideddoses, carefully increased to 300 mgdaily as tolerated. When effective dose isA

74amoxapineachieved, a single dose may be given at bedtime,not to exceed 300 mg.Route Onset Peak DurationP.O. 2–3 wk Unknown UnknownMechanism of ActionBlocks serotonin and norepinephrine reuptakeby adrenergic nerves, thus raising serotoninand norepinephrine levels at nervesynapses. This action may elevate moodand reduce depression.Normally, when an impulse reachesadrenergic nerves, they release serotoninand norepinephrine from their storagesites. Some serotonin and norepinephrinereach receptor sites on target tissues. Themajority is taken back into the nerves andstored by the reuptake mechanism.ContraindicationsAcute recovery phase after MI, hypersensitivityto amoxapine or its components,MAO inhibitor therapy within 14 daysInteractionsDRUGSanticholinergics, epinephrine, norepinephrine:Increased effects of these drugsbarbiturates: Decreased amoxapine levelcarbamazepine: Decreased serum amoxapinelevel; increased serum carbamazepinelevel, increasing its therapeutic and toxiceffectscimetidine, disulfiram, fluoxetine, fluvoxamine,haloperidol, H 2 -receptor antagonists,methylphenidate, oral contraceptives, paroxetine,phenothiazines, sertraline: Increasedblood amoxapine levelclonidine, guanethidine, other antihypertensives:Decreased antihypertensive effectsdicumarol: Increased anticoagulant effectlevodopa: Decreased levodopa absorption;agitation, hypertension, sinus tachycardia,sympathetic hyperactivityMAO inhibitors: Possibly seizures and deaththyroid replacement drugs: Arrhythmias andincreased antidepressant effectsACTIVITIESalcohol use: Increased CNS depressionsmoking: Decreased amoxapine effectsAdverse ReactionsCNS: Agitation, anxiety, ataxia, chills, confusion,dizziness, drowsiness, excitement,extrapyramidal reactions, fatigue, fever,headache, insomnia, nervousness, nightmares,paresthesia, restlessness, sedation,seizures, stroke, syncope, tremor, weaknessCV: Atrial arrhythmias, heart block, heartfailure, hypertension, hypotension, MI, palpitations,tachycardiaEENT: Blurred vision, dry mouth, increasedsalivation, nasal congestion, taste perversion,tinnitusENDO: Gynecomastia, increased ordecreased blood glucose level, increasedprolactin level, syndrome of inappropriateADH secretionGI: Anorexia, constipation, diarrhea, elevatedliver function test results, flatulence,increased appetite, nausea, vomitingGU: Impotence, libido changes, menstrualirregularities, testicular swelling, urinaryhesitancy, urine retentionHEME: Agranulocytosis, leukopeniaSKIN: Diaphoresis, flushing, photosensitivity,pruritus, rashOther: Weight gain or loss; withdrawalsymptoms, such as headache, nausea, nightmares,and vertigoNursing ConsiderationsWARNING Don’t give an MAO inhibitorwithin 14 days of amoxapine.• To avoid withdrawal, don’t stop drugabruptly.• Watch patients closely (especially children,adolescents, and young adults), for suicidaltendencies, particularly when therapystarts and dosage changes, because depressionmay worsen temporarily during thesetimes.PATIENT TEACHING• Advise patient to take amoxapine at bedtimeif daytime sedation occurs.• Caution patient that stopping amoxapineabruptly may cause withdrawal symptoms.• Urge patient to avoid alcohol because itcan potentiate amoxapine’s effects.• Tell patient to report adverse effects ofamoxapine.• Instruct patient to take drug with food toprevent GI upset.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes andparticularly if patient is a child, teenager,or young adult.

amoxicillintrihydrate(amoxycillin)Amoxil, Apo-Amoxi (CAN), DisperMox,Moxatag, Novamoxin (CAN), Nu-Amoxi(CAN), Polymox, Trimox, WymoxClass and CategoryChemical class: AminopenicillinTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat ear, nose, throat, GU tract, skin,and soft-tissue infections caused by susceptiblegram-positive and gramnegativeorganismsCAPSULES, CHEWABLE TABLETS, ORALSUSPENSION, PEDIATRIC DROPS, POWDER ORTABLETS FOR ORAL SUSPENSION, TABLETSAdults and children weighing 20 kg (44 lb)or more. 250 mg every 8 hr; for severeinfections, 500 mg every 8 hr or 875 mgevery 12 hr.Children age 12 wk and over weighing lessthan 20 kg. 20 mg/kg daily in divided dosesevery 8 hr; for severe infections, 40 to45 mg/kg/day in divided doses every 8 hr.Children under age 12 wk. 30 mg/kg/ dayin divided doses every 12 hr. To treat tonsillitis or pharyngitis causedby Streptococcus pyogenesE.R. TABLETS (MOXATAG)Adults and children age 12 and over.775 mg once dailyfor 10 days, taken within1 hr of finishing a meal. To treat lower respiratory tract infectionscaused by susceptible gram-positiveand gram-negative organismsCAPSULES, CHEWABLE TABLETS, ORALSUSPENSION, PEDIATRIC DROPS, POWDER ORTABLETS FOR ORAL SUSPENSION, TABLETSAdults and children weighing 20 kg ormore. 875 mg every 12 hr; for severe infections,500 mg every 8 hr.Children age 12 wk and over weighing lessthan 20 kg. 40 to 45 mg/kg daily in divideddoses every 8 hr.Children under age 12 wk. 30 mg/kg dailyin divided doses every 12 hr. To treat gonorrhea and acute uncomplicatedanogenital and urethral infectionsamoxicillin trihydrate 75caused by susceptible strains of grampositiveand gram-negative organismsCAPSULES, CHEWABLE TABLETS, ORALSUSPENSION, POWDER OR TABLETS FOR ORALSUSPENSION, TABLETSAdults and postpubertal children. 3 g as asingle dose.Prepubertal children age 2 and over.50 mg/kg of amoxicillin plus 25 mg/kg ofpro-benecid as a single dose. As adjunct to eradicate Helicobacterpylori to reduce risk of duodenal ulcerrecurrenceCAPSULES, CHEWABLE TABLETS, ORALSUSPENSION, POWDER OR TABLETS FOR ORALSUSPENSION, TABLETSAdults. 1 g every 12 hr with 500 mg of clarithromycinevery 12 hr and 30 mg of lansoprazoleevery 12 hr for 14 days. Or, 1 gevery 8 hr with 30 mg of lansoprazole every8 hr for 14 days. To prevent bacterial endocarditis beforedental, oral, or upper respiratory tractproceduresCAPSULES, CHEWABLE TABLETS, ORALSUSPENSION, POWDER OR TABLETS FOR ORALSUSPENSION, TABLETSAdults and children weighing 20 kg ormore. 2 g 1 hr before procedure.Children weighing less than 20 kg. 50 mg/kg 1 hr before procedure.Route Onset Peak DurationP.O. Unknown Unknown 6–8 hrMechanism of ActionKills bacteria by binding to and inactivatingpenicillin-binding proteins on the innerbacterial cell wall, weakening the bacterialcell wall and causing lysis.ContraindicationsHypersensitivity to amoxicillin or its componentsInteractionsDRUGSallopurinol: Increased risk of rashchloramphenicol, erythromycins, sulfonamides,tetracyclines: Reduced bactericidaleffect of amoxicillinmethotrexate: Increased risk of methotrexatetoxicityoral contraceptives with estrogen: PossiblyA

76amphetamine sulfatereduced effectiveness of contraceptiveprobenecid: Increased amoxicillin effectsAdverse ReactionsCNS: Agitation, anxiety, behavior changes,confusion, dizziness, insomnia, reversiblehyperactivity, seizuresCV: Hypersensitivity vasculitisEENT: Black, hairy tongue; mucocutaneouscandididasis; tooth discolorationGI: Diarrhea, diarrhea related to Clostridiumdifficile, elevated liver enzymes, hemorrhagicor pseudomembranous colitis, jaundice,hepatic dysfunction, nausea, vomitingGU: Crystalluria, vaginal mycosisHEME: Agranulocytosis, anemia (includinghemolytic anemia), eosinophilia, granulocytosis,leukopenia, thrombocytopenia,thrombocytopenic purpuraSKIN: Erythema multiforme, erythematousmaculopapular rash, generalized exanthematouspustulosis, Stevens-Johnson syndrome,toxic epidermal necrolysis, urticariaOther: Allergic reaction, anaphylaxis, serumsicknesslike reaction (such as arthralgia,arthritis, fever, myalgia, rash, and urticaria)Nursing Considerations• Patients with mononucleosis shouldn’treceive amoxicillin because this class ofdrugs may cause an erythematous rash.• Use drug cautiously in patients with hepaticimpairment. Monitor hepatic and renalfunction and CBC, as ordered, in patientson prolonged therapy. Also use cautiouslyin breast-feeding and elderly patients.• Expect to start therapy before culture andsensitivity test results are known.• Be aware that chewable tablets and tabletsfor oral suspension contain phenylalanine.• Don’t confuse amoxicillin tablets withamoxicillin tablets for oral suspension(DisperMox). They’re not interchangeable.WARNING If allergic reaction occurs, stopamoxicillin immediately and provideemergency care as indicated and ordered.• Monitor patient closely for diarrhea,which may indicate pseudomembranouscolitis caused by Clostridium difficile. Ifdiarrhea occurs, notify prescriber, expectto withhold amoxicillin, and treat withfluids, electrolytes, protein, and an antibioticeffective against C. difficile.• Expect treatment that lasts at least 10 daysfor hemolytic streptococci infections.• Monitor patient for superinfection. If itoccurs, expect to discontinue drug andprovide treatment as ordered.PATIENT TEACHING• Tell patient to refrigerate reconstituted suspensionand to shake well before each use.• When amoxicillin suspension is prescribedfor a child, instruct parents to place itdirectly on child’s tongue to swallow. Ifthis doesn’t work, tell parents to mix doseof suspension with formula or cold drink(milk, fruit juice, ginger ale, water) andhave child drink it immediately.• Instruct patient using DisperMox tabletsto place one tablet and about 2 teaspoonfulsof water in a glass, drink entire mixture,add more water to the glass, anddrink again to ensure delivery of full dose.• Tell patient to chew or crush chewabletablets and not to swallow them whole.• To prevent infection from recurring, urgepatient to take amoxicillin for full lengthof time prescribed, even if he feels better.• Teach patient to report adverse reactionsand notify prescriber if infection worsensor doesn’t improve after 72 hours.• Urge patient to tell prescriber about diarrheathat’s severe or lasts longer than3 days. Remind patient that watery orbloody stools can occur 2 or more monthsafter antibiotic therapy and may be serious,requiring prompt treatment.amphetaminesulfatedexamphetaminesulfateLiquaddClass, Category, and ScheduleChemical class: Sympathomimetic amineTherapeutic class: CNS stimulantPregnancy category: CControlled substance schedule: IIIndications and Dosages To treat attention deficit hyperactivitydisorder (ADHD)ORAL SOLUTION (LIQUADD)Children ages 3 to 6. Initial: 2.5 mg daily.

Increased by 2.5 mg daily at 1-wk intervalsuntil desired response occurs.Children age 6 and over. Initial: 5 mg dailyor b.i.d. Increased by 5 mg daily at 1-wkintervals until desired response occurs.TABLETSChildren age 6 and over. Initial: 5 mg dailyor b.i.d. Increased by 5 mg daily at 1-wkintervals until desired response occurs.Usual: 0.1 to 0.5 mg/kg daily.Children ages 3 to 5. Initial: 2.5 mg daily.Increased by 2.5 mg daily at 1-wk intervalsuntil desired response occurs. Usual: 0.1 to0.5 mg/kg daily. To treat narcolepsyORAL SOLUTION (LIQUADD)Adults and children age 12 and over. Initial:10 mg daily. Increased by 10 mg daily at 1-wk intervals until desired response occurs.Children ages 6 to 12. Initial: 2.5 mg b.i.d.Increased by 5 mg daily at 1-wk intervalsuntil desired response occurs.TABLETSAdults and children age 12 and over. Initial:10 mg daily. Increased by 10 mg daily at 1-wk intervals until desired response occurs.Children ages 6 to 12. Initial: 2.5 mg b.i.d.Increased by 5 mg daily at 1-wk intervalsuntil desired response occurs or adultdosage is reached to a maximum of 60 mgdaily.Mechanism of ActionMay produce its CNS stimulant effects byfacilitating release and blocking reuptake ofnorepinephrine at adrenergic nerve terminalsand by direct stimulation of alpha andbeta receptors in the peripheral nervoussystem. It also releases and blocks reuptakeof dopamine in limbic regions of the brain.The drug’s main action appears to be in thecerebral cortex and, possibly, the reticularactivating system. These actions causedecreased motor restlessness, increasedalertness, and diminished drowsiness andfatigue. Its peripheral actions includeincreased blood pressure and mild bronchodilationand respiratory stimulation.ContraindicationsAdvanced arteriosclerosis, agitation (fornarcolepsy treatment), glaucoma, history ofdrug abuse, hypersensitivity or idiosyncraticreaction to sympathomimetic amines,hyperthyroidism, MAO inhibitor therapyAdverse ReactionsCNS: Anxiety, dizziness, dyskinesia, dysphoria,euphoria, exacerbation of motor andphonic tics and Tourette’s syndrome, halluamphetaminesulfate 77within 14 days, moderate to severe hypertension,symptomatic cardiovascular diseaseInteractionsDRUGSadrenergic blockers: Inhibited adrenergicblockadeacetazolamide, alkalinizers (such as sodiumbicarbonate), some thiazides: Increasedblood level and effects of amphetamineantihistamines: Possibly reduced sedationfrom antihistamineantihypertensives: Possibly decreased antihypertensiveeffectschlorpromazine: Inhibited CNS stimulanteffects of amphetamineethosuximide: Possibly delayed ethosuximideabsorptionGI acidifiers (such as ascorbic acid), reserpine:Decreased amphetamine absorptionguanethidine: Decreased antihypertensiveeffect and decreased amphetamine absorptionhaloperidol: Decreased CNS stimulationlithium carbonate: Possibly decreasedanorectic and stimulant effects of amphetamineMAO inhibitors: Potentiated effects ofamphetamine; possibly hypertensive crisismeperidine: Increased analgesiamethenamine: Increased urine excretionand decreased effects of amphetaminenorepinephrine: Possibly increased adrenergiceffect of norepinephrinephenobarbital, phenytoin: Synergistic anticonvulsantactionpropoxyphene: Increased CNS stimulation,potentially fatal seizurestricyclic antidepressants: Possibly enhancedantidepressant effects and decreased effectsof amphetamineurinary acidifiers (such as ammonium chlorideand sodium acid phosphate): Increasedamphetamine excretion and decreasedamphetamine blood level and effectsveratrum alkaloids: Decreased hypotensiveeffectFOODSacidic fruit juices: Decreased amphetamineabsorptionA

78amphotericin Bcinations, headache, insomnia, overstimulation,paranoia, psychotic episodes, restlessness,tremorCV: Cardiomyopathy, hypertension, palpitations,tachycardiaEENT: Dry mouth, unpleasant tasteGI: Anorexia, constipation, diarrheaGU: Impotence, libido changesSKIN: UrticariaOther: Weight lossNursing Considerations• Keep in mind that when symptoms ofADHD occur with acute stress reactions,treatment with amphetamines usually isn’tindicated.WARNING To prevent hypertensive crisis,don’t give amphetamine during or for upto 14 days after MAO therapy.• Give first dose when patient awakens andadditional doses at 4- to 6-hour intervals.• Be aware that 5 ml of oral solution contains5 mg of dexamphetamine.• If patient has bothersome adverse reactions,such as insomnia and anorexia,expect to decrease dosage. To minimizeinsomnia, administer drug earlier in day.• Be alert for evidence of long-termamphetamine abuse, such as severe dermatoses,marked insomnia, irritability,hyperactivity, and personality changes. Ifpatient suddenly stops drug after longterm,high-dose regimen, watch forextreme fatigue and depression.PATIENT TEACHING• Instruct breast-feeding patient to avoidbreast-feeding during amphetamine therapybecause drug is excreted in breast milk.• Teach patient to take first dose on awakeningand subsequent doses at 4- to 6-hourintervals. Tell him not to take last dose latein evening because insomnia may occur.• Inform patient or caregiver that each 5 mlof oral solution contains 5 mg of dexamphetamine.Advise patient to use a calibratedmeasuring device for accurate dose.• Urge patient to avoid hazardous activitiesuntil drug’s effects are known.• Advise patient not to take amphetaminewith acidic fruit juice because doing sodecreases drug absorption.• Explain drug’s abuse potential, and cautionagainst altering dosage unless prescribed.amphotericin BAmphocin, Fungizone Intravenousamphotericin Bcholesteryl sulfatecomplexAmphotecamphotericin B lipidcomplexAbelcetamphotericin Bliposomal complexAmBisomeClass and CategoryChemical class: Amphoteric polyenemacrolideTherapeutic class: AntifungalPregnancy category: B (I.V.); C (oral suspension)Indications and Dosages To treat severe fungal infections, usingamphotericin BI.V. INFUSIONAdults and adolescents. Initial: 1-mg testdose in 20 ml of D 5 W infused over 20 to30 min; if test dose is tolerated, then 0.25 to0.3 mg/kg daily prepared as a 0.1 mg/mlinfusion, given over 2 to 6 hr. Increased in5- to 10-mg increments up to 50 mg daily,based on patient tolerance and infectionseverity, not to exceed a total daily dose of1.5 mg/kg. Maximum: 50 mg daily infusedover 2 to 6 hr.Children. Initial: 0.25 mg/kg daily in D 5 Winfused over 6 hr; then increased in 0.125-to 0.25-mg/kg increments daily or everyother day as tolerated. Maximum: 1 mg/kgor 30 mg/m 2 of body surface daily. To treat oral candidiasis, using amphotericinBORAL SUSPENSIONAdults and children. 1 ml (100 mg) q.i.d.for 14 days. To treat aspergillosis, using amphotericinB cholesteryl sulfate complex

I.V. INFUSIONAdults and children. Test dose of 1.6 to8.3 mg in 10 ml of D 5 W infused over 15 to30 min; if test dose is tolerated, then 3 to4 mg/kg once daily infused at 1 mg/kg/hr. To treat invasive amphotericin B-resistant fungal infections, using amphotericinB lipid complexI.V. INFUSIONAdults and children. 5 mg/kg daily infusedat 2.5 mg/kg/hr. To treat severe aspergillosis, candidiasis,or cryptococcosis, using amphotericin Bliposomal complexI.V. INFUSIONAdults and children. 3 to 5 mg/kg dailyinfused over 2 hr. Infusion time may bedecreased to 1 hr if tolerated or increased ifpatient experiences discomfort. To treat leishmaniasis, using amphotericinB liposomal complexI.V. INFUSIONImmunocompetent adults and children.3 mg/kg daily on days 1 through 5 and ondays 14 and 21, infused over 2 hr. Infusiontime may be decreased to 1 hr if toleratedor increased if patient has discomfort.Immunocompromised adults and children.4 mg/kg daily on days 1 through 5 and days10, 17, 24, 31, and 38 infused over 2 hr. Infusiontime may be decreased to 1 hr if toleratedor increased if patient has discomfort. To treat presumed fungal infections inpatients with febrile neutropenia, usingamphotericin B lipid complexI.V. INFUSIONAdults and children. 3 mg/kg daily infusedover 2 hr. Infusion time may be decreasedto 1 hr if tolerated or increased if patienthas discomfort.Route Onset Peak DurationI.V. Immediate Unknown UnknownMechanism of ActionBinds to sterols in fungal cell plasma membranes,which changes membrane permeabilityand allows loss of potassium andsmall molecules from cells. This actionresults in cell impairment or death.IncompatibilitiesDon’t reconstitute amphotericin B withdiluents other than those recommendedamphotericin B 79because solutions with sodium chloride orbacteriostatic agents (such as benzyl alcohol)may cause drug precipitation.ContraindicationsHypersensitivity to amphotericin B or itscomponentsInteractionsDRUGSantineoplastics: Increased risk of bronchospasm,hypotension, and nephrotoxicitycorticosteroids, corticotropin: Increased riskof hypokalemia and cardiac dysfunctioncyclosporine, nephrotoxic drugs: Increasedrisk of nephrotoxicitydigitalis glycosides: Possibly hypokalemiaand more severe digitalis toxicityflucytosine: Possibly increased flucytosinetoxicityleukocyte transfusion: Possibly dyspnea,hypoxemia, and pulmonary infiltratesskeletal muscle relaxants: Possibly hypokalemiaand increased muscle relaxationzidovudine: Possibly myelotoxicity andnephrotoxicityAdverse ReactionsCNS: Fever, headache, shaking chills, tiredness,weaknessCV: Chest pain, hypotension, irregularheartbeatEENT: Difficulty swallowing, pharyngitisGI: Abdominal pain, anorexia, diarrhea,hepatic failure, indigestion, nausea, vomitingGU: Decreased or increased urine output,impaired renal functionHEME: Anemia, leukopenia, thrombocytopenia,unusual bleeding or bruisingMS: Arthralgia, muscle spasms, myalgiaRESP: Apnea, dyspnea, hypoxia, pulmonaryedema, tachypneaSKIN: Flushing, jaundice, maculopapularrash, pruritus and redness especially aroundears, urticariaOther: Anaphylaxis, hypocalcemia,hypokalemia, hypomagnesemia, infusionsite pain and thrombophlebitisNursing Considerations• To prepare amphotericin B, add 10 ml ofsterile water for injection without a bacteriostaticagent to vial containing 50 mg ofamphotericin B. For I.V. infusion, dilutesolution containing 5 mg/ml to 0.1 mg/mlA

80amphotericin Bby adding 1 ml (5 mg) of solution to49 ml of D 5 W with a pH above 4.2.• Before using D 5 W to dilute amphotericinB solution, determine the injection’s pHaseptically. If pH is below 4.2, follow manufacturer’sinstructions for buffering it.• Because reconstituted amphotericin B is acolloidal suspension, avoid using in-linemembrane filter or use one with a meanpore diameter of more than 1 micron toprevent significant drug removal.• To prepare amphotericin B cholesteryl sulfatecomplex, reconstitute with sterilewater for injection. Using a sterile syringeand 20G needle, rapidly add 10 or 20 mlsterile water for injection to a 50- or 100-mg vial, respectively, to obtain a solutioncontaining 5 mg of amphotericin B permilliliter. Shake gently by hand, rotatingvial until solids are dissolved; fluid may beclear or opalescent. For infusion, furtherdilute reconstituted solution to about0.6 mg/ml. Don’t filter solution or use anin-line filter. Flush existing line with D 5 Wor use a separate line.• To prepare amphotericin B lipid complex,shake vial gently until you see no yellowsediment. Using an 18G needle, withdrawprescribed dose from required number ofvials into one or more 20-ml syringes.Replace needle with 5-micron filter needlesupplied with each vial. Empty syringecontents into bag of D 5 W so that finalconcentration is 1 mg/ml. Expect to use aconcentration of 2 mg/ml for children andpatients with cardiovascular disease.Before infusion, shake bag until contentsare mixed thoroughly. Flush existing linewith D 5 W, or use a separate line. Don’t usean in-line filter. If infusion exceeds 2 hours,shake infusion bag every 2 hours.• To prepare amphotericin B liposomalcomplex, add 12 ml sterile water for injection(without bacteriostatic agent) to each50-mg vial to achieve a concentration of4 mg amphotericin B per milliliter.Immediately shake vial vigorously for atleast 30 seconds until all particles completelydisperse. Withdraw prescribed doseof amphotericin B liposomal complex suspension.Then use a 5-micron filter toinject it into D 5 W to provide a final concentrationof 1 to 2 mg/ml. Expect to use alower concentration (0.2 to 0.5 mg/ ml)for infants and young children. Flushexisting line with D 5 W, or use a separateline. You may use an in-line filter with amean pore diameter of at least 1 micron.• To help minimize fever and shaking chills,expect to give an antipyretic, antihistamine,meperidine, or corticosteroid justbefore infusing amphotericin B.• Before giving amphotericin B oral suspension,shake well. Drop suspension ontongue with calibrated dropper. Then tellpatient to swish suspension in mouth foras long as possible before swallowing. Ifdrug must be swabbed on, use a nonabsorbentswab.• Give amphotericin B oral suspensionbetween meals to permit prolonged contactwith oral lesions.• Assess I.V. insertion site regularly to detectextravasation of amphotericin B, whichmay cause severe local irritation. To minimizelocal thrombophlebitis, plan to addheparin to infusion or expect to administeramphotericin on alternate days, whichalso may help prevent anorexia. Alternatedaydose shouldn’t exceed 1.5 mg/kg.• Monitor renal function because of the riskof renal impairment. Plan to obtain serumcreatinine level every other day whileamphotericin B dosage is increasing andthen at least twice weekly during therapy.If serum creatinine or BUN level increasessignificantly, expect to stop amphotericinB until renal function improves. Knowthat a cumulative dose of more than 4 gmay cause irreversible renal dysfunction.• Expect to monitor CBC and platelet countweekly during therapy to detect adversehematologic effects. Also monitor serumcalcium, magnesium, and potassium levelstwice weekly to detect abnormalities.• Use reconstituted amphotericin B within24 hours if stored at room temperature,1 week if refrigerated. Use reconstitutedamphotericin B cholesteryl sulfate complexwithin 24 hours. Use amphotericin Blipid complex within 6 hours if stored atroom temperature, 48 hours if refrigerated.Use diluted amphotericin B liposomalcomplex within 24 hours if refrigerated,but begin infusion within 6 hours.PATIENT TEACHING• Instruct patient to shake bottle of oral suspensionwell before each dose; to drop

suspension directly on his tongue usingcalibrated dropper; and then to swish suspensionin his mouth for as long as possiblebefore swallowing. If prescriber ordersdrug to be swabbed onto oral lesions, tellpatient to use nonabsorbent swab. Instructhim to take drug four times a day(between meals and at bedtime).• Tell patient to notify prescriber if he developslocal irritation, if existing symptomsworsen or return, or if new symptomsarise.ampicillinApo-Ampi (CAN), Novo-Ampicillin(CAN), Nu-Ampi (CAN), Omnipenampicillin sodiumAmpicin (CAN), Omnipen-N, Polycillin-N, Totacillin-Nampicillin trihydrateD-Amp, Omnipen, Penbritin (CAN),Polycillin, Principen-250, Principen-500, TotacillinClass and CategoryChemical class: Semisynthetic aminopenicillinTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat GI infections and genitourinaryinfections (other than gonorrhea) causedby susceptible strains of Shigella,Salmonella typhi and other species,Escherichia coli, Proteus mirabilis, andenterococciCAPSULES, ORAL SUSPENSION, I.V. INFUSION,I.M. INJECTIONAdults and children weighing 20 kg (44 lb)or more. 500 mg P.O. every 6 hr or 250 to500 mg I.V. or I.M. every 6 hr.Children weighing less than 20 kg. 50 to100 mg/kg daily in divided doses P.O. every6 hr or 12.5 mg/kg I.V. or I.M. every 6 hr. To treat gonorrhea caused by susceptiblestrains of non–penicillinase-producingNeisseria gonorrhoeaeCAPSULES, ORAL SUSPENSIONAdults and children. 3.5 g as a single doseampicillin 81with 1 g of probenecid.I.V. INFUSION, I.M. INJECTIONAdults and children weighing 45 kg (99 lb)or more. 500 mg every 6 hr.Children weighing less than 40 kg (88 lb).50 mg/kg daily in divided doses every 6 to8hr. To treat respiratory tract infectionscaused by susceptible strains of nonpenicillinase–producingHaemophilusinfluenzae, staphylococci, and streptococci,including Streptococcus pneumoniaeCAPSULES, ORAL SUSPENSION, I.V. INFUSION,I.M. INJECTIONAdults and children weighing 40 kg ormore. 250 to 500 mg I.V. or I.M. every 6 to8 hr.Adults and children weighing 20 kg ormore. 250 mg P.O. every 6 hr.Children weighing less than 40 kg. 25 to50 mg/kg daily I.V. or I.M. in divided dosesevery 6 to 8 hr.Children weighing less than 20 kg. 50 mg/kg daily P.O. in divided doses every 6 or8 hr or 12.5 mg/kg I.V. or I.M. every 6 hr. To treat septicemiaI.V. INFUSION, I.M. INJECTIONAdults. 8 to 14 g I.V. daily in divided dosesevery 3 to 4 hr for at least 3 days; then I.M.Children. 150 to 200 mg/kg daily I.V. individed doses every 3 to 4 hr for at least3 days; then I.M. To prevent bacterial endocarditis fromdental, oral, or upper respiratory tractproceduresI.V. INFUSION, I.M. INJECTIONAdults. 2 g within 30 min of procedureChildren. 50 mg/kg within 30 min of procedure To treat bacterial meningitis caused bysusceptible strains of Neisseria meningitidisI.V. INFUSION, I.M. INJECTIONAdults. 8 to 14 g daily or 150 to 200 mg/kgdaily I.V. in equally divided doses every 3 to4 hr for at least 3 days; then I.M. at samedosage and schedule.Children. 100 to 200 mg/kg daily I.V. inequally divided doses every 3 to 4 hr for atleast 3 days; then I.M. at same dosage andschedule. To treat listeriosisI.V. INFUSION, I.M. INJECTIONA

82ampicillinAdults and children weighing 20 kg ormore. 50 mg/kg every 6 hr.Children weighing less than 20 kg.12.5 mg/kg every 6 hr.Route Onset Peak DurationI.V. Immediate Unknown UnknownMechanism of ActionInhibits bacterial cell wall synthesis. Therigid, cross-linked cell wall is assembled inseveral steps. Ampicillin exerts its effects onsusceptible bacteria in the final stage of thecross-linking process by binding with andinactivating penicillin-binding proteins(enzymes responsible for linking the cellwall strands). This action causes bacterialcell lysis and death.IncompatibilitiesDon’t mix ampicillin and any aminoglycosidein the same I.V. bag, bottle, or tubing;otherwise, both drugs will be inactivated. Ifpatient must receive both drugs, administerthem in separate sites at least 1 hour apart.ContraindicationsHypersensitivity to any penicillin, infectioncaused by penicillinase-producing organismInteractionsDRUGSallopurinol: Increased risk of rash, particularlyin hyperuricemic patientaminoglycosides: Possibly inactivated actionof aminoglycoside and ampicillin whengiven togetherheparin, oral anticoagulants: Increased riskof bleedingoral contraceptives: Possibly reduced contraceptiveeffectiveness and breakthroughbleedingprobenecid: Possibly increased serum ampicillinlevel and ampicillin toxicitytetracyclines: Possibly impaired action ofampicillinAdverse ReactionsCNS: Chills, fatigue, fever, headache,malaiseCV: Chest pain, edema, thrombophlebitisEENT: Epistaxis, glossitis, laryngeal stridor,mucocutaneous candidiasis, stomatitis,throat tightnessGI: Abdominal distention, diarrhea, diarrhearelated to Clostridium difficile, enterocolitis,flatulence, gastritis, nausea,pseudomembranous colitis, vomitingGU: Dysuria, urine retention, vaginal candidiasisHEME: Agranulocytosis, anemia,eosinophilia, leukopenia, thrombocytopenia,thrombocytopenic purpuraSKIN: Erythema multiforme; erythematous,mildly pruritic maculopapular rash orother types of rash; exfoliative dermatitis;pruritus; urticariaOther: Anaphylaxis, facial edema, injectionsite painNursing Considerations• Avoid giving ampicillin to patients withmon-nucleosis because of increased risk ofrash.• Expect to give ampicillin for 48 to72 hours after patient becomes asymptomatic.For streptococcal infection, expectto give ampicillin for at least 10 days aftercultures show streptococcal eradication toreduce risk of rheumatic fever orglomerulonephritis.• To dilute ampicillin for I.M. use, add(depending on manufacturer) 1.2 ml ofsterile water or bacteriostatic water forinjection to each 125-mg vial, 1 ml ofdiluent to each 250-mg vial, 1.8 ml ofdiluent to each 500-mg vial, 3.5 ml ofdiluent to each 1-g vial, or 6.8 ml of diluentto each 2-g vial.• To dilute ampicillin for intermittent infusion,add 5 ml of sterile water or bacteriostaticwater for injection to each 125-,250-, or 500-mg vial or 7.4 to 10 ml ofdiluent to each 1- or 2-g vial. Infuse insuitable diluent at less than 30 mg/ml.WARNING Infuse I.V. solution for 3 to5 minutes for each 125 or 500 mg or 10 to15 minutes for each 1 or 2 g. More rapidinfusion may cause seizures.• Monitor patient closely for anaphylaxis,which may be life-threatening. Patients atgreatest risk are those with a history ofmultiple allergies, hypersensitivity tocephalosporins, or a history of asthma,hay fever, or urticaria.WARNING In an anaphylactic reaction, stopdrug, notify prescriber immediately, andprovide immediate treatment with epinephrine,airway management, oxygen,and I.V. corticosteroids, as needed.• Notify prescriber if patient has evidence of

superinfection; expect to stop drug andprovide appropriate treatment.• If long-term or high-dose ampicillin therapyis required, closely monitor results ofrenal and liver function tests and CBCs.• Monitor patient closely for diarrhea,which may be pseudomembranous colitiscaused by Clostridium difficile. If diarrheaoccurs, notify prescriber and expect towithhold ampicillin and administer fluids,electrolytes, protein, and an antibioticeffective against C. difficile.PATIENT TEACHING• Stress the importance of taking the fullcourse of ampicillin exactly as prescribed.• Tell patient to take dose with 8 oz of water30 minutes before or 2 hours after meals.• Instruct patient to shake suspension wellbefore each use, keep bottle tightly closedbetween uses, and discard unused portionafter 14 days if refrigerated or 7 days ifstored at room temperature.• Review signs of allergic reaction; if theyoccur, tell patient to hold next ampicillindose and contact prescriber immediately.• Urge patient to tell prescriber about diarrheathat’s severe or lasts longer than3 days. Remind patient that watery orbloody stools may occur 2 or moremonths after antibiotic therapy and maybe serious, requiring prompt treatment.amyl nitriteClass and CategoryChemical class: Nitrite esterTherapeutic class: AntianginalPregnancy category: CIndications and Dosages To treat acute attacks of angina pectorisCRUSHABLE AMPULESAdults. 1 ampule (0.18 or 0.3 ml) inhaledand repeated in 3 to 5 min, if needed.Route Onset Peak DurationInhalation 10–30 sec Unknown 3–5 minamyl nitrite 83Mechanism of ActionAfter inhalation, is absorbed by pulmonaryalveoli, which causes relaxation of vascularsmooth-muscle cells, dilation of large coronaryblood vessels, decreased systemic vascularresistance, decreased venous return tothe heart, reduced afterload, decreased cardiacouput, and subsequent relief of angina.ContraindicationsHypersensitivity to amyl nitrite, its components,or nitratesInteractionsDRUGSaspirin: Increased serum level and action ofamyl nitritecalcium channel blockers: Possibly severesymptomatic hypotensionsildenafil: Increased risk of hypotensionsympathomimetics: Possibly decreasedantianginal effects and severe hypotensionand tachycardiaACTIVITIESalcohol use: Increased risk of severehypotension and cardiovascular collapseAdverse ReactionsCNS: Dizziness, headache, restlessness, syncope,weaknessCV: Orthostatic hypotension, tachycardiaGI: Fecal incontinence, nausea, vomitingGU: Urinary incontinenceHEME: Hemolytic anemia, methemoglobin-emiaSKIN: Face and neck flushing, pallor, rashNursing Considerations• Use amyl nitrite cautiously in elderlypatients and patients with cerebral hemorrhage,glaucoma, hyperthyroidism, recenthead trauma or MI, or severe anemia.• Monitor blood pressure during and afterdrug administration. Also monitor cardiacfunction periodically in patients who useamyl nitrite regularly.WARNING Stop drug and notify prescriber ifevidence of overdose, such as bluish lips,fingernails, or palms; dizziness; fainting;extreme pressure in head; dyspnea; unusualtiredness or weakness; a weak or fastheartbeat; or increased methemoglobinlevel. Cyanosis may occur when methemoglobinlevel reaches 1.5 g/dl. More pronouncedsigns occur at 20 to 50 g/dl.• Expect to treat overdose with high-flowoxygen and I.V. methylene blue. Ifhypotension is severe, place patient headdown. If he needs a vasopressor, avoid epinephrine;it may cause severe hypotension.A

84anagrelide hydrochloridePATIENT TEACHING• Advise patient to store amyl nitrate in atight container, protected from light.• Tell patient to crush ampule between fingerand thumb, hold it to nostrils, andinhale 1 to 6 times.• Instruct patient to remain seated or supineduring administration and to rise slowlyafterward to prevent dizziness.• Inform patient that relief usually occurs in1 to 5 minutes. If pain continues, heshould repeat dose. If pain continues afteranother 5 minutes, he should seek emergencyhelp.• Urge patient not to use any more drug thanprescribed because of possible overdose.WARNING Caution patient that drug isflammable and must be kept from flameand heat.• Inform patient that amyl nitrite commonlycauses headaches. Tell him to notify prescriberif they’re severe or bothersome.anagrelidehydrochlorideAgrylinClass and CategoryChemical class: ImidazoquinazolinoneTherapeutic class: Platelet count–reducingagentPregnancy category: CIndications and Dosages To treat essential thrombocythemiaCAPSULESAdults. 0.5 mg q.i.d. or 1 mg b.i.d. for 1 wk;then adjusted to lowest dose that keepsplatelet count below 600,000/mm 3 or withinnormal range. Shouldn’t be increased bymore than 0.5 mg daily in any 1 wk.Maximum: 10 mg daily or 2.5 mg in a singledose.DOSAGE ADJUSTMENT For patients withmoderate hepatic impairment, 0.5 mg dailyfor at least 1 wk, increased as needed by nomore than 0.5 mg daily in any 1-wk period.Mechanism of ActionMay decrease megakaryocyte hypermaturation(bone marrow cells from which plateletsform), reducing platelet count. Higherdoses may inhibit platelet aggregation.Route Onset Peak DurationP.O. 7–14 days Unknown Up to 4daysContraindicationsHypersensitivity to anagrelide, severe hepaticimpairmentInteractionsDRUGSamrinone, cilostazol, enoximone, milrinone,olprinone: Increased effects of these drugs;possible risk of increased adverse effectsaspirin: Possibly increased risk of bleedingsucralfate: Possibly interference with anagrelideabsorptionAdverse ReactionsCNS: Amnesia, asthenia, chills, confusion,depression, dizziness, fever, headache,insomnia, malaise, nervousness, paresthesia,seizures, somnolence, stroke, syncope,weaknessCV: Angina, arrhythmias, edema, heart failure,hypertension, MI, orthostatic hypotension,palpitations, tachycardia, vasodilationEENT: Amblyopia, diplopia, epistaxis,rhinitis, sinusitis, stomatitis, tinnitus, visionor visual field abnormalityGI: Abdominal pain, anorexia, constipation,diarrhea, elevated liver function test results,eructation, flatulence, gastric and duodenalulceration, gastritis, GI hemorrhage, hepatotoxicity,indigestion, melena, nausea, pancreatitis,vomitingGU: Dysuria, hematuria, renal failureHEME: Anemia, hemorrhage,thrombocytopeniaMS: Arthralgia, back pain, leg cramps,myalgia, neck painRESP: Allergic alveolitis, asthma, bronchitis,dyspnea, eosinophilic pneumonia, interstitialpneumonitis, lung infiltrations, pneumoniaSKIN: Alopecia, ecchymosis, photosensitivity,pruritus, rash, urticariaOther: Dehydration, flulike symptoms, generalizedbody pain, lymphadenomaNursing Considerations• Use anagrelide cautiously in patients withheart disease because it may cause cardiovascularproblems, such as heart failure.

Use drug cautiously in patients with renalinsufficiency (serum creatinine level 2 mg/dl or more) or hepatic dysfunction (liverfunction tests more than 1.5 times normal)because of the increased risk ofnephrotoxicity and hepatotoxicity.• Determine whether patient takes aspirinbefore starting anagrelide therapy and, ifso, monitor patient closely because bleedingrisk may be higher when aspirin andanagrelide are taken concurrently.• To assess efficacy and prevent thrombocytopenia,expect to monitor platelet countevery 2 days for first week, then at leastweekly until reaching lowest effective dose.• While platelet count is declining (usuallyduring first 2 weeks of therapy), assessWBC count and hemoglobin, AST, ALT,creatinine, and BUN levels to detectabnormalities.• Monitor blood pressure to detect orthostatichypotension.PATIENT TEACHING• Stress need to return for laboratory tests,such as platelet counts, to monitor anagrelide’seffectiveness and adjust its dosage.• Tell patient to keep drug bottle tightlycapped and to protect drug from light.• Urge patient to ask prescriber before takingaspirin or aspirin-containing products.anakinraKineretClass and CategoryChemical class: Recombinant humaninterleukin-1 receptor antagonistTherapeutic class: AntirheumaticPregnancy category: BIndications and Dosages To reduce signs and symptoms and slowstructural damage in moderate to severeactive rheumatoid arthritis in patientswho have not responded to diseasemodifyingantirheumaticsSUBCUTANEOUS INJECTIONAdults. 100 mg daily.DOSAGE ADJUSTMENT Interval reduced toevery other day in severe renal insufficiencyor end-stage renal disease (creatinine clearanceless than 30 ml/min/1.73 m 2 ).anakinra 85Mechanism of ActionInhibits the binding of interleukin-1 (IL-1)to its type 1 receptor, blocking its activity.Inflammatory stimuli prompt T cells torelease IL-1, a mediator of inflammation,pain, and stiffness in rheumatoid arthritis.ContraindicationsActive infection; hypersensitivity to anakinra,its components, or Escherichia coli–derived proteinsInteractionsDRUGSetanercept, infliximab, and other drugs thatblock tumor necrosis factor: Increased risk ofserious infectionlive-virus vaccines Possibly decreased antibodyresponse to vaccine, potential forinfection with live virusAdverse ReactionsCNS: HeadacheEENT: SinusitisGI: Abdominal pain, diarrhea, nauseaHEME: NeutropeniaMS: Bone and joint infectionsRESP: Pneumonia, upper respiratory tractinfectionSkin: CellulitisOther: Flulike symptoms; hypersensitivityreaction; injection site ecchymosis, erythema,inflammation, pain, and pruritus;malignancies; positive results for antianakinraantibodies; serious infectionsNursing Considerations• Expect to obtain baseline neutrophil countbefore therapy and to monitor neutrophilcount every month for 3 months andevery 3 months for up to 1 year.• Discard solution if it contains particles oris discolored. Use prefilled syringe andneedles to administer drug. Don’t shakesyringe; allow time for solution to clear ifit becomes foamy.• Give drug about the same time each day.WARNING Anakinra isn’t recommended forpatients with active infections. Monitorpatient for evidence of infection, such asfever, chills, sore throat, and mouth sores,before and during therapy because drugincreases the risk of infections, such as cellulitis,pneumonia, and bone and jointinfections. Notify prescriber if signs arepresent. Patients with asthma and thoseA

86anastrozolereceiving etanercept or infliximab are atincreased risk for serious infections.Expect anakinra to be stopped if seriousinfection develops.• Be aware that live-virus vaccines shouldn’tbe given to patients receiving anakinrabecause drug decreases immune response.• Monitor patients with impaired renalfunction for signs of anakinra toxicity;they’re at increased risk because drug isexcreted primarily by the kidneys.• Store anakinra at 2° to 8° C (36° to 46° F).Protect from freezing and light.PATIENT TEACHING• Teach proper injection technique if patientwill self-administer drug. Make surepatient understands the process and cancorrectly prepare and inject doses.• Instruct patient to rotate injection sitesamong thighs, stomach, and upper armsand to avoid areas that are tender, hard,red, or bruised. Advise him to make surethat each injection site is at least 1 inchaway from the previous site.• Urge patient to discard used needles andsyringes in a puncture-resistant containerand not to reuse them. Instruct him toreturn container to prescriber for disposal.• Review evidence of allergic reaction,including rash and shortness of breath.• Urge patient to immediately report signsof infection, such as cough, fever, chills,dyspnea, or headache, to prescriber.anastrozoleArimidexClass and CategoryChemical class: Nonsteroidal selective aromataseinhibitorTherapeutic class: AntineoplasticPregnancy category: DIndications and Dosages To treat postmenopausal women withunknown or positive hormone receptorand locally advanced or metastaticbreast cancer, and those with advancedbreast cancer that progresses aftertamoxifen therapy; as adjunct to treatearly breast cancer in postmenopausalwomen with positive hormone receptorTABLETSAdult women. 1 mg daily.ContraindicationsHypersensitivity to anastrozole or its components,pregnancy, premenopausal womenAdverse ReactionsCNS: Asthenia, depression, dizziness,headache, hypertonia, insomnia, lethargy,paresthesiaCV: Angina, MIEENT: Dry mouth, pharyngitisENDO: Hot flashes, weight gainCV: Chest pain, hypertension, peripheraledema, thromboembolic disease, vasodilationGI: Abdominal or pelvic pain, anorexia,increased appetite, constipation, diarrhea,nausea, vomitingGU: Leukorrhea; vaginal bleeding, dryness,or hemorrhageMS: Back or bone painRESP: Increased cough, dyspneaSKIN: Diaphoresis, rash, urticariaOther: Anaphylaxis, angioedema, flulikesymptoms, pain, tumor flareNursing Considerations• Assess patient for evidence of thromboembolicevents during anastrozole therapy,such as shortness of breath, leg pain, andaltered mental status.• Assess patient for evidence of ischemiccardiovascular disorders, such as anginaand MI, especially in women withischemic heart disease.• Store drug in a tightly closed container atroom temperature.PATIENT TEACHING• Urge patient to report menopausal statusaccurately because drug is contraindicatedand ineffective in premenopausal women.• Inform patient about possible dizzinessand lethargy, and advise her to avoidpotentially hazardous activities untildrug’s CNS effects are known.• Urge patient to tell prescriber about legpain or calf swelling, which may indicate ablood clot.• Advise patient to consume adequate calciumand to follow an exercise program;drug may reduce bone mineral density.• Urge patient taking anastrozole to complywith follow-up appointments.

InteractionsDRUGSabciximab, acetaminophen, allopurinol, alteplase,amiodarone, amitriptyline, amoxapine,androgens, aspirin, beta blockers,cephalosporins, chloral hydrate, chloramanisindione87Mechanism of ActionAnastrozole treats certain breast cancersin postmenopausal women by inhibitingthe enzyme aromatase, as shown in theillustrations below, thus preventing productionof estrone and estradiol. This isAndrostenedionehow, in women with breast tumors thatcontain estrogen receptors, anastrozoleprevents the stimulatory effects of estrogenon tumor growth.AndrostenedioneAAromataseAnastrozoleAromataseEstroneEstroneBreast cancercellEstradiolEstrogenreceptorNucleusBreast cancercellEstradiolEstrogenreceptor NucleusEstradiolanisindioneMiradonClass and CategoryChemical class: Indanedione derivativeTherapeutic class: AnticoagulantPregnancy category: XIndications and Dosages To prevent and treat venous thrombosis,atrial fibrillation with embolization,and pulmonary embolism; as adjunct totreat coronary artery occlusion, usuallyin patients who can’t tolerate coumarinanticoagulantsTABLETSAdults. Initial: 300 mg on day 1; then200 mg on day 2, and 100 mg on day 3.Maintenance: 25 to 250 mg daily.Route Onset Peak DurationP.O. In 6 hr 48–72 hr 1–3 daysMechanism of ActionInterferes with the liver’s ability to synthesizevitamin K–dependent clotting factors,which results in the depletion of clottingfactors II (prothrombin), VII, IX, and X. Bydepleting levels of vitamin K–dependentclotting factors that are needed to form astable fibrin clot, anisindione interfereswith the clotting cascade and preventscoagulation.ContraindicationsAscorbic acid deficiency; blood dyscrasias;continuous small-intestine drainage tube;diverticulitis; emaciation; GI, GU, or respiratorytract bleeding; hemophilia; hemorrhagictendency; history of warfarininducednecrosis; hypersensitivity to anisindioneor its components; leukemia; majorrecent surgery; malnutrition; pericardialeffusion; pericarditis; polyarthritis; pregnancy;prostatectomy; recent spinal puncture,percutaneous invasive procedure,diagnostic testing, or insertion of intrauterinedevice; recent or possible CNS oreye surgery; severe renal or hepatic disease;severe uncontrolled diabetes; severe uncontrolledmalignant hypertension; subacutebacterial endocarditis; thrombocytopenicpur-pura; visceral carcinomas; ulcerativecolitis

88anistreplasephenicol, chlorpropamide, cimetidine, cisapride,clofibrate, clomipramine, corticosteroids,co-trimoxazole, cyclophosphamide,danazol, desipramine, dextrothyroxine,diclofenac, diflunisal, disulfiram, doxepin,erythromycin, etodolac, fluconazole, fluoxymesterone,fosphenytoin, gemfibrozil,glucagon, hydantoins, ifosfamide, influenzavirus vaccines, imipramine, indomethacin,isoniazid, itraconazole, ketoconazole,ketolorac, lepirudin, loop diuretics, lovastatin,low–molecular-weight heparins, meclofenamate,mefenamic acid, methyltestosterone,metronidazole, miconazole, moricizine,nabumetone, naproxen, nalidixic acid,neomycin, nortriptyline, NSAIDs, omeprazole,oxandrolone, penicillins, phenylbutazones,phenytoin, piroxicam, propafenone,propoxyphene, protriptyline, quinidine, quinine,quinolones, reteplase, salicylates, stanazolol,streptokinase, sulfamethoxazole, sulfinpyrazone,sulindac, tamoxifen, testosterone,thioamines, thyroid hormones, tomentin,urokinase: Increased anticoagulant effectsaminoglutethimide, ascorbic acid, barbiturates,carbamazepine, cholestyramine, corticosteroids,dicloxacillin, estrogen, ethanol,ethchlorvynol, etretinate, glutethimide, griseofulvin,nafcillin, oral contraceptives,rifampin, spironolactone, sucralfate, thiazidediuretics, thiopurines, trazodone, vitamin K:Decreased anticoagulant effectsaminoglycosides, mineral oil, tetracycline,vitamin E: Interference with vitamin K,leading to increased anticoagulant effectsFOODSenteral products and foods high in vitamin K,such as dark green leafy vegetables:Interference with anticoagulant effectsACTIVITIESalcohol use: Possibly increased or decreasedanticoagulationAdverse ReactionsCNS: Fever, headacheEENT: Blurred vision, mouth ulcers,pharyngitisGI: Abdominal cramps, diarrhea, hepaticdysfunction, hepatitis, nausea, steatorrheaGU: Albuminuria, anuria, priaprism, redorangeurine, renal tubular necrosisHEME: Agranulocytosis, anemia, atypicalmononuclear cells, eosinophilia, hemorrhage,leukocytosis, leukopenia, RBCaplasia, thrombocytopeniaSKIN: Alopecia, exfoliative dermatitis,jaundice, necrosis of the skin and tissuesevidenced by gangrene and purple toes,urticariaNursing Considerations• Watch for PT to become prolonged 6hours after anisindione administration,although maximum therapeutic effectsmay take 48 to 72 hours to appear.WARNING Watch for signs of overanticoagulation,such as microscopic hematuria,excessive menstrual bleeding, melena,petechiae, and bleeding from superficialtrauma, such as tooth brushing or shaving.• Monitor INR, CBC, fecal occult blood test,and urinalysis results for signs of overanticoagulation.PATIENT TEACHING• Advise patient to avoid alcohol, salicylates,and drastic changes in his intake of vitaminK–rich food.• Instruct patient to promptly report pregnancyto prescriber.• Provide patient with a list of foods rich invitamin K. Advise him to eat consistentdaily amounts of vitamin K.• Urge patient to consult prescriber beforehaving dental work or elective surgery.• Tell patient to immediately report unusualbleeding, bruising, red or red-orangeurine, red or tarry black stools, diarrhea,bleeding from gums or nose, or excessivebleeding from minor cuts or scratches.anistreplase(anisoylatedplasminogenstreptokinaseactivatorcomplex)EminaseClass and CategoryChemical class: p-Anisoylated derivative ofthe Lys-plasminogen-streptokinase activatorcomplexTherapeutic class: Thrombolytic enzymePregnancy category: CIndications and Dosages To treat acute MI, lyse thrombi that are

obstructing coronary arteries, reduceinfarct size, improve ventricular functionafter acute MI, reduce mortality fromacute MII.V. INFUSIONAdults. 30 units injected over 2 to 5 min.Route Onset Peak DurationI.V. Immediate 20 min– 4–6 hr2 hrMechanism of ActionIndirectly promotes conversion of plasminogento plasmin, an enzyme that breaksdown fibrin clots, fibrinogen, and otherplasma proteins, including procoagulantfactors V and VIII.IncompatibilitiesDon’t add other drugs to anistreplase solutionor infuse other drugs through sameI.V. line.ContraindicationsActive internal bleeding, arteriovenous malformationor aneurysm, bleeding diathesis,history of stroke, hypersensitivity toanistreplase or streptokinase, intracranialneoplasm, intracranial or intraspinal surgeryor trauma within past 2 months,severe uncontrolled hypertensionInteractionsDRUGSaspirin, dipyridamole, and other drugs thatalter platelet function; heparin; vitamin Kantagonists: Possibly increased risk of bleedingif administered before anistreplaseAdverse ReactionsCNS: Dizziness, fever, headache, intracranialhemorrhageCV: Ankle edema, arrhythmias (especiallyaccelerated idioventricular rhythm, conductiondisorders, premature ventricular beats,sinus bradycardia, ventricular fibrillation,ventricular tachycardia), hypotension, vasculitisEENT: EpistaxisGI: Abdominal pain or swelling, constipation,GI bleeding, nausea, vomitingGU: Hematuria, proteinuria, vaginal bleedingHEME: Bleeding tendency, eosinophilia,mild to severe hemorrhageMS: Arthralgia, back pain, joint stiffness,myalgiaanistreplase 89RESP: Bronchospasm, dyspnea, hemoptysisSKIN: Flushing, pruritus, rash, urticariaOther: Anaphylaxis (rare), angioedemaNursing Considerations• Use anistreplase cautiously in patientswith acute pericarditis; cerebrovasculardisease; hemorrhagic ophthalmic conditions;history of major surgery, GI or GUbleeding, or trauma within past 10 days;hypertension; mitral stenosis with atrialfibrillation; pregnancy; septic thrombophlebitis;severe hepatic or renal disease;or subacute bacterial endocarditis.• Reconstitute anistreplase by slowly directing5 ml of sterile water for injection USPor sodium chloride for injection againstside of vial. Then gently roll vial to mixdry powder and fluid and minimize foaming.Don’t shake vial. The resulting solutionshould be colorless to pale yellow andtransparent.• Before administering, inspect solution forparticles and discoloration. If present, discardand reconstitute drug from a newvial. Then withdraw entire contents ofvial. Don’t dilute reconstituted solutionfurther or add it to I.V. fluid. Don’t addother drugs to vial or syringe that containsanistreplase. Discard drug if not givenwithin 30 minutes after reconstitution.• For maximum effectiveness, expect toadminister anistreplase as soon as possibleafter onset of MI symptoms.• Closely monitor all puncture sites, such ascatheter insertion and needle puncturesites, for bleeding.• Don’t give I.M. injections, and avoid handlingpatient unnecessarily during anistreplasetherapy. Perform venipuncture onlywhen necessary.• If an arterial puncture is needed afteranistreplase administration, use an armvessel that allows easy manual compression.Apply a pressure dressing afterward,and check puncture site often for bleeding.• Use continuous cardiac monitoringbecause arrhythmias may occur duringreperfusion. Keep antiarrhythmics onhand during anistreplase therapy, andmanage arrhythmias using facility policy.• Keep epinephrine nearby for anaphylaxis.• Know that anistreplase may be less effectiveif given more than 5 days after anistreplaseor streptokinase administration. ThisA

90antihemophilic factoroccurs because patient may have developedantistreptokinase antibodies, whichmakes him more resistant to the drug anddrug therapy less effective. Elevated serumantistreptokinase antibody levels andreduced drug effectiveness can persist for5 days to 12 months.• Closely monitor blood coagulation testresults. The drug markedly decreases plasminogenand fibrinogen levels andincreases thrombin time, APTT, and PT.PATIENT TEACHING• Instruct patient to report adverse reactionsimmediately, especially bleeding, dizziness,and chest pain.antihemophilicfactor(recombinant),plasma/albuminfreemethod(rAHF-PFM)Advate, Kogenate FS, Xynthaantihemophilicfactor (human)Alphanateantihemophilicfactor–von Willebrandfactor complex(human, dried,pasteurized)Humate-PClass and CategoryChemical class: Recombinant proteinTherapeutic class: Antihemophilic factorPregnancy category: CIndications and Dosages To prevent and control bleeding episodesin patients with hemophilia A andfactor VIII inhibitors not exceeding10 Bethesda Units/mlI.V. INJECTIONAdults and children. Highly individualized.For early hemarthrosis, muscle bleedingepisode, or mild oral bleeding episode: Dosegiven to achieve peak post-infusion factorVIII activity in blood (determined by multiplyingdose given/kg body weight by 2)20% to 40% of normal with infusions every12 to 24 hr for 1 to 3 days until bleedingepisode resolved. For more extensivehemarthrosis, muscle bleeding episode, orhematoma: Dose given to achieve peakpost-infusion factor VIII activity in blood30% to 60% of normal with infusions every12 to 24 hr for 3 or more days until painand disability are resolved. For life-threateningbleeding episodes: Dose given to achievepeak postinfusion factor VIII activity inblood 60% to 100% with infusions every8 to 24 hr until bleeding episode stops. To prevent and control perioperativebleeding in patients with hemophilia AI.V. INJECTIONAdults and children. Highly individualized.For minor surgery, including tooth extraction:Dose given to achieve peak postinfusionfactor VIII activity in blood (determined bymultiplying dose given/kg body weight by2) between 60% and 100% of normal, givenas a single bolus infusion within 1 hr ofoperation, with optional additional doseevery 12 to 24 hr, as needed. For major surgery:Dose given to achieve peak postinfusionfactor VIII activity in blood 80% to100% before and after surgery with infusionsevery 8 to 24 hr.I.V. INJECTION (KOGENATE FS)Adults and children. Highly individualizedbased on this formula: Body weight (kg) desired factor VIII rise (internationalunits/dL or % of normal) 0.5 (internationalunits/kg per international units/dL).For minor surgery, including tooth extraction:15 to 30 international units/kg to achievedesired factor VIII rise to 30% to 60% ofnormal with injections repeated every 12 to24 hr until bleeding has resolved. For majorsurgery: 50 international units/kg preoperativelyto achieve a desired factor VIII rise to100% of normal with dosage repeated 6 to12 hr after initial dose as needed, and for10 to 14 days thereafter, as needed, untilhealing is complete.I.V. INFUSION (XYNTHA)

Adults and children. Highly individualizedbased on this formula: Body weight (kg) desired factor VIII rise (internationalunits/dL or % of normal) 0.5 (internationalunits/kg per international units/dL).For minor surgery, including tooth extraction:Desired factor VIII rise is 30% to 60% ofnormal with infusions every 12 to 24 hr for3 to 4 days or until adequate local hemostasisis achieved (for tooth extraction, a singleinfusion plus oral antifibrinolytic therapywithin 1 hr may be sufficient). For majorsurgery: Desired factor VIII rise is 60% to100% of normal with infusions every 8 to24 hr until adequate local hemostasis andwound healing are achieved. To prevent or treat bleeding in hemophiliaAI.V. INJECTION (HUMATE-P)Adults. Highly individualized. For mildhemorrhage, such as early joint or musclebleed or severe epistaxis: Loading dose of15 international units/kg to achieve factorVIII:C plasma level about 30% of normal,with half the loading dose repeated once ortwice daily for 1 to 2 days as needed. Formoderate hemorrhage, such as advanced jointor muscle bleed; neck, tongue, or pharyngealhematoma without airway compromise;tooth extraction; or severe abdominal pain:Loading dose of 25 international units/kgto achieve factor VIII:C plasma level about50% of normal, followed by 15 internationalunits/kg every 8 to 12 hr for first 1 to2 days to maintain factor VIII:C plasmalevel at 30% of normal, and then 15 internationalunits/kg once or twice daily fortotal of up to 7 days or until adequatewound healing. For life-threatening hemorrhage,as may occur in major surgery; GIbleeding; neck, tongue, or pharyngealhematoma with potential for airway compromise;intracranial, intra-abdominal, orintrathoracic bleeding; or fractures: Loadingdose of 40 to 50 international units/kg, followedby 20 to 25 international units/kgevery 8 hr to maintain factor VIII:C plasmalevel at 80% to 100% of normal for 7 days,followed by 20 to 25 international units/kgonce or twice daily for another 7 days tomaintain factor VIII:C level at 30% to 50%of normal.I.V. INJECTION (KOGENATE FS)Adults and children. Highly individualizedantihemophilic factor 91based on this formula: Body weight (kg) desired factor VIII rise (internationalunits/dL or % of normal) 0.5 (internationalunits/kg per international units/dL).For early hemarthrosis or minor muscle ororal bleeds: 10 to 20 international units/kgto achieve desired factor VIII rise of 20% to40% of normal, dosage repeated, if needed.For moderate bleeding into muscles, mildhead trauma, or bleeding into oral cavity:15 to 30 international units/kg to achievedesired factor VIII rise of 30% to 60% ofnormal with injections every 12 to 24 hruntil bleeding has resolved. For major GIbleeding; intracranial, intra-abdominal orintrathoracic bleeding; or fractures: Initialdose of 40 to 50 international units/kg followedby repeat dose of 20 to 25 internationalunits/kg to achieve desired factor VIIIrise of 60% to 100% of normal with injectionsof 20 to 25 international units/kgrepeated every 8 to 24 hr until bleeding hasresolved.I.V. INFUSION (XYNTHA)Adults and children. Highly individualizedbased on this formula: Body weight (kg) desired factor VIII rise (internationalunits/dL or % of normal) 0.5 (internationalunits/kg per international units/dL).For early hemarthrosis or minor muscle ororal bleeds: Desired factor VIII rise is 20%to 40% of normal with infusions every12 to 24 hr for at least 1 day, depending onthe severity of the bleeding episode. Formoderate bleeding into muscles, mild headtrauma, or bleeding into the oral cavity:Desired factor VIII rise is 30% to 60% ofnormal with infusions every 12 to 24 hr for3 to 4 days or until adequate local hemostasisis achieved. For major GI bleeding;intracranial, intra-abdominal, or intrathoracicbleeding; or fractures: Desired factorVIII rise is 60% to 100% of normal withinfusions every 8 to 24 hr until bleeding hasresolved. To treat spontaneous and traumainducedbleeding episodes and preventexcessive bleeding during and after surgeryin patients with von Willebranddisease when use of desmopressin isinadequateI.V. INJECTION (HUMATE-P)Adults and children. 40 to 80 internationalunits/kg every 8 to 12 hr as needed.A

92antihemophilic factor To prevent excessive bleeding during andafter surgery in patients with vonWillebrand diseaseI.V. INJECTION (HUMATE-P)Adults and children. Highly individualized.For emergency surgery: Loading dose of50 to 60 international uits/kg, followed byhalf the loading dose every 6 to 12 hr asneeded. For preplanned surgery: Individualizedloading dose based on patient need1 to 2 hr before surgery, followed by halfthe loading dose every 6 to 12 hr for at least12 hr (oral surgery), 48 hr (minor surgery),or 72 hr (major surgery).Route Onset Peak DurationI.V. Immediate 5 min UnknownMechanism of ActionProvides supplemental factor VIII, thecoagulation factor required for blood toclot that’s missing in patients with hemophiliaA and diminished in patients withfactor VIII inhibitors. After blood clots,bleeding stops.ContraindicationsLife-threatening, immediate hypersensitivityreactions, including anaphylaxis, experiencedwith prior administration of drug orexposure to mouse or hamster proteinsAdverse ReactionsCNS: Dizziness, fever, headache, rigidityCV: Chest pain, hypotensionEENT: Taste perversionENDO: Hot flashesGI: Abdominal pain, diarrhea, nausea, vomitingHEME: Bleeding tendency, decreased coagulationfactor VIII, decreased hematocrit,hematoma, hemolytic anemiaMS: Joint swelling, lower limb edemaRESP: Dyspnea, shortness of breathSKIN: Diaphoresis, pruritus, rash, urticariaOther: Anaphylaxis, angioedema, catheterrelatedinfection, injection site reactionsNursing Considerations• Check to confirm that clotting defect isfactor VIII deficiency (Kogenate FS orXyntha only) or von Willebrand disease(Humate-P only) before giving antihemophilicfactor (recombinant) because drugisn’t effective in treating other coagulationfactor deficiencies.• Reconstitute Advate or Alphanate usingsterile water for injection. Bring both drugand diluent to room temperature; thenclean stoppers with antiseptic solution andlet dry. Remove protective covering fromone end of double-ended needle andinsert through center of diluent stopper.Remove protective covering from otherend of double-ended needle. Invert diluentbottle over upright drug bottle; then rapidlyinsert free end of needle through drugstopper at center. The vacuum in bottlewill draw in the diluent. Then disconnectthe two bottles by removing needle fromdiluent bottle stopper, and remove theneedle from drug bottle. Swirl gently untilall drug is dissolved. Avoid shaking to preventfoaming and degradation of drug.Administer in a separate line within3 hours of reconstitution.• Reconstitute Humate-P, Kogenate FS, andXyntha according to manufacturerinstructions in package insert.• Take patient’s pulse before and periodicallyduring drug administration. If pulserate increases significantly, reduce administrationrate or temporarily halt injectionto let pulse rate return to preadministrationlevel before resuming administration.• To administer Advate or Alphanate, useonly plastic material because protein indrug will adhere to glass. Attach filter needleto syringe and draw back plunger todraw air into syringe. Insert needle intoreconstituted drug vial. Inject air into bottleand then withdraw drug from vial.Remove and discard filter needle fromsyringe, attach a suitable needle, and injectI.V. bolus at no more than 10 ml/min overno more than 5 minutes.• To give Humate-P, slowly inject I.V. bolusat no more than 4 ml/min using a venipunctureor other suitable I.V. injection set.• To give Kogenate FS, check patient’s pulse;then slowly inject intravenously over 1 to15 minutes, checking pulse rate throughoutadministration. If pulse rises significantly,slow administration or temporarilystop delivery to let pulse rate to return tonormal; then continue administration.• To administer Xyntha, slowly infuse intravenouslyover several minutes at a ratecomfortable for the patient. Don’t infuse

in tubing or container that contains otherdrugs.• Monitor patient’s plasma factor VIII levels(and von Willebrand factor: Ristocetincofactor if patient has von Willebrand disease)during and after treatment to ensureadequate levels have been reached and arebeing maintained, as ordered.• Monitor patient for anaphylaxis, and haveemergency equipment nearby.• After giving drug, monitor patient for formationof neutralizing antibodies to factorVIII, a known complication in hemophiliaA treatment that may cause continuedbleeding. Obtain laboratory analysis todetect neutralizing antibodies, as ordered.• Watch for hemolysis when giving largedoses to patients with blood types A, B,and AB.PATIENT TEACHING• Teach patient and caregivers how toadminister antihemophilic factor (recombinant)at home in an emergency.• Explain that drug may be stored in therefrigerator or at room temperature butthat it shouldn’t be exposed to temperaturesabove 77° F (25° C) or below freezingbecause they may alter effectiveness.• Instruct patient to stop drug and seekemergency help immediately if he has anacute allergic reaction, such as hives, chesttightness, wheezing, low blood pressure, orfainting, during or after administration.antithrombin III,human(AT-III, heparinco-factor I)ATnativ, Thrombate IIIClass and CategoryChemical class: Alpha 2 -globulinTherapeutic class: Anticoagulant,antithromboticPregnancy category: CIndications and Dosages To treat patients with hereditary antithrombinIII (AT-III) deficiency who areundergoing surgery or obstetric proceduresor who have thromboembolismantithrombin III, human 93I.V. INJECTIONAdults and children. Initial: Individualized(based on weight, degree of AT-III deficiency,and desired level of AT-III to be achieved)sufficient to increase AT-III activity to120% of normal, given at 50 to 100 internationalunits/min. Maintenance: Individualizeddosage sufficient to keep AT-III activityat 80% or more of normal, administeredevery 24 hr, continued for 2 to 8 days,depending on the patient’s condition andhistory and prescriber’s judgment. A pregnant,immobilized, or postsurgical patientmay need more prolonged therapy.Route Onset Peak DurationI.V. Immediate Unknown 4 daysMechanism of ActionInhibits blood coagulation by inactivatingthrombin; activated forms of factors IX, X,XI, and XII; and plasmin.InteractionsDRUGSheparin: Enhanced anticoagulant effectAdverse ReactionsCNS: Chills, dizziness, fever, light-headednessCV: Chest pain or tightness, hypotension,vasodilationEENT: Unpleasant tasteGI: Abdominal cramps, bowel fullness, nauseaGU: DiuresisHEME: HematomaRESP: DyspneaSKIN: Oozing lesions, urticariaNursing Considerations• Reconstitute AT-III with 10 ml sterilewater for injection (provided by manufacturer)or alternate solution, such as normalsaline solution or D 5 W injection.Don’t shake vial during reconstitution. Letsolution come to room temperature beforeadministration. If desired, dilute reconstitutedsolution further, using same diluent.WARNING Don’t use diluent that containsbenzyl alcohol to reconstitute drug for aneonate. It can cause a fatal toxic syndromewith metabolic acidosis, CNSdepression, respiratory problems, renalfailure, hypotension, seizures, andA

94apomorphine hydrochlorideintracranial hemorrhage.• Don’t refrigerate reconstituted solution.Use within 3 hours; discard unused portion.• Administer AT-III alone. Don’t mix it withother drugs or solutions.• If after 30 minutes the initial dose doesn’tincrease AT-III activity to 120% of normal,expect prescriber to increase dosage.• If patient requires a dosage increase, monitorAT-III activity more often and expectto adjust dosage accordingly.• To avoid bleeding, anticipate a reductionin heparin dosage during AT-III therapy.• If mild adverse reactions occur, decreaseinfusion rate, as prescribed. If severe reactionsoccur, discontinue infusion, as prescribed,until they subside.• Evaluate serum AT-III level twice dailyuntil dosage is stabilized. After that, evaluatelevel once daily, just before a dose.PATIENT TEACHING• Tell patient that blood will be drawn periodicallyto guide dosage adjustments.apomorphinehydrochlorideApokynClass and CategoryChemical class: Nonergoline dopamineagonistTherapeutic class: Hypomobilic antiparkinsonianPregnancy category: CIndications and Dosages To treat hypomobility “off” episodes(end-of-dose wearing off and unpredictableon/off episodes) in advancedParkinson’s diseaseSUBCUTANEOUS INJECTIONAdults. Initial: 0.2 ml (2 mg) p.r.n. adjustedas needed in 0.1-ml (1-mg) incrementsevery few days. Maximum: 0.6 ml (6 mg).DOSAGE ADJUSTMENT For patients who tolerate0.2 ml (2 mg) but have no response, a0.4-ml (4-mg) dose may be given undermedical supervision, with standing andsupine blood pressure checked every 20 minfor 1 hr at the next observed “off” period,as long as it is at least 2 hr after the initial0.2-ml (2-mg) test dose. If tolerated, a dose0.1 ml (1 mg) lower may be given p.r.n. andincreased in 0.1-ml (1-mg) incrementsevery few days as needed to a maximumdose of 0.6 ml (6 mg).If patient doesn’t tolerate a 0.4-ml (4-mg)test dose, a 0.3-ml (3-mg) test dose may begiven under medical supervision, withstanding and supine blood pressurechecked every 20 min for 1 hr at the nextobserved “off” period, as long as it is at least2 hr after the initial 0.4-ml (4-mg) testdose. If tolerated, a 0.2-ml (2-mg) dose canbe started p.r.n. and increased to no morethan 0.3 ml (3 mg) if needed after a fewdays.For patients with mild to moderaterenal impairment, the initial dose should bereduced to 0.1 ml (1 mg).Route Onset Peak DurationSubQ 10–60 min Unknown UnknownMechanism of ActionMay stimulate postsynaptic dopamine D 2receptors in the caudate-putamen of thebrain. As a result, apomorphine improvesmotor function and activity levels inpatients with Parkinson’s disease.ContraindicationsConcurrent use of 5-HT 3 antagonists, suchas alosetron, dolasetron, granisetron,ondansetron, and palonosetron; hypersensitivityto apomorphine or its components,including sodium metabisulfiteInteractionsDRUGS5-HT 3 antagonists: Increased risk of profoundhypotension and loss of consciousnessantihypertensives, vasodilators: Increasedrisk of serious adverse reactions, such ashypotension, MI, and bone or joint injuriesdopamine antagonists (such as butyrophenones,metoclopramide, phenothiazines,thioxanthenes): Decreased apomorphineeffectivenessdrugs that prolong QT interval: Increasedrisk of torsades de pointesentacapone, tolcapone: Increased risk oftachycardia, hypertension, and arrhythmiasACTIVITIESalcohol use: Increased risk of hypotension

Adverse ReactionsCNS: Aggravated Parkinson’s disease, anxiety,confusion, depression, dizziness,drowsiness, dyskinesia, euphoria, fatigue,hallucinations, headache, insomnia, somnolence,weakness, yawningCV: Angina, chest pain, congestive heartfailure, edema, MI, orthostatic hypotension,prolonged QT intervalEENT: RhinorrheaGI: Constipation, diarrhea, nausea, vomitingGU: UTIMS: Arthralgia, back or limb painRESP: Dyspnea, pneumonia, tachypneaSKIN: Contact dermatitis, diaphoresis,ecchymosis, flushing, pallorOther: Dehydration; injection site bruising,granuloma, or pruritus; intense urges toperform certain activities, such as gamblingand sexual actsNursing Considerations• Use apomorphine cautiously in patientswith hepatic or renal insufficiency.• An antiemetic, such as trimethobenzamide300 mg t.i.d., should be started 3 daysbefore apomorphine starts and continuefor at least the first 2 months of therapy.Apomorphine may cause severe nauseaand vomiting, even with an antiemetic.• Monitor patient’s blood pressure closelybecause drug can cause severe orthostatichypotension.• Give a 0.2-ml (2-mg) test dose of apomorphine,as prescribed, and then checkpatient’s supine and standing blood pressure20, 40, and 60 minutes later.• Monitor patient closely if he has anincreased risk of prolonged QT interval, asfrom hypokalemia, hypomagnesemia,bradycardia, use of certain drugs, orgenetic predisposition. QT-interval prolongationmay lead to torsades de pointes.• Monitor patient for evidence of apomorphineabuse. Although rare, drug maycause psychosexual stimulation andincreased libido, which may cause patientto use it more often than needed forreducing Parkinson’s disease symptoms.• Assess patient regularly for skin changesbecause melanoma risk is higher in thosewith Parkinson’s disease. It isn’t clearwhether the risk is increased by the diseaseor by its treatment.PATIENT TEACHING• Explain that an antiemetic will be prescribedstarting 3 days before first apomorphinedose. Urge patient to take theantiemetic exactly as prescribed. Explainthat it will be needed for 2 months orlonger during apomorphine therapy.• Explain that a test dose will determineresponse and drug’s effects on blood pressurebefore patient goes home with drug.• Teach patient how to use dosing pen andhow to give drug subcutaneously.• Emphasize that apomorphine doses areexpressed as milliliters, not milligrams.Tell patient to draw up each dose carefullyto reduce the chance of dosage error.• Instruct patient to rotate injection sites ina systematic manner.• Stress importance of taking apomorphineonly as prescribed because serious adversereactions may occur.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known. Inparticular, caution patient that apomorphineincreases the risk of falling asleepsuddenly, without feeling sleepy.• Urge patient to have regular skin examinationsby a dermatologist or other qualifiedhealth professional.• Instruct patient to notify prescriber aboutintense urges, such as for gambling or sex,because dosage may need to be reduced ordrug discontinued.aprepitantEmendfosaprepitantdimeglumineEmend for Injectionaprepitant 95Class and CategoryChemical class: Substance P/neurokinin 1(NK1) receptor antagonistTherapeutic class: AntiemeticPregnancy category: BIndications and Dosages To prevent acute and delayed nauseaand vomiting associated with highlyemetogenic chemotherapy, includinghigh-dose cisplatinA

96aprepitantCAPSULESAdults. 125 mg 1 hr before chemotherapytreatment, followed by 80 mg daily inmorning on next 2 days.I.V. INFUSIONAdults. 115 mg 30 min before chemotherapybegins (day 1 only). To prevent postoperative nausea andvomitingCAPSULESAdults. 40 mg within 3 hr before inductionof anesthesiaRoute Onset Peak DurationP.O., I.V. Unknown 4 hr UnknownMechanism of ActionCrosses the blood–brain barrier to occupybrain NK1 receptors, which prevents nervetransmission of signals that cause nauseaand vomiting.ContraindicationsHypersensitivity to aprepitant, polysorbate80, or their components; use of astemizole,cisapride, pimozide, or terfenadineInteractionsDRUGScarbamazepine, phenytoin, rifampin:Possibly decreased blood aprepitant levelcorticosteroids: Increased blood corticosteroidlevelCYP2C9 metabolizers (such as phenytoin,tolbutamide, and warfarin): Decreasedblood level and effectiveness of CYP2C9metabolizersCYP3A4 inhibitors (such as clarithromycin,diltiazem, itraconazole, ketoconazole, nefazodone,nelfinavir, and troleandomycin):Increased blood aprepitant levelCYP3A4 substrates (such as astemizole, benzodiazepines,cisapride, docetaxel, etoposide,ifosfamide, imatinib, irinotecan, paclitaxel,pimozide, terfenadine, vinblastine, vincristine,and vinorelbine): Increased level ofCYP3A4 substrates, resulting in possiblyserious or life-threatening adverse reactionsoral contraceptives: Possibly decreased effectivenessof oral contraceptivesparoxetine: Possibly decreased blood level ofboth drugsAdverse ReactionsCNS: Anxiety, asthenia, confusion, depression,dizziness, fatigue, fever, headache,insomnia, malaise, peripheral or sensoryneuropathy, somnolenceCV: Deep vein thrombosis, edema, hypertension,hypotension, tachycardiaEENT: Increased salivation, mucous membranealteration, nasal discharge, pharyngitis,stomatitis, taste perversion, tinnitus,vocal disturbanceENDO: Hot flashes, hyperglycemiaGI: Abdominal pain, anorexia, constipation,diarrhea, dysphagia, elevated liver functiontest results, epigastric discomfort, flatulence,gastritis, gastroesophageal reflux,heartburn, hiccups, nausea, obstipation,vomitingGU: Dysuria, elevated BUN and serum creatininelevels, hematuria, leukocyturia,renal insufficiencyHEME: Anemia, febrile neutropenia, leukocytosis,thrombocytopeniaMS: Muscle weakness, myalgia, pelvic painRESP: Cough, dyspnea, non–small-cell lungcarcinoma, pneumonitis, pulmonaryembolism, respiratory insufficiency, respiratorytract infectionSKIN: Alopecia, diaphoresis, flushing, pruritus,rash, urticariaOther: Anaphylaxis, angioedema, dehydration,hypokalemia, hyponatremia, infusionsite pain or induration, malignant neoplasm,septic shock, weight lossNursing Considerations• Use caution when giving aprepitant topatients with severe hepatic insufficiencybecause drug’s effects on such patientsaren’t known.• For maximum antiemetic effects, expect toadminister aprepitant with dexamethasoneand a 5-HT 3 antagonist, such asdolasetron, granisetron, or ondansetron.• Drug is given intravenously only as thefirst dose 30 minutes before chemotherapy.Later doses are given orally.• To reconstitute parental aprepitant, inject5 ml normal saline for injection along vialwall to prevent foaming. Swirl vial gently.Withdraw contents from vial and add toan infusion bag containing 110 ml normalsaline solution. Gently invert the bag twoor three times. Administer over 15 minutes.Reconstituted solution may be storedat room temperature for 24 hours.

PATIENT TEACHING• Instruct patient to take 125-mg dose oforal aprepitant 1 hour before chemotherapy,80-mg dose in the morning for 2 daysafter chemotherapy, or 40-mg dose within3 hours before induction of anesthesia.• Tell female patients taking oral contraceptivesto use an alternative or backupmethod of contraception during aprepitanttherapy and for 1 month after lastdose because drug reduces effectiveness oforal contraceptives.• Tell patient taking warfarin to have clottingstatus monitored closely for 2 weeksafter first aprepitant dose, especially every7 to 10 days during each chemotherapycycle in which the drug is used.• Caution patient to inform prescriber ofany drugs he’s taking, including OTCdrugs and herbal preparations, becausethey may interact with aprepitant.arformoterolBrovanaClass and CategoryChemical class: Selective beta 2 -adrenergicagonist, sympathomimeticTherapeutic class: BronchodilatorPregnancy category: CIndications and Dosages To provide maintenance treatment ofbronchoconstriction in patients withCOPD, including chronic bronchitis andemphysemaINHALATION SOLUTIONAdults. 15 mcg (contents of one 2-ml vial)b.i.d. (morning and evening) via nebulization.Do not exceed 30 mcg daily.Mechanism of ActionAttaches to beta 2 receptors on bronchial cellmembranes, stimulating the intracellularenzyme adenylate cyclase to convert adenosinetriphosphate to cyclic adenosinemonophosphate (cAMP). The resultingincrease in intracellular cAMP level relaxesbronchial smooth-muscle cells, stabilizesmast cells, and inhibits histamine release.ContraindicationsHypersensitivity to arformoterol, racemicarformoterol 97formoterol, or its components; acute bronchospasm;symptoms of COPDInteractionsDRUGSbeta blockers: Decreased effectiveness ofeither drugcorticosteroids, methylxanthines such asaminophylline or theophylline, non–potassium-sparing(such as loop and thiazide)diuretics: Increased risk of hypokalmiadrugs known to prolong the QT interval,MAO inhibitors, tricyclic antidepressants:Increased risk of life-threatening ventriculararrhythmiasthyroid hormones: Increased risk of coronaryinsufficiencyAdverse ReactionsCNS: Agitation, asthenia, circumoral paresthesia,fatigue, fever, headache, hypokinesia,insomnia, malaise, nervousness, paralysis,somnolence, stroke, tremorCV: Angina, arrhythmias, atrial flutter, chestpain, congestive heart failure, dizziness,heart block, hyperlipemia, hypertension,hypertension, MI, palpitations, peripheraledema, prolonged QT intervalEENT: Abnormal vision, dry mouth, glaucoma,herpes simplex or zoster, oral candidiasis,rectal hemorrhage, sinusitis, voicealterationENDO: Hyperglycemia, hypoglycemiaGI: Constipation, diarrhea, gastritis, melena,nausea, pelvic pain, retroperitonealhemorrhage, vomitingGU: Cystitis, hematuria, nocturia, PSA elevation,pyuria, renal calculiHEME: LeukocytosisMS: Arthralgia, arthritis, back pain, leg ormuscle cramps, neck rigidityRESP: Bronchitis, bronchospasm, COPD,pulmonary congestionSKIN: Discoloration, dryness, hypertrophy,photosensitivity, rash, urticariaOther: Anaphylaxis, angioedema, dehyrdation,flulike syndrome, gout, hyperkalemia,hypokalemia, metabolic acidosisNursing Considerations• Use cautiously in patients with cardiovasculardisorders, especially insufficiency,cardiac arrhythmias, and hypertension;convulsive disorders; thyrotoxicosis; andunusual sensitivity to sympathomimeticA

98argatrobanamines because arformoterol may causesignificant adverse effects.• Arformoterol shouldn’t be used to relievebronchospasm quickly because of its prolongedonset of action. Patients alreadytaking the drug twice daily shouldn’t takeadditional doses for exercise-inducedbronchospasm.• Arformoterol shouldn’t be used with otherinhaled, long-acting beta 2 -agonists or withother medications containing long-actingbeta 2 -agonists.WARNING Asthma-related deaths mayincrease in patients receiving salmeterol, adrug in the same class as arformoterol.Monitor patient closely, and notify prescriberimmediately of any changes inpatient’s respiratory status.• Watch for arrhythmias and changes inheart rate or blood pressure after use inpatients with cardiovascular disordersbecause of drug’s beta-adrengeric effects.WARNING Stop arformoterol immediatelyand notify prescriber if patient developsparadoxical bronchospasm or an allergicreaction.• Monitor patient’s blood glucose level,especially if diabetic, and plasma potassiumlevel, as ordered, because arformoterolmay cause significant changes.PATIENT TEACHING• Advise patient to take doses 12 hoursapart, morning and evening, for optimumeffect. Caution against using drug morethan every 12 hours.• Teach patient to self-administer drug witha standard jet nebulizer connected to anair compressor and to use vial immediatelyafter removing from foil package.• Caution patient not to swallow solution.• Tell patient to return unused vials topouch and store arformoterol in therefrigerator.• Instruct patient taking inhaled, shortactingbeta 2 -agonists on a regular basis todiscontinue regular use of these drugs andto use them only for symptomatic relief ofacute respiratory symptoms.• Instruct patient to notify prescriber if heneeds four or more oral inhalations ofrapid-acting inhaled bronchodilator a dayfor 2 or more consecutive days, or if heuses more than one canister of rapid-actingbronchodilator in an 8-week period.argatrobanAcovaClass and CategoryChemical class: N2-substituted derivative ofarginineTherapeutic class: AnticoagulantPregnancy category: BIndications and Dosages To prevent or treat thrombosis inpatients with heparin-induced thrombocytopenia(HIT)I.V. INFUSIONAdults. 2 mcg/kg/min as a continuous infusion.Maximum: 10 mcg/kg/min.DOSAGE ADJUSTMENT Dosage adjusted asprescribed to maintain patient’s APTT at1.5 to 3 times the initial baseline value, notto exceed 100 sec. Initial dosage reduced to0.5 mcg/kg/min for patients with moderatehepatic impairment. To prevent or treat thrombosis inpatients with or at risk for HIT whenundergoing percutaneous coronaryintervention (PCI)I.V. INFUSIONAdults. Initial: 350 mcg/kg over 3 to 5 minfollowed by continuous infusion of 25 mcg/kg/min.DOSAGE ADJUSTMENT Dosage adjusted asprescribed to keep activated clotting time(ACT) at 300 to 450 sec. If ACT is less than300 sec, give additional I.V. bolus dose of150 mcg/kg and increase infusion to30 mcg/kg/min; if ACT exceeds 450 sec,reduce dosage to 15 mcg/kg/min. For dissection,impending abrupt closure, thrombusformation during PCI, or inability toreach or keep ACT above 300 sec, give additionalbolus dose of 150 mcg/kg andincrease infusion to 40 mcg/kg/min.Route Onset Peak DurationI.V. Immediate 3–4 hr UnknownMechanism of ActionForms a tight bond with thrombin, neutralizingthis enzyme’s actions, even when theenzyme is trapped within clots. Thrombincauses fibrinogen to convert to fibrin,which is essential for clot formation.

ContraindicationsActive major bleeding, hypersensitivity toargatroban or its componentsInteractionsDRUGSalteplase, antineoplastic drugs, antiplatelets,antithymocyte globulin, heparin, NSAIDs,reteplase, salicylates, streptokinase, strontiumchloride Sr 89, warfarin: Increased risk ofbleedingporfimer: Possibly decreased efficacy of porfimerphotodynamic therapyAdverse ReactionsCNS: Cerebrovascular bleeding, fever, headacheCV: Atrial fibrillation, cardiac arrest, hypotension,unstable angina, ventricular tachycardiaGI: Abdominal pain, anorexia, diarrhea,elevated liver function test results, GI bleeding,melena, nausea, vomitingGU: Elevated BUN and serum creatininelevels, hematuria (microscopic), UTIHEME: Hypoprothrombinemia, unusualbleeding or bruisingRESP: Cough, dyspnea, hemoptysis, pneumoniaSKIN: Bleeding at puncture site, rashOther: SepsisNursing ConsiderationsWARNING Argatroban isn’t recommendedfor PCI patients with significant hepaticdisease or AST/ALT levels three times ormore the upper limits of normal.• Reconstitute drug to 1 mg/ml before giving.• Protect solution from direct sunlight.WARNING Monitor patients with thrombocytopeniaor those receiving daily doses ofsalicylates greater than 6 g for signs andsymptoms of bleeding because they’re atincreased risk of bleeding from hypoprothrombinemia.WARNING Expect to perform blood coagulationtests before and 2 hours after startof therapy because of the major risk ofbleeding associated with argatroban. Beaware that coagulopathy must be ruled outbefore therapy starts. When giving drug toa patient undergoing PCI, expect to checkACT 5 to 10 minutes after each bolus andeach infusion rate change and every 20 to30 minutes during the PCI.• Monitor the following patients for signsand symptoms of bleeding because they’reat increased risk during argatroban therapy:women with active menstruation;patients with vascular or organ abnormalities,such as severe uncontrolled hypertension,advanced renal disease, infectiveendocarditis, dissecting aortic aneurysm,diverticulitis, hemophilia, hepatic disease(especially if associated with a deficiencyof vitamin K–dependent clotting factors),inflammatory bowel disease, or pepticulcer disease; and those who have recentlyhad a stroke, major surgery (including eye,brain, or spinal cord surgery), large vesselpuncture or organ biopsy, lumbar puncture,spinal anesthesia, or major bleeding(including intracranial, GI, intraocular,retroperitoneal, or pulmonary bleeding).• Whenever possible, avoid I.M. injectionsin patients receiving argatroban todecrease the risk of bleeding.• Thrombin times may not be helpful formonitoring argatroban activity becausethe drug affects all thrombin-dependentcoagulation tests.• Expect dosage to be tapered before stoppingto prevent the risk of rebound hypercoagulopathy;drug’s effects last only ashort time once drug is discontinued.PATIENT TEACHING• Inform patient that argatroban is a bloodthinner that’s given in the hospital byinfusion into a vein. If he needs long-termanticoagulation, he’ll be switched toanother drug before discharge.• Advise patient to immediately reportunusual or unexplained bleeding, such asblood in urine, easy bruising, nosebleeds,tarry stools, and vaginal bleeding.• Instruct patient to avoid injury whilereceiving argatroban. For example, suggestthat he brush his teeth gently, using a softbristledtoothbrush, and take special carewhen flossing.aripiprazoleAbilify, Abilify Discmeltaripiprazole 99Class and CategoryChemical class: DihydrocarbostyrilTherapeutic class: Atypical antipsychoticPregnancy category: CA

100Adverse ReactionsCNS: Abnormal gait, agitation, akathisia,anxiety, asthenia, cognitive and motorimpairment, confusion, delusions, depression,dizziness, dream disturbances, dystonia,extrapyramidal reactions, fatigue, fever,hallucinations, headache, hostility, insomnia,intracranial hemorrhage, lethargy,light-headedness, mania, nervousness, neurolepticmalignant syndrome, paranoia,restlessness, schizophrenic reaction,seizures, somnolence, stroke (elderly), suicidalideation, tardive dyskinesia, transientischemic attack (elderly), tremorCV: Arrhythmias, bradycardia, cardiopulmonaryarrest, chest pain, circulatory collapse,deep vein thrombosis, elevated serumCK levels, heart failure, hypertension, MI,orthostatic hypotension, peripheral edema,prolonged QT interval, tachycardiaEENT: Blurred vision, conjunctivitis, drymouth, hepatitis, increased salivation,laryngospasm, nasopharyngitis, oropharyngealspasm, pharyngitis, rhinitis, sinusitisENDO: HyperglycemiaGI: Abdominal discomfort, constipation,decreased appetite, diarrhea, difficulty swalaripiprazoleIndications and Dosages To treat acute schizophrenia; to maintainstability in patients with schizophreniaORAL SOLUTION, ORALLY DISINTEGRATINGTABLETS, TABLETSAdults. Initial: 10 or 15 mg daily. Increasedto 30 mg daily, as needed, with dosageadjustments at 2-wk intervals. Maintenance:15 mg daily. To treat acute manic and mixed episodesin bipolar I disorder with or withoutpsychotic features; to maintain stabilityin patients with bipolar I disorder; asadjunct with lithium or valproate inpatients with bipolar I disorderORAL SOLUTION, ORALLY DISINTEGRATINGTABLETS, TABLETSAdults. Initial: 15 mg daily, increased to30 mg daily, as needed. Maintenance: 15 to30 mg daily. Maximum: 30 mg daily.Children ages 10 to 17. Initial: 2 mg daily,increased after 2 days to 5 mg daily andthen after 2 days to 10 mg daily. Increasedin 5-mg increments, as needed, at 2-wkintervals. Maintenance: Lowest dose possibleto maintain remission. Maximum:30 mg daily. As adjunct to treat depression in patientsalready taking an antidepressantORAL SOLUTION, ORALLY DISINTEGRATINGTABLETS, TABLETSAdults. Initial: 2 to 5 mg daily, with dosageincreased to 5 mg daily at 1-wk intervals. To treat agitation in schizophrenia orbipolar maniaI.M. INJECTIONAdults. Initial: Depending on severity ofagitation, 5.25 to 15 mg. May be repeated2 or more hr later, as needed. Maximum:30 mg daily. To treat irritability associated withautistic disorderORAL SOLUTION, ORALLY DISINTEGRATINGTABLETS, TABLETSChildren. Initial: 2 mg daily, with dosageincreased after 1 wk to 5 mg daily and thenafter 1 wk to 10 mg daily and then after1 wk to 15 mg daily, as needed.DOSAGE ADJUSTMENT Dosage reduced tohalf normal amount when given with clarithromycin,fluoxetine, itraconazole, ketoconazole,paroxetine, or quinidine. Dosagedoubled when given with carbamazepine.Mechanism of ActionMay produce antipsychotic effects throughpartial agonist and antagonist actions.Aripiprazole acts as a partial agonist atdopamine (especially D 2 ) receptors andserotonin (especially 5-HT 1A ) receptors.The drug acts as an antagonist at 5-HT 2Aserotonin receptor sites.ContraindicationsBreast-feeding, hypersensitivity to aripiprazoleor its componentsInteractionsDRUGSanticholingerics: Increased risk for potentiallyfatal elevation of body temperaturecarbamazepine and other CYP3A4 inducers:Possibly increased clearance and decreasedblood level of aripiprazoleclarithromycin, fluoxetine, paroxetine, quinidine,and other CYP2D6 inhibitors; ketoconazoleand other CYP3A4 inhibitors:Possibly inhibited aripiprazole eliminationand increased blood levelCNS depressants: Increased CNS depressionACTIVITIESalcohol use: Increased CNS depression

lowing, GI bleeding, indigestion, jaundice,nausea, vomitingGU: Renal failure, urinary incontinenceHEME: Agranulocytosis, anemia, leukopenia,neutropenia, thrombocytopeniaMS: Arthralgia, elevated blood CK level,muscle spasms, muscleskeletal pain, myalgia,neck and limb rigidity, rhabdomyolysisRESP: Apnea, aspiration, asthma, cough,dyspnea, pneumonia, pulmonary edema orembolism, respiratory failureSKIN: Diaphoresis, dry skin, ecchymosis,pruritus, rash, ulceration, urticariaOther: Anaphylaxis, angioedema, dehydration,flulike symptoms, heat stroke, weightgainaripiprazole 101Nursing Considerations• Aripiprazole shouldn’t be used to treatdementia-related psychosis in the elderlybecause of an increased risk of death.• Use cautiously in patients with CV disease,cerebrovascular disease, or conditions thatwould predispose them to hypotension.Also use cautiously in those with a historyof seizures or with conditions that lowerthe seizure threshold, such as Alzheimer’sdisease.• Also use cautiously in elderly patientsbecause of increased risk of seriousadverse cerebrovascular effects, such asstroke and transient ischemic attack.• Oral solution may be given on a milligram-per-milligrambasis in place oftablets up to 25 mg. For example, ifpatient needs 30 mg of tablet and isswitched to oral solution, expect to give25 mg of solution.• Inject parenteral form slowly, deep intothe muscle, and never I.V. or subcutaneously.• Monitor patient for difficulty swallowingor excessive somnolence, which could predisposeto accidental injury or aspiration.WARNING Aripiprazole rarely may causeneuroleptic malignant syndrome, tardivedyskinesia, and seizures. Monitor patientclosely throughout therapy, and take safetyprecautions as needed.• Monitor patient’s blood glucose level routinely;risk of hyperglycemia may increase.• Watch patients closely (especially children,adolescents, and young adults) for suicidaltendencies, particularly when therapystarts and dosage changes, because depressionmay worsen temporarily during thesetimes.• Monitor patient’s CBC, as ordered,because serious adverse hematologic reactionsmay occur, such as agranulocytosis,leukopenia, and neutropenia. Assess moreoften during first few months of therapy ifpatient has a history of drug-inducedleukopenia or neutropenia or a significantlylow WBC count. If abnormalitiesoccur during therapy, watch for fever orother signs of infection, notify prescriberand, if severre, expect drug to be stopped.PATIENT TEACHING• Instruct patient prescribed orally disintegratingtablets to open the blister packonly when ready to take the tablet. Tellhim to peel back the foil and not to pushtablet through the foil because doing socould damage the tablet. Tell him to placethe tablet on his tongue without breakingit and let it dissolve. If needed, he maytake a drink.• Advise patient to get up slowly from alying or sitting position during aripiprazoletherapy to minimize orthostatichypotension.• Urge patient to avoid alcohol during aripiprazoletherapy.• Instruct patient to avoid hazardous activitiesuntil drug’s effects are known.• Urge patient to avoid activities that raisebody temperature suddenly, such as strenuousexercise and exposure to extremeheat, and to compensate for situations thatcause dehydration, such as vomiting ordiarrhea.• Instruct patient to inform all prescribersof any drugs he’s taking, including OTCdrugs, because of risk of interactions.• Advise female patient of childbearing ageto notify prescriber if she intends tobecome or suspects that she is pregnantduring therapy.• Instruct diabetic patient taking the oralsolution to monitor blood glucose levelsclosely because each milliliter of solutioncontains 400 mg of sucrose and 200 mg offructose.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes andparticularly if patient is a child, teenager,or young adult.A

102Adverse ReactionsCNS: Agitation, anxiety, attention disturbance,depression, dizziness, fatigue, fever,headache (including migraine), insomnia,nervousness, paresthesia, suicidal ideation,thirst, tremorCV: Increased heart rate, palpitationsEENT: Dry mouthGI: Abdominal pain (upper), anorexia, conarmodafinilarmodafinilNuvigilClass and CategoryChemical class: Diphenylmethyl sulfinylacetamideTherapeutic class: CNS stimulantPregnancy category: CIndications and Dosages To treat narcolepsy or as adjunct tostandard therapy for excessive daytimesleepiness in obstructive sleep apnea/hypopnea syndromeTABLETSAdults. 150 or 250 mg once daily in themorning. To improve daytime wakefulness inpatients with excessive sleepiness fromcircadian rhythm disruption (shift-worksleep disorder)TABLETSAdults. 150 mg once daily about 1 hr beforestart of work shift.DOSAGE ADJUSTMENT Decreased dosage recommendedfor patients who are elderly,have severe hepatic impairment, or takesteroidal contraceptives.Route Onset Peak DurationP.O. Unknown 2 hr Unknown(fasting)4–6 hr(with food)Mechanism of ActionMay produce CNS-stimulant effects bybinding to dopamine transporter in thebrain and inhibiting dopamine reuptake inlimbic regions. These actions increase alertnessand reduce drowsiness and fatigue.ContraindicationsHypersensitivity to armodafinil, modafinil,or their componentsInteractionsDRUGSamitriptyline, citalopram, clomipramine,diazepam, imipramine, propranolol, tolbutamide,topiramate: Possibly prolongedelimination time and increased blood levelsof these drugsbarbiturates (such as phenobarbital, primidone),dexamethasone, rifabutin, rifampin:Possibly decreased blood level and effectivenessof armodafinilcarbamazepine: Possibly decreasedarmodafinil effectiveness and decreasedblood carbamazepine levelcimetidine, clarithromycin, erythromycin,fluconazole, fluoxetine, fluvoxamine, itraconazole,ketoconazole, nefazodone, sertraline:Possibly inhibited metabolism,decreased clearance, and increased bloodlevel of armodafinilclozapine: Possibly increased levels of clozapinecaused by decreased secondary hepaticmetabolismcontraceptive-containing implants or devices:Possibly contraceptive failurecyclosporine: Possibly decreased bloodcyclosporine level and increased risk oforgan transplant rejectiondextroamphetamine, methylphenidate:Possibly 1-hr delay in armodafinil absorptionwhen these drugs are given togetherfosphenytoin, mephenytoin, phenytoin:Possibly decreased effectiveness ofarmodafinil, increased blood phenytoinlevel, and increased risk of phenytoin toxicitymidazolam, triazolam: Possibly decreasedeffectiveness of triazolam or midazolamoral contraceptives: Possibly decreased effectivenessof oral contraceptivetheophylline: Possibly decreased blood leveland effectiveness of theophyllinewarfarin: Possibly decreased warfarinmetabolism and increased risk of bleedingFOODSalcohol use: Possibly adverse CNS effectsall foods: 2- to 4-hr delay for armodafinil toreach peak levels and possibly delayed onsetof actioncaffeine: Increased CNS stimulationgrapefruit juice: Possibly decreasedarmodafinil metabolism

stipation, decreased appetite, diarrhea, dyspepsia,loose stools, nausea, vomitingGU: PolyuriaRESP: DyspneaSKIN: Contact dermatitis, hyperhydrosis,rashOther: Angioedema, flulike illnessNursing Considerations• Armodafinil shouldn’t be given to patientswith mitral valve prolapse syndrome or ahistory of left ventricular hypertrophybecause drug may cause ischemic changes.WARNING If patient has a history of alcoholism,stimulant abuse, or other substanceabuse, ensure compliance witharmodafinil therapy. Watch for signs ofmisuse or abuse, including frequent prescriptionrefill requests, increased frequencyof dosing, and drug-seeking behavior.Also watch for evidence of excessivearmodafinil use, including agitation, anxiety,diarrhea, nausea, nervousness, palpitations,sleep disturbances, and tremor.• Be aware that armodafinil, like other CNSstimulants, may alter mood, perception,thinking, judgment, feelings, and motorskills and may produce signs that patientneeds sleep.• If giving drug to patient with a history ofpsychosis, emotional instability, or psychologicalillness with psychotic features, beprepared for baseline behavioral assessmentor frequent clinical observation.PATIENT TEACHING• Inform patient that armodafinil can help,but not cure, narcolepsy and that drug’sfull effects may not be seen right away.• Advise patient to avoid taking armodafinilwithin 2 hours of eating because food maydelay time to peak drug effect and onset ofaction. If patient drinks grapefruit juice,encourage him to drink a consistentamount daily.• Inform patient that drug can affect hisconcentration and ability to function andcan hide signs of fatigue. Urge him not todrive or perform activities that requiremental alertness until drug’s full CNSeffects are known.• Because alcohol may decrease alertness,advise patient to avoid it with armodafinil.• Encourage a regular sleeping pattern.• Caution patient to avoid excessive intakeof foods, beverages, and OTC drugs thatcontain caffeine because caffeine may leadto increased CNS stimulation.• Inform woman that armodafinil candecrease effectiveness of certain contraceptives,including birth control pills andimplantable hormonal contraceptives. Ifshe uses such contraceptives, urge her touse an alternate birth control method duringarmodafinil therapy and for up to1 month after it stops.• Advise patient to keep follow-up appointmentswith prescriber so that her progresscan be monitored.asenapineSaphrisasenapine 103Class and CategoryChemical: Dibenzo-oxepino pyrroleTherapeutic: Second-generation antipsychotic,atypical antipsychoticPregnancy category: CIndications and Dosages To treat schizophreniaSUBLINGUAL TABLETSAdults. 5 mg twice daily. To treat manic or mixed episodesassociated with bipolar I disorderSUBLINGUAL TABLETSAdults. 10 mg twice daily.DOSAGE ADJUSTMENT Dosage may bedecreased to 5 mg twice daily if adversereactions occur.Route Onset Peak DurationP.O. Unknown 30–90 min UnknownMechanism of ActionMay produce antipsychotic effects throughantagonist actions at dopamine receptors,especially D 2 , and serotonin receptors, especially5-HT 2A .ContraindicationsHypersensitivity to asenapine or its componentsInteractionsDRUGSantihypertensives, CNS depressants: Possiblyenhanced effectsclass I A and III antiarrhythmics, gatifloxacin,moxifloxacin, other antipsychoticA

104Ancasal (CAN), Apo-As (CAN), Apo-ASEN (CAN), Arthrinol (CAN), Arthrisin(CAN), Aspergum, Aspirin, Atria S.R.(CAN), Bayer, Easprin, Ecotrin, EcotrinMaximum Strength, 8-Hour BayerTime Release, Empirin, Genprin,Maximum Bayer, Norwich Extraaspirindrugs: Increased risk of prolonged QTintervalparoxetine: Possibly increased paroxetineeffectACTIVITIESalcohol use: Possibly enhanced effectAdverse ReactionsCNS: Akathisia, anxiety, depression, dizziness,dystonia, dyskinesia, extrapyramidalsymptoms, fatigue, gait disturbance, hyperkinesias,insomnia, irritability, maskedfacies, parkinsonism, seizures, somnolence,syncope, tardive dyskinesia, torticollis,tremorCV: Hypertension, orthostatic hypotension,prolonged QT intervalEENT: Blepharospasm, dry mouth, oralhypoesthesia, salivary hypersecretion,toothacheENDO: Hyperglycemia, hyperprolactinemiaGI: Constipation, dyspepsia, increasedappetite, stomach discomfort, vomitingHEME: Anemia, leukopenia, neutropenia,thrombocytopeniaMS: Arthralgia, extremity pain, musclerigidityOther: Hyponatremia, weight gainNursing Considerations• Asenapine should be avoided in patientswith a history of cardiac arrhythmias; conditionsthat might prolong the QT interval,such as bradycardia, hypokalemia, orhypomagnesemia; or congenital QT-intervalprolongation because of increased riskof torsades de pointes or sudden death.• Asenapine shouldn’t be used for dementia-relatedpsychosis in elderly patientsbecause of an increased risk of death.• Use cautiously in patients with mild tomoderate hepatic impairment. Asenapineisn’t recommended in patients with severehepatic impairment (Child-Pugh Class C).• Use cautiously in patients with a history ofseizures or who have conditions that maylower the seizure threshold, such asAlzheimer’s dementia, because drugincreases risk of seizures in these patients.• Monitor patients with diabetes mellitusfor increased blood glucose levels.WARNING Asenapine rarely may cause neurolepticmalignant syndrome or tardivedyskinesia. Monitor patient closelythroughout therapy, and take safety precautionsas needed. Expect to stop drug ifany of these adverse effects occur.• Monitor patient’s CBC regularly, asordered. Notify prescriber of any changebecause drug may need to be stopped.• Monitor patient for trouble swallowing orexcessive somnolence, which could predisposehim to injury or aspiration.PATIENT TEACHING• Tell patient to remove tablet from packageonly when ready to take it and to use dryhands. Tell him to firmly press and holdthumb button, and then pull out tabletpack from case. Then, he should peel backthe colored tab, being careful not to pushtablet through the tab because doing socould damage tablet. Instruct patient toplace tablet under his tongue and let it dissolvecompletely. Tell him to then slidetablet pack back into case until it clicks.• Caution patient not to crush, chew orswallow tablets.• Advise him not to eat or drink for at least10 minutes after taking asenapine.• Urge patient to avoid alcohol while takingasenapine.• Instruct diabetic patient taking asenapineto monitor blood glucose levels closelybecause hyperglycemia may occur.• Advise patient to get up slowly from lyingor sitting position during asenapine therapyto minimize orthostatic hypotension.• Caution patient to avoid hazardous activitiesuntil drug’s effects are known.• Urge patient to avoid activities that raisebody temperature suddenly, such as strenuousexercise and exposure to extremeheat, and to compensate for situations thatcause dehydration, such as vomiting ordiarrhea.aspirin(acetylsalicylic acid,ASA)

Strength, Novasen (CAN), Sal-Adult(CAN), Sal-Infant (CAN), St. JosephChildren’s, Supasa (CAN), TherapyBayer, ZORprinClass and CategoryChemical class: SalicylateTherapeutic class: Anti-inflammatory,antiplatelet, antipyretic, nonopioid analgesicPregnancy category: DIndications and Dosages To relieve mild pain or feverCHEWABLE TABLETS, CHEWING GUM, CONTROLLED-RELEASE TABLETS, ENTERIC-COATED TABLETS,SOLUTION, TABLETS, TIMED-RELEASE TABLETS,SUPPOSITORIESAdults and adolescents. 325 to 650 mgevery 4 hr, p.r.n., or 500 mg every 3 hr,p.r.n., or 1,000 mg every 6 hr, p.r.n.Children ages 2 to 14. 10 to 15 mg/kg/doseevery 4 hr, p.r.n., up to 80 mg/kg daily. To relieve mild to moderate pain frominflammation, as in rheumatoid arthritisand osteoarthritisCHEWABLE TABLETS, CHEWING GUM, CONTROLLED-RELEASE TABLETS, ENTERIC-COATED TABLETS,SOLUTION, TABLETS, TIMED-RELEASE TABLETS,SUPPOSITORIESAdults and adolescents. 3.2 to 6 g daily individed doses. Maximum: 6 g daily.Children. 10 to 15 mg/kg daily, up to 80 mg/kg daily, in divided doses every 4 to 6 hr. To treat juvenile rheumatoid arthritisCHEWABLE TABLETS, CHEWING GUM, CONTROLLED-RELEASE TABLETS, ENTERIC-COATED TABLETS,SOLUTION, TABLETS, TIMED-RELEASE TABLETS,SUPPOSITORIESChildren. 60 to 110 mg/kg daily in divideddoses every 6 to 8 hr. To treat acute rheumatic feverCHEWABLE TABLETS, CHEWING GUM, CONTROLLED-RELEASE TABLETS, ENTERIC-COATED TABLETS,SOLUTION, TABLETS, TIMED-RELEASE TABLETS,SUPPOSITORIESAdults and adolescents. 5 to 8 g daily individed doses.Children. Initial: 100 mg/kg daily in divideddoses for first 2 wk. Maintenance: 75 mg/kg/day in divided doses for next 4 to 6 wk. To reduce the risk of recurrent transientischemic attacks or stroke in menCHEWABLE TABLETS, CHEWING GUM, CONTROLLED-aspirin 105RELEASE TABLETS, ENTERIC-COATED TABLETS,SOLUTION, TABLETS, TIMED-RELEASE TABLETS,SUPPOSITORIESAdults. 650 mg b.i.d. or 325 mg q.i.d. To reduce the severity of or preventacute MICHEWABLE TABLETS, CHEWING GUM, CONTROLLED-RELEASE TABLETS, ENTERIC-COATED TABLETS,SOLUTION, TABLETS, TIMED-RELEASE TABLETS,SUPPOSITORIESAdults. Initial: 160 to 162.5 mg (half of a325-mg tablet or two 80- or 81-mg tablets)as soon as MI is suspected. Maintenance:160 to 162.5 mg daily for 30 days. To reduce risk of MI in patients withprevious MI or unstable anginaCHEWABLE TABLETS, CHEWING GUM, CONTROLLED-RELEASE TABLETS, ENTERIC-COATED TABLETS,SOLUTION, TABLETS, TIMED-RELEASE TABLETS,SUPPOSITORIESAdults. 325 mg daily.Route Onset Peak DurationP.O. Rapid Unknown 1–4 hr(chewabletablets)P.O. 5–30 1–4 hr 4–6 hr(controlled-minrelease)P.O. 5–30 Unknown 1–4 hr(enteric- mincoated)P.O. 5–30 15–40 1–4 hr(solution) min minP.O. 15–30 1–2 hr 4 –6 hr(tablets) minP.O. 5–30 1–4 hr 4–6 hr(timed- minrelease)P.R. Unknown Unknown 4–6 hrMechanism of ActionBlocks the activity of cyclooxygenase, theenzyme needed for prostaglandin synthesis.Prostaglandins, important mediators in theinflammatory response, cause local vasodilationwith swelling and pain. With blockingof cyclooxygenase and inhibition ofprostaglandins, inflammatory symptomssubside. Pain is also relieved becauseprostaglandins play a role in pain transmissionfrom the periphery to the spinal cord.A

106atenololAspirin inhibits platelet aggregation byinterfering with production of thromboxaneA 2 , a substance that stimulates plateletaggregation. Aspirin acts on the heatregulatingcenter in the hypothalamus andcauses peripheral vasodilation, diaphoresis,and heat loss.ContraindicationsAllergy to tartrazine dye, asthma, bleedingproblems (such as hemophilia), hypersensitivityto aspirin or its components, pepticulcer diseaseInteractionsDRUGSACE inhibitors: Decreased antihypertensiveeffectactivated charcoal: Decreased aspirinabsorptionantacids, urine alkalinizers: Decreasedaspirin effectivenessanticoagulants: Increased risk of bleeding;prolonged bleeding timecarbonic anhydrase inhibitors: Salicylismcorticosteroids: Increased excretion anddecreased blood level of aspirinheparin: Increased risk of bleedingibuprofen: Possibly reduced cardioprotectiveand stroke preventive effects of aspirinmethotrexate: Increased blood level anddecreased excretion of methotrexate, causingtoxicitynizatidine: Increased blood aspirin levelNSAIDs: Possibly decreased blood NSAIDlevel and increased risk of adverse GI effectssulfonylureas: Possibly enhanced effect ofsulfonylureas with large doses of aspirinurine acidifiers (such as ammonium chloride,ascorbic acid): Decreased aspirin excretionvancomycin: Increased risk of ototoxicityACTIVITIESalcohol use: Increased risk of ulcersAdverse ReactionsCNS: Confusion, CNS depressionEENT: Hearing loss, tinnitusGI: Diarrhea, GI bleeding, heartburn, hepatotoxicity,nausea, stomach pain, vomitingHEME: Decreased blood iron level,leukopenia, prolonged bleeding time, shortenedlife span of RBCs, thrombocytopeniaSKIN: Ecchymosis, rash, urticariaOther: Angioedema, Reye’s syndrome, salicylism(dizziness, tinnitus, difficulty hearing,vomiting, diarrhea, confusion, CNSdepression, diaphoresis, headache, hyperventilation,and lassitude) with regular useof large dosesNursing Considerations• Don’t crush timed-release or controlledreleaseaspirin tablets unless directed.• Ask about tinnitus. This reaction usuallyoccurs when blood aspirin level reaches orexceeds maximum for therapeutic effect.PATIENT TEACHINGWARNING Advise parents not to give aspirinto a child or adolescent with chickenpoxor flu symptoms because of risk of Reye’ssyndrome (rare life-threatening reactioncharacterized by vomiting, lethargy, belligerence,delirium, and coma). Tell themto consult prescriber for alternative drugs.• Advise adult patient taking low-doseaspirin not to also take ibuprofen becauseit may reduce the cardioprotective andstroke preventive effects of aspirin.• Instruct patient to take aspirin with foodor after meals because it may cause GIupset if taken on an empty stomach.• Advise patient with tartrazine allergy notto take aspirin.• Tell patient to consult prescriber beforetaking aspirin with any prescription drugfor blood disorder, diabetes, gout, orarthritis.• Tell patient not to use aspirin if it has astrong vinegar-like odor.atenololApo-Atenol (CAN), Novo-Atenol ( CAN),TenorminClass and CategoryChemical class: Beta-adrenergic blocker(beta 1 and at high doses beta 2 )Therapeutic class: Antianginal, antihypertensivePregnancy category: DIndications and Dosages To treat angina pectoris and controlhypertensionTABLETSAdults. 50 mg daily increased, p.r.n., after1 to 2 wk to 100 mg daily. To treat acute MI

TABLETS, I.V. INFUSIONAdults. Initial: 5 mg I.V. over 5 min followedby 5 mg I.V. 10 min later. Afteranother 10 min, 50 mg given and followedby another 50 mg in 12 hr. Maintenance:50 mg P.O. b.i.d. or 100 mg P.O. daily for 6to 9 days or until discharged from hospital.DOSAGE ADJUSTMENT Dosage reduced to50 mg daily P.O. for renally impairedpatients and for elderly, renally impairedpatients with creatinine clearance of 15 to35 ml/min/1.73 m 2 . Dosage reduced to25 mg daily P.O. for renally impairedpatients and for elderly, renally impairedpatients with creatinine clearance less than15 ml/min/1.73 m 2 .Route Onset Peak DurationP.O. 1 hr 2–4 hr 24 hrI.V. Immediate 5 min 12 hrMechanism of ActionInhibits stimulation of beta 1 -receptor sites,located mainly in the heart, decreasing cardiacexcitability, cardiac output, and myocardialoxygen demand. Atenolol also actsto decrease release of renin from the kidneys,aiding in reducing blood pressure. Athigh doses, it inhibits stimulation of beta 2receptors in the lungs, which may causebronchoconstriction.ContraindicationsCardiogenic shock, heart block greater thanfirst degree, hypersensitivity to beta blockers,overt heart failure, sinus bradycardiaInteractionsDRUGSamiodarone: Additive atenolol effectscalcium channel blockers, such as verapamiland diltiazem: Possibly symptomatic bradycardiaand conduction abnormalitiescatecholamine-depleting drugs, such as reserpine:Additive antihypertensive effectclonidine: Rebound hypertensiondisopyramide: Increased risk of severebradycardia, asystole, and heart failureAdverse ReactionsCNS: Depression, disorientation, dizziness,drowsiness, emotional lability, fatigue, fever,lethargy, light-headedness, short-termmemory loss, vertigoCV: Arrhythmias, including bradycardiaatenolol 107and heart block; cardiogenic shock; coldarms and legs; heart failure; mesentericartery thrombosis; mitral insufficiency;myocardial reinfarction; orthostatichypotension; Raynaud’s phenomenonEENT: Dry eyes, laryngospasm, pharyngitisGI: Diarrhea, ischemic colitis, nauseaGU: Renal failureHEME: AgranulocytosisMS: Leg painRESP: Bronchospasm, dyspnea, pulmonaryemboli, respiratory distress, wheezingSKIN: Erythematous rashOther: Allergic reactionNursing Considerations• Use atenolol cautiously in patients withheart failure controlled by digitalis glycosidesor diuretics, patients with conductionabnormalities or left ventricular dysfunctionwho take verapamil or diltiazem,patients with arterial circulatory disorders,and patients with impaired renal function.• Use atenolol cautiously in diabetic patientsbecause it may mask tachycardia caused byhypoglycemia. Unlike other beta-adrenergicblockers, it doesn’t mask other signs ofhypoglycemia, cause hypoglycemia, ordelay the return of blood glucose to a normallevel.• At first sign of heart failure, expect patientto receive a digitalis glycoside, a diuretic,or both and to be monitored closely. Iffailure continues, expect to stop atenolol.• Closely monitor patient with hyperthyroidismbecause atenolol may mask somesigns of thyrotoxicosis. Abrupt withdrawalof atenolol may precipitate thyrotoxicosis.• If patient also receives clonidine, expect tostop atenolol several days before graduallywithdrawing clonidine. Then expect torestart atenolol therapy several days afterclonidine has been discontinued.• During I.V. atenolol therapy, monitor vitalsigns and cardiac rhythm closely.• Discard parenteral mixture with atenolol ifit isn’t used within 48 hours.• Stop atenolol and notify prescriber ifpatient develops bradycardia, hypotension,or other serious adverse reaction.PATIENT TEACHING• Instruct patient not to stop taking atenololabruptly. Otherwise, angina may worsen,and an MI or arrhythmia may occur.A

108atomoxetine hydrochloride• While patient is being weaned from atenolol,tell him to perform minimal physicalactivity to prevent chest pain.• Instruct patient to take a missed dose assoon as possible. However, if it’s within8 hours of the next scheduled dose, tellhim to skip the missed dose and return tohis regular schedule.• Explain that atenolol may alter serum glucoselevel and mask hypoglycemia.• Inform the patient that he may experiencefatigue and reduced tolerance to exerciseand that he should notify his prescriber ifthis interferes with his normal lifestyle.atomoxetinehydrochlorideStratteraClass and CatgegoryChemical class: Selective norepinephrinereuptake inhibitorTherapeutic class: Anti–ADHD agentPregnancy category: CIndications and Dosages To treat attention deficit hyperactivitydisorder (ADHD)CAPSULESAdults and children weighing 70 kg(154 lb) or less. Initial: 0.5 mg/kg daily,increased after at least 3 days to 1.2 mg/kgdaily given either as a single dose in themorning or in evenly divided doses morningand late afternoon or early evening, asneeded. Maximum: 1.4 mg/kg or 100 mgdaily, whichever is less.Adults and children weighing more than70 kg. Initial: 40 mg daily, increased after atleast 3 days to 80 mg daily given either as asingle dose in the morning or in evenlydivided doses morning and late afternoonor early evening. After 2 to 4 additional wk,dosage may be increased to 100 mg daily ifoptimal response hasn’t been achieved.Maximum: 100 mg daily.DOSAGE ADJUSTMENT For patients withmoderate (Child-Pugh Class B) hepaticimpairment, dosage reduced by 50%. Forpatients with severe (Child-Pugh Class C)hepatic impairment, dosage reduced by75%. For patients weighing 70 kg or lessand taking strong CYP2D6 inhibitors, suchas paroxetine, fluoxetine, or quinidine, initialdosage of 0.5 mg/kg daily should beincreased to 1.2 mg/kg daily only if symptomsfail to improve after 4 wk. For patientsweighing more than 70 kg and takingstrong CYP2D6 inhibitors, initial dosage of40 mg daily should be increased to 80 mgdaily only if symptoms fail to improve after4 wk.Mechanism of ActionSelectively inhibits presynaptic norepinephrinetransport in the nervous system toincrease attention span and produce acalming effect.ContraindicationsAngle-closure glaucoma, hypersensitivity toatomoxetine or its components, use within14 days of MAO inhibitor therapyInteractionsDRUGSalbuterol and other beta 2 agonists: Maypotentiate action of albuterol and otherbeta 2 agonists on cardiovascular systemCYP2D6 inhibitors (such as fluoxetine,paroxetine, and quinidine): Increased bloodatomoxetine levelMAO inhibitors: Possibly induced hypertensivecrisispressor agents: Possibly altered blood pressureAdverse ReactionsCNS: Aggressiveness, anxiety, chills, crying,depression, dizziness, early morning awakening,fatigue, headache, hostility, insomnia,irritability, lethargy, mood changes,paresthesia, peripheral coldness, pyrexia,rigors, sedation, seizures, sleep disturbance,somnolence, stroke, suicidal ideation (childrenand adolescents), syncope, tremor,unusual dreamsCV: Chest pain, hypertension, orthostatichypotension, MI, palpitations, QT-intervalprolongation, Raynaud’s phenomenon,tachycardiaEENT: Conjunctivitis, dry mouth, ear infection,mydriasis, nasal congestion, nasopharyngitis,pharyngitis, rhinorrhea, sinuscongestionENDO: Hot flashesGI: Abdominal pain (upper), anorexia, constipation,diarrhea, elevated liver function

test results, flatulence, gastroenteritis(viral), indigestion, nausea, severe hepaticdysfunction, vomitingGU: Decreased libido, dysmenorrhea,dysuria, ejaculation disorders, erectile dysfunction,impotence, male pelvic pain,menstrual irregularities, orgasm abnormality,priapism, prostatitis, urinary hesitancy,urine retentionMS: Arthralgia, back pain, myalgiaRESP: Cough, upper respiratory tract infectionSKIN: Dermatitis, diaphoresis, pruritus,rash, urticariaOther: Angioedema, influenza, weight lossNursing Considerations• Use atomoxetine cautiously in patientswith cerebrovascular or CV disease (especiallyhypertension or tachycardia)because drug may increase blood pressureand heart rate. Also use cautiously in thoseprone to orthostatic hypotension andthose with serious structural cardiacabnormlities, cardiomyopathy, seriousheart rhythm abnormalities, or other seriouscardiac problems because drug mayincrease risk of sudden death from theseconditions.WARNING Monitor children and adolescentsclosely for evidence of suicidal thinkingand behavior as well as for psychotic ormanic symptoms such as hallucinations,delusional thinking, or mania because atomoxetineincreases the risk of suicidalideation and the onset of psychotic ormanic symptoms in these age-groups.• Obtain baseline blood pressure and heartrate before starting therapy. Monitorpatient’s vital signs after dosage increasesand periodically during therapy.• Monitor patient closely for allergic reactions.If these occur, notify prescriber.• Monitor child’s or adolescent’s growth andweight. Expect to interrupt therapy, as prescribed,if patient isn’t growing or gainingweight appropriately.• Monitor patient’s liver function studies, asordered. Notify prescriber immediately ifenzyme levels are elevated or patient hasevidence of hepatic dysfunction (jaundice,dark urine, pruritus, right-upper-quadranttenderness, or unexplained flulike symptoms).Expect to stop drug permanently.atorvastatin calcium 109PATIENT TEACHING• Caution patient not to open capsules. If acapsule opens, urge patient to promptlywash his hands and any surface drugtouches. If drug gets in his eyes, tell him toflush immediately with water and seekmedical care.• Instruct patient or parent to immediatelyreport to prescriber any adverse reactionsto atomoxetine therapy, such as facialswelling, itching, or rash.WARNING Urge parents to watch their childor adolescent closely for evidence ofabnormal thinking or behavior orincreased aggression or hostility. Stressneed to notify prescriber about unusualchanges.• Urge patient to tell prescriber immediatelyabout yellowing of his skin or eyes, itchiness,right upper abdominal pain, darkurine, or flulike symptoms. Also tellpatient to notify prescriber immediately ifhe experiences exertional chest pain, unexplainedsyncope, or other symptoms suggestiveof heart disease.• Caution patient to assume sitting orstanding position slowly because of drug’spotential effect on blood pressure.• Urge male patient to seek immediate medicalattention for a penile erection thatbecomes prolonged or painful.• Advise patient to report urinary hesitancyor urine retention to prescriber.• Remind patient of the importance ofalerting all prescribers to any OTC drugs,dietary supplements, or herbal remedieshe’s taking.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Reassure patient or parent that drug doesn’tcause physical or psychologicaldependence.• Instruct patient or parent to monitorweight during therapy.atorvastatin calciumLipitorClass and CategoryChemical class: Synthetically derived fermentationproductTherapeutic class: Antihyperlipidemic,A

110atorvastatin calciumHMG-CoA reductase inhibitorPregnancy category: XIndications and Dosages To control lipid levels as adjunct to dietin primary (heterozygous familial andnonfamilial) hypercholesterolemia andmixed dyslipidemiaTABLETSAdults. Initial: 10 or 20 mg once daily; thenincreased according to lipid level.Maintenance: 10 to 80 mg once daily.DOSAGE ADJUSTMENT Initial dose may beincreased to 40 mg once daily for patientswho need cholesterol level reduced morethan 45%. To control lipid levels in homozygousfamilial hypercholesterolemiaTABLETSAdults. 10 to 80 mg daily. To control lipid levels in pediatric heterozygousfamilial hypercholesterolemiaTABLETSAdolescents and children ages 10 to 17.Initial: 10 mg daily, adjusted at intervals of4 wk or more, as needed. Maximum: 20 mgdaily. To reduce debilitating cardiovascularevents such as stroke and MI in patientswith multiple risk factors but withoutknown coronary artery diseaseTABLETSAdults. 10 mg once daily.Mechanism of ActionReduces plasma cholesterol and lipoproteinlevels by inhibiting HMG-CoA reductaseand cholesterol synthesis in the liver and byincreasing the number of LDL receptors onliver cells to enhance LDL uptake andbreakdown.ContraindicationsActive hepatic disease, hypersensitivity toatorvastatin or its components, unexplainedpersistent rise in serum transaminase levelInteractionsDRUGSamlodipine, cimetidine, clarithromycin, diltiazem,erythromycin, itraconazole, ritonavirwith saquinavir: Increased atorvastatin levelantacid, colestipol, efavirenz, rifampin:Possibly decreased blood atorvastatin levelazole antifungals, clarithromycin,cyclosporine, erythromycin, fibric acid derivatives,lopinavir with ritonavir, niacin (atdosage used for lipid modification), nicotinicacid, ritonavir with saquinavir: Increasedrisk of severe myopathy or rhabdomyolysiscyclosporine: Increased atorvastatinbioavailability and risk of adverse reactionsdigoxin: Possibly increased blood digoxinlevel, causing toxicityoral contraceptives (such as ethinyl estradioland norethindrone): Increased hormonelevelFOODSgrapefruit juice (more than 1.2 L daily):Increased blood atorvastatin levelAdverse ReactionsCNS: Abnormal dreams, amnesia, asthenia,emotional lability, facial paralysis, fever,headache, hyperkinesia, lack of coordination,malaise, paresthesia, peripheral neuropathy,somnolence, syncope, weaknessCV: Arrhythmias, elevated serum CK level,orthostatic hypotension, palpitations,phlebitis, vasodilationEENT: Amblyopia, altered refraction, dryeyes, dry mouth, epistaxis, eye hemorrhage,gingival hemorrhage, glaucoma, glossitis,hearing loss, lip swelling, loss of taste,pharyngitis, sinusitis, stomatitis, taste perversion,tinnitusENDO: Hyperglycemia or hypoglycemiaGI: Abdominal or biliary pain, anorexia,colitis, constipation, diarrhea, duodenal orstomach ulcers, dysphagia, eructation,esophagitis, flatulence, gastroenteritis,hepatic failure, hepatitis, increased appetite,indigestion, melena, pancreatitis, rectalhemorrhage, tenesmus, vomitingGU: Abnormal ejaculation; cystitis;decreased libido; dysuria; epididymitis;hematuria; impotence; nephritis; nocturia;renal calculi; urinary frequency, incontinence,or urgency; urine retention; vaginalhemorrhageHEME: Anemia, thrombocytopeniaMS: Arthralgia, back pain, bursitis, gout, legcramps, myalgia, myasthenia gravis, myositis,neck rigidity, tendon contracture,tenosynovitis, torticollisRESP: Dyspnea, pneumoniaSKIN: Acne, alopecia, contact dermatitis,diaphoresis, dry skin, ecchymosis, eczema,jaundice, petechiae, photosensitivity, pruritus,rash, seborrhea, ulceration, urticaria

Other: Allergic reaction, facial or generalizededema, flulike symptoms, infection,lymphadenopathy, weight gainNursing Considerations• Atorvastatin is used in patients withhomozygous familial hypercholesterolemiaas an adjunct to other lipid-lowering treatmentsor alone only if other treatmentsaren’t available.• Atorvastatin may be used with colestipolor cholestyramine for additive antihyperlipidemiceffects.• Expect atorvastatin to be used in patientswithout obvious coronary artery disease(CAD) but with multiple risk factors (suchas age 55 or over, smoker, history ofhypertension or low HDL level, or familyhistory of early CAD). Drug is used toreduce risk of MI, angina, and adverseeffects of revascularization procedures.• Also expect drug to be used in patientswith type 2 diabetes who have no obviousCAD but multiple risk factors, such asretinopathy, albuminuria, smoking, orhypertension. Drug is used in thesepatients to reduce risk of MI and stroke.• Expect liver function tests to be performedbefore atorvastatin therapy starts, after6 and 12 weeks, with each dosage increase,and every 6 months thereafter.• Expect to measure lipid levels 2 to 4 weeksafter therapy starts, to adjust dosage asdirected, and to repeat periodically untillipid levels are within desired range.PATIENT TEACHING• Stress that atorvastatin is an adjunct to—not a substitute for—low-cholesterol diet.• Tell patient to take drug at the same timeeach day to maintain its effects.• Instruct patient to take a missed dose assoon as possible. If it’s almost time for hisnext dose, he should skip the missed dose.Tell him not to double the dose.• Instruct patient to consult prescriberbefore taking OTC niacin because ofincreased risk of rhabdomyolysis.• Advise patient to notify prescriber immediatelyif he develops unexplained musclepain, tenderness, or weakness, especially ifaccompanied by fatigue or fever.• Be aware that atorvastatin is expensive.Reinforce the benefits of therapy, and urgepatient to comply if possible.atovaquoneMepronatovaquone 111Class and CategoryChemical class: Hydroxy-1,4-naphthoquinoneTherapeutic class: AntiprotozoalPregnancy category: CIndications and Dosages To prevent Pneumocystis jiroveci (formerlycarinii) pneumonia in patientswho can’t tolerate co-trimoxazoleSUSPENSION, TABLETSAdults and adolescents. 750 mg (5 ml)b.i.d. with meals for 21 days. To treat mild to moderate P. jirovecipneumonia in patients who can’t tolerateco-trimoxazoleSUSPENSION, TABLETSAdults and adolescents. 750 mg (5 ml)b.i.d. with meals for 21 days. Maximum:1,500 mg/day.Mechanism of ActionMay destroy P. jiroveci organisms byinhibiting the enzymes needed to synthesizenucleic acid and adenosine triphosphate.ContraindicationsHypersensitivity to atovaquone or its componentsInteractionsDRUGSrifabutin, rifampin: Possibly decreasedblood atovaquone levelAdverse ReactionsCNS: Fever, headache, insomniaEENT: Rhinitis, throat tightness, vortexkeratopathyGI: Abdominal pain, diarrhea, elevated liverenzyne levels, hepatitis, hepatic failure, nausea,pancreatitis, vomitingGU: Acute renal dysfunctionHEME: Anemia, thrombocytopeniaRESP: Bronchospasm, cough, dyspneaSKIN: Desquamation, erythema multiforme,Stevens-Johnson syndrome, rash,urticariaOther: Allergic reaction, angioedema,methemoglobinemiaNursing Considerations• Use atovaquone cautiously in patient withA

112Nursing Considerations• Use atracurium cautiously in patients withhypotension, and monitor blood pressureclosely.• Watch closely for adverse reactions, especiallythose related to histamine release.Atracurium is more likely than other neuromuscularblockers to cause skin flushing.• Anticipate using lower doses for patientswith neuromuscular disease, severe elecatracuriumbesylatesevere hepatic impairment because,although rare, serious adverse reactionsaffecting liver function may occur.• Monitor blood test results because atovaquonemay decrease serum sodium andhemoglobin levels and neutrophil countand may increase AST, ALT, alkaline phosphatase,and serum amylase levels.• Crush atovaquone tablets, if needed.• Don’t use tablets and oral suspensioninterchangeably; they aren’t bioequivalent.PATIENT TEACHING• Instruct patient to take atovaquone withmeals for maximum effectiveness.• Instruct patient to take a missed dose assoon as possible. If it’s almost time for thenext dose, tell him to skip the missed dose.Tell him not to double the next dose.• Tell patient to notify prescriber if his conditiondoesn’t improve in a few days or ifhe develops signs of an allergic reaction,such as fever or rash.atracurium besylateTracriumClass and CategoryChemical class: Biquaternary ammoniumesterTherapeutic class: Skeletal muscle relaxantPregnancy category: CIndications and Dosages To facilitate endotracheal intubationand induce skeletal muscle relaxation forsurgery or mechanical ventilation asadjunct to anesthesiaI.V. INFUSION OR INJECTIONAdults and children age 2 or over. Initial:0.4 to 0.5 mg/kg by I.V. bolus for nearlycomplete neuromuscular blockade.Maintenance: 0.08 to 0.10 mg/kg 20 to45 min after initial dose during prolongedsurgery. Maintenance doses may be givenevery 15 to 25 min for patients under balancedanesthesia. For patients havingextended surgical procedures, after an initialI.V. bolus, an infusion of 9 to 10 mcg/kg/min may be needed to counteract thespontaneous return of neuromuscularfunction and thereafter 5 to 10 mcg/kg/minas a constant infusion.Children ages 1 month to 2 years havinghalothane anesthesia. Initial: 0.3 to 0.4 mg/kg. Frequent maintenance doses may beneeded.Route Onset Peak DurationI.V. 2–2.5 min 3–5 min 35–70 minMechanism of ActionInhibits nerve impulse transmission bycompeting with acetylcholine for cholinergicreceptors on motor end plate.IncompatibilitiesDon’t mix atracurium in same syringe orgive it through same I.V. needle as an alkalinesolution, such as a barbiturate injection.Don’t mix atracurium with lactatedRinger’s injection.ContraindicationsHypersensitivity to atracurium, its components,or benzyl alcoholInteractionsDRUGSaminoglycosides, enflurane, furosemide,halothane, isoflurane, lithium, magnesiumsalts, polymyxin antibiotics, procainamide,quinidine, thiazide diuretics: Possiblyenhanced or prolonged atracurium effectsopioid analgesics: Possibly additive histaminerelease and increased risk and severityof bradycardia and hypotensionAdverse ReactionsCNS: SeizuresCV: Bradycardia, hypertension, hypotension,tachycardiaMS: Inadequate or prolonged neuromuscularblockadeRESP: Apnea, bronchospasm, dyspnea,laryngospasm, wheezingSKIN: Flushing, rash, urticariaOther: Anaphylaxis, injection site reaction

trolyte disorders, or carcinomatosisbecause of risk of enhanced neuromuscularblockade and difficulties with reversal.• Keep atropine nearby to treat atracuriuminducedbradycardia.• For I.V. infusion, dilute atracurium withnormal saline solution, D 5 W, or dextrose5% in normal saline solution. To prepare asolution that yields 200 mcg/ml atracurium,add 2 ml atracurium to 98 ml diluent.To prepare a solution that yields 500 mcg/ml, add 5 ml atracurium to 95 ml diluent.• Refrigerate solution or store at room temperaturefor up to 24 hours.PATIENT TEACHING• Explain atracurium’s purpose and administrationduring anesthesia. Keep in mindthat the patient can still hear.atropineAtroPenatropine sulfateClass and CategoryChemical class: Belladonna alkaloidTherapeutic class: Anticholinergic, antimuscarinicPregnancy category: CIndications and Dosages To reduce respiratory tract secretionsrelated to anesthesiaTABLETS (ATROPINE SULFATE)Adults. 0.4 to 0.6 mg preoperatively.Children. 0.01 mg/kg up to total of 0.4 mgpreoperatively and repeated every 4 to 6 hr,p.r.n.I.V.,I.M., OR SUBCUTANEOUS INJECTIONAdults. 0.4 to 0.6 mg preoperatively.Children. 0.01 mg/kg up to total of 0.4 mgpreoperatively and repeated every 4 to 6 hr,p.r.n. To correct bradycardiaI.V. INJECTION (ATROPINE SULFATE)Adults. 0.4 to 1 mg. If no response to firstdose, repeat once after 5 min.Children. 0.01 to 0.02 mg/kg with a minimumdose of 0.1 mg and a maximum doseof 0.5 mg. If no response to first dose,repeat once after 5 min. To treat cholinesterase inhibitor (such asatropine 113neostigmine, pilocarpine, and methacholine)toxicityI.V. INJECTION (ATROPINE SULFATE)Adults. 2 to 4 mg. Then 2 mg every 5 to10 min until muscarinic signs (bradycardia,vasodilation, and pupil dilation) disappearor signs of atropine intoxication develop.I.V. OR I.M. INJECTION (ATROPINE SULFATE)Children. 1 mg. Then 0.5 to 1 mg every 5 to10 min until muscarinic signs disappear orsigns of atropine intoxication develop. To treat mushroom (muscarine) toxicityI.V. OR I.M. INJECTION (ATROPINE SULFATE)Adults. 1 to 2 mg every hr until respiratorysigns and symptoms subside. To treat pesticide (organophosphate)toxicityI.V. OR I.M. INJECTION (ATROPINE SULFATE)Adults. 1 to 2 mg, repeated in 20 to 30 minas soon as cyanosis has cleared. Then continueduntil definite improvement is maintained,possibly for 2 or more days. To treat known or suspected exposure tochemical nerve agent or insecticideI.M. INJECTION (ATROPEN)Adults and children weighing over 41 kg(90 lb) with two or more mild symptoms.2 mg. If severe symptoms develop afterinjection, two or more 2-mg injectionsgiven in rapid succession 10 min after initialinjection.Adults and children weighing over 41 kgwho are unconscious or have other severesymptoms. 2 mg given immediately 3 timesin rapid succession.Children weighing 18 to 41 kg (40 to 90 lb)with two or more mild symptoms. 1 mg. Ifsevere symptoms develop after injection,two more 1-mg injections given in rapidsuccession 10 min after initial injection.Children weighing 18 to 41 kg who areunconscious or exhibit any other severesymptoms. 1 mg given immediately 3 timesin rapid succession.Children weighing 7 to 18 kg (15 to 40 lb)with two or more mild symptoms. 0.5 mg.If severe symptoms develop after injection,two more 0.5-mg injections given in rapidsuccession 10 min after initial injection.Children weighing 7 to 18 kg who areunconscious or exhibit any other severesymptoms. 0.5 mg given immediately3 times in rapid succession.A

114atropineMechanism of ActionInhibits acetylcholine’s muscarinic action atthe neuroeffector junctions of smooth muscles,cardiac muscles, exocrine glands, SAand AV nodes, and the urinary bladder. Insmall doses, atropine inhibits salivary andbronchial secretions and diaphoresis. Inmoderate doses, it increases impulse conductionthrough the AV node and increasesheart rate. In large doses, it decreases GIand urinary tract motility and gastric acidsecretion.Route Onset Peak DurationP.O. 30–120 1–2 hr 4–6 hrminI.V. Immediate 2–4 min BriefI.M. 5–40 20–60 Briefmin minSubQ Unknown Unknown BriefContraindicationsAngle-closure glaucoma, asthma, GIobstructive disease (achalasia, pyloricobstruction, pyloroduodenal stenosis),hepatic disease, hypersensitivity to atropineor its components, ileus, intestinal atony,myasthenia gravis, myocardial ischemia,obstructive uropathy, renal disease, severeulcerative colitis, tachycardia, toxic megacolon,unstable cardiovascular status inacute hemorrhageInteractionsDRUGSadsorbent antidiarrheals, antacids: Decreasedatropine absorptionamantadine, anticholinergics, antidyskinetics,glutethimide, meperidine, muscle relaxants,phenothiazines, tricyclic antidepressants andother drugs with anticholinergic properties,including antiarrhythmics (disopyramide,procainamide, quinidine), antihistamines,buclizine, meclizine: Increased atropineeffectsantimyasthenics: Reduced intestinal motilitycyclopropane: Risk of ventricular arrhythmiashaloperidol: Decreased antipsychotic effectketoconazole: Decreased ketoconazoleabsorptionmetoclopramide: Decreased effect on GImotilityopioid analgesics: Increased risk of ileus,severe constipation, and urine retentionpotassium chloride, especially wax-matrixforms: Possibly GI ulcersurinary alkalizers (calcium or magnesiumantacids, carbonic anhydrase inhibitors, citrates,sodium bicarbonate): Delayed excretion,increased risk of adverse atropine effectsAdverse ReactionsCNS: Agitation, amnesia, anxiety, ataxia,Babinski’s or Chaddock’s reflex, behavioralchanges, CNS stimulation (at high doses),coma, confusion, decreased concentration,decreased tendon reflexes, delirium, dizziness,drowsiness, fever, hallucinations,headache, hyperreflexia, insomnia, lethargy,mania, mental disorders, nervousness, paranoia,restlessness, seizures, somnolence, stupor,syncope, vertigo, weaknessCV: Arrhythmias, bradycardia (at lowdoses), cardiac dilation, chest pain, hypertension,hypotension, left ventricular failure,MI, palpitations, tachycardia (at high doses),weak or impalpable peripheral pulsesEENT: Acute angle-closure glaucoma,altered taste, blepharitis, blindness, blurredvision, conjunctivitis, cyclophoria, cycloplegia,decreased visual acuity or accommodation,dry eyes or conjunctiva, dry mucousmembranes, dry mouth, eye irritation, eyelidcrusting, heterophoria, increasedintraocular pressure, keratoconjunctivitis,lacrimation, laryngitis, laryngospasm,mydriasis, nasal congestion, oral lesions,photophobia, pupils poorly reactive to light,strabismus, tongue chewingGI: Abdominal distention, abdominal pain,bloating, constipation, decreased bowelsounds or food absorption, delayed gastricemptying, dysphagia, heartburn, ileus, nausea,vomitingGU: Bladder distention, enuresis, impotence,urinary hesitancy, urinary urgency,urine retentionMS: Dysarthria, hypertonia, muscle twitchingRESP: Bradypnea, dyspnea, inspiratory stridor,pulmonary edema, respiratory failure,shallow breathing, subcostal recession,tachypneaSKIN: Cold skin, cyanosis, decreased sweating,dermatitis, flushing, rash, urticariaOther: Anaphylaxis, dehydration, injectionsite reaction, polydipsia, sensations ofwarmth

Nursing ConsiderationsWARNING For patient prescribed AtroPenfor suspected nerve gas or insecticideexposure, dosage is determined by severityof symptoms. Mild symptoms includeblurred vision, miosis, excessive unexplainedteary eyes or runny nose,increased salivation, chest tightness, difficultybreathing, tremors, muscle twitching,nausea, vomiting, unexplained wheezingor coughing, acute onset of stomachcramps, tachycardia, and bradycardia.Severe symptoms include confusion orother strange behavior, severe difficultybreathing, extreme secretions from airwayor lungs, severe muscle twitching and generalweakness, involuntary urination anddefecation, seizures, and unconsciousness.• Avoid using high-dose atropine sulfate inpatients with ulcerative colitis because ofrisk of toxic megacolon or in patients withhiatal hernia and reflux esophagitisbecause of risk of esophagitis• AtroPen has no absolute contraindicationswhen used to treat life-threatening nervegas or insecticide exposure.WARNING Assess for symptoms of toxicdoses of atropine, such as excitement, agitation,drowsiness, and confusion, whichare likely to affect elderly patients evenwith low doses. If symptoms occur, takesafety precautions to prevent injury.• Assess bowel and bladder elimination.Notify prescriber of diarrhea, constipation,urinary hesitancy, or urine retention.PATIENT TEACHING• For patient prescribed an AtroPen to carrybecause of risk of nerve gas or insecticideexposure, explain when and how to selfadministerthe drug.• Instruct patient to take atropine sulfate30 to 60 minutes before meals.• Advise patient to notify prescriber if hehas persistent or severe diarrhea, constipation,or difficulty urinating.auranofinRidauraClass and CategoryChemical class: Gold saltTherapeutic class: Anti-inflammatoryPregnancy category: Cauranofin 115Indications and Dosages To treat active rheumatoid arthritisthat’s unresponsive to NSAIDsCAPSULESAdults. Initial: 6 mg daily or 3 mg b.i.d.Maintenance: Up to 9 mg daily after 3 moof treatment, if needed.Children age 6 and over. Initial: 0.1 mg/kgdaily. Maintenance: 0.15 mg/kg daily.Maximum: 0.2 mg/kg daily.DOSAGE ADJUSTMENT Drug discontinued iftherapeutic response isn’t adequate after3 mo at 9 mg daily.Route Onset Peak DurationP.O. 3–6 mo 1–2 hr Up to 26 daysMechanism of ActionDecreases rheumatoid factor and humoralantibody (immunoglobulin) levels.Although exact anti-inflammatory action isunknown, drug may suppress the increasedphagocytic activity of macrophages andpolymorphonuclear leukocytes that occurswith rheumatoid arthritis and therebyinhibit release of destructive enzymes thatcause joint inflammation.ContraindicationsAgranulocytosis, blood dyscrasias, bonemarrow aplasia, colitis, eczema, exfoliativedermatitis, hepatic disease, history of goldor heavy metal toxicity, hypersensitivity toauranofin, marked hypertension, necrotizingenterocolitis, pulmonary fibrosis, recentradiation therapy, renal disease, severe debilitation,systemic lupus erythematosus,uncontrolled diabetes mellitus, uncontrolledheart failure, urticaria, youth (under age 6)InteractionsDRUGSphenytoin: Possibly increased phenytoin levelAdverse ReactionsCNS: Confusion, dizziness, EEG abnormalities,hallucinations, seizuresEENT: Gingivitis, glossitis, iritis or cornealulcers from gold deposits in ocular tissue,metallic taste, stomatitisGI: Abdominal cramps, anorexia, constipation,diarrhea, enterocolitis, flatulence, indigestion,melena, nausea, vomitingGU: Hematuria, elevated BUN and serumA

116azathioprinecreatinine levels, proteinuria, vaginitisHEME: Agranulocytosis, aplastic anemia,eosinophilia, leukopenia, neutropenia,thrombocytopeniaRESP: Cough, dyspnea, fibrosis, interstitialpneumonitisSKIN: Alopecia, dermatitis, exfoliative dermatitis,jaundice, photosensitivity, pruritus,rash, urticariaNursing Considerations• Monitor blood and urine tests for signs ofgold toxicity during auranofin therapy.WARNING Gold toxicity may occur duringtreatment or several months afterward. Itusually occurs with a cumulative dose of400 to 800 mg and may cause decreasedhemoglobin level, WBC count less than4,000/mm 3 , granulocyte count less than1,500/mm 3 , platelet count less than150,000/mm 3 , severe diarrhea, stomatitis,hematuria, proteinuria, rash, and pruritus.• Monitor fluid intake and output imbalance.If urine output decreases, assessBUN and serum creatinine levels for signsof renal impairment.• Notify prescriber about possible allergicreaction (dermatitis, rash, pruritus). Drugmay need to be discontinued.PATIENT TEACHINGvAdvise patient that diarrhea is commonbut that he should notify prescriberimmediately if it becomes severe.• Tell patient to take drug exactly as prescribedand to have monthly blood tests.• Inform patient that drug may take 3 to4 months to reach a therapeutic level.• Urge patient to report skin problems,fatigue, or stomatitis (possible blooddyscrasias).• Tell patient to report blood in stool orurine, easy bruising, and bleeding gums.azathioprineImuranazathioprinesodiumImuranClass and CategoryChemical class: Purine analogueTherapeutic class: Antimetabolite, immunosuppressantPregnancy category: DIndications and Dosages To prevent kidney rejection after transplantationTABLETS, I.V. INFUSIONAdults and children. Initial: 3 to 5 mg/kgdaily P.O. or I.V. as a single dose on, or 1 to3 days before, day of transplantation, followedby 3 to 5 mg/kg daily I.V. after surgeryuntil P.O. dose is tolerated.Maintenance: 1 to 3 mg/kg daily P.O.DOSAGE ADJUSTMENT Dosage reduced forpatients with oliguria (as from tubularnecrosis) after transplantation because drugor metabolite excretion may be delayed. To treat refractory rheumatoid arthritisTABLETSAdults. Initial: 1 mg/kg (50 to 100 mg)daily as a single dose or b.i.d. for 6 to 8 wk.Maintenance: If initial therapy doesn’t producetherapeutic effects or serious adverseeffects, dosage increased every 4 wk by0.5 mg/kg up to 2.5 mg/kg. Optimal dosageis 2 to 2.5 mg/kg daily.DOSAGE ADJUSTMENT Dosage reduced to25% to 33% of usual dosage for patientswho also take allopurinol.Route Onset Peak DurationP.O., I.V. 4–8 wk Unknown SeveraldaysMechanism of ActionMay prevent proliferation and differentiationof activated B and T cells by interferingwith purine (protein) and nucleic acid(DNA and RNA) synthesis.ContraindicationsHypersensitivity to azathioprineInteractionsDRUGSACE inhibitors and drugs that affect bonemarrow and cell development in bone marrow,such as co-trimoxazole: Possibly severeleukopeniaallopurinol: Possibly increased therapeuticand adverse effects of azathioprineanticoagulants: Possibly decreased anticoagulantactioncyclosporine: Possibly decreased plasma

cyclosporine levelmethotrexate: Possibly increased plasmalevel of azathioprine’s metabolite, 6-mercaptopurine,which can lead to cell deathnondepolarizing neuromuscular blockers:Possibly decreased or reversed action ofneuromuscular blockerAdverse ReactionsCNS: Fever, malaiseGI: Abdominal pain, diarrhea, hepatoxicity(elevated liver function test results), nausea,pancreatitis, steatorrhea, vomitingHEME: Leukopenia, macrocytic anemia,pancytopenia, thrombocytopeniaMS: Arthralgia, myalgiaSKIN: Alopecia, rashRESP: Reversible interstitial pneumonitisOther: Infection, lymphomas and otherneoplasms, negative nitrogen balanceNursing Considerations• Before I.V. use, add 20 ml sterile water forinjection to azathioprine vial and swirluntil clear solution forms. Resulting drugconcentration is 100 mg and can be dilutedfurther as prescribed. Calculate infusionrate based on final volume to beinfused. Then give over 30 to 60 minutesor as prescribed (5 minutes to 8 hours).• Obtain results of baseline laboratory tests,including WBC, RBC, and platelet counts.Expect to monitor results once a weekduring first month of therapy, twice amonth during second and third months,and once a month or more thereafter.• Hematologic reactions typically are doserelatedand may occur late in therapy,especially in patients with transplant rejection.WARNING If WBC count decreases rapidlyor remains significantly and consistentlylow, expect to reduce dosage or discontinueazathioprine.• Periodically monitor liver function testresults for early signs of hepatotoxicity.• If patient develops thrombocytopenia,take bleeding precautions, such as avoidingI.M. injections and venipunctures,applying ice to areas of trauma, andchecking I.V. infusion sites every 2 hoursfor bleeding.• If patient also receives an oral anticoagulant,monitor his PT.• Azathioprine therapy increases risk ofMechanism of ActionBinds nonselectively to central and periphazelastinehydrochloride 117viral, fungal, bacterial, and protozoalinfections. Watch for evidence of infection,such as fever, chills, sore throat, andmouth sores. Expect to administer aggressiveantibiotic, antiviral, or other drugtherapy and reduce azathioprine dosage.• Minimize the risk of infection. If patienthas severe leukopenia, take neutropenicprecautions, such as placing him in a privateroom and limiting visitors.• Rheumatoid arthritis requires at least12 weeks of azathioprine therapy. Duringthis time, continue other pain-relief measures,such as rest, physical therapy, andother drugs, such as salicylates andcorticosteroids.• If oral azathioprine causes GI upset, give itin divided doses or with meals.• Expect to use lowest possible maintenancedosage for rheumatoid arthritis, reducingit gradually in 0.5-mg/kg (about 25-mg)increments at 4-week intervals.• Drug can be stopped abruptly, but itseffects may persist several days.PATIENT TEACHING• Advise patient to take oral drug with foodor meals to minimize GI upset.WARNING Teach patient to recognize andreport signs of infection, such as sorethroat and fever.• Teach patient how to reduce the risk ofbleeding and falling.azelastinehydrochlorideAstelinClass and CategoryChemical class: Phthalazinone derivativeTherapeutic class: Antihistamine,H 1 -receptor antagonistPregnancy category: CIndications and Dosages To treat symptoms of seasonal rhinitis(rhinorrhea, sneezing, and nasal itching)NASAL SPRAYAdults and children age 12 and over.2 sprays in each nostril b.i.d.A

118azithromycineral H 1 receptors, preventing histaminefrom reaching its site of action, whichreduces or prevents most of histamine’sphysiologic effects. By blocking histamineat its site of action, azelastine inhibits respiratory,vascular, and GI smooth-musclecontraction; decreases capillary permeability,which reduces wheals, flares, and itching;and decreases salivary and lacrimal glandsecretions.Route Onset Peak DurationNasal In 3 hr Unknown 12 hrContraindicationsHypersensitivity to azelastine or its componentsInteractionsDRUGScimetidine, ketoconazole: Possibly increasedblood azelastine levelCNS depressants: Possibly increased sedativeeffects and reduced mental alertnessACTIVITIESalcohol use: Possibly increased sedativeeffects and reduced mental alertnessAdverse ReactionsCNS: Dizziness, fatigue, headache, somnolenceCV: Atrial fibrillation, palpitationsEENT: Bitter taste, dry mouth, epistaxis,nasal burning, paroxysmal sneezing,pharyngitis, rhinitisGI: NauseaOther: Weight gainNursing Considerations• Assess for changes in alertness, and takesafety precautions, if needed.PATIENT TEACHING• Teach patient how to use azelastine nasalspray properly to achieve maximum therapeuticeffects.• Before patient’s first use of nasal spray,instruct him to prime pump by placing histhumb on base and his index and middlefingers on shoulder area of bottle and thenpressing thumb firmly and quickly againstbottle four times or until fine mist appears.• If patient hasn’t used spray in more than3 days, instruct him to reprime pump withtwo sprays or until fine mist appears.• Advise patient to clear nostrils gently, ifneeded, before using spray.• Teach patient to inhale deeply after eachspray and then exhale through his mouthand tilt his head back so drug can spreadover nasopharynx.• Advise patient to store bottle upright andtightly closed.WARNING Emphasize that patient mustconsult prescriber before taking any OTCdrug, such as cough syrup or a cold remedy,because of the risk of extreme CNSdepression.• Inform patient that decreased alertnessmay occur. Advise him to avoid hazardousactivities or those that require alertness,such as driving or operating machinery,until drug’s effects are known.azithromycinZithromax, ZmaxClass and CategoryChemical class: Azalide (subclass ofmacrolide)Therapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat mild community-acquiredpneumonia, otitis media, pharyngitis,tonsillitis, and uncomplicated skin andsoft-tissue infectionsCAPSULES, ORAL SUSPENSION, TABLETSAdults. 500 mg as a single dose on day1, followed by 250 mg daily on days2 through 5.Children age 6 months or over with acuteotitis media or community-acquiredpneumonia. 10 mg/kg as a single dose (notto exceed 500 mg daily) on day 1, followedby 5 mg/kg (not to exceed 250 mg daily)daily on days 2 through 5. Or, for acute otitismedia, 30 mg/kg of oral suspension as asingle dose or 10 mg/kg daily for 3 days.Children age 12 or over with pharyngitisor tonsillitis. 12 mg/kg (not to exceed500 mg daily) as single dose daily for 5 days. To treat mild to moderate acute bacterialexacerbations of COPDCAPSULES, ORAL SUSPENSION, TABLETSAdults. 500 mg daily for 3 days. Or, 500 mgas single dose on day 1, followed by 250 mg

daily on days 2 through 5. To treat community-acquired pneumoniaCAPSULES, ORAL SUSPENSION, TABLETS, I.V.INFUSIONAdults and adolescents age 16 or over.500 mg I.V. as a single dose daily for at least2 days, followed by 500 mg P.O. as a singledose daily until patient completes 7 to10 days of therapy. To treat community-acquired pneumoniacaused by Chlamydophila pneumoniae,Haemophilus influenzae,Mycoplasma pneumoniae, orStreptococcus pneumoniaeE.R. ORAL SOLUTION (ZMAX)Adults. 2 g as a single dose on an emptystomach. To treat chancroid caused byHaemophilus ducreyi; gonococcalpharyngitis; urethritis, cervicitis, orother infections caused by ChlamydiatrachomatisCAPSULES, ORAL SUSPENSION, TABLETSAdults. 1 g as a one-time dose.Children age 8 or over and children underage 8 weighing 45 kg (99 lb) or more (withinfections caused by C. trachomatis). 1 gas a one-time dose. To treat urethritis or cervicitis caused byNeisseria gonorrhoeaeCAPSULES, ORAL SUSPENSION, TABLETSAdults. 2 g as a one-time dose. To prevent Mycobacterium avium complexin patients with advanced HIVinfectionCAPSULES, ORAL SUSPENSION, TABLETS, I.V.INFUSIONAdults. 1.2 g once weekly, as indicated. To treat pelvic inflammatory diseaseCAPSULES, ORAL SUSPENSION, TABLETS, I.V.INFUSIONAdults. 500 mg I.V. as a single dose daily for1 to 2 days, followed by 250 mg P.O. as asingle dose daily until patient completes7 days of therapy. To treat acute bacterial sinusitisORAL SUSPENSION, TABLETSAdults. 500 mg daily for 3 days.Children. 10 mg/kg daily for 3 days. To treat acute bacterial sinusitis causedby H. influenzae, Moraxella catarrhalis,or S. pneumoniaeE.R. ORAL SOLUTION (ZMAX)azithromycin 119Adults. 2 g as a single dose on an emptystomach.Route Onset Peak DurationP.O. Varies Unknown UnknownMechanism of ActionBinds to a ribosomal subunit of susceptiblebacteria, blocking peptide translocation andinhibiting RNA-dependent protein synthesis.Drug concentrates in phagocytes,macrophages, and fibroblasts, which releaseit slowly and may help move it to infectionsites.IncompatibilitiesDon’t add I.V. substances, additives, ordrugs to azithromycin I.V. solution, anddon’t infuse through the same I.V. line.ContraindicationsHypersensitivity to azithromycin, erythromycin,ketolide antibiotics, or othermacrolide antibioticsInteractionsDRUGSantacids that contain aluminum or magnesium:Possibly decreased peak bloodazithromycin level, but extent of absorptionis unchangedcarbamazepine, cyclosporine, phenytoin, terfenadine(drugs metabolized by P-450 cytochromesystem): Possibly increased bloodlevels of these drugsdigoxin: Possibly increased blood digoxinleveldihydroergotamine, ergotamine: Possiblysevere peripheral vasospasm and abnormalsensations (acute ergot toxicity)HMG-CoA reductase inhibitors: Increasedrisk of severe myopathy or rhabdomyolysispimozide: Possibly sudden deathoral anticoagulants: Possibly potentiatedeffects of oral anticiagulantstheophylline: Possibly increased blood theophyllineleveltriazolam: Possibly decreased excretion andincreased therapeutic effects of triazolamwarfarin: Possibly increased anticoagulationFOODSfood: Dramatically increased absorptionrate of azithromycinAdverse ReactionsCNS: Aggressiveness, agitation, anxiety,A

120aztreonamasthenia, dizziness, fatigue, headache, hyperactivity,malaise, nervousness, paresthesia,seizures, somnolence, syncope, vertigoCV: Chest pain, edema, elevated serum CKlevel, hypotension, palpitations, prolongedQT interval, torsades de pointes, ventriculartachycardiaEENT: Hearing loss, mucocutaneous candidiasis,perversion or loss of taste or smell,tinnitusENDO: HyperglycemiaGI: Abdominal pain, anorexia, cholestaticjaundice, constipation, diarrhea, dyspepsia,elevated liver function test results, flatulence,hepatic necrosis or failure, hepatitis,nausea, pancreatitis, pseudomembranouscolitis, vomitingGU: Acute renal failure, elevated BUN andserum creatinine levels, nephritis, vaginalcandidiasisHEME: Leukopenia, neutropenia, thrombocytopeniaMS: ArthralgiaSKIN: Erythema multiforme, photosensitivity,pruritus, rash, Stevens-Johnson syndrome,toxic epidermal necrolysis, urticariaOther: Allergic reaction, anaphylaxis,angioedema, elevated serum phosphoruslevel, hyperkalemia, infusion site reaction(such as pain and redness), new or worseningmyasthenia syndrome, superinfectionNursing Considerations• Obtain culture and sensitivity test results,if possible, before starting therapy.• Use azithromycin cautiously in patientswith hepatic dysfunction (drug is metabolizedin the liver) or renal dysfunction(effects are unknown in this group).• Give azithromycin capsules 1 hour beforeor 2 to 3 hours after food. Give tablets orsuspension without regard to food.WARNING Don’t give azithromycin by I.V.bolus or I.M. injection because it maycause erythema, pain, swelling, tenderness,or other reaction at the site. Infuse it over60 minutes or longer, as prescribed (typically1 mg/ml over 3 hours or 2 mg/mlover 1 hour.)• If hepatic function is impaired, monitorliver function studies because drug is eliminatedmainly by the liver.• Assess patient for bacterial or fungalsuperinfection, which may occur with prolongedor repeated therapy. If it occurs,expect to give another antibiotic or antifungal.• Monitor bowel elimination; if needed,obtain stool culture to rule out pseudomembranouscolitis. If it occurs, expect tostop azithromycin and give fluid, electrolytes,and antibiotics effective withClostridium difficile.PATIENT TEACHING• Tell patient to take azithromycin capsules1 hour before or 2 to 3 hours after food.Instruct patient to take tablets or suspensionwithout regard to food.WARNING Urge patient to consult prescriberbefore taking OTC drugs, includingantacids. If they’re prescribed, tell patientto take azithromycin 1 hour before or 2 to3 hours after taking antacids.• Tell patient to immediately report signsand symptoms of allergic reaction (such asrash, itching, hives, chest tightness, andtrouble breathing).• Warn patient that abdominal pain andloose, watery stools may occur. If diarrheapersists or becomes severe, urge him tocontact prescriber and replace fluids.• Because azithromycin may destroy normalflora, teach patient to watch for andimmediately report signs of superinfection,such as white patches in the mouth.aztreonamAzactamClass and CategoryChemical class: MonobactamTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat infections of the urinary tract,lower respiratory tract, skin, soft tissue,female reproductive tract; intra-abdominalinfections; septicemia; and surgicalabscesses caused by susceptible strains ofgram-negative bacteriaI.V. INFUSION, I.V. OR I.M. INJECTIONAdults. 0.5 to 2 g every 8 to 12 hr to maximumof 8 g daily. For life-threatening systemicinfection, 2 g every 6 to 8 hr to maximumof 8 g daily.Children ages 9 months to 16 years.30 mg/kg every 6 to 8 hr up to 120 mg/kg

daily; 50 mg/kg every 4 to 6 hr (forPseudomonas aeruginosa).DOSAGE ADJUSTMENT If creatinine clearanceis 10 to 30 ml/min/1.73 m 2 , initial dose is1 to 2 g; then 50% of usual dose at usualinterval. If creatinine clearance is less than10 ml/ min/1.73 m 2 , initial dose is 500 mgto 2 g; then 25% of the usual dose every 6,8, or 12 hr.Route Onset Peak DurationI.V. Immediate Immediate UnknowninfusionI.V. Immediate Immediate UnknowninjectionI.M. Variable 60 min UnknownMechanism of ActionInhibits bacterial cell wall synthesis in susceptibleaerobic gram-negative bacteria.These bacteria assemble rigid, cross-linkedcell walls in several steps. Aztreonam affectsthe final cross-linking step by inactivatingpenicillin-binding protein 3 (the enzymethat links cell wall strands), which causescell lysis and death.IncompatibilitiesDon’t mix aztreonam in same I.V. solutionas cephradine, metronidazole, or nafcillinsodium. Don’t mix it in same I.M. injectionsolution as local anesthetic.ContraindicationsHypersensitivity to aztreonam or its componentsInteractionsDRUGSaminoglycosides (prolonged or high-dosetherapy): Increased risk of nephrotoxicityand ototoxicitycefoxitin, imipenem: Possibly antagonizedaction of aztreonamfurosemide, probenecid: Possibly increasedblood aztreonam levelAdverse ReactionsCNS: Confusion, dizziness, fever, headache,insomnia, malaise, paresthesia, seizures,vertigoCV: Chest pain, hypotension, transient ECGchangesEENT: Altered taste, diplopia, halitosis,mouth ulcers, mucocutaneous candidiasis,aztreonam 121nasal congestion, sneezing, tinnitus, tonguenumbnessGI: Abdominal cramps, diarrhea, elevatedliver function test results, GI bleeding, hepatitis,nausea, pseudomembranous colitis,vomitingGU: Breast tenderness, elevated serum creatininelevel, vaginal candidiasisHEME: Anemia, eosinophilia, leukocytosis,neutropenia, pancytopenia, positiveCoombs’ test, prolonged PT and APTT,thrombocytopenia, thrombocytosisMS: MyalgiaRESP: Bronchospasm, dyspnea, wheezingSKIN: Diaphoresis, erythema multiforme,exfoliative dermatitis, flushing, jaundice,petechiae, pruritus, purpura, rash, toxic epidermalnecrolysis, urticariaOther: Allergic reaction; injection site pain,phlebitis, swelling, or thrombophlebitisNursing Considerations• Obtain culture and sensitivity test results,if possible, before starting aztreonam therapy.If patient is acutely ill, expect to begintherapy before results are available.• Keep in mind that other antimicrobialsmay be used with aztreonam in seriouslyill patients at risk for gram-positive infection.• Expect to use I.V. route for patients whoneed single doses over 1 g and those withlife-threatening systemic infections, suchas septicemia or peritonitis.• To reconstitute aztreonam for I.V. bolusinjection, use sterile water for injection.• Immediately after adding diluent to vial,shake it vigorously to mix. After obtainingcorrect dose, discard unused solution.• Reconstituted solution may turn light pinkon standing at room temperature. Thisdoesn’t affect drug potency.• Give I.V. bolus injection directly into I.V.tubing over 3 to 5 minutes.WARNING When preparing aztreonam forI.V. infusion, use at least 50 ml of appropriateinfusion solution per gram of aztreonam.Further dilute drug in I.V. solution,such as normal saline solution, D 5 W, dextrose5% in normal saline solution, lactatedRinger’s solution, or Ringer’s solution.• Know that I.V. infusion may be administeredover 20 to 60 minutes.• Flush I.V. tubing with solution, such asA

122aztreonamnormal saline solution, before and afteradministering I.V. infusion to reduce riskof incompatibilities.• If prescribed, mix aztreonam in same I.V.solution with other antibiotics (such asampicillin sodium, cefazolin sodium, clindamycinphosphate, gentamicin sulfate, ortobramycin sulfate), or mix it with cloxacillinsodium and vancomycin hydrochloridein peritoneal dialysis solution.• Prepare solution for I.M. injection usingsterile or bacteriostatic water or sodiumchloride for injection. Administer injectiondeep into large muscle, such as indorsogluteal or ventrogluteal area.• Assess for signs of bacterial or fungalsuperinfection, which may occur with prolongedor repeated therapy. If superinfectionoccurs, treat it as prescribed.• Monitor bowel elimination; if needed,obtain stool culture to rule outpseudomembranous colitis. If it occurs,expect to discontinue aztreonam andadminister fluid, electrolytes, and antibioticseffective against Clostridium difficile.• Evaluate patient’s renal and liver functiontest results, as ordered, if patient has renalor hepatic impairment.• Monitor renal function if patient is receivingan aminoglycoside because of theincreased risk of nephrotoxicity.PATIENT TEACHING• Stress the need to take full course of aztreonamexactly as prescribed, even if patientfeels better before finishing it.• Teach patient to recognize and immediatelyreport signs and symptoms of allergicreactions, such as chest tightness, difficultybreathing, hives, itching, and rash.• Warn patient that abdominal pain andloose, watery stools may occur 2 monthsor more after aztreonam therapy stops. Ifdiarrhea persists or becomes severe, urgehim to contact prescriber and replacefluids.• Because aztreonam may destroy normalflora, teach patient to watch for andimmediately report signs of superinfection,such as white patches in mouth.

BbacampicillinhydrochloridePenglobe (CAN), SpectrobidClass and CategoryChemical class: AminopenicillinTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat upper respiratory tract infections(including otitis media) caused bystreptococci, pneumococci, non–penicillinase-producingstaphylococci, andHaemophilus influenzae; UTI causedby Escherichia coli, Proteus mirabilis,or Streptococcus faecalis; skin and softtissueinfections caused by streptococciand susceptible staphylococciTABLETSAdults. 400 mg every 12 hr; 800 mg every12 hr for severe infections and those causedby less susceptible organisms.Children weighing 25 kg (55 lb) or more.25 mg/kg daily in divided doses every 12 hr;50 mg/kg daily in divided doses every 12 hrfor severe infections and those caused byless susceptible organisms. To treat lower respiratory tract infectionscaused by streptococci, pneumococci,non–penicillinase-producing staphylococci,and H. influenzaeTABLETSAdults. 800 mg every 12 hr.Children weighing 25 kg or more. 50 mg/kg/day in divided doses every 12 hr. To treat uncomplicated gonorrheacaused by Neisseria gonorrhoeaeTABLETSAdults. 1.6 g plus 1 g of probenecid as asingle dose.Route Onset Peak DurationP.O. Variable Unknown 12 hrbacampicillin hydrochloride 123Mechanism of ActionInhibits bacterial cell wall synthesis in susceptiblebacteria. These bacteria assemblerigid, cross-linked cell walls in several steps.Bacampicillin, which undergoes hydrolysisto ampicillin, affects final stage of crosslinkingby binding with and inactivatingpenicillin-binding protein (enzyme responsiblefor linking cell wall strands). This actioninhibits bacterial cell wall synthesis andcauses cell lysis and death.ContraindicationsCholestatic jaundice and hepatic dysfunctionassociated with amoxicillin and clavulanatepotassium; hypersensitivity to penicillins,cephalosporins, imipenem and cilastatin,or beta-lactamase inhibitors, such aspiperacillin and tazobactamInteractionsDRUGSallopurinol: Increased risk of rash from bacampicillinusebeta-adrenergic blockers: Increased risk ofanaphylaxisdisulfiram: Possibly disulfiram reactionwhen administered togetheroral contraceptives: Possibly reduced effectivenessof oral contraceptives, contraceptivefailure, and breakthrough bleedingtetracyclines: Possibly impaired bactericidaleffects of bacampicillinAdverse ReactionsCNS: Anxiety, confusion, depression,fatigue, fever, hallucinations, lethargy,malaise, neuromuscular irritability, seizures,stroke, syncopeCV: Hypotension, palpitations, periarteritisnodosa, pulmonary hypertension, tachycardia,vascular collapseEENT: Altered taste, black “hairy” tongue,blurred vision, glossitis, laryngospasm,mouth soreness, mucocutaneous candidiasis,stomatitis, taste disordersGI: Abdominal cramps or pain, anorexia,diarrhea, enterocolitis, epigastric distress,elevated liver function test results, gastritis,nausea, pseudomembranous colitis, vomitingGU: Elevated BUN and serum creatininelevels, hematuria, impotence, interstitialnephritis, neurogenic bladder, priapism,renal failure, vaginal candidiasisHEME: Agranulocytosis, anemia, bonemarrow depression, decreased hemoglobinlevel and hematocrit, eosinophilia, leukope-B

124bacitracinnia, neutropenia, prolonged PT, thrombocytopenia,thrombocytopenic purpuraMS: Arthralgia, arthritis exacerbationRESP: BronchospasmSKIN: Exfoliative dermatitis, rash, urticariaOther: Allergic reaction, lymphadenopathy,serum sicknessNursing Considerations• Obtain culture and sensitivity test results,if possible, before starting therapy. Expectto start drug before results are available.• Expect to continue treatment for at least48 hours after symptoms resolve or culturedetects no signs of infection.WARNING Expect to give bacampicillin for10 days to treat infection caused by groupA beta-hemolytic streptococci to preventdevelopment of acute rheumatic fever oracute glomerulonephritis.• Assess patient for bacterial or fungalsuperinfection, which may occur with prolongedor repeated therapy. If it occurs,expect to administer another antibiotic orantifungal drug.• Monitor bowel elimination; if needed,obtain stool culture to rule out pseudomembranouscolitis. If this adverse reactionoccurs, expect to discontinue bacampicillinand give fluid, electrolytes, andantibiotics effective against Clostridiumdifficile.PATIENT TEACHING• Teach patient to recognize and immediatelyreport signs of allergic reaction, includingrash, itching, hives, chest tightness,and difficulty breathing.• Warn that abdominal pain and loose,watery stools may occur. If diarrhea persistsor becomes severe, urge him to contactprescriber and drink plenty of fluids.• Because bacampicillin may destroy normalflora, teach patient to watch for andimmediately report signs of superinfection,such as white patches in mouth andvaginal itching and discharge.bacitracinBaci-IMClass and CategoryChemical class: Bacillus subtilis derivative(polypeptide)Therapeutic class: AntibioticPregnancy category: CIndications and Dosages To treat pneumonia and empyemacaused by susceptible staphylococciI.M. INJECTIONInfants weighing more than 2.5 kg (5.5 lb).1,000 units/kg daily in 2 or 3 divided doses.Infants weighing less than 2.5 kg. 900 units/kg daily in 2 or 3 divided doses.Route Onset Peak DurationI.M. Rapid Unknown About 6 hrMechanism of ActionInterferes with bacterial cell wall synthesisby binding with isoprenyl pyrophosphate (alipid-carrying molecule that transports substancesout of bacterial cells to help buildnew cell walls), forming an unusable complexin bacterial cells. This weakens cellwalls and causes lysis and death. Bacitracinis considered bacteriostatic and bactericidal.IncompatibilitiesDon’t dilute bacitracin with a solution thatcontains parabens.ContraindicationsHypersensitivity or toxic reaction to bacitracinInteractionsDRUGSaminoglycosides: Increased risk of respiratoryparalysis and renal dysfunctionnondepolarizing neuromuscular blockers:Possibly increased neuromuscular blockadeAdverse ReactionsGI: Nausea, vomitingGU: Albuminuria, azotemia, cylindricalmucus casts in urine, nephrotoxicitySKIN: RashOther: Injection site pain, superinfectionNursing Considerations• Obtain culture and sensitivity test resultsbefore therapy begins, if possible. Be preparedto start bacitracin therapy beforeresults are available.WARNING Use parenteral bacitracin for I.M.injection only.• For I.M. solution of 5,000 units/ml, reconstitute50,000 units bacitracin powderwith 9.8 ml sodium chloride for injection

that contains 2% procaine hydrochloride.• Administer I.M. injection into upper outerquadrant of buttocks, alternating betweenright and left sides. To prevent pain atinjection site, avoid giving multiple injectionsin same site.• During therapy, compare daily results ofrenal function tests with baseline results,as appropriate.• Assess urine output often (hourly, if needed),and replace fluids orally and parenterallyto maintain adequate renal function.WARNING Because of increased risk ofnephrotoxicity, avoid concurrent use ofother nephrotoxic drugs, such as streptomycin,kanamycin, polymyxin B, andneomycin.• Assess infant for signs of superinfection,especially white patches in mouth andperineum. If superinfection develops, planto treat with appropriate antibiotics.PATIENT TEACHING• Advise parents that daily blood tests areneeded to assess infant’s renal function.• Encourage parents to provide oral fluids topromote renal function. Teach them howto record infant’s fluid intake.• Instruct parents to report signs or symptomsof superinfection, such as whitepatches in mouth or perineal area andbright red diaper rash.baclofenApo-Baclofen (CAN), Lioresal, LioresalIntrathecal, Novo-Baclofen (CAN)Class and CategoryChemical class: Gamma-aminobutyric acid(GABA) chlorophenyl derivativeTherapeutic class: Skeletal muscle relaxant,spasmolyticPregnancy category: CIndications and Dosages To relieve symptoms of spasticity causedby multiple sclerosis (particularly flexorspasms and pain, clonus, and musclerigidity) and spasticity from spinal cordinjury or disease and brain injuryTABLETSAdults and children age 12 and over. 5 mgt.i.d. for 3 days; then 10 mg t.i.d. for 3 days;then 15 mg t.i.d. for 3 days; then 20 mgbaclofen 125t.i.d. for 3 days; then increased if needed upto 80 mg daily. Usual dosage ranges from40 to 80 mg daily. To relieve severe symptoms of spasticityof spinal cord origin when symptomsdon’t respond to oral drug or when oraldrug causes severe adverse CNS effectsINTRATHECAL BOLUS, INTRATHECAL INFUSIONAdults. For screening before implantablepump insertion: 50 mcg in 1 ml sterilepreservative-free sodium chloride for injectionas bolus injection into intrathecalspace over 1 min or more. After 4 to 8 hr, ifsymptoms don’t improve as much asdesired, second bolus of 75 mcg in 1.5 ml ofsterile preservative-free sodium chloride forinjection, injected after 24 hr, followed bythird bolus of 100-mcg/2 ml dilutioninjected after another 24 hr, if needed.After implantable pump insertion: Effectivescreening dose doubled and infused over24 hr. Or effective screening dose (if it provideddesired effects for more than 12 hr)infused over 24 hr.For spasticity of spinal cord origin afterimplantable pump insertion: After first 24 hr,daily dose increased by 10% to 30% onceevery 24 hr until desired effects achieved.For spasticity of cerebral origin afterimplantable pump insertion: Daily doseincreased by 5% to 15% once every 24 hruntil desired effects achieved.For long-term maintenance therapy in spasticityof spinal cord origin: 12 to 2,003 mcg/day (usual dose 300 to 800 mcg daily).Lowest possible therapeutic dose should beused. If adverse effects occur, daily dosemay be decreased by 10% to 20%. Duringperiodic pump refills, daily dose may beincreased by 10% up to 40% to controlsymptoms adequately.For long-term maintenance therapy in spasticityof cerebral origin: 90 to 703 mcg daily(usual) but ranging from 22 to 1,400 mcg/day. If adverse effects occur, daily dose maybe decreased by 10% to 20%. During periodicpump refills, daily dose may beincreased by 5% to 20% to control symptomsadequately.Children. For screening before implantablepump insertion: 1 ml of 50-mcg/ml dilutionor 1 ml of 25-mcg/ml dilution (if child isvery young) as bolus injection intointrathecal space over 1 min or more. AfterB

126baclofen4 to 8 hr, if symptoms don’t improve asdesired, second bolus of 75 mcg in 1.5 ml ofsterile preservative-free sodium chloride forinjection, injected after 24 hr, followed bythird bolus of 100-mcg/2 ml dilution,injected after another 24 hr, if needed.After implantable pump insertion: Dailydose increased by 5% to 15% once every24 hr until desired effect is achieved.For maintenance therapy: In children overage 12—90 to 703 mcg daily (usual), rangingfrom 22 to 1,400 mcg daily. In childrenunder age 12—274 mcg daily (average),ranging from 24 to 1,199 mcg daily.DOSAGE ADJUSTMENT Dosage reduced forpatients with renal impairment becausedrug is excreted primarily unchanged bykidneys.Route Onset Peak DurationP.O. Hours– Unknown UnknownweeksIntrathecal 30–60 About 4–8 hrbolus min 4 hrinjectionIntrathecal 6–8 hr 24–48 hr UnknowninfusionMechanism of ActionMay inhibit transmission of monosynapticand polysynaptic impulses, similar to effectsof gamma-aminobutyric acid (GABA).Baclofen may work in the spinal cord at theafferent spinal end of upper motor neurons,where it hyperpolarizes nerve fibersand inhibits impulse transmission. Thisreduces excess muscle activity caused bymuscle hypertonia, spasms, and spasticity.ContraindicationsHypersensitivity to baclofen; treatment ofskeletal muscle spasm resulting from rheumaticdisorders, cerebral palsy, Parkinson’sdisease, or stroke (oral form only)InteractionsDRUGSCNS depressants: Possibly increased CNSdepressionepidural morphine: Possibly hypotensionand dyspneaACTIVITIESalcohol use: Possibly increased CNS depressionAdverse ReactionsCNS: Abnormal gait, anxiety, ataxia, chills,coma, confusion, depression, dizziness,drowsiness, dystonia, emotional lability,euphoria, excitement, fatigue, fever, hallucinations,headache, hypertonia, hypothermia,hypotonia, impaired concentration,insomnia, lack of coordination, lethargy,memory loss, paresthesia, personality disorder,seizures, somnolence, stroke, syncope,tremor, weaknessCV: Bradycardia, chest pain, chest tightness,deep vein thrombosis, hypertension, orthostatichypotension, palpitations, peripheraledemaEENT: Amblyopia, blurred vision, diplopia,dry mouth, miosis, mydriasis, nasal congestion,nystagmus, photophobia, ptosis, rhinitis,slurred speech, strabismus, taste loss,tinnitusENDO: HyperglycemiaGI: Abdominal pain, anorexia, constipation,dysphagia, elevated liver function testresults, flatulence, ileus, indigestion, nausea,vomitingGU: Albuminuria, bladder spasms, dysuria,enuresis, hematuria, impotence, renal failure,sexual dysfunction, urinary frequency,urinary incontinence, urine retentionHEME: AnemiaMS: Muscle twitchingRESP: Aspiration pneumonia, pulmonaryembolism, respiratory depressionSKIN: Alopecia, diaphoresis, facial edema,flushing, pruritus, rash, urticaria, wounddehiscenceOther: Dehydration, infection at pumpimplantation site, weight lossNursing Considerations• Expect to start baclofen therapy at a lowdose and gradually increase until desiredeffects are achieved.WARNING Before screening dose is given,expect prescriber to make sure patient isfree of infection to prevent systemic infectionfrom interfering with patient’sresponse. Before implantable pump insertion,also expect prescriber to make surepatient is free of infection to reduce risk ofcomplications and interference with determiningmost appropriate dose.• Use baclofen cautiously in patients with ahistory of autonomic dysreflexia.Nociceptor stimulation may precipitate

autonomic dysreflexia. Be aware thatabrupt withdrawal of intrathecal infusionmay produce symptoms similar to autonomicdysreflexia, high fever, life-threateningcomplications such as multiple organsystemfailure, and death.WARNING Never give intrathecal form ofbaclofen by I.V., I.M., or subcutaneousroutes.• Assess for signs of effectiveness, such asrelief of spasms, pain, and muscle rigidity.• Because CNS depression can occur, takeprecautions to prevent injury. Also takeprecautions for patients who use spasticityto maintain locomotion or upright postureand balance. Relief of spasticity mayincrease risk of falls and injury.WARNING Because continuous intrathecalinfusion increases risk of life-threateningCNS depression, keep emergency equipmentnearby.• Expect baclofen to be discontinued slowly;hallucinations and seizures may occurwith abrupt withdrawal.PATIENT TEACHING• Teach patient how to care for and operateprogrammable implanted pump. Have herdemonstrate all procedures.• Advise against stopping baclofen abruptly.Stress the importance of keeping followupappointments for intrathecal infusion.• Instruct patient to avoid driving and otheractivities that require mental alertness,coordination, or physical dexterity untilbaclofen’s effects are known.• Urge patient to contact prescriber beforetaking OTC drugs, such as cough syrupsand cold remedies, which may increaserisk of sedation.• Urge patient to notify prescriber if spasticityincreases or drug is no longer effective.balsalazidedisodiumColazalClass and CategoryChemical class: Prodrug of 5-aminosalicylicacid (5-ASA)Therapeutic class: Anti-inflammatoryPregnancy category: Bbalsalazide disodium 127Indications and Dosages To treat mildly to moderately activeulcerative colitisCAPSULESAdults. 2.25 g t.i.d. for 8 wk. Maximum:6.75 g daily for 12 wk.Children ages 5 to 17. 750 mg or 2.25 gt.i.d. for up to 8 wk.Mechanism of ActionAfter it has been metabolized to 5-ASA, balsalazidemay reduce inflammation byinhibiting the enzyme cyclooxygenase anddecreasing production of arachidonic acidmetabolites, which may be increased inpatients with inflammatory bowel disease.Cyclooxygenase is needed to formprostaglandin from arachidonic acid.Prostaglandin mediates inflammatory activityand produces signs and symptoms ofinflammation. By inhibiting prostaglandinsynthesis, balsalazide may reduce signs andsymptoms of inflammation in inflammatorybowel disease.Balsalazide also interferes withleukotrine synthesis and inhibits theenzyme lipoxygenase. These substances areinvolved in the inflammatory response.ContraindicationsHypersensitivity to balsalazide, salicylates,or their componentsAdverse ReactionsCNS: Fatigue, fever, headache, insomniaCV: Myocarditis, pericarditis, vasculitisEENT: Dry mouth, nasopharyngitis,pharyngitis, rhinitis, stomatitisGI: Abdominal cramps or pain, anorexia,cirrhosis, constipation, diarrhea, dyspepsia,elevated liver enzyme levels, exacerbation ofcolitis, flatulence, hepatotoxicity, jaundice,nausea, pancreatitis, vomitingGU: Dysmenorrhea, interstitial nephritis,renal failure, UTIMS: Arthralgia, myalgiaRESP: Alveolitis, cough, flulike syndrome,pleural effusion, pneumonia, respiratorytract infectionSKIN: Alopecia, pruritusNursing ConsiderationsWARNING Monitor patients who are sensitiveto sulfasalazine or olsalazine for possiblecross-sensitivity to balsalazide.• Monitor patients with pyloric stenosis forB

128basiliximabdecreased or delayed drug effects due toprolonged gastric retention of balsalazidecapsules.• Monitor patient for possible exacerbationof colitis symptoms.PATIENT TEACHING• Inform patient that balsalazide is used toreduce bowel inflammation and pain inulcerative colitis and to minimize recurringinflammation.• Instruct patient to swallow capsules whole,with a full glass of water, and not to crushor chew them.• Advise patient to notify prescriber of anyother drugs she may be taking, includingOTC drugs, nutritional supplements, andherbal products, because they may interactwith balsalazide.• Instruct patient to notify prescriber immediatelyif colitis symptoms worsen.• Inform patient that she can expect someimprovement in symptoms in 3 to 21 daysbut that optimal results may take up to6 weeks of treatment.basiliximabSimulectClass and CategoryChemical class: Chimeric (murine orhuman) monoclonal antibodyTherapeutic class: ImmunosuppressantPregnancy category: BIndications and Dosages To prevent acute rejection in kidneytransplantationI.V. INFUSION OR INJECTIONAdults and adolescents over age 15. 20 mgwithin 2 hr before transplantation; then20 mg 4 days after transplantation.Children and adolescents ages 2 to 15.12 mg/m 2 within 2 hr before transplantation;then 12 mg/m 2 4 days after transplantation.Maximum: 20 mg/dose.Route Onset Peak DurationI.V. Unknown Unknown 22–50 daysMechanism of ActionInitiates immunosuppression by blockinginterleukin-2 receptors located on the surfaceof activated T cells. Normally, interleukin-2is released by stimulated T lymphocytes,causing activation and differentiationof other T lymphocytes responsiblefor cell-mediated immunity.IncompatibilitiesDon’t add or infuse any other drugs simultaneouslythrough same I.V. line.ContraindicationsHypersensitivity to basiliximab or its componentsAdverse ReactionsCNS: Asthenia, dizziness, fever, headache,insomnia, tremorCV: Hypertension, peripheral edemaEENT: Oral candidiasis, pharyngitis, rhinitisENDO: HyperglycemiaGI: Abdominal pain, constipation, diarrhea,indigestion, nausea, vomitingGU: Dysuria, increased urinary nitrogenlevel, UTIHEME: AnemiaMS: Back pain, leg painRESP: Cough, dyspnea, upper respiratorytract infectionSKIN: AcneOther: Hypercholesterolemia, hyperkalemia,hyperuricemia, hypocalcemia,hypokalemia, hypophosphatemia, impairedwound healing, injection site reaction,metabolic acidosis, weight gainNursing Considerations• To reconstitute basiliximab, add 5 ml sterilewater for injection to powder and shakevial gently to dissolve. Further dilute withnormal saline solution or D 5 W for infusionto a volume of 50 ml. Gently invertinfusion bag to avoid foaming; don’tshake. Drug should appear clear to opalescentand colorless.• Give reconstituted drug I.V. over 20 to30 minutes or as bolus dose directlythrough central or peripheral I.V. line. Beaware that bolus dose may cause nausea,vomiting, and a localized injection-sitereaction, including pain.• Expect drug to be given as adjunct tocyclosporine and corticosteroids.• Don’t store drug at room temperature forlonger than 4 hours; don’t refrigerate forlonger than 24 hours.

WARNING Patient may develop hypersensitivityreactions (anaphylaxis, bronchospasm,dyspnea, hypotension, pruritus,rash, respiratory failure, sneezing, tachycardia,urticaria, wheezing) on initialexposure or following re-exposure afterseveral months. Notify prescriber immediatelyif such reactions occur.PATIENT TEACHING• Inform patient that second dose of basiliximabwill be given 4 days after transplantationand that she may also receivecyclosporine and corticosteroid therapy.• Inform patient that because of drug’simmunosuppressant effects, she may experienceslower wound healing and be moresusceptible to upper respiratory tractinfections.beclomethasonedipropionateBeclodisk (CAN), Beclovent Rotacaps(CAN), Beconase, Beconase AQ, QVAR,Vancenase, VancerilClass and CategoryChemical class: Synthetic glucocorticoidTherapeutic class: Antiasthmatic, antiinflammatoryPregnancy category: CIndications and Dosages To control and prevent symptoms inpatients with chronic asthma and thosewho also require oral corticosteroidsINHALATION AEROSOL (84 MCG)Adults and children age 12 and over.Initial: 2 inhalations (168 mcg) b.i.d. Forpatients with severe asthma, 6 to 8 inhalations(504 to 672 mcg) daily with dosagereduced based on patient response.Maximum: 10 inhalations (840 mcg) daily.Children ages 6 to 12. Initial: 2 inhalations(168 mcg) b.i.d. Maximum: 5 inhalations(420 mcg) daily.INHALATION AEROSOL (42 MCG)Adults and children age 12 and over.Initial: 2 inhalations (84 mcg) t.i.d. or q.i.d.or 4 inhalations (168 mcg) b.i.d. Forpatients with severe asthma, 12 to 16inhalations (504 to 672 mcg) daily withdosage reduced based on patient response.ContraindicationsHypersensitivity to beclomethasone’s ingrebeclomethasonedipropionate 129Maximum: 20 inhalations (840 mcg) daily.Children ages 6 to 12. Initial: 1 or 2 inhalations(42 mcg or 84 mcg) t.i.d. or q.i.d. or4 inhalations (168 mcg) b.i.d. with dosagereduced based on patient response.Maximum: 10 inhalations (420 mcg) daily.INHALATION AEROSOL (40 MCG, 80 MCG [QVAR])Adults and adolescents. Initial for patientspreviously taking bronchodilators alone: 1 to2 inhalations (40 to 80 mcg) b.i.d., dependingon strength used. Maximum: 4 to8 inhalations (320 mcg) b.i.d., dependingon strength used. Initial for patients previouslytaking inhaled corticosteroids: 1 to4 inhalations (160 mcg) b.i.d., dependingon strength used. Maximum: 4 to 8 inhalations(320 mcg) b.i.d., depending onstrength used.Children ages 5 to 11. 1 inhalation(40 mcg) b.i.d. Maximum: 1 to 2 inhalations(80 mcg) b.i.d., depending onstrength used. To relieve symptoms of seasonal orperennial allergic and nonallergic (vasomotor)rhinitis and prevent nasal polypsfrom recurring after surgical removalNASAL INHALATION AEROSOLAdults and children age 12 and over.Initial: 1 inhalation (42 mcg) in each nostrilb.i.d. to q.i.d. for total dose of 168 to336 mcg daily. Maintenance: 1 inhalation(42 mcg) in each nostril t.i.d. for total doseof 252 mcg daily.Children ages 6 to 12. 1 inhalation (42 mcg)in each nostril t.i.d. for total dose of252 mcg daily.NASAL SPRAYAdults and children age 12 and over. 1 or2 inhalations (42 or 84 mcg) in each nostrilb.i.d. for total dose of 168 or 336 mcg daily.Mechanism of ActionMay decrease number and activity of cellsinvolved in the inflammatory response ofasthma, allergies, and rhinitis, such as mastcells, eosinophils, basophils, lymphocytes,macrophages, and neutrophils. Also mayinhibit production or secretion of chemicalmediators, such as histamine, eicosanoids,leukotrienes, and cytokines. May producedirect smooth-muscle cell relaxation anddecrease airway hyperresponsiveness.B

130• If patient has acute asthma attack orincreased wheezing after receivingbeclomethasone, give fast-acting bronchodilator,as prescribed. Expect to discontinuebeclomethasone.• Assess for signs of candidiasis, such asthick white plaques or coating on tongueand sides of mouth. If present, notify prescriberand expect to reduce dose or frequencyor to stop beclomethasone. Alsoanticipate treatment with antifungal drug.• When administering beclomethasonenasal spray, periodically assess nasal dischargefor color or consistency changes,which may indicate infection.• Monitor the growth of children receivingbeclomethasone nasally.PATIENT TEACHING• Advise patient not to abruptly stop takingbeclomethasone because adrenal insufficiencymay occur. Urge her to notify prescriberif she develops signs of adrenalinsufficiency, such as nausea, fatigue,anorexia, dyspnea, hypotension, fever,malaise, dizziness, and fainting.• Before patient uses nasal spray for firsttime, instruct her to prime pump by placingher thumb on its base and her indexand middle fingers on its shoulder areaand then pressing her thumb firmly andquickly against the bottle several times oruntil fine mist appears. Before patient usesnasal inhalation canister for first time,instruct her to shake it and check that it’sworking properly by spraying it once inthe air while looking for fine mist.• Teach patient to inhale deeply after eachnasal spray or inhalation, exhalingthrough mouth and tilting head back tolet drug spread over the nasopharynx.• Teach patient how to properly use oralinhalation aerosol, shaking canister wellbefore using. If patient has trouble usingdevice and coordinating inhalation with it,suggest using a spacer device.• If two inhalations are prescribed, advisepatient to wait a minute between them.• If patient uses an inhaled bronchodilatorwith beclomethasone oral inhalation, tellher to use bronchodilator first, wait5 minutes, and then use beclomethasone.WARNING Warn patient that beclomethasoneisn’t intended to relieve acute bronchospasm.Urge patient to notify prebeclomethasonedipropionatedients, infrequent oral corticosteroid treatment,primary treatment of status asthmaticusor other acute asthma attack, reliefof acute bronchospasm or of asthma controlledby bronchodilators or other nonsteroidaldrugs, treatment of nonasthmaticbronchitisAdverse ReactionsCNS: Depression, fatigue, fever, headache,insomnia, light-headednessCV: Chest pain, tachycardiaEENT: Cataracts, dry mouth, dysphonia,earache, epistaxis, glaucoma, hoarseness,lacrimation, nasal congestion, nose andthroat dryness and irritation, oral candidiasis,pharyngitis, rhinorrhea, sinusitis, sneezing,unpleasant smell and tasteENDO: Adrenal insufficiency, cushingoidsymptomsGI: Diarrhea, indigestion, nausea, rectalhemorrhageGU: Dysmenorrhea, UTIMS: Arthralgia, growth suppression in children(nasal aerosol)RESP: Bronchitis, bronchospasm, chestcongestion, cough, pulmonary infiltrates,upper respiratory tract infection, wheezingSKIN: Acne, eczema, pruritus, rash, skindiscoloration, urticariaOther: Angioedema, flulike symptoms,lymphadenopathy, weight gainNursing Considerations• If patient also takes an oral corticosteroid,expect to taper dosage slowly (by decreasingdaily dosage or taking drug every otherday) about 1 week after beclomethasonetherapy begins. Expect dosage reductionsof more than 2.5 mg daily.WARNING When gradually switchingpatient from oral corticosteroid to inhaledbeclomethasone, watch for signs of lifethreateningadrenal insufficiency, such asfatigue, lassitude, weakness, nausea, vomiting,and hypotension, during transitionperiod and when exposed to trauma, surgery,infection, or other stressor. If signsoccur, notify prescriber immediately.• Expect to resume oral corticosteroid duringa stressful period or severe asthmaattack.• Because beclomethasone may be absorbedsystemically, watch for signs of adrenalinsufficiency during periods of stress.

scriber if asthma symptoms don’t respond.• Advise patient to wear medical identificationthat states need for supplemental oralcorticosteroids during stress or severeasthma attack. Inform patient that prescribermay order high-dose oral corticosteroidtherapy.WARNING Caution patient to avoid exposureto chickenpox and measles becausedrug may cause immunosuppression. Ifshe’s exposed to these disorders, urge herto notify prescriber immediately.belladonnaalkaloidsClass and CategoryChemical class: Tertiary amineTherapeutic class: GI anticholinergicPregnancy category: CIndications and Dosages To treat peptic ulcer disease, functionaldigestive disorders (including spastic,mucous, and ulcerative colitis), diarrhea,diverticulitis, pancreatitis, dysmenorrhea,nocturnal enuresis, idiopathicand postencephalitic parkinsonism,motion sickness, and nausea andvomiting of pregnancyTABLETSAdults. 0.25 to 0.5 mg t.i.d.Children over age 6. 0.125 to 0.25 mg t.i.d.TINCTUREAdults. 0.6 to 1 ml t.i.d. or q.i.d.Children. 0.03 ml/kg (0.8 ml/m2) t.i.d.Route Onset Peak DurationP.O. 1–2 hr Unknown 4 hrMechanism of ActionInhibits acetylcholine’s muscarinic actionsat postganglionic parasympathetic receptorsites, including smooth muscles, secretoryglands, and CNS. These actions relaxsmooth muscles and diminish GI, GU, andbiliary tract secretions.belladonna alkaloids 131ContraindicationsHepatic disease, hypersensitivity to anticholinergicdrugs or scopolamine, ileus, myastheniagravis, myocardial ischemia, narrowangleglaucoma, obstructive condition of GIor GU tract, renal disease, severe ulcerativecolitis, tachycardia, toxic megacolon, unstablecardiovascular status in acute hemorrhageInteractionsDRUGSamantadine: Increased adverse anticholinergiceffectsatenolol, digoxin: Possibly increased therapeuticand adverse effects of these drugsphenothiazines: Possibly decreasedphenothiazine effectiveness and increasedadverse effects of belladonna alkaloidstricyclic antidepressants: Possibly increasedadverse anticholinergic effectsAdverse ReactionsCNS: CNS stimulation (with high doses),confusion, dizziness, drowsiness, headache,insomnia, nervousness, weaknessCV: Bradycardia, palpitations, tachycardiaEENT: Altered taste, blurred vision, drymouth, increased intraocular pressure,mydriasis, nasal congestion, photophobiaGI: Bloating, constipation, dysphagia,heartburn, ileus, nausea, vomitingGU: Impotence, urinary hesitancy, urineretentionSKIN: Decreased sweating, flushing,urticariaOther: AnaphylaxisNursing Considerations• Avoid using high doses of belladonnaalkaloids in ulcerative colitis because theymay inhibit intestinal motility and precipitateor aggravate toxic megacolon. Alsoavoid high doses in hiatal hernia andreflux esophagitis because they may aggravateesophagitis.• Use belladonna alkaloids cautiously inpatients with allergies, arrhythmias, asthma,autonomic neuropathy, coronaryartery disease, debilitating chronic lungdisease, heart failure, hypertension, hyperthyroidism,and prostatic hypertrophy.• Give drug 30 to 60 minutes before a meal.WARNING Monitor patient for excitement,agitation, drowsiness, and confusion.Elderly patients are more sensitive to theeffects of the drug, even small doses, andare more likely to develop adverse reactions.Dosage may need to be decreased.• Take safety precautions to protect patientB

132Adverse ReactionsCNS: Anxiety, asthenia, dizziness, drowsiness,fatigue, headache, hypertonia, insomnia,nervousness, paresthesia, sleep disturbance,somnolence, syncope, weaknessCV: Angina, ECG changes, hypotension,orthostatic hypotension, palpitations, peripheraledemaEENT: SinusitisENDO: HyperglycemiaGI: Abdominal pain, constipation, elevatedliver function test results, gastritis, melena,nausea, pancreatitis, small bowel angiobenazeprilhydrochloridefrom injury from falling.PATIENT TEACHING• Instruct patient to take belladonna alkaloids30 to 60 minutes before eating.• Tell patient to notify prescriber if she haspersistent or severe diarrhea, constipation,or difficulty urinating.• Caution patient to avoid driving and similaractivities until the effects of belladonnaalkaloids are known.WARNING Urge patient to avoid extremeheat and humidity because heatstrokecould occur.benazeprilhydrochlorideLotensinClass and CategoryChemical class: Ethylester of benazeprilatTherapeutic class: AntihypertensivePregnancy category: DIndications and Dosages To control hypertension alone or with athiazide diureticTABLETSAdults who don’t receive a diuretic. Initial:10 mg daily. Maintenance: 20 to 40 mg dailyas a single dose or in two divided doses.Adults who receive a diuretic. 5 mg daily.DOSAGE ADJUSTMENT Initial dosage of5 mg/day for patients with impaired renalfunction and creatinine clearance less than30 ml/min/1.73 m 2 ; then increased graduallyuntil blood pressure is controlled ordosage reaches maximum of 40 mg daily.TABLETS, SUSPENSIONChildren age 6 and over with glomerularfiltration rate of 30 ml/min/1.73 m 2 orhigher. Initial: 0.2 mg/kg daily. Maximum:0.6 mg/kg daily or 40 mg daily.Route Onset Peak DurationP.O. 1 hr 2–4 hr 24 hrMechanism of ActionMay reduce blood pressure by affectingrenin-angiotensin-aldosterone system. Byinhibiting angiotensin-converting enzyme,benazepril:• prevents conversion of angiotensin I toangiotensin II, a potent vasoconstrictorthat also stimulates aldosterone release.• may inhibit renal and vascular productionof angiotensin II.• decreases serum angiotensin II level andincreases serum renin activity. Thisdecreases aldosterone secretion, slightlyincreasing serum potassium level and fluidloss.• decreases vascular tone and blood pressure.• inhibits aldosterone release, which reducessodium and water resorption, increasestheir excretion, and reduces blood pressure.ContraindicationsHistory of angioedema, hypersensitivity tobenazepril or other ACE inhibitorInteractionsDRUGSantacids: Possibly decreased bioavailabilityof benazepril; separate doses by 2 hoursantidiabetics (oral): Possibly increased riskof hypoglycemiacapsaicin: Possibly induction or exacerbationof ACE cough caused by benazeprildigoxin: Increased serum digoxin leveldiuretics: Possibly excessive hypotensionindomethacin: Reduced hypotensive effectsof benazeprillithium: Increased serum lithium level andrisk of lithium toxicityphenothiazines: Possibly increased therapeuticand adverse effects of benazeprilpotassium preparations, potassium-sparingdiuretics: Possibly increased serum potassiumlevelsodium aurothiomalate: Increased risk ofnitritoid reactions, such as facial flushing,nausea, vomiting, and hypotension

edema, vomitingGU: Decreased libido, elevated BUN andserum creatinine levels, impotence,nephrotic syndrome, proteinuria, renalinsufficiency, UTIHEME: Agranulocytosis, decreased hemoglobinlevel, leukopenia, neutropenia,thrombocytopeniaMS: Arthralgia, arthritis, myalgiaRESP: ACE cough, asthma, bronchitis,bronchospasm, dyspneaSKIN: Dermatitis, diaphoresis, flushing,photosensitivity, pruritus, rashOther: Anaphylaxis, angioedema, hyperkalemia,hyponatremiabenzonatate 133Nursing Considerations• Evaluate blood pressure with patient lyingdown, sitting, and standing before startingbenazepril and then every 4 to 8 hours, asappropriate, to monitor effectiveness.• Monitor urine output and BUN andserum creatinine levels, as needed, beforetherapy.WARNING Be alert for angioedema, especiallyafter first dose. If it extends to larynxand patient has laryngeal stridor or signsof airway obstruction, prepare to give epinephrinesubcutaneously immediately, asprescribed, and discontinue benazepril.• Monitor WBC count periodically to detectneutropenia and agranulocytosis.• Check serum potassium and other electrolytelevels to detect electrolyte imbalances.• To prevent injury caused by orthostatichypotension, take safety precautions, suchas having patient change positions slowlyand sit on edge of bed before arising.PATIENT TEACHING• Teach patient how to monitor blood pressure,if appropriate, and how to recognizesigns of hypertension and hypotension.WARNING Strongly urge patient to contactprescriber before using any OTC salt substitutes,which may contain potassium, orpotassium supplements. These substancesincrease the risk of hyperkalemia.• Explain that a persistent dry cough maydevelop and may not subside unlessbenazepril is stopped. If cough becomesbothersome or interferes with sleep oractivities, tell her to notify prescriber.WARNING Instruct patient to contact prescriberimmediately if she has signs ofangioedema, such as swelling of the face,eyes, lips, or tongue.• Caution patient to avoid sudden positionchanges and to rise slowly from sitting orlying to minimize orthostatic hypotension.WARNING Advise patient to stop benazepriland notify prescriber as soon as possible ifshe experiences syncope.WARNING Caution women of childbearingage to use reliable contraception and tonotify prescriber immediately if pregnancyis suspected. Benazepril may cause fetalharm and should be discontinued.benzonatateBenzonatate Softgels, Tessalon PerlesClass and CategoryChemical class: Para-aminobenzoic acid(tetracaine-like)Therapeutic class: Nonnarcotic antitussivePregnancy category: CIndications and Dosages To relieve coughCAPSULESAdults and children over age 10. 100 mgt.i.d. up to 600 mg daily.Route Onset Peak DurationP.O. 15–20 min Unknown 3–8 hrMechanism of ActionAnesthetizes stretch receptors in respiratorytract, lung tissue, and pleura, interferingwith their activity and reducing coughreflex at its source. In usual doses, benzonatatedoesn’t inhibit respiratory center.ContraindicationsHypersensitivity to benzonatate or relatedcompoundsAdverse ReactionsCNS: Confusion, hallucinations, headache,mild dizziness, sedationCV: Cardiogenic shock, chest numbnessEENT: Burning eyes, laryngospasm, nasalcongestionGI: Constipation, GI upset, nauseaRESP: BronchospasmSKIN: Pruritus, rashB

134benzquinamide hydrochloride; benztropine mesylateNursing Considerations• Assess type and frequency of cough. Don’ttry to suppress cough with benzonatate ifcough has therapeutic benefit, such as tomove secretions and improve airflow.WARNING Don’t break or crush capsules orlet patient chew or dissolve them in hermouth. Releasing drug in the mouth mayanesthetize mouth and throat, causing riskof choking. Also don’t let patient suck orchew capsule to prevent severe hypersensitivityreaction.PATIENT TEACHING• Instruct patient to swallow capsules wholeand not to chew, suck, or open them.• Warn patient that mild dizziness and sedationmay occur. Teach her to take safetymeasures, and encourage her to avoidactivities that require mental alertnessuntil benzonatate’s effects are known.benzquinamidehydrochlorideEmete-ConClass and CategoryChemical class: Benzoquinolizine amideTherapeutic class: AntiemeticPregnancy category: Not ratedIndications and Dosages To treat nausea and vomiting related toanesthesia or surgeryI.V. OR I.M. INJECTIONAdults. 50 mg or 0.5 to 1 mg/kg I.M.,repeated in 1 hr, then every 3 to 4 hr, p.r.n.Or 25 mg or 0.2 to 0.4 mg/kg by slow infusion(1 ml every 0.5 to 1 min) as a singledose. Then, I.M. doses begin. To prevent nausea and vomiting relatedto anesthesia and surgeryI.M. INJECTIONAdults. 50 mg or 0.5 to 1 mg/kg 15 minbefore emergence from anesthesia.Route Onset Peak DurationI.V., I.M. 15 min Unknown UnknownMechanism of ActionExhibits antiemetic, antihistaminic, mildcholinergic, and sedative effects byunknown mechanism.ContraindicationsHypersensitivity to benzquinamide or itscomponentsInteractionsDRUGSvasopressors: Increased hypertensive effectsAdverse ReactionsCNS: Chills, dizziness, drowsiness, excitement,fatigue, fever, headache, insomnia,nervousness, restlessness, tremor, weaknessCV: Atrial fibrillation, hypertension, hypotension,premature atrial or ventricularcontractionsEENT: Blurred vision, dry mouth, increasedsalivationGI: Anorexia, hiccups, nauseaMS: Muscle twitchingSKIN: Diaphoresis, flushing, rash, urticariaNursing ConsiderationsWARNING Avoid I.V. route in patients withcardiovascular disease because suddenblood pressure increases and transientarrhythmias may occur. Use I.V. route onlyfor patients without cardiovascular diseasewho aren’t receiving a preanesthetic orcardiovascular drug.• Administer benzquinamide I.M. into large,well-developed muscle. Avoid using deltoidmuscle unless it’s well developed.• Take safety precautions to reduce the riskof injury from CNS depression.PATIENT TEACHING• Advise patient to stay in bed and call forassistance to reduce risk of injury.• Tell patient to report whether nausea andvomiting have been relieved.benztropinemesylateApo-Benztropine (CAN), Cogentin, PMSBenztropine (CAN)Class and CategoryChemical class: Tertiary amineTherapeutic class: Antiparkinsonian, centralactinganticholinergicPregnancy category: CIndications and Dosages As adjunct, to treat all forms ofParkinson’s disease

TABLETS, I.M. OR I.V. INJECTIONAdults with Parkinson’s disease. 1 to 2 mgdaily (usual dose) with a range of 0.5 to6 mg daily.Adults with idiopathic Parkinson’s disease.Initial: 0.5 to 1 mg at bedtime.Maximum: 4 to 6 mg daily.Adults with postencephalitic Parkinson’sdisease. 2 mg daily in one or more doses;may begin with 0.5 mg at bedtime andincrease as needed. To control extrapyramidal symptoms(except tardive dyskinesia) caused byphenothiazines and other neurolepticsTABLETS, I.M. OR I.V. INJECTIONAdults. 1 to 4 mg once or twice daily. To treat acute dystonic reactionsTABLETS, I.M. OR I.V. INJECTIONAdults. Initial: 1 to 2 ml (1 to 2 mg totaldose) I.V. or I.M. Maintenance: 1 to 2 mgP.O. b.i.d. to prevent recurrence.Route Onset Peak DurationP.O. 1–2 hr Unknown 24 hrI.V., I.M 15 min Unknown 24 hrMechanism of ActionBlocks acetylcholine’s action at cholinergicreceptor sites. This restores the brain’s normaldopamine and acetylcholine balance,which relaxes muscle movement anddecreases drooling, rigidity, and tremor.Benztropine also may inhibit dopaminereuptake and storage, which prolongsdopamine’s action.ContraindicationsAchalasia, bladder neck obstruction, glaucoma,hypersensitivity to benztropine mesylateor its components, megacolon, myastheniagravis, prostatic hypertrophy, pyloricor duodenal obstruction, stenosing pepticulcerInteractionsDRUGSamantadine: Possibly increased adverseanticholinergic effectsdigoxin: Possibly increased digoxin levelhaloperidol: Possibly increased schizophrenicsymptoms, decreased serumhaloperidol level, and development of tardivedyskinesialevodopa: Possibly decreased levodopa effectivenessbenztropine mesylate 135phenothiazines: Possibly reduced phenothiazineeffects and increased psychiatricsymptomsAdverse ReactionsCNS: Agitation, confusion, delirium, delusions,depression, disorientation, dizziness,drowsiness, euphoria, excitement, fever, hallucinations,headache, light-headedness,listlessness, memory loss, nervousness,paranoia, psychosis, weaknessCV: Hypotension, mild bradycardia, orthostatichypotension, palpitations, tachycardiaEENT: Blurred vision, diplopia, dry mouth,increased intraocular pressure, mydriasis,narrow-angle glaucoma, suppurativeparotitisGI: Constipation, duodenal ulcer, epigastricdistress, ileus, nausea, vomitingGU: Dysuria, urinary hesitancy, urineretentionMS: Muscle spasms, muscle weaknessSKIN: Decreased sweating, dermatoses,flushing, rash, urticariaNursing Considerations• Expect to administer I.V. or I.M. benztropinewhen patient needs more rapidresponse than oral drug can provide. Beaware that I.M. route is commonly usedbecause it provides effects in about thesame time as I.V. route. Watch forimprovement a few minutes after administration.If Parkinsonian symptoms reappear,expect to repeat dose.• Therapy typically begins with a low dosefollowed by gradual increases of 0.5 mgevery 5 or 6 days because benztropine hasa cumulative action.• Assess muscle rigidity and tremor at baseline.Then monitor them often forimprovement, which indicates drug’seffectiveness.• Give drug before or after meals based onpatient’s need and response. If patient hasincreased salivary secretions, expect toadminister benztropine after meals. Ifpatient has dry mouth, plan to give drugbefore meals unless nausea develops.WARNING When giving drug to patient withdrug-induced extrapyramidal reactions,watch for worsening psychiatric symptoms.• High-dose benztropine therapy may causeweakness and inability to move specificmuscle groups. If this occurs, expect toB

136Adverse ReactionsCNS: Amnesia, anxiety, asthenia, depression,dizziness, drowsiness, fever, hallucinations,headache, insomnia, nervousness,paranoia, paresthesia, psychosis, syncope,tremor, vertigoCV: Edema, hypertension, palpitations,premature ventricular contractions, prolongedQT interval, sinus bradycardia ortachycardia, torsades de pointes, vasodilation,ventricular fibrillation, ventriculartachycardiaEENT: Altered taste, blurred vision, drymouth, pharyngitis, rhinitis, tinnitusGI: Abdominal cramps or discomfort, anorexia,appetite increase, constipation, diarbepridilhydrochloridereduce benztropine dosage.PATIENT TEACHING• Warn patient that drug has a cumulativeeffect, increasing risk of adverse reactionsand overdose.• Caution against driving and similar activitiesuntil benztropine’s effects are knownbecause it may cause blurred vision, dizziness,or drowsiness.WARNING Because benztropine decreasessweating, urge patient to avoid extremelyhot or humid conditions to reduce risk ofheatstroke and severe hyperthermia. Thisis especially important for elderly patientsand those who abuse alcohol or havechronic illness or CNS disease.• Stress need for periodic eye examinationsand intraocular pressure measurementsbecause drug may cause narrow-angle glaucomaand increase intraocular pressure.bepridilhydrochlorideVascorClass and CategoryChemical class: Calcium channel blocker,diarylammopropylamine derivativeTherapeutic class: AntianginalPregnancy category: CIndications and Dosages To treat chronic stable angina inpatients who don’t respond to or can’ttolerate other antianginal drugsTABLETSAdults. Initial: 200 mg daily for 10 days followedby dosage increases, depending onpatient’s response (ability to perform dailyactivities, length of QT interval, heart rate,and frequency and severity of anginaattacks). Maintenance: 300 to 400 mg daily(maximum).Route Onset Peak DurationP.O. Unknown 8 days UnknownMechanism of ActionInhibits calcium movement into coronaryand vascular smooth-muscle cells by blockingslow calcium channels in their membranes.This decreases intracellular calciumlevel, which inhibits smooth-muscle cellcontractions and causes:• relaxation of coronary and vascularsmooth muscles, decreased peripheral vascularresistance, and reduced systolic anddiastolic blood pressure, which decreasemyocardial oxygen demand• depression of impulse formation (automaticity)and conduction velocity.Bepridil also inhibits fast inward sodiumchannels, reducing speed and degree ofaction potential and increasing its durationin cardiac muscle.ContraindicationsCongenital prolonged QT interval, historyof serious ventricular arrhythmias, hypersensitivityto bepridil, hypotension (systolicpressure below 90 mm Hg), sick sinus syndromeand second- or third-degree AVblock unless artificial pacemaker in place,uncompensated cardiac insufficiency, use ofother drugs that prolong QT intervalInteractionsDRUGSantiarrhythmics, such as quinidine and procainamide,with actions similar to bepridil’s:Exaggerated and prolonged QT intervalbeta blockers: Possibly increased depressionof myocardial contractility and AV conductiondigoxin: Possibly increased serum digoxinlevelfentanyl: Severe hypotension and increasedneed for fluidnitrates: Additive hypotensive effecttricyclic antidepressants: Exaggerated andprolonged QT interval

hea, flatulence, gastritis, nauseaGU: Decreased libido, impotenceHEME: Agranulocytosis, leukopenia, neutropeniaMS: Arthritis, myalgiaRESP: Cough, dyspnea, respiratory tractinfectionSKIN: Dermatitis, diaphoresis, rashOther: Flulike symptomsNursing Considerations• Use bepridil cautiously in patients withheart failure because it can induce newarrhythmias and may worsen heart failure.• Because bepridil is metabolized by theliver and its metabolites are excreted inurine, monitor results of liver functionstudies as well as BUN and serum electrolyteand creatinine levels as appropriate.• Assess patient’s heart rate and rhythm toobtain baseline. Then monitor frequentlyduring therapy. Also, monitor serial 12-lead ECG tracings. Be aware that bepridilcan induce new arrhythmias, includingventricular tachycardia and fibrillation(which are more difficult to convert), torsadesde pointes, and prolonged QT intervals.WARNING Be alert for QT intervals thatexceed 0.52 second. If this occurs, expectto reduce bepridil dose or discontinuedrug.• Monitor WBC count to detect agranulocytosis,which may warrant stopping bepridiltherapy.WARNING Be aware that bepridil shouldn’tbe discontinued abruptly. Instead, graduallytaper dosage as prescribed to preventincreased frequency and duration of chestpain as increased calcium moves into cells,causing coronary artery spasm.• Monitor blood pressure often if patienttakes a nitrate or beta blocker. Assess forhypotension.• Monitor serum electrolyte levels.Especially note decreased potassium level,which may worsen existing arrhythmias orinduce new ones.PATIENT TEACHING• Advise patient to avoid driving and otheractivities that require alertness and coordinationuntil bepridil’s CNS effects areknown.betamethasone 137betamethasoneCelestonebetamethasoneacetatebetamethasonesodium phosphateCelestone Soluspanbetamethasonesodium phosphateBetnesol (CAN), Celestone Phosphate,SelestojectClass and CategoryChemical class: Synthetic glucocorticoidTherapeutic class: Anti-inflammatoryPregnancy category: CIndications and Dosages To treat conditions with severe inflammationand conditions requiringimmunosuppressionSYRUP, TABLETS (BETAMETHASONE)Adults. 0.6 to 7.2 mg daily.I.M. INJECTION (BETAMETHASONE ACETATE-BETAMETHASONE SODIUM PHOSPHATE)Adults. 0.5 to 9 mg I.M. daily, or one-thirdto one-half of P.O. dose every 12 hr.I.M. OR I.V. INJECTION (BETAMETHASONE SODIUMPHOSPHATE)Adults. Initial: Variable (given in emergencysituations or when oral therapy isn’t possible).Maximum: 9 mg daily. To treat bursitis, gouty arthritis, osteoarthritis,periostitis of cuboid, peritendinitis,rheumatoid arthritis, skinlesions, tenosynovitisINTRA-ARTICULAR, INTRABURSAL, OR INTRADERMALINJECTION (BETAMETHASONE ACETATE-BETAMETHASONE SODIUM PHOSPHATE)Adults with bursitis, peritendinitis, ortenosynovitis. 1 ml by intrabursal or intraarticularinjection. Three or four injectionsgiven every 1 to 2 wk.Adults with osteoarthritis or rheumatoidarthritis. 0.5 to 2 ml, based on joint size.Adults with foot bursitis. 0.25 to 0.5 mlevery 3 to 7 days.B

138betamethasoneAdults with foot tenosynovitis or periostitisof cuboid. 0.5 ml every 3 to 7 days.Adults with acute gouty arthritis. 0.5 to1 ml every 3 to 7 days.Adults with skin lesions. 0.2 ml/cm 2 intradermally,up to 1 ml weekly.DOSAGE ADJUSTMENT Dosage reduced forelderly patients and accompanied by periodicmonitoring of blood pressure andblood glucose and electrolyte levels.Route Onset Peak DurationP.O. Unknown 1–2 hr 3.25 daysI.V., I.M.*Rapid Unknown UnknownI.M. † 1–3 hr Unknown 1 wkOther † Unknown Unknown 1–2 wk ‡Mechanism of ActionBinds to intracellular glucocorticoid receptorsand suppresses inflammatory andimmune responses by:• inhibiting neutrophil and monocyte accumulationat inflammation site and suppressingtheir phagocytic and bactericidalactivity• stabilizing lysosomal membranes• suppressing antigen response of macrophagesand helper T cells• inhibiting synthesis of inflammatoryresponse mediators, such as cytokines,interleukins, and prostaglandins.ContraindicationsIdiopathic thrombocytopenic purpura(I.M. injection), live virus vaccination, systemicfungal infectionInteractionsDRUGSanticholinesterase drugs: Possibly antagonizedanticholinesterase effects in myastheniagravisbarbiturates: Possibly decreased effects ofbetamethasonecyclosporine: Possibly increased risk ofcyclosporine toxicitydigitalis glycosides: Possibly increased risk ofdigitalis toxicity* Sodium phosphate.† Acetate-sodium phosphate.‡ For intra-arterial or intrasynovial injection;1 week for intralesional injection insoft tissue.estrogens: Possibly decreased excretion ofbetamethasonehydantoins, rifampin: Possibly increasedexcretion and decreased therapeutic effectsof betamethasoneisoniazid: Possibly decreased serum isoniazidlevelketoconazole: Possibly decreased excretionof betamethasoneoral anticoagulants: Possibly increased ordecreased action of anticoagulants, requiringadjusted anticoagulant dosageoral contraceptives: Possibly increased halflifeand concentration and decreased excretionof betamethasonepotassium-wasting diuretics: Increased riskof hypokalemiasalicylates: Possibly decreased serum leveland therapeutic effects of salicylatessomatrem: Possibly inhibition of somatrem’sgrowth-promoting effectstheophyllines: Possibly changes in bothdrugs’ effectsAdverse ReactionsCNS: Fatigue, headache, increased intracranialpressure with papilledema, insomnia,malaise, neuritis, paresthesia, seizures,steroid psychosis, syncope, vertigoCV: Arrhythmias, ECG changes, fatembolism, heart failure, hypertension,thromboembolism, thrombophlebitisEENT: Cataracts, exophthalmos, glaucoma,increased intraocular pressureENDO: Cushingoid symptoms (buffalohump, central obesity, decreased carbohydratetolerance, fat pad enlargement, moonface), fluid retention, growth suppression inchildren, hyperglycemia, masked signs ofinfection, negative nitrogen balance, secondaryadrenocortical and pituitary unresponsiveness(in times of stress)GI: Abdominal distention, increasedappetite, nausea, pancreatitis, peptic ulcerpossibly with perforation, ulcerativeesophagitis, vomitingGU: Amenorrhea, glycosuria, menstrualirregularitiesHEME: LeukocytosisMS: Aseptic necrosis of femoral andhumeral heads, loss of muscle mass, muscleweakness, osteoporosis, spontaneous pathologicand vertebral compression fractures,tendon rupture

SKIN: Acneiform lesions, allergic dermatitis,ecchymosis, facial erythema, hirsutism,impaired wound healing, increased sweating,petechiae, lupuslike lesions, purpura,subcutaneous fat atrophy, thin and fragileskin, urticariaOther: Angioedema, hypocalcemia, hypokalemia,sodium retention, suppressed reactionto skin tests, weight gainbetamethasone 139Nursing Considerations• Expect prescriber to order baseline ophthalmologicexamination before startingtherapy because prolonged betamethasoneuse may lead to increased intraocular pressure,glaucoma, and optic nerve damage.Use betamethasone cautiously in patientswith ocular herpes simplex becausecorneal perforation may occur.• Determine if latent or active amebiasis hasbeen ruled out in patients who have spenttime in the tropics or who have unexplaineddiarrhea before betamethasonetherapy starts because drug may worsen it.WARNING Give betamethasone withextreme care in patients with known orsuspected Strongyloides (threadworm)infestation because corticosteroids such asbetamethasone may result in immunosuppression,Strongyloides hyperinfection anddissemination, and widespread larvalmigration, resulting in severe enterocolitisand potentially life-threatening gram-negativesepticemia.• Assess for signs of infection before administeringbetamethasone because drug maymask those signs. Because drug may causeimmunosuppression, new infection maydevelop during therapy. If so, expect toadminister appropriate antibiotic.• Review serum electrolyte levels, asordered, before starting therapy. Monitorthese levels often during therapy to detectimbalances. Sodium and water retentionand potassium and calcium depletion mayoccur with high-dose betamethasone therapy.If so, expect to restrict sodium intakeand provide potassium and calcium supplements.• Because betamethasone is linked to pepticulcer formation, expect to administer itwith an antacid or H2-receptor blocker.WARNING Monitor ECG tracings forarrhythmias, and evaluate patient for anaphylacticreactions, such as angioedemaand seizures, which have been associatedwith rapid I.V. administration of highdosecorticosteroids.WARNING During long-term betamethasonetherapy, assess for signs of adrenal suppressionand insufficiency (fatigue,hypotension, lassitude, nausea, vomiting,and weakness) when patient is exposed tostress. If she exhibits these signs, notifyprescriber at once.• Watch for signs of steroid psychosis, suchas delirium, clouded sensorium, euphoria,insomnia, mood swings, personalitychanges, and severe depression, which maydevelop 15 to 30 days after therapy begins.Expect to stop therapy. If this isn’t possible,expect to give psychotropic drugs.• Rotate I.M. injection sites. To preventmuscle atrophy, avoid subcutaneous injection,injection in deltoid site, and repeatedI.M. injections into same site.• Administer oral betamethasone before9 a.m., if appropriate, to mimic body’snatural release of corticosteroids.• After intra-articular injection, assess jointfor marked increase in pain, local swelling,and more restricted movement. If patientalso develops fever and malaise, suspectseptic arthritis and notify prescriberimmediately. Expect to assist with jointfluid aspiration to confirm septic arthritis.• Monitor patient for cushingoid signs andsymptoms, such as moon face, buffalohump, central obesity, striae, acne, ecchymosis,and weight gain. Notify prescriberif you detect these symptoms.• Expect to slowly taper oral betamethasonedosage to prevent adrenal insufficiency.PATIENT TEACHING• Instruct patient to take betamethasonewith food if GI upset occurs.• Review signs of adrenal insufficiency andpossible need for dosage increases duringstress. Advise patient to notify prescriberimmediately if signs of insufficiency occuror if she’s exposed to stress.• Instruct patient to avoid exposure to infectionsbecause drug can cause immunosuppression.Also teach patient to recognizeand immediately report signs of infection.• After intra-articular use, advise patient notto overuse joint and to continue othertreatments such as physical therapy.B

140Adverse ReactionsCNS: Amnesia, anxiety, behavior changes,confusion, depression, dizziness, emotionallability, fatigue, fever, hallucinations, headache,insomnia, lethargy, malaise, moodchanges, nightmares, paresthesia, peripheralneuropathy, sedation, stroke, syncope,tremor, vertigoCV: Arrhythmias, including asystole, bradycardia,heart block, and torsades de pointes;cardiogenic shock; chest pain; claudication;heart failure; hypercholesterolemia; hyperlipidemia;hypotension; mitral insufficiency;MI; orthostatic hypotension; peripheralvascular insufficiency; Raynaud’s phenomenon;renal and mesenteric artery thrombosisEENT: Altered taste, blurred vision, burningeyes, conjunctivitis, dry eyes, dry mouth,earache, eye irritation, eye pain or pressure,increased salivation, laryngospasm, mouthulcers, nasal stuffiness, pharyngitis, ptosis,rhinitis, sinusitis, tinnitusENDO: Breast pain (women), hyperglycemia,hypoglycemiaGI: Acute pancreatitis, anorexia, bloating,constipation, diarrhea, elevated liver funcbetaxololhydrochloridebetaxololhydrochlorideKerloneClass and CategoryChemical class: Selective beta 1 -adrenergicblockerTherapeutic class: AntihypertensivePregnancy category: CIndications and Dosages To treat hypertension alone or withother antihypertensivesTABLETSAdults. Initial: 10 mg daily. If no responsein 7 to 14 days, then 20 mg daily.DOSAGE ADJUSTMENT For elderly patientsand patients who have renal failure or areundergoing hemodialysis, initial dosagereduced to 5 mg daily. If desired responseisn’t achieved, dosage increased by 5-mgincrements every 2 wk up to 20 mg daily.Route Onset Peak DurationP.O. Unknown 3–4 hr UnknownMechanism of ActionInhibits stimulation of beta 1 -adrenergicreceptor sites, primarily in the heart. Thisdecreases myocardial excitability, cardiacoutput, and myocardial oxygen demand. Italso decreases renin release from the kidneys,which helps reduce blood pressure.ContraindicationsCardiogenic shock, heart failure unlesscaused by tachyarrhythmia or overt heartfailure, hypersensitivity to betaxolol,second- or third-degree heart block, sinusbradycardiaInteractionsDRUGSaluminum salts, barbiturates, calcium salts,cholestyramine, colestipol, NSAIDs, penicillins,rifampin, salicylates, sulfinpyrazone:Decreased therapeutic and adverse effects ofbetaxololamiodarone, beta blockers, digoxin:Increased risk of additive systemic betablockade, especially bradycardiacalcium channel blockers: Possibly increasedtherapeutic and adverse effects of betaxololciprofloxacin, other quinolones: Possiblyincreased bioavailability of betaxolol,increasing the drug’s pharmacologic effectclonidine: Possibly severe hypertensionwhen both drugs (or just clonidine) aresimultaneously withdrawndisopyramide: Possibly severe bradycardia,asystole, and heart failureepinephrine: Possibly severe hypertensionfollowed by bradycardiaergot alkaloids: Possibly peripheral ischemiaand gangreneflecainide: Possibly increased therapeuticand adverse effects of both drugslidocaine: Possibly increased risk of lidocainetoxicitynondepolarizing neuromuscular blockers:Possibly increased or decreased neuromuscularblockadeoral contraceptives: Possibly increasedbioavailability and plasma level of betaxolol,increasing pharmacologic effectprazosin: Possibly increased orthostatichypotensionquinidine: Possibly increased effects ofbetaxololsulfonylureas: Possibly masking of hypoglycemicsymptoms

tion test results, epigastric pain, flatulence,gastritis, heartburn, hepatomegaly,increased appetite, indigestion, nausea,vomitingGU: Decreased libido, dysuria, impotence,nocturia, Peyronie’s disease, prostatitis,renal colic, renal failure, urinary frequency,urine retention, UTIHEME: Agranulocytosis, eosinophilia,leukopenia, thrombocytopeniaMS: Arthralgia, arthritis, gout, musclespasms or twitching, myalgia, neck pain,tendinitisRESP: Bronchial obstruction, bronchitis,bronchospasm, cough, pulmonary embolus,respiratory distress, upper respiratory tractinfection, wheezingSKIN: Acne, aggravation of psoriasis,diaphoresis, dry skin, eczema, erythema,exfoliative dermatitis, flushing, increasedpigmentation, pallor, photophobia, pruritus,rashOther: Acidosis, facial edema, hyperkalemia,hyperuricemia, lupus erythematosus,lymphadenopathy, positive ANA titer,weight gainNursing Considerations• Betaxolol shouldn’t be given to patientswith untreated pheochromocytoma.• Use drug cautiously in peripheral vasculardisease. Assess color, temperature, andpulses in arms and legs, and ask aboutnumbness, tingling and pain.• Check blood pressure with patient lying,sitting, and standing before starting betaxololtherapy and periodically throughoutthe day to detect changes.• Review renal function test results beforeand during therapy.• Closely monitor diabetic patient for hypoglycemiabecause betaxolol may masktachycardia, but not dizziness anddiaphoresis. Be aware that betaxolol maymask tachycardia and blood pressurechanges associated with hyperthyroidism.WARNING Avoid abrupt withdrawal ofbetaxolol, which can worsen or cause thyroidstorm. Expect to withdraw drug graduallyand monitor patient closely.• Expect to taper betaxolol over 2 weeks toprevent MI, ventricular arrhythmias, andpossibly death from catecholamine hypersensitivitycaused by beta blocker therapy.• If systolic pressure falls below 90 mm Hg,bethanechol chloride 141expect to discontinue drug and prepare forhemodynamic monitoring.• Take precautions to prevent injury fromfalls caused by orthostatic hypotension.PATIENT TEACHING• Teach patient how to check her bloodpressure, if appropriate. Also discuss signsand symptoms of hypertension andhypotension.• Advise patient to avoid sudden positionchanges and to rise slowly from a sittingor lying position to minimize the effects oforthostatic hypotension.• Advise patient to avoid driving and activitiesthat require mental alertness untildrug’s CNS effects are known.• Counsel patient to consult prescriberbefore using an OTC product, such as acold remedy or nasal decongestant.bethanecholchlorideDuvoid, PMS-Bethanechol Chloride(CAN), Urabeth, UrecholineClass and CategoryChemical class: Synthetic choline esterTherapeutic class: Cholinergic, parasympathomimeticPregnancy category: CIndications and Dosages To treat postoperative and postpartalurine retention and retention caused byneurogenic atony of bladderTABLETSAdults. 10 to 50 mg t.i.d. or q.i.d. To determineminimum effective dose: 5 to 10 mgrepeated every hr until response is obtainedor maximum of 50 mg is reached.SUBCUTANEOUS INJECTIONAdults. 2.5 to 5 mg t.i.d. or q.i.d. To determineminimum effective dose: 2.5 mg repeatedevery 15 to 30 min until response isobtained or maximum of four doses isreached. Minimum effective dose may berepeated t.i.d. or q.i.d., p.r.n.Mechanism of ActionActs directly on muscarinic receptors of theparasympathetic nervous system, increasingdetrusor muscle tone in the bladder andB

142biperidenallowing contraction strong enough to startvoiding. Like natural neurotransmitteracetylcholine, bethanechol stimulates gastricmotility, increases gastric tone, andenhances peristalsis.Route Onset Peak DurationP.O. 30–90 min 60 min 6 hrSubQ 5–15 min 15–30 min 2 hrContraindicationsAcute inflammatory lesions of GI tract,atrioventricular conduction defects,bronchial asthma, coronary artery disease,epilepsy, hypersensitivity to bethanecol orits components, hypertension, hyperthyroidism,hypotension, marked vagotonia,mechanical obstruction of GI or GU tract,Parkinson’s disease, peptic ulcer disease,peritonitis, pronounced bradycardia, questionableintegrity of GI or GU mucosa,spastic GI disorders, vasomotor instabilityInteractionsDRUGScholinergic drugs: Possibly increased effectsof bethanecholganglionic blockers: Possibly severe hypotension,usually first manifested by severeadverse GI reactionsprocainamide, quinidine: Possibly decreasedeffects of bethanecholAdverse ReactionsCNS: Headache, malaiseCV: Hypotension with reflex tachycardia,vasomotor responseEENT: Excessive salivation, lacrimation,miosisGI: Abdominal cramps, colicky pain, diarrhea,eructation, nausea, vomitingGU: Urinary urgencyRESP: Asthma attack, bronchoconstrictionNursing Considerations• Assess urine elimination before startingbethanechol therapy.WARNING Be aware that patient must havefunctioning urinary sphincter because asphincter that doesn’t relax when bladdercontracts can push urine upward intorenal pelvis and cause reflux infection.• Give oral bethanechol 1 hour before or2 hours after meals to reduce risk of nauseaand vomiting.WARNING Don’t give bethanechol I.M. orI.V. because of risk of cholinergic overstimulation,which can cause abdominalcramps, bloody diarrhea, hypotension,shock, or sudden cardiac arrest. Alwayskeep atropine nearby during subcutaneousadministration.PATIENT TEACHING• Advise patient to take bethanechol on anempty stomach 1 hour before or 2 hoursafter meals to reduce risk of nausea andvomiting.biperidenhydrochlorideAkinetonbiperiden lactateAkineton LactateClass and CategoryChemical class: Tertiary amineTherapeutic class: Anticholinergic, antidyskineticPregnancy category: CIndications and Dosages As adjunct to treat all forms ofParkinson’s diseaseTABLETSAdults. 2 mg t.i.d. or q.i.d up to 16 mgdaily. To control extrapyramidal symptoms(except tardive dyskinesia) caused byphenothiazines and other neurolepticdrugsTABLETSAdults. 2 mg one to three times daily.I.V. OR I.M. INJECTIONAdults. 2 mg repeated every 30 min untilsymptoms resolve or maximum of fourconsecutive doses in 24 hr is reached.Route Onset Peak DurationI.V. 15 min Unknown 1–8 hrI.M. 10–30 min Unknown UnknownMechanism of ActionBlocks acetylcholine’s action at cholinergicreceptor sites. This action restores thebrain’s normal dopamine and acetylcholine

alance, which relaxes muscle movementand decreases rigidity and tremors.Biperiden also may inhibit dopamine reuptakeand storage, which prolongsdopamine’s action.ContraindicationsAchalasia, bladder neck obstruction, hypersensitivityto biperiden, myasthenia gravis,narrow-angle glaucoma, prostatic hypertrophy,pyloric or duodenal obstruction,stenosing peptic ulcer, toxic megacolonInteractionsDRUGSamantadine: Possibly increased adverseanticholinergic effectsdigoxin: Possibly increased serum digoxinlevelhaloperidol: Possibly increased schizophrenicsymptoms, decreased serum haloperidollevel, and development of tardivedyskinesialevodopa: Possibly decreased levodopa effectivenessphenothiazines: Possibly reduced phenothiazineeffects and increased psychiatric symptomsAdverse ReactionsCNS: Agitation, confusion, delirium, delusions,depression, disorientation, dizziness,drowsiness, euphoria, excitement, fever, hallucinations,headache, light-headedness,listlessness, memory loss, nervousness,paranoia, psychosis, weaknessCV: Hypotension, mild bradycardia, orthostatichypotension, palpitations, tachycardiaEENT: Blurred vision, diplopia, dry mouth,increased intraocular pressure, mydriasis,narrow-angle glaucoma, suppurativeparotitisGI: Constipation, duodenal ulcer, epigastricdistress, ileus, nausea, vomitingGU: Dysuria, urinary hesitancy, urineretentionMS: Muscle spasms, muscle weaknessSKIN: Decreased sweating, dermatosis,flushing, rash, urticariabisoprolol fumarate 143Nursing Considerations• Expect to give I.V. or I.M. biperiden whenpatient needs more rapid response thanoral drug can provide.• Assess muscle rigidity and tremor as baseline.Then check them often for improvement,indicating biperiden’s effectiveness.WARNING When giving biperiden to patientwith drug-induced extrapyramidal reactions,be alert for worsening of psychiatricsymptoms.PATIENT TEACHING• Caution patient to avoid driving and otheractivities that require alertness untilbiperiden’s CNS effects are known.WARNING Because biperiden decreasessweating, urge patient to avoid extremelyhot and humid conditions to reduce riskof heatstroke and severe hyperthermia.This is especially important for elderlypatients and those who abuse alcohol orhave chronic illness or CNS disease.• Emphasize the need for periodic eyeexaminations and intraocular pressuremeasurement because biperiden maycause narrow-angle glaucoma and increaseintraocular pressure.bisoprolol fumarateZebetaClass and CategoryChemical class: Selective beta 1 -adrenergicblockerTherapeutic class: AntihypertensivePregnancy category: CIndications and Dosages To treat hypertension, alone or withother antihypertensivesTABLETSAdults. 5 mg daily, increased to 10 to 20 mgdaily if blood pressure doesn’t respond tolower dosage.DOSAGE ADJUSTMENT Dosage reduced to2.5 mg daily initially and then increasedgradually for patients with impaired renalfunction and creatinine clearance less than40 ml/min/1.73 m 2 or who have impairedhepatic function, as from cirrhosis or hepatitis.Mechanism of ActionInhibits stimulation of beta 1 -receptors primarilyin the heart, which decreases cardiacexcitability, cardiac output, and myocardialoxygen demand. Bisoprolol also decreasesrenin release from kidneys, which helpsreduce blood pressure.B

144bisoprolol fumarateContraindicationsCardiogenic shock, heart failure unlesscaused by tachyarrhythmia, overt heart failure,second- or third-degree heart block,sinus bradycardiaInteractionsDRUGSaluminum salts, barbiturates, calcium salts,cholestyramine, colestipol, NSAIDs, penicillins,rifampin, salicylates, sulfinpyrazone:Possibly decreased therapeutic and adverseeffects of bisoprololbeta blockers, digoxin: Increased risk ofbradycardiacalcium channel blockers: Possibly increasedtherapeutic and adverse effects of bisoprololciprofloxacin, quinolones: Possibly increasedbioavailability of bisoprololclonidine: Possibly severe hypertension fromwithdrawal of clonidine or both drugsepinephrine: Possibly hypertension followedby bradycardiaergot alkaloids: Possibly peripheral ischemiaand gangreneflecainide: Possibly increased therapeuticand adverse effects of either druglidocaine: Possibly increased risk of lidocainetoxicityoral contraceptives: Possibly increased bioavailabilityand plasma level of bisoprololprazosin: Possibly increased orthostatichypotensionquinidine: Possibly increased bisoprololeffectssulfonylureas: Possibly masking of hypoglycemicsymptomsAdverse ReactionsCNS: Anxiety, confusion, depression, dizziness,emotional lability, fatigue, fever, hallucinations,headache, insomnia, malaise,nightmares, paresthesia, sleep disturbances,syncope, tremor, unsteadiness, vertigoCV: Bradycardia, heart block, and otherarrhythmias; chest pain; claudication; coldarms and legs; edema; heart failure; hypercholesterolemia;hyperlipidemia; hypotension;MI; orthostatic hypotension; palpitations;peripheral vascular insufficiency;renal and mesenteric artery thrombosisEENT: Altered taste, blurred vision, drymouth, eye pain or pressure, hearing loss,increased salivation, laryngospasm, pharyngitis,rhinitis, sinusitis, tinnitusGI: Constipation, diarrhea, epigastric pain,gastritis, indigestion, ischemic colitis, nausea,vomitingGU: Cystitis, decreased libido, impotence,Peyronie’s disease, renal colicHEME: Agranulocytosis, eosinophilia,leukopenia, thrombocytopenia, thrombocytopenicpurpuraMS: Arthralgia, gout, muscle twitching,neck painRESP: Asthma, bronchitis, bronchospasm,cough, dyspnea, respiratory distress, upperrespiratory tract infectionSKIN: Alopecia, dermatitis, diaphoresis,eczema, exfoliative dermatitis, flushing,pruritus, psoriasis, rashOther: Angioedema, hyperkalemia, hyperuricemia,weight gainNursing Considerations• Administer bisoprolol cautiously inpatients with peripheral vascular diseasebecause reduced cardiac output can causeor worsen arterial insufficiency. Assesspatient’s arms and legs for changes incolor, temperature, and pulses; ask aboutnumbness, tingling, and pain.• Measure blood pressure with patient lying,sitting, and standing before starting bisoprololand then every 4 to 8 hours, asappropriate, to evaluate effectiveness.• If patient has diabetes, monitor closely forsigns of hypoglycemia, which drug maymask.• If patient has hyperthyroidism, watch fortachycardia and hypertension, which maybe masked by bisoprolol.WARNING Keep in mind that abrupt withdrawalof bisoprolol may cause or worsenthyroid storm. During drug withdrawal,monitor patient closely.• Expect to stop bisoprolol over 1 to 2 weeksto prevent MI, ventricular arrhythmias,and, possibly, death from catecholaminehypersensitivity caused by beta blockertherapy.• If systolic blood pressure falls to less than90 mm Hg, expect to discontinue drug.Prepare for hemodynamic monitoring, ifneeded.WARNING If patient is scheduled for surgerywith general anesthesia, expect to discontinuebisoprolol about 48 hours beforehandto reduce risk of excessive myocardialdepression during anesthesia.

PATIENT TEACHING• Teach patient how to monitor her bloodpressure, if appropriate, and to recognizesigns of hypertension and hypotension.• Instruct patient to avoid sudden positionchanges and to rise slowly from a sittingor lying position to minimize the effects oforthostatic hypotension.• Advise patient to avoid driving and otheractivities that require mental alertnessuntil bisoprolol’s CNS effects are known.• Instruct patient to contact prescriberbefore using any OTC product, such as acold remedy or nasal decongestant.bitolterol mesylateTornalateClass and CategoryChemical class: Acid ester of colterolTherapeutic class: Bronchodilator,sympathomimeticPregnancy category: CIndications and Dosages To prevent and treat asthma and otherconditions associated with reversiblebronchospasm, such as emphysema andchronic bronchitisINTERMITTENT AEROSOL SOLUTIONAdults and children age 12 and over. 1 mgbitolterol diluted in 0.5 ml normal salinesolution and inhaled over 10 to 15 mint.i.d. Maximum: 8 mg daily.CONTINUOUS AEROSOL SOLUTIONAdults and children age 12 and over.2.5 mg bitolterol diluted in 1.25 ml normalsaline solution and inhaled over 10 to15 min t.i.d. Maximum: 14 mg daily.METERED-DOSE INHALERAdults and children age 12 and over. Totreat acute bronchospasm: 2 inhalations over1 to 3 min and, if needed, a third inhalation.To prevent bronchospasm: 2 inhalationsevery 8 hr, not to exceed 3 inhalations every6 hr or 2 inhalations every 4 hr.Mechanism of ActionIs hydrolyzed to active agent colterol (along-acting agent that primarily affectsbeta 2 -adrenergic receptors). Then it attachesto beta 2 receptors on bronchial cellmembranes. This action stimulates thebitolterol mesylate 145intracellular enzyme adenylate cyclase toconvert adenosine triphosphate to cyclicadenosine monophosphate (cAMP). Anincreased intracellular level of cAMP relaxesbronchial smooth-muscle cells, stabilizesmast cells, and inhibits histamine release.Route Onset Peak DurationAerosol, 2–3 min 30–60 min 6–8 hrinhalationMetered- 3–5 min 30–120 min 4–8 hrdoseinhalationIncompatibilitiesDon’t mix bitolterol in inhalation solutionwith cromolyn sodium or acetylcysteine.ContraindicationsHypersensitivity to bitolterol or ingredientsInteractionsDRUGSbeta blockers: Possibly inhibition of bronchodilatingeffect of bitolterolepinephrine, other sympathomimetic drugs:Possibly additive effects of either drugMAO inhibitors, tricyclic antidepressants:Possibly potentiation of bitolterol’s actionon cardiovascular systemAdverse ReactionsCNS: Dizziness, fatigue, headache, hyperkinesia,insomnia, light-headedness, nervousness,paresthesia, somnolence, tremor,vertigoCV: Chest pain, hypertension, irregularpulse, palpitations, tachycardia, transientECG changesEENT: Mouth and throat irritation, rhinitisGI: Elevated liver function test results,nauseaHEME: Decreased hemoglobin level, hematocrit,and WBC countRESP: Bronchospasm, coughNursing Considerations• Assess respiratory rate, rhythm, and depthand breath sounds before, during, andafter bitolterol therapy. Expect improvedair movement and improvement in abnormalbreath sounds.• Because beta-adrenergic bronchodilatorscan significantly increase blood pressureand pulse rate, monitor them often.B

146bivalirudin• Expect therapy to begin with lowest effectivedose because higher doses or morefrequent use may reduce effectiveness andcause paradoxical reactions or overdose.PATIENT TEACHING• Teach patient how to properly use andcare for aerosol nebulizer or metered-doseinhaler. Before patient uses aerosol nebulizer,advise her to look for slight bubblingin solution-filled chamber and fine mistwhen nebulizer is turned on. Beforepatient uses inhaler for first time, instructher to make sure it’s working properly byspraying it once in the air and looking forfine mist.• Teach patient to mix nebulizer solutionimmediately before use. Afterward, sheshould clean nebulizer and solution chamberaccording to manufacturer’s recommendations.WARNING Advise patient not to use morethan the recommended dosage ofbitolterol; excessive use of sympathomimeticdrugs may be fatal.• Tell patient to wait 1 to 3 minutes betweenmetered-dose inhalations.bivalirudinAngiomaxClass and CategoryChemical class: Hirudin analogueTherapeutic class: AnticoagulantPregnancy category: BIndications and Dosages As adjunct to provide anticoagulationand prevent thrombosis in patients withunstable angina who are having percutaneoustransluminal coronary angioplastyor percutaneous coronary interventionI.V. INFUSIONAdults. Initial: Immediately before angioplasty,0.75-mg/kg bolus; then 1.75 mg/kg/hr as continuous infusion for durationof procedure. Five min after bolus dose andwith continuous infusion running, another0.3-mg/kg dose may be given if needed.After procedure, 1.75 mg/kg/hr may begiven for 4 hr by continuous infusion, followedby 0.2 mg/kg/hr for up to 20 hr ifneeded.DOSAGE ADJUSTMENT Infusion dosage possiblyreduced to 1 mg/kg/hr for patientswith severe renal impairment (glomerularfiltration rate of 10 to 29 ml/min) and to0.25 mg/kg/hr for patients having dialysis.Route Onset Peak DurationI.V. Immediate Unknown 1 hr afterend ofinfusionMechanism of ActionSelectively binds to thrombin, includingthrombin trapped in established clots.Without thrombin, fibrinogen can’t convertto fibrin and clots can’t form.IncompatibilitiesDon’t mix other drugs in same I.V. linebefore or during bivalirudin administration.Mixing with alteplase, amiodarone,amphotericin B, chlorpromazine HCL,diazepam, prochlorperazine edisylate,reteplase, streptokinase, or vancomycinHCL can result in haze, particulate formation,or precipitation.ContraindicationsActive major bleeding, hypersensitivity tobivalirudin or its componentsInteractionsDRUGSalteplase, antineoplastics, antithymocyteglobulin, heparin, NSAIDs, plateletinhibitors, reteplase, streptokinase, strontiumchloride Sr 89, warfarin: Risk of bleedingporfimer: Possibly decreased efficacy of porfimerphotodynamic therapysalicylates: Increased risk of hypoprothrombinemiaand bleedingAdverse ReactionsCNS: Headache, intracranial hemorrhageCV: Hypotension, thrombosis (with gammabrachytherapy)EENT: Epistaxis, gingival bleedingGI: Abdominal cramps, diarrhea, GI orretroperitoneal bleeding, nausea, vomitingGU: Hematuria, vaginal bleedingMS: Back painRESP: Hemoptysis, hemothoraxSKIN: EcchymosisOther: Injection site bleeding, hematoma,or pain

Nursing Considerations• To reconstitute bivalirudin, add 5 ml sterilewater for injection to 250-mg vial andswirl gently until dissolved. For initialinfusion, dilute reconstituted vial in 50 mlD 5 W or normal saline solution to yield5 mg/ml.• For subsequent low-rate infusion, furtherdilute reconstituted drug in 500 ml D 5 Wor normal saline solution to final concentrationof 0.5 mg/ml.• Expect to give 300 to 325 mg of aspirinP.O. daily during bivalirudin therapy.WARNING Monitor blood coagulation testsbefore and regularly during therapy;bleeding is a major bivalirudin risk.WARNING Monitor patient often for bleedingbecause there’s no antidote forbivalirudin. If life-threatening bleedingoccurs, notify prescriber immediately, stopdrug, and monitor APTT and other coagulationtests as ordered. Blood transfusionsmay be needed. Patients withincreased bleeding risk include menstruatingwomen; patients with vascular ororgan abnormalities, such as severeuncontrolled hypertension, advanced renaldisease, infective endocarditis, dissectingaortic aneurysm, diverticulitis, hemophilia,hepatic disease (especially from deficientvitamin K–dependent clotting factors),inflammatory bowel disease, or pepticulcer disease; and those with recentstroke, major surgery (including eye,brain, or spinal cord), large vessel or lumbarpuncture, organ biopsy, spinal anesthesia,or major bleeding (includingintracranial, GI, intraocular, retroperitoneal,or pulmonary bleeding).• If patient is receiving gamma brachytherapy,watch closely for evidence of thrombosis(weak or absent pulse, pallor, pain); useof bivalirudin may increase the risk inthese patients.• If possible, avoid I.M. injections of anykind to decrease the risk of bleeding.• Discard any unused portion of drug.PATIENT TEACHING• Inform patient that bivalirudin is a bloodthinner administered only in the hospital.• Urge patient to check her skin for bruisingor red spots and to immediately reportback or stomach pain, trouble breathing,dizziness, fainting, and unusual bleeding(black, tarry stool; blood in urine; coughingblood; heavy menses; nosebleeds).Drug may need to be stopped.• Encourage patient to reduce the risk ofinjury while receiving bivalirudin, such asby brushing her teeth gently with a softbristledtoothbrush.• Caution patient not to take anti-inflammatories,such as ibuprofen, naproxen,ketoprofen, aspirin, and aspirin-like products,or other blood thinners, such as warfarin,while receiving bivalirudin unlessdirected.bosentanTracleerbosentan 147Class and CategoryChemical class: Endothelin receptor antagonist,pyrimidine derivativeTherapeutic class: AntihypertensivePregnancy category: XIndications and Dosages To treat pulmonary arterial hypertensionin patients with World HealthOrganization class III or IV symptoms,to improve exercise ability, and to slowworsening of clinical conditionTABLETSAdults. Initial: 62.5 mg b.i.d., morning andevening for 4 wk. Maintenance: 125 mgb.i.d., morning and evening.DOSAGE ADJUSTMENT For adults weighingless than 40 kg (88 lb), maintenance dosageis 62.5 mg b.i.d. morning and evening. Forpatients who have already received ritonavirfor 10 days or more, initial dosage is62.5 mg once daily or once every other day.ContraindicationsHypersensitivity to bosentan or its components,concurrent use of cyclosporine orglyburide, pregnancyInteractionsDRUGSatorvastatin, lovastatin, simvastatin:Decreased level and efficacy of these drugscyclosporine, ritonavir: Markedly increasedblood bosentan levelglyburide: Increased liver enzyme and possiblyglucose levels; possibly decreased bloodB

148bosentanMechanism of ActionBosentan is an endothelin (ET) receptorantagonist that inhibits the effects of ET, apotent vasoconstrictor. ET, a neurohormoneproduced by endothelial cells thatline blood vessels, normally increases duringcardiovascular stress. Patients withpulmonary arterial hypertension have anabnormal increase in serum ET level.ET binds with its receptors, ETA andETB, which are located on endothelial andvascular smooth-muscle cells. When ETbinds with these receptors, it causes vasoconstriction,as shown below left, andsuch long-term effects as fibrosis andhypertrophy. By binding to ETA and ETBreceptors, as shown below right, bosentanblocks the vasoconstrictive effects of ET,causing pulmonary artery vasodilationand decreased pulmonary artery pressure.As a result, the patient experiencesincreased exercise tolerance and decreasedbreathlessness.Endothelial cellET ET AAreceptorET ET BBreceptorET ETPulmonary arteryBosentan bindingto to receptorVascular smoothmusclecellVasoconstrictionVasodilationlevel of both drugs (and of other oralantidiabetics metabolized by CYP2C9 orCYP3A4)hormonal contraceptives (oral, injected,implanted): Possibly decreased effects ofthese drugsketoconazole and other CYP3A4 inhibitors:Increased bosentan blood level and effectsrifampicin: Possibly decreased blood bosentanleveltacrolimus: Possibly marked increase inblood bosentan levelwarfarin: Increased elimination anddecreased blood level of warfarinAdverse ReactionsCNS: Fatigue, headacheCV: Edema, hypotension, palpitationsEENT: NasopharyngitisGI: Elevated liver function test results,hepatic injury, indigestion, liver failureGU: Decreased sperm countHEME: Decreased hemoglobin level andhematocrit, thrombocytopeniaSKIN: Flushing, pruritus, rashOther: HypersensitivityNursing Considerations• Before giving bosentan, obtain baselinehemoglobin level and liver function testresults, as ordered.WARNING Because bosentan use may causemajor birth defects, make sure femalepatient of childbearing age has had a negativepregnancy test before giving drug.WARNING Bosentan may cause risk of serioushepatic injury. Assess patient for evidenceof hepatic dysfunction, includingabdominal pain, fatigue, fever, jaundice,nausea, and vomiting. Monitor liver functiontest results every month, as ordered.• Expect dosage to be adjusted or drugstopped if liver function test resultsbecome elevated. Expect treatment to bestopped if bilirubin level increases to twicethe upper limit of normal (or higher) or ifclinical symptoms occur in conjunctionwith liver function test elevations.Bosentan probably won’t be prescribed forpatients with moderate to severe hepaticdysfunction or for those with liver functiontest levels higher than three times the

upper limit of normal.• Monitor hemoglobin level 1 and 3 monthsafter start of therapy and every 3 monthsthereafter, as ordered.• Monitor patient’s response to drug, andevaluate her activity tolerance.PATIENT TEACHINGWARNING Because major birth defects areassociated with bosentan, caution femalepatient of childbearing age to have a urineor serum pregnancy test monthly duringbosentan therapy to verify that she isn’tpregnant. Advise her to notify prescriberimmediately if she has a late or missedmenstrual period. Instruct her to use areliable nonhormonal method of contraceptionbecause bosentan may decreaseeffectiveness of hormonal contraceptives.• Urge patient to immediately report evidenceof hepatic dysfunction, includingyellow skin or eyes, fever, nausea, vomiting,fatigue, and abdominal pain.• Stress the importance of keeping appointmentsfor follow-up testing so that drug’seffects can be evaluated.• Inform patient that bosentan is dispensedonly by a special access program set up bythe drug’s manufacturer and isn’t availablefrom commercial pharmacies. Advisepatient to allow for adequate delivery timewhen refilling prescription so that shedoesn’t run out of drug. Instruct her toreview the medication guide that comeswith each renewed prescription.• Explain to man that drug may reducesperm count. Urge him to consult prescriberif he has concerns about fertility.bretylium tosylateBretylate (CAN), BretylolClass and CategoryChemical class: Bromobenzyl quaternaryammonium compoundTherapeutic class: Class III antiarrhythmicPregnancy category: CIndications and Dosages To prevent and treat ventricular fibrillationand treat life-threatening ventriculararrhythmias that don’t respond to firstlineantiarrhythmics, such as lidocaineI.V. INFUSION, I.V. OR I.M. INJECTIONbretylium tosylate 149Adults with immediate life-threateningventricular arrhythmias. Initial: 5 mg/kg,undiluted, by rapid I.V. injection; if ventricularfibrillation persists, 10 mg/kg repeatedas often as needed. Continuous suppression:1 to 2 mg/min or 5 to 10 mg/kg of dilutedI.V. solution infused over at least 8 minevery 6 hr.Adults with other ventricular arrhythmias.Initial: 5 to 10 mg/kg of diluted I.V.solution infused over at least 8 min, repeatedevery 1 to 2 hr if arrhythmia continues;or 5 to 10 mg/kg undiluted I.M. injection,repeated every 1 to 2 hr if arrhythmia continues.Maintenance: 5 to 10 mg/kg dilutedI.V. solution infused over at least 8 minevery 6 hours, 1 to 2 mg/min infused continuously,or 5 to 10 mg/kg undiluted I.M.injection every 6 to 8 hr.DOSAGE ADJUSTMENT Interval betweendosages increased for patients withimpaired renal function because bretyliumis excreted mainly by kidneys.Children with acute ventricular fibrillation.5 mg/kg I.V. given over 8 to 10 min,followed by 10 mg/kg every 15 to 30 minup to total dose of 30 mg/kg. Maintenance:5 to 10 mg/kg every 6 hr.Children with other ventricular arrhythmias.5 to 10 mg/kg every 6 hr.Route Onset Peak DurationI.V. 5–10 min* 6–9 hr 6–24 hrI.M. 20–60 min* 6–9 hr 6–24 hrContraindicationsDigitalis toxicity, hypersensitivity to bretyliumInteractionsDRUGScatecholamines (such as dopamine and norepinephrine):Increased vasopressor effectsof catecholaminesdigoxin: Possibly worsened digitalis toxicityAdverse ReactionsCNS: Anxiety, confusion, dizziness,emotional lability, fever, lethargy, lightheadedness,paranoia, psychosis, syncope,vertigo* For suppression of ventricular fibrillation;20 to 120 min for suppression of ventriculartachycardia.B

150bromocriptine mesylateMechanism of ActionBretylium prolongs the repolarizationphase of the action potential andlengthens the effective refractory period,which helps terminate reentryarrhythmias. The drug also acts onadrenergic nerve terminals initiallycausing early release of norepinephrine,which increases heart rate and bloodpressure. Then it blocks release of norepinephrine,as shown below. Thisreduces heart rate and blood pressure.Bretylium also increases the ventricularthreshold, making the ventricular myocardiumless responsive to ectopicimpulses and preventing ventricularfibrillation.AdrenergicnerveterminalNorepinephrinerelease blockedby bretyliumNorepinephrinePostsynapticreceptorsaline solution, dextrose 5% in lactatedRinger’s solution, normal saline solution,5% sodium bicarbonate, 20% mannitol,1/6 molar sodium lactate, lactated Ringer’ssolution, calcium chloride in D 5 W, andpotassium chloride in D 5 W.WARNING Patient may experience hypotensionwhile supine. Have her remain supineuntil tolerance develops. If supine systolicblood pressure falls below 75 mm Hg,expect to give dopamine or norepinephrineand monitor blood pressure closelybecause vasopressor effects are increasedwhen these drugs are given together.• Be alert for transient hypertension andincreased frequency of arrhythmiasbecause bretylium initially triggers releaseof norepinephrine. Monitor patient’s ECGtracings and blood pressure continuously,and notify prescriber of changes.• Monitor blood bretylium level. Notify prescriberif level falls outside therapeuticrange of 0.5 to 1.5 mcg/ml.PATIENT TEACHING• Advise patient to immediately report chestpain or pressure, pain at I.V. site, or rash.• Warn patient that she may feel dizzy orlight-headed even when lying down. Tellher to stay supine and ask for help whentrying to move or sit up. Tell her that thissensation usually subsides in a few days.CV: Angina, arrhythmias (including bradycardiaand more frequent PVCs), hypotension,orthostatic hypotension, transienthypertensionEENT: Mild conjunctivitis, nasal stuffinessGI: Abdominal pain, diarrhea, hiccups,nausea, vomitingGU: Renal impairmentRESP: DyspneaSKIN: Diaphoresis, erythematous macularrash, flushingOther: Injection site painNursing ConsiderationsWARNING Use bretylium cautiously inpatients with severe aortic stenosis or pulmonaryhypertension because hypotensionmay occur.• For I.V. infusion, dilute bretylium andadminister at 1 to 2 mg/min.• Dilute bretylium in compatible I.V. solution,such as D 5 W, dextrose 5% in normalbromocriptinemesylateAlti-Bromocriptine (CAN), Apo-Bromocriptine (CAN), Cycloset,Parlodel, Parlodel SnapTabsClass and CategoryChemical class: Ergot alkaloid derivativeTherapeutic class: Antidiabetic, antidyskinetic,antihyperprolactinemic, dopaminereceptoragonist, growth hormone suppressant,infertility therapy adjunctPregnancy category: BIndications and Dosages To treat amenorrhea, galactorrhea, malehypogonadism, and infertility fromhyperprolactinemiaCAPSULES, TABLETSAdults. Initial: 1.25 to 2.5 mg at bedtime

with snack. Increased by 2.5 mg every 3 to7 days as needed to a total daily dose of 5 to7.5 mg given in divided doses with snacks.Maintenance: 2.5 mg b.i.d. or t.i.d. withmeals. To treat prolactin-secreting adenomaCAPSULES, TABLETSAdults and adolescents age 15 and over.Initial: 1.25 mg b.i.d. or t.i.d. with meals.Increased gradually over several weeks, ifneeded, to 10 to 20 mg daily in divideddoses with meals. Some patients may needhigher doses. Maintenance: 2.5 to 20 mgdaily in divided doses with meals. To treat Parkinson’s diseaseCAPSULES, TABLETSAdults. Initial: 1.25 mg at bedtime withsnack or b.i.d. with meals. Increased by2.5 mg every 14 to 28 days, if needed.Maintenance: 2.5 to 40 mg daily in divideddoses with meals. To treat acromegalyCAPSULES, TABLETSAdults and children age 15 and over.Initial: 1.25 to 2.5 mg at bedtime withsnack for 3 days. Then increased by 1.25 to2.5 mg every 3 to 7 days, if needed, up to30 mg daily. Maintenance: Usually 10 to30 mg daily at bedtime with snack or individed doses with meals. To control blood glucose level in type 2diabetes mellitus, with diet and exerciseTABLETSAdults. Initial: 0.8 mg once daily within2 hr after waking up in morning. Increasedweekly in increments of 0.8 mg, as needed.Maximum: 4.8 mg daily.Route Onset Peak DurationP.O.* 2 hr 8 hr 24 hrP.O.† 30–90 min 2 hr UnknownP.O.‡ 1–2 hr 4–8 wk 4–8 hrMechanism of ActionInhibits release of prolactin and growthhormone from the anterior pituitary gland,thus restoring testicular or ovarian functionand suppressing lactation. Bromocriptine* For amenorrhea, galactorrhea, male hypogonadism,infertility from hyperprolactinemia,and prolactin-secreting adenoma.† For Parkinson’s disease.‡ For acromegaly.Adverse ReactionsCNS: Asthenia, confusion, dizziness,drowsiness, fatigue, hallucinations, headache,light-headedness, syncopeCV: Hypertension, hypotension, orthostatichypotension, pericarditis, pericardial effusion,Raynaud’s phenomenonEENT: Amblyopia, dry mouth, nasal congestion,rhinitis, sinusitisENDO: HypoglycemiaGI: Abdominal cramps, anorexia, constipation,diarrhea, GI bleeding, indigestion,nausea, vomitingRESP: Pleural effusion or thickening, pulbromocriptinemesylate 151decreases dopamine turnover in the CNS,depleting dopamine or blocking its receptorsin the brain, alleviating dyskinesia.ContraindicationsBreast-feeding; hypersensitivity tobromocriptine, other ergot alkaloids, ortheir components; ketoacidosis; severeischemic heart disease or peripheral vasculardisease; syncopal migraine; type 1 diabetesmellitusInteractionsDRUGSantihypertensives: Increased hypotensiveeffectsclarithromycin, erythromycin, troleandomycin:Increased risk of bromocriptine toxicityCYP3A4 inhibitors: Increased bromocriptinelevelCYP3A4 inducers: Decreased bromocriptineleveldopamine receptor antagonists, includingneuroleptic drugs (such as butyrophenones,phenothiazines, or thioxanthenes), metoclopramide:Possibly decreased effectiveness ofboth drugsergot alkaloids or derivatives: Increased riskof hypertensionhaloperidol, loxapine, MAO inhibitors, methyldopa,metoclopramide, molindone, phenothiazines,pimozide, reserpine, risperidone,thioxanthenes: Increased serum prolactinlevel, decreased bromocriptine effectivenesslevodopa: Additive effects requiring reducedlevodopa doseritonavir: Increased bromocriptine levelsympathomimetic drugs: Possibly increasedrisk of hypertension and tachycardiaACTIVITIESalcohol use: Possibly disulfiram-like reactionB

152budesonidemonary fibrosisOther: Intense impulse to gambleNursing Considerations• Use bromocriptine cautiously if patient hasa history of psychosis or cardiovascular disease,especially after MI with residualarrhythmia. In severe psychotic disorder,bromocriptine isn’t recommended becauseit may worsen the disorder or reduce theeffects of drugs used to treat it.• Expect to perform a pregnancy test every4 weeks during the amenorrheic period.Once menses resume, test whenever aperiod is missed, as ordered.• Plan to withhold bromocriptine if patientbecomes pregnant.• If rapidly expanding adenoma needs continuedtherapy, watch closely for hypertensivecrisis.• Bromocriptine shouldn’t be given postpartumif patient has a history of coronaryartery disease or other severe cardiovascularproblem unless risk of withdrawingdrug is greater than risk of use. If so, monitorclosely for signs and symptoms of CVdysfunction, such as chest pain.• Expect to give drug with levodopa if patientis being treated for Parkinson’s disease.• Assess for hypotension when bromocriptinetherapy starts and hypertension (typicallyduring second week). Monitor bloodpressure often if patient takes other antihypertensives.• If patient has a history of peptic ulcer orGI bleeding, watch for new bleeding.• Take safety precautions, such as keepingbed in low position with side rails up,because drug can cause dizziness, drowsiness,light-headedness, and syncope.PATIENT TEACHING• Tell patient to take each dose with a meal,milk, or a snack to minimize nausea.• Caution patient about possible dizziness,drowsiness, and light-headedness. Urgepatient to avoid hazardous activities untildrug effects are known.• Advise against sudden position changes tominimize orthostatic hypotension.• Warn patient to avoid alcohol while takingbromocriptine because it may cause disulfiram-likereactions, such as chest pain,confusion, a fast or pounding heartbeat,facial flushing, diaphoresis, nausea, vomiting,a throbbing headache, blurred vision,and severe weakness.• Tell patient to take a missed dose as soonas she remembers it, unless it’s almosttime for the next dose. In that case, tell herto wait until the next scheduled dose.Warn her not to double the dose. Adviseher to contact prescriber if she missesmore than one dose.• Urge patient to report adverse reactions,such as an unremitting headache, nausea,vomiting, or other signs of CNS toxicity.• Tell patient who takes large doses of bromocriptineto schedule regular dentalcheckups because the drug can decreasesaliva flow, which may encourage dentalcaries, periodontal disease, oral candidiasis,and discomfort.• Tell patient with acromegaly to keep herfingers warm to prevent cold-sensitive digitalvasospasm.• If patient has type 2 diabetes, provideinstruction about diet, exercise, effects ofhyperglycemia and hypoglycemia, hygiene,foot care, and ways to avoid infection.budesonideEntocort EC, Pulmicort Flexhaler,Pulmicort Respules, PulmicortTurbuhaler, Rhinocort, RhinocortAqua, Rhinocort Turbuhaler (CAN)Class and CategoryChemical class: GlucocorticoidTherapeutic class: Antiasthmatic, antiinflammatoryPregnancy category: BIndications and Dosages To manage symptoms of seasonal orperennial allergic rhinitisNASAL AEROSOLAdults and children over age 6. 64 mcg ineach nostril b.i.d. or 128 mcg in each nostrildaily. Maximum: 256 mcg daily.Maintenance: Lowest dosage that controlssymptoms.NASAL POWDERAdults and children over age 6. 200 mcg ineach nostril daily. Maximum: 800 mcg daily(adults and adolescents); 400 mcg daily(children). Maintenance: Lowest dosage thatcontrols symptoms.NASAL SUSPENSION

Adults and children over age 6. 32 mcg ineach nostril daily. Maximum: 256 mcg daily(adults and adolescents); 128 mcg daily(children). Maintenance: Lowest dosage thatcontrols symptoms. To manage symptoms of perennial nonallergicrhinitisNASAL AEROSOLAdults and adolescents. 64 mcg in each nostrilb.i.d. or 128 mcg in each nostril daily.Maximum: 256 mcg daily. Maintenance:Lowest dosage that controls symptoms.NASAL POWDERAdults and adolescents. 200 mcg in eachnostril daily. Maximum: 800 mcg daily.Maintenance: Lowest dosage that controlssymptoms. To provide maintenance therapy inchronic bronchial asthmaORAL INHALATIONAdults previously on bronchodilatorsalone. 1 or 2 inhalations (200 to 400 mcg)b.i.d. Maximum: 800 mcg daily.Adults previously on inhaled corticosteroids.1 or 2 inhalations (200 to 400 mcg)b.i.d. Maximum: 800 mcg b.i.d. as neededand tolerated.Adults previously on systemic corticosteroids.2 to 4 inhalations (400 to 800 mcg)b.i.d. Maximum: 1,600 mcg daily.Children age 6 and over. 1 inhalation(200 mcg) b.i.d. Maximum: 400 mcg b.i.d.as needed and tolerated.ORAL INHALATION (PULMICORT FLEXHALER)Adults and adolescents age 18 and over.Initial: 180 or 360 mcg b.i.d., increased asneeded. Maximum: 720 mcg b.i.d.Children ages 6 to 17. Initial: 180 or360 mcg b.i.d. Maximum: 360 mcg b.i.d. To prevent or provide maintenance therapyin chronic bronchial asthmaNEBULIZED INHALATION (PULMICORT RESPULES)Children ages 1 to 8 previously onbronchodilators alone. 0.25 mg b.i.d. or0.5 mg daily by jet nebulizer. Maximum:0.5 mg/day.Children ages 1 to 8 previously on inhaledsteroids. 0.25 mg b.i.d. or 0.5 mg daily inhaledby jet nebulizer. Maximum: 1 mg/day.Children ages 1 to 8 previously on systemiccorticosteroids. 0.5 mg b.i.d. or 1 mgdaily inhaled by jet nebulizer. Maximum:1 mg/day. To treat mild to moderate active Crohn’sbudesonide 153disease involving the ileum, the ascendingcolon, or bothCAPSULESAdults. 9 mg daily in the morning for 8 wk. To maintain clinical remission of mild tomoderate Crohn’s disease involving theileum, the ascending colon, or bothCAPSULESAdults. 6 mg daily in the morning for up to3 months.DOSAGE ADJUSTMENT Dosage reduced forpatients with heptic insufficiency and thosetaking ketoconazole or other CYP3A4inhibitor.Route Onset Peak DurationNasal 10 hr– 3 days– Unknownaerosol 3 days 3 wkNasal In 4 wk Unknown Unknownpowder orsuspensionOral In 4 wk Unknown UnknowninhalationNebulized 2–8 days 4–6 wk UnknowninhalationP.O. Unknown 30 min– Unknown(capsules)10 hrMechanism of ActionInhibits inflammatory cells and mediators,possibly by decreasing influx into nasal passagesor bronchial walls. As a result, nasal orairway inflammation decreases. Oralinhalation form also inhibits mucus secretionin airways, decreasing the amount andviscosity of sputum.ContraindicationsHypersensitivity to budesonide or its components,recent septal ulcers or nasal surgeryor trauma (nasal spray); status asthmaticusor other acute asthma episodes(oral inhalation)InteractionsDRUGSclarithromycin, erythromycin, itraconazole,ketoconazole, other CYP3A4 inhibitors:Possibly increased blood budesonide levelAdverse ReactionsCNS: Amnesia, asthenia, benign intracranialhypertension, dizziness, fatigue, fever,headacheB

154budesonideEENT: Bad taste, cataracts, dry mouth,epistaxis, glaucoma, nasal irritation, oral orpharyngeal candidiasis, pharyngitis, rhinitis,sinusitisENDO: Growth suppression in childrenGI: Abdominal pain, diarrhea, dyspepsia,flatulence, indigestion, nausea, vomitingGU: UTIMS: Arthralgia, back painRESP: Bronchospasm, increased cough, respiratorytract infectionSKIN: Contact dermatitis, purpura, rash,urticariaOther: Anaphylaxis, angioedemaNursing Considerations• Use budesonide cautiously if patient hastubercular infection; untreated fungal,bacterial, or systemic viral infection; orocular herpes simplex.• Closely monitor a child’s growth pattern;budesonide may stunt growth.WARNING Assess patient who switches froma systemic corticosteroid to inhaled budesonidefor adrenal insufficiency (fatigue,hypotension, lassitude, nausea, vomiting,weakness), which may be life-threatening.Hypothalamic-pituitary-adrenal axis functionmay take several months to recoverafter stopping systemic corticosteroids.Stopping budesonide abruptly may causeadrenal insufficiency.• Administer Respules by jet nebulizer connectedto an air compressor.• Patient exposed to chickenpox may receivevaricella zoster immune globulin orpooled I.V. immunoglobulin. If chickenpoxdevelops, give antiviral as ordered. Apatient exposed to measles may needpooled I.M. immunoglobulin.• Assess patient for effectiveness of budesonidetherapy, especially if being weanedfrom a systemic corticosteroid. If patienthas increased asthma or an immunologiccondition previously suppressed by systemiccorticosteroid—such as rhinitis,conjunctivitis, an eosinophilic condition,eczema, or arthritis—notify prescriber.• Pulmicort Flexhaler contains smallamounts of lactose, which may triggercoughing, wheezing, or bronchospasm in apatient with a severe milk-protein allergy.• Monitor patient for evidence of hypersensitivity,such as contact dermatitis, rash,urticaria, angioedema, bronchospasm, oranaphylaxis. If present, notify prescriberimmediately. Expect to stop budesonideand provide emergency supportive care.PATIENT TEACHING• Urge patient taking oral capsules to swallowthem whole and not to chew or breakthem.• Instruct patient who uses nasal spray toshake container before each use. Instructher to blow her nose, tilt her head slightlyforward, and insert tube into a nostril,pointing toward inner corner of eye, awayfrom nasal septum. Tell her to hold theother nostril closed and spray while inhalinggently. Then have her repeat in theother nostril.• Instruct patient to prime oral inhalerbefore using it for first time by holdingcanister upright with mouthpiece on topand twisting base of device fully to rightand then fully to left until it clicks. Teachher to load each each dose just before usein the same way. After loading a dose, cautionpatient not to shake device or blowinto it. Tell patient to turn her head awayfrom device and exhale. Then have herhold device upright, place her lips aroundmouthpiece, and inhale deeply. Device willdischarge a dose. Tell patient to removeher lips from mouthpiece to exhale.• Caution patient not to use an oral inhalerwith a spacer device.• Advise patient to rinse her mouth withwater after each dose and to spit the waterout. Tell her to contact her prescriber ifshe develops a mouth or throat infection.• Instruct patient not to use budesonide as arescue inhaler.• Tell patient to contact prescriber if symptomspersist or have worsened after3 weeks. Caution against increasing thedose on her own.• Inform parents of small children usingnebulized Respules that improvement maybegin within 2 to 8 days but that full effectmay not be evident for 4 to 6 weeks.• Caution patient to avoid exposure tochickenpox and measles and, if exposed, tocontact prescriber immediately.• Caution against stopping drug abruptly.• Instruct patient on long-term therapy tohave regular eye examinations.• Urge female patient to notify prescriber ifshe is or could be pregnant.

umetanideBumexClass and CategoryChemical class: Sulfonamide derivativeTherapeutic class: Loop diureticPregnancy category: CIndications and Dosages To treat edema caused by heart failure,hepatic disease, and renal disease,including nephrotic syndromeTABLETSAdults. 0.5 to 2 mg daily, increased as needed,with a second or third dose every 4 to5 hr or 0.5 to 2 mg every other day or dailyfor 3 or 4 days each week. Maximum: 10 mgdaily.I.V. INFUSION, I.V. OR I.V. INJECTIONAdults. 0.5 to 1 mg over 1 to 2 min daily,increased p.r.n. with a second or third doseevery 2 to 3 hr. Maximum: 10 mg daily.DOSAGE ADJUSTMENT In patients withsevere chronic renal insufficiency, continuousinfusion (12 mg over 12 hr) may bemore effective and less toxic than intermittentinfusion.Route Onset Peak DurationP.O. 30–60 min 1–2 hr 4–6 hrI.V. In min 15–30 min 3.5–4 hrMechanism of ActionInhibits reabsorption of sodium, chloride,and water in the ascending limb of the loopof Henle, which promotes their excretionand reduces fluid volume.ContraindicationsAnuria, hepatic coma, hypersensitivity tobumetanide or its components, severe electrolytedepletionInteractionsDRUGSaminoglycosides: Increased risk of ototoxicityantihypertensives: Increased hypotensiveeffectindomethacin: Slowed increase in urine andsodium excretion, inhibited plasma reninactivitylithium: Reduced lithium renal clearance,increased risk of lithium toxicityprobenecid: Reduced sodium excretionbumetanide 155Adverse ReactionsCNS: Dizziness, encephalopathy, headacheCV: HypotensionEENT: OtotoxicityENDO: HyperglycemiaGI: NauseaGU: Azotemia, elevated serum creatininelevelMS: Muscle spasmsOther: Hyperuricemia, hypocalcemia, hypochloremia,hypokalemia, hyponatremia,hypovolemiaNursing ConsiderationsWARNING A patient hypersensitive to sulfonamidesmay be hypersensitive tobumetanide. Monitor such a patient closelywhen starting therapy.• Expect to use parenteral route for patientswith impaired GI absorption or in whomthe oral route isn’t practical. Switch to oralroute, as prescribed, as soon as possible.• Discard unused parenteral solution24 hours after preparation.• Assess fluid and electrolyte balance closelybecause bumetanide is a potent diuretic(40 to 60 times more potent than furosemide).Monitor fluid intake and outputonce every 8 hours, evaluate serum electrolytelevels when ordered, and assess forimbalances.WARNING Be aware that high-dose or toofrequentadministration can cause profounddiuresis and water and electrolytedepletion, especially in elderly patients.• Monitor serum potassium level regularlyto check for hypokalemia, especially ifpatient takes a digitalis glycoside for heartfailure or has hepatic cirrhosis, ascites,aldosteronism, potassium-losingnephropathy, diarrhea, or a history of ventriculararrhythmias.• Assess for evidence of ototoxicity, such astinnitus, daily. Rarely, drug may cause ototoxicity,especially with I.V. use, highdoses, and increased frequency of dosingin a patient with renal impairment.• Monitor results of renal function testsduring therapy to detect adverse reactions.PATIENT TEACHING• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Stress importance of monitoring fluidintake and output and watching for evidenceof electrolyte imbalance, such asB

156buprenorphine hydrochloridedizziness, headache, and muscle spasms.• Review adverse reactions, and tell patientto report severe or persistent reactions.• Review potassium-rich foods, and urgepatient to include them in her daily diet.• Urge patient to return for appropriate follow-upcare, especially if she’s receivingbumetanide for a chronic condition.• Tell diabetic patient to monitor blood glucoselevel regularly and to notify prescriberabout persistent hyperglycemia.buprenorphinehydrochlorideBuprenex, SubutexClass, Category, and ScheduleChemical class: Opioid, thebaine derivativeTherapeutic class: Opioid analgesicPregnancy category: CControlled substance schedule: VIndications and Dosages To control moderate to severe painI.V. OR I.M. INJECTIONAdults and children age 12 and over.0.3 mg every 6 hr or more, p.r.n. A second0.3-mg dose given 30 to 60 min after firstdose, if needed.DOSAGE ADJUSTMENT In patients not athigh risk for opioid toxicity, I.M. doseincreased to 0.6 mg or frequency increasedto every 4 hr, if needed, depending on painseverity and patient response. I.V. or I.M.dose reduced by half in elderly or debilitatedpatients and those who have respiratorydisease or also use another CNS depressant.Children ages 2 to 12. 0.002 to 0.006 mg/kg every 4 to 6 hr, p.r.n. To treat opioid dependenceSUBLINGUAL TABLETSAdults. 12 to 16 mg daily.Mechanism of ActionMay bind with CNS receptors to alter theperception of and emotional response topain. Buprenorphine may act by displacingnarcotic agonists from their binding sitesand competitively inhibiting their actions.IncompatibilitiesDon’t give I.V. buprenorphine through thesame I.V. line as diazepam or lorazepam.ContraindicationsHypersensitivity to buprenorphine or itscomponentsRoute Onset Peak DurationI.V. Under Under 6–10 hr*15 min 1 hrI.M. 15 min 1 hr 6–10 hr*InteractionsDRUGSCNS depressants, MAO inhibitors: Additivehypotensive and respiratory and CNSdepressant effects of these drugsopioid analgesics: Reduced therapeuticeffects if buprenorphine is given beforeanother opioid analgesicAdverse ReactionsCNS: Dizziness, headache, sedation, vertigoCV: Bradycardia, hypertension, hypotensionEENT: MiosisGI: Nausea, vomitingRESP: Bronchospasm, hypoventilationSKIN: Diaphoresis, pruritus, rash, urticariaOther: Anaphylaxis; angioedema; injectionsite pain, redness, and swellingNursing Considerations• Use buprenorphine cautiously in patientswith severe hepatic or renal impairment,myxedema, hypothyroidism, adrenalinsufficiency, CNS depression, coma, toxicpsychosis, prostatic hypertrophy, urethralstricture, acute alcoholism, alcohol withdrawalsyndrome, kyphoscoliosis, or biliarytract dysfunction. Also use cautiouslyin patients who take a drug that decreaseshepatic clearance, are known drug abusers,or have been addicted to opioids.• Use drug cautiously in patients with headinjury, intracranial lesions, or other conditionsthat could increase CSF pressure.• To avoid causing withdrawal, drug shouldn’tbe given for opioid dependence untilsigns of withdrawal occur.• Give I.V. form over at least 2 minutes.• Inspect injection site for local reactions;don’t use the same site twice.• Monitor vital signs and response to drugoften, especially after giving first dose.PATIENT TEACHING• Instruct patient taking sublingual form to* 4 to 5 hr in children ages 2 to 12.

place tablets under her tongue until theydissolve. If patient takes more than twotablets per dose, tell her to place all tabletsunder her tongue at the same time. If theywon’t fit, tell her to place two at a timeunder her tongue until full dose has dissolved.Caution against swallowing tablets.bupropionhydrochlorideWellbutrin, Wellbutrin SR, WellbutrinXL, ZybanbupropionhydrobromideAplenzinClass and CategoryChemical class: Aminoketone derivativeTherapeutic class: Antidepressant, smokingcessation adjunctPregnancy category: CIndications and Dosages To treat depressionE.R. TABLETS (WELLBUTRIN SR)Adults. Initial: 150 mg daily in morning for3 days; then 150 mg b.i.d. and, after severalwk, 200 mg b.i.d., as needed and tolerated.Maximum: 400 mg daily or 200 mg/dose.E.R. TABLETS (WELLBUTRIN XL)Adults. Initial: 150 mg daily in morning forat least 3 days; then 300 mg daily and, after4 wk, 450 mg daily, as needed and tolerated.Maximum: 450 mg daily.E.R. TABLETS (APLENZIN)Adults. Initial: 174 mg daily in the morningfor 3 days. Then, if tolerated well, dosageincreased to 348 mg daily in the morning.After 4 wk of therapy, dosage increased to522 mg daily in the morning, if needed.TABLETSAdults. Initial: 100 mg b.i.d., increased after3 or more days to 100 mg t.i.d., as needed.Maximum: 450 mg daily or 150 mg/dose. To aid in smoking cessationE.R. TABLETSAdults. Initial: 150 mg daily for 3 days andthen 150 mg b.i.d. for 7 to 12 wk.Maximum: 300 mg daily or 150 mg/dose. To prevent seasonal major depressivebupropion 157episodes in patient with seasonal affectivedisorderE.R. TABLETSAdults. Initial: 150 mg once daily in morningstarting in autumn, increased after 1 wkto 300 mg once daily in morning, if toleratedand needed. Decreased to 150 mg oncedaily 2 wk before stopping in early spring.DOSAGE ADJUSTMENT For patients withsevere hepatic cirrhosis, no more than75 mg daily of Wellbutrin, 100 mg daily or150 mg every other day of Wellbutrin SR,150 mg every other day of Wellbutrin XL orZyban, and 174 mg every other day ofAplenzin. In renal impairment, dosage orfrequency decreased on an individual basis.Route Onset Peak DurationP.O. 1–3 wk Unknown UnknownMechanism of ActionMay inhibit norepinephrine, serotonin, anddopamine uptake by neurons, which significantlyrelieves evidence of depression.ContraindicationsAnorexia, bulimia, use of another form ofbupropion, hypersensitivity to bupropionor its components, seizure disorder, treatmentrequiring abrupt discontinuation ofalcohol or sedatives (including benzodiazepines),use within 14 days of an MAOinhibitorInteractionsDRUGSamantadine, levodopa: Increased adversereactions to bupropioncarbamazepine, cimetidine, phenobarbital,phenytoin: Increased bupropion metabolismclozapine, fluoxetine, haloperidol, lithium,loxapine, maprotiline, molindone, phenothiazines,thioxanthenes, trazodone, tricyclicantidepressants: Increased risk of majormotor seizureslevodopa: Increased adverse bupropioneffectsMAO inhibitors: Increased risk of acutebupropion toxicitynicotine: Possibly increased blood pressurewarfarin: Possibly altered PT and INR; riskof hemorrhagic or thrombotic complicationsACTIVITIESalcohol use, recreational drug abuse: Loweredseizure thresholdB

158buspirone hydrochlorideAdverse ReactionsCNS: Agitation, akathisia, anxiety, asthenia,CNS stimulation, coma, confusion,decreased concentration or memory, delusions,depression, dizziness, euphoria, fever,general or migraine headache, hallucinations,hostility, insomnia, irritability, mania,nervousness, paranoia, paresthesia, seizures,sleep disorder, somnolence, stroke, suicidalideation, syncope, tremor, vertigoCV: Arrhythmias, chest pain, complete AVblock, hypertension, MI, orthostatichypotension, palpitations, phlebitis, tachycardia,vasodilationEENT: Altered taste, amblyopia, blurredvision, dry mouth, hearing loss, increasedocular pressure, pharyngitis, sinusitis, tasteperversion, tinnitusENDO: Hyperglycemia, hypoglycemia, syndromeof inappropriate ADH secretionGI: Abdominal pain, anorexia, constipation,diarrhea, dysphagia, flatulence, GI hemorrhage,GI ulceration, hepatitis, increasedappetite, intestinal perforation, nausea,pancreatitis, vomitingGU: Urinary frequency and urgency, UTI,vaginal hemorrhageHEME: Anemia, leukocytosis, leukopenia,lymphadenopathy, pancytopenia, thrombocytopeniaMS: Arthralgia, arthritis, muscle twitching,myalgia, rhabdomyolysisRESP: Bronchospasm, cough, pulmonaryembolismSKIN: Diaphoresis, exfoliative dermatitis,flushing, pruritus, rash, urticariaOther: Angioedema, generalized pain, hotflashes, infection, serum sicknesslike reaction,weight lossNursing Considerations• Use cautiously in patients with renalimpairment; drug is excreted by kidneys.• Monitor children, adolescents, anddepressed patients closely for worseneddepression and increased suicide risk,especially when therapy starts or dosagechanges.• If patient takes bupropion for smokingcessation, watch for neuropsychiatricsymptoms, including changes in behavior,hostility, agitation, depressed mood, suicidalideation, and worsening of psychiatricillness. If present, notify prescriber immediately,begin safety measures, and expectto discontinue drug.• To reduce seizure risk, allow at least4 hours (tablets) or 8 hours (E.R. tablets)between doses.• Use seizure precautions, especially inpatients who take OTC stimulants oranorectics; use excessive alcohol or sedatives;are addicted to opioids, cocaine, orstimulants; take drugs that lower theseizure threshold; have a history ofseizures, head trauma, or CNS tumors;have severe hepatic cirrhosis; or takeinsulin or an oral antidiabetic.• Using transdermal nicotine with bupropionmay cause hypertension. Watch closely.PATIENT TEACHING• Advise patient to take bupropion for 7 ormore days before stopping smoking.• Tell patient to swallow E.R. tablets wholeand not to cut, crush, or chew them.• Tell patient to take bupropion with food.• Urge patient to avoid or minimize consumingalcohol and sedatives during therapyand not to stop drug abruptly becauseseizures may occur.• Urge caregivers to monitor depressedpatient closely for worsened depression,especially when therapy starts or dosagechanges.• If patient takes bupropion for smokingcessation, explain that it may cause seriousadverse effects, including changes inbehavior, hostility, agitation, depressedmood, suicidal ideation, and worsening ofpsychiatric illness. If present, patientshould notify prescriber immediately andexpect to discontinue drug.buspironehydrochlorideBuSpar, BuSpar DIVIDOSE,Bustab (CAN)Class and CategoryChemical class: AzaspirodecanedioneTherapeutic class: AntianxietyPregnancy category: BIndications and Dosages To manage anxietyTABLETSAdults. Initial: 5 mg t.i.d. or 7.5 mg b.i.d.

increased by 5 mg daily at 2- to 3-day intervalsuntil desired response occurs.Maintenance: 20 to 30 mg daily (usual therapeuticrange). Maximum: 60 mg daily.DOSAGE ADJUSTMENT When used with nefazodone,dosage as little as 2.5 mg daily.Route Onset Peak DurationP.O. 1–4 wk 3–6 wk UnknownMechanism of ActionMay act as a partial agonist at serotonin 5-hydroxytryptamine 1A receptors in thebrain, producing antianxiety effects.ContraindicationsHypersensitivity to buspirone or its components,severe hepatic or renal impairmentInteractionsDRUGSdiltiazem, erythromycin, itraconazole,nefazodone, nordiazepam, verapamil:Increased blood level and adverse effects ofbuspironehaloperidol: Increased haloperidol levelhepatic enzyme CYP3A4 inducers, such asdexamethasone and certain anticonvulsants(phenytoin, phenobarbital, carbamazepine):Possibly increased rate of buspirone metabolismhepatic enzyme CYP3A4 inhibitors, such asketoconazole and ritonavir: Possibly inhibitedbuspirone metabolism and increasedblood levelMAO inhibitors: Increased risk of hypertensionrifampin: Decreased blood buspirone leveland pharmacodynamic effectsFOODSfood: Possibly decreased buspirone clearancegrapefruit juice: Increased blood buspironelevelAdverse ReactionsCNS: Akathisia, anger, ataxia, cogwheelrigidity, confusion, decreased concentration,depression, dizziness, dream disturbances,drowsiness, dyskinesias, dystonia,excitement, extrapyramidal symptoms,fatigue, headache, hostility, insomnia, lackof coordination, light-headedness, moodswings, nervousness, paresthesia, parkinsonism,restless leg syndrome, restlessness,serotonin syndrome, transient recallbutabarbital sodium 159impairment, tremor, weaknessCV: Chest pain, palpitations, tachycardiaEENT: Blurred vision, dry mouth, nasalcongestion, pharyngitis, tinnitus, tunnelvisionGI: Abdominal or gastric distress, constipation,diarrhea, nausea, vomitingGU: Urine retentionMS: MyalgiaSKIN: Diaphoresis, ecchymosis, rash,urticariaOther: AngioedemaNursing Considerations• Use buspirone cautiously in patients withhepatic or renal impairment.• Institute safety precautions because ofpossible adverse CNS reactions.• Follow closely if patient is being withdrawnfrom long-term therapy with benzodiazepinesor other sedative-hypnoticdrugs while starting buspirone becausebuspirone won’t prevent withdrawalsymptoms.PATIENT TEACHING• Advise patient to take buspirone consistently,either always with or always withoutfood.• Caution patient to avoid drinking largeamounts of grapefruit juice.• Inform patient that 1 to 2 weeks of therapymay be needed before she noticesdrug’s antianxiety effect.• Stress the importance of not taking morebuspirone than prescribed.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.butabarbital sodiumBusodium, Butalan, Butisol,Sarisol No. 2Class, Category, and ScheduleChemical class: BarbiturateTherapeutic class: Sedative-hypnoticPregnancy category: DControlled substance schedule: IIIIndications and Dosages To provide daytime sedationELIXIR, TABLETSAdults. 15 to 30 mg t.i.d. or q.i.d. To treat insomniaB

160butabarbital sodiumELIXIR, TABLETSAdults. 50 to 100 mg every at bedtime. To provide preoperative sedationELIXIR, TABLETSAdults. 50 to 100 mg 60 to 90 min beforesurgery.Children. 2 to 6 mg/kg. Maximum: 100 mg/dose.DOSAGE ADJUSTMENT Dosage reduced inpatients with impaired renal or hepaticfunction and in elderly or debilitatedpatients because they may be more sensitiveto drug.Route Onset Peak DurationP.O. 45–60 min Unknown 6–8 hrMechanism of ActionInhibits the upward conduction of nerveimpulses in the brain’s reticular formation,which disrupts impulse transmission to thecortex. As a result, butabarbital depressesthe CNS and produces drowsiness, sedation,and hypnosis.ContraindicationsHistory of addiction to sedative or hypnoticdrug, hypersensitivity to butabarbital or itscomponents, porphyria, severe hepatic orrespiratory diseaseInteractionsDRUGSacetaminophen: Increased risk of hepatotoxicity(with large doses of or long-term therapywith butabarbital)activated charcoal: Reduced butabarbitalabsorptioncarbamazepine: Decreased blood carbamazepinelevelchloramphenicol, corticosteroids, digitalis glycosides:Increased metabolism anddecreased effects of these drugsclonazepam: Increased clearance andreduced efficacy of clonazepamCNS depressants, including OTC sedativesand hypnotics: Additive CNS depressiondoxycycline: Shortened half-life anddecreased effects of doxycyclinefenoprofen: Reduced bioavailability andeffects of fenoprofengriseofulvin: Reduced griseofulvin absorptionhydantoins, such as phenytoin: Unpredictableeffects on barbiturate metabolismMAO inhibitors: Prolonged barbiturateeffectsmeperidine: Prolonged CNS depressanteffects of meperidinemethadone: Reduced methadone actionsmethoxyflurane: Increased risk of nephrotoxicitymetronidazole: Decreased antimicrobialeffect of metronidazoleoral anticoagulants: Decreased anticoagulanteffectoral contraceptives with estrogen: Decreasedcontraceptive effectphenylbutazone: Reduced elimination halflifeof phenylbutazonerifampin: Decreased butabarbital effectivenesssodium valproate, valproic acid: Decreasedbutabarbital metabolism and increasedadverse CNS effectstheophylline: Decreased blood level andeffects of theophyllineACTIVITIESalcohol use: Additive CNS depressionAdverse ReactionsCNS: Agitation, anxiety, ataxia, clumsiness,CNS depression, confusion, depression, dizziness,drowsiness, fever, hallucinations,headache, hyperkinesia, insomnia, irritability,nervousness, nightmares, psychiatric disturbance,sleep driving (see PatientTeaching section), somnolence, syncopeCV: HypertensionEENT: LaryngospasmGI: Constipation, hepatic dysfunction, nausea,vomitingMS: RicketsRESP: Apnea, bronchospasm, respiratorydepressionSKIN: Exfoliative dermatitis, Stevens-Johnson syndromeOther: Anaphylaxis, angioedema, drug tolerance,physical and psychological dependenceNursing Considerations• Use butabarbital cautiously, if at all, inpatients with depression, suicidal tendency,history of drug abuse, or hepatic dysfunction.Don’t administer drug topatients with premonitory signs of hepaticcoma.WARNING Monitor patient closely followingbutabarbital ingestion because anaphylaxis

or angioedema, although rare, may occurwith first dose or later doses. Notify prescriberimmediately, and provide supportiveemergency care.• Expect to give drug for no more than2 weeks to treat insomnia because, like allbarbiturates, it loses effectiveness for sleepinduction and sleep maintenance after2 weeks.• Monitor butabarbital intake closely duringlong-term use because tolerance and psychologicaland physical dependence maydevelop.• Avoid abrupt withdrawal of butabarbitalto prevent withdrawal symptoms.• Monitor elderly and debilitated patientsclosely because drug may cause markedexcitement, depression, and confusion inthese patients.• If patient experiencing pain receivesbutabarbital, monitor closely for paradoxicalexcitement.• If pregnant woman took butabarbital duringlast trimester, monitor infant for withdrawalsymptoms.• Monitor patient for worsening of insomniaor emergence of abnormal thinking orbehavior during therapy. If butabarbitalunmasks them, patient will need furtherassessment.PATIENT TEACHING• Stress the importance of taking butabarbitalexactly as prescribed because it can beaddictive. Warn against increasing the doseor decreasing the dosage interval withoutconsulting prescriber.• Advise patient to notify prescriber ifinsomnia persists after 7 days of butabarbitaltherapy.• Tell patient to avoid alcohol and OTCsedatives and hypnotics during butabarbitaltherapy because of additive CNSeffects.• Advise patient to avoid hazardous activitiesuntil butabarbital’s CNS effects areknown.• Advise female patient not to rely on oralcontraceptives during butabarbital therapy.• Explain that butabarbital may cause sleepdriving, in which the patient drives whilenot fully awake and typically cannot recalldoing so. Tell family members to reportany episodes of sleep driving.butorphanoltartrateStadol, Stadol NSbutorphanol tartrate 161Class, Category, and ScheduleChemical class: OpioidTherapeutic class: Anesthesia adjunct,opioid analgesicPregnancy category: CControlled substance schedule: IIIndications and Dosages To manage painI.V. INJECTIONAdults. 0.5 to 2 mg (usually 1 mg) every3 to 4 hr, as needed.I.M. INJECTIONAdults. 1 to 4 mg (usually 2 mg) every 3 to4 hr, as needed. Maximum: 4 mg/singledose.NASAL INHALATIONAdults. 1 spray (1 mg) in one nostril. Doserepeated after 60 to 90 min; two-dosesequence repeated every 3 to 4 hr, as needed.For severe pain, 2 sprays (1 in each nostril)every 3 to 4 hr, as needed.DOSAGE ADJUSTMENT Dose reduced to1 spray in one nostril for elderly patientsand those with impaired hepatic or renalfunction. Dose repeated after 90 to120 min; two-dose sequence repeated every6 hr or more, as needed. As adjunct to provide preoperative anesthesiaI.V. OR I.M. INJECTIONAdults. Individualized. Average: 2 mg 60 to90 min before surgery. As adjunct to provide anesthesiaI.V. INJECTIONAdults. Individualized. Average: 1 to 4 mgand then supplemental doses of 0.5 to1 mg, p.r.n. Total usually required duringsurgery is 60 to 180 mcg/kg.DOSAGE ADJUSTMENT Paarenteral dosesreduced by half for elderly patients andpatients with impaired hepatic or renalfunction.Mechanism of ActionBinds with specific CNS receptors to alterthe perception of and emotional responseto pain.B

162butrophanol tartrateContraindicationsHypersensitivity to butorphanol or its components(including the preservative benzethoniumchloride)Route Onset Peak DurationI.V. 2–3 min 30 min 2–4 hrI.M. 10–30 min 30–60 min 3–4 hrInhalationIn 15 min 1–2 hr 4–5 hrInteractionsDRUGSCNS depressants: Additive CNS depressionnasal vasoconstrictors, such as oxymetazoline:Decreased absorption rate and delayedonset of butorphanolACTIVITIESalcohol use: Additive CNS depressionAdverse ReactionsCNS: Anxiety, confusion, difficulty makingpurposeful movements, difficulty speaking,dizziness, euphoria, floating feeling,headache, insomnia (with nasal form), lethargy,nervousness, paresthesia, sensation ofheat, somnolence, syncope, tremor, vertigoCV: Chest pain, hypotension, palpitations,tachycardia, vasodilationEENT: Blurred vision, dry mouth, ear pain,epistaxis, nasal congestion or irritation(with nasal form), pharyngitis, rhinitis,sinus congestion, sinusitis, tinnitus,unpleasant tasteGI: Anorexia, constipation, epigastric pain,nausea, vomitingRESP: Apnea, bronchitis, cough, dyspnea,respiratory depression, shallow breathing,upper respiratory tract infectionSKIN: Clammy skin, pruritusNursing Considerations• Use butorphanol cautiously, if at all, inpatients with depression, suicidal tendency,history of drug abuse, or hepatic orrenal dysfunction.• Because drug can raise CSF pressure, use itcautiously, if at all, in patients with headinjury. Because it can increase cardiacworkload, use with extreme caution inpatients with acute MI, ventricular dysfunction,or coronary insufficiency.• Be aware that butorphanol has a highpotential for abuse.• Monitor patient after first dose of nasalform; hypotension and syncope mayoccur.• Take safety precautions because butorphanolcauses CNS depression.• Assess respiratory status closely becausedrug causes respiratory depression.• Monitor blood pressure often after givingdrug. If severe hypertension develops(rare), stop drug at once and notify prescriber.If patient isn’t narcotic-dependent,expect to administer naloxone to reversebutorphanol’s effects.PATIENT TEACHING• Stress the importance of taking butorphanolexactly as prescribed because it canbe addictive. Warn patient not to increasethe dose or decrease the dosage intervalwithout consulting prescriber.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Tell patient to avoid alcohol and otherCNS depressants, including OTC drugs,while taking butorphanol because of additiveadverse CNS reactions.• Teach patient how to use nasal form properlyby giving these instructions: Afterblowing nose to clear the nostrils, pullclear cover from the pump unit andremove protective clip from its neck.Prime pump unit by placing the nozzlebetween first and second fingers withthumb on the bottom of the bottle. Thenpump sprayer unit firmly and quicklyuntil a fine spray appears (7 or 8 strokes).Insert spray tip about 1 cm (one-thirdinch) into one nostril, pointing tip towardthe back of the nose. Close other nostrilwith one finger and tilt head slightly forward.Then pump sprayer firmly andquickly by pushing down on the pumpunit’s finger grips and against the thumbat the bottom of the bottle. Sniff gentlywith mouth closed. After spraying, removepump from nose, tilt head back, and sniffgently for a few more seconds. Thenreplace protective clip and clear cover.

CC1 esteraseinhibitor (human)BerinertClass and CategoryChemical class: GlycoproteinTherapeutic class: Human plasma C1esterase inhibitor replacementPregnancy category: CIndications and Dosages To treat acute abdominal or facialattacks of hereditary angioedemaI.V. INJECTIONAdults and adolescents. 20 units/kg givenat 4 ml/min.Mechanism of ActionSuppresses activation of the contact systemthat may mediate increased vascular permeabilityand evidence of hereditary angioedemaby inactivating plasma kallikrein andfactor XIIa, which prevents generation ofbradykinin. Patients with hereditaryangioedema have low levels of endogenousor functional C1 esterase inhibitor, a normalconstituent of plasma. By increasingthese levels, the contact system becomessufficiently inactivated to relieve signs andsymptoms.IncompatibilitiesDo not mix C1 esterase inhibitor with otherdrugs or solutions. Administer by a separateinfusion line.ContraindicationsHypersensitivity (including anaphylaxis) toC1 esterase inhibitor preparation or itscomponentsInteractionsDRUGSanticoagulants, thrombolytics: Possiblydecreased effectivenessAdverse ReactionsCNS: Chills, fever, headacheCV: ThrombosisEENT: Laryngeal edema, laryngospasm,C1 esterase inhibitor (human) 163nasopharyngitis, taste abnormalityGI: Abdominal pain, diarrhea, nausea, vomitingMS: Back pain, muscle spasmOther: Anaphylaxis, facial or generalizedpain, injection site pain and redness, shock,swelling in area of shoulder and chest,worsening of hereditary angioedemaNursing Considerations• Reconstitute C1 esterase inhibitor usingthe Mix2Vial transfer set or a doubleendedneedle and vented filter spike. Aftercleaning tops of drug and diluent vialswith alcohol and letting them dry, grip theMix2Vial transfer set together with theclear package (after peeling away the lid)and snap blue end of transfer set ontodiluent vial stopper at a 90-degree angle.Carefully remove clear package fromtransfer set. With drug vial sitting on a flatsurface, invert diluent vial with transfer setattached and snap transparent adapteronto drug vial stopper at a 90-degreeangle. Gently swirl drug vial to fully dissolve.Do not shake vial. Once drug is dissolved,grasp drug side of transfer set and,with the other hand, grasp blue diluentside of transfer set to unscrew set into twopieces. Draw air into an empty, sterilesyringe. With drug vial upright, screwsyringe to transfer set and inject air. Invertsystem upside down while keeping syringeplunger pressed, and draw concentrateinto syringe by pulling plunger back slowly.Then unscrew syringe from transfer setkeeping plunger of syringe facing down.• Attach filled syringe to an I.V. administrationset and infuse 4 ml/minute within8 hours after reconstitution. Do not refrigerateor freeze reconstituted solution.• If patient needs more than one vial, contentsof multiple vials may be pooled in asingle administration device, using a newunused Mix2Vial transfer set for each drugvial.• Do not give C1 esterase inhibitor with anyother drug. Administer it using a separateinfusion line.• Store C1 esterase inhibitor in its originalcarton to protect from light. Do notfreeze.WARNING Severe hypersensitivity reactionsmay occur with signs and symptoms forhereditary angioedema. Monitor patientC

164cabergolineclosely for evidence of anaphylaxis, generalizedurticaria, hives, hypotension, tightnessof chest, or wheezing. Discontinue C1esterase inhibitor immediately and providesupportive care, including epinephrine, asprescribed.• Thrombotic events may occur, especiallywhen higher-than-recommended doses aregiven or drug is given for off-label uses.• Monitor patient for evidence of infectionbecause C1 esterase inhibitor is extractedfrom human blood. Although safeguardsare used, the potential exists for an infectiousagent to be transmitted. Reports ofacute hepatitis C have been documentedafter giving C1 esterase inhibitor.PATIENT TEACHING• Stress importance of reporting new orpersistent signs and symptoms during andafter C1 esterase inhibitor therapy.• Inform patient about the potential forpain, such as back pain or muscle spasms,and reassure patient that comfort measureswill be provided.cabergolineDostinexClass and CategoryChemical class: Ergot alkaloid derivativeTherapeutic class: AntihyperprolactinemicPregnancy category: BIndications and Dosages To treat idiopathic or adenoma-inducedhyperprolactinemic disordersTABLETSAdults. 0.25 mg twice/wk. Increased by0.25 mg/wk at 4-wk intervals, if needed, upto 1 mg twice/wk.Route Onset Peak DurationP.O. Unknown 48 hr Up to 14 daysMechanism of ActionBinds with dopamine D 2 receptors to blockprolactin synthesis and secretion by theanterior pituitary gland, thereby reducingthe serum prolactin level.ContraindicationsHistory of pulmonary, pericardial, cardiacvalvular, or retroperitoneal fibrotic disorders;hypersensitivity to cabergoline, ergotderivatives, or their components; uncontrolledhypertensionInteractionsDRUGSantihypertensives: Increased risk of hypotensiondopamine antagonists (butyrophenones, metoclopramide,phenothiazines, or thioxanthenes):Decreased cabergoline effectivenessAdverse ReactionsCNS: Aggression, asthenia, depression,fatigue, headache, nervousness, paresthesia,pathological gambling behavior, somnolence,psychotic disorder, vertigoCV: Orthostatic hypotension, valvulopathyEENT: Dry mouthENDO: Breast painGI: Abdominal pain, constipation, diarrhea,flatulence, indigestion, nausea, vomitingGU: Dysmenorrhea, increased libidoRESP: Pulmonary effusion or fibrosisSKIN: AlopeciaNursing Considerations• Before each dose increase, check serumprolactin level to assess cabergoline’s effectiveness.• If patient has moderate to severe hepaticimpairment, monitor closely for adversereactions because of decreased cabergolinemetabolism.• Expect patient who takes cabergolinelong-term to undergo periodic reassessmentof cardiac status, including echocardiography,because valvulopathy can occurwith prolonged cabergoline use.• Erythrocyte sedimentation rate mayincrease in a patient with pleural effusionor pleural fibrosis.WARNING If you detect evidence of overdose,such as syncope, hallucinations, lightheadedness,tachycardia, and nasal congestion,notify prescriber and treat as ordered.PATIENT TEACHING• Urge patient to read and follow printedinformation that explains how to usecabergoline for best therapeutic results.• Advise patient to take drug with meals tohelp decrease GI distress.• Tell patient to take a missed dose as soonas possible within 1 to 2 days. If misseddose isn’t remembered until it’s time forthe next dose, instruct him to double the

dose if drug is generally well tolerated anddoesn’t cause nausea. If drug isn’t well tolerated,instruct patient to consult prescriberbefore taking the missed dose.• Urge patient to change positions slowly toavoid orthostatic hypotension. Tell him tonotify prescriber if it occurs.• Urge patient to keep regular appointmentsto monitor drug effectiveness.• Advise patient that drug therapy will endwhen serum prolactin level is normal for6 months. Explain that he’ll need periodicmonitoring to determine whether therapyshould resume.• Tell female patient to notify prescriber ifshe is, could be, or plans to become pregnantduring therapy; drug may need to bediscontinued.• Caution patient to avoid gambling duringtherapy because drug may increase the riskof pathological gambling behaviors.calcifediolCalderolClass and CategoryChemical class: Sterol derivative, vitamin DanalogueTherapeutic class: AntihypocalcemicPregnancy category: CIndications and Dosages To treat metabolic bone disease orhypocalcemia in patients receiving renaldialysisCAPSULESAdults and children age 10 and over. 300 to350 mcg/wk given in divided doses daily orevery other day. Increased at 4-wk intervals,p.r.n. Usual dosage 50 to 100 mcg daily or100 to 200 mcg every other day.Children ages 2 to 10. 0.05 mg daily.Children up to age 2. 0.02 to 0.05 mg daily.DOSAGE ADJUSTMENT Dosage decreased toas low as 20 mcg every other day in patientswith normal serum calcium level.Route Onset Peak DurationP.O. Unknown Unknown 15–20 daysMechanism of ActionIs converted to calcitriol in kidneys andNursing Considerations• Use calcifediol cautiously in patients withsarcoidosis or other granulomatous diseasebecause of increased sensitivity toeffects of vitamin D.• If hypercalcemia develops, expect to stopdrug. Calcium level usually returns to normalin 2 to 4 weeks. To manage acutehypercalcemia, give I.V. normal salinesolution and possibly a loop diuretic, asprescribed, to enhance diuresis or preparefor dialysis with a calcium-free dialysate ifneeded. Chronic hypercalcemia may leadto diffuse vascular calcification, nephrocalcalcifediol165then binds to specific receptors in intestinalmucosa to increase calcium absorptionfrom intestine. Calcifediol also may regulatecalcium ion transfer from bone to bloodand stimulate calcium reabsorption in distalrenal tubules, making more calciumavailable in the body.ContraindicationsAbnormal sensitivity to vitamin D effects,decreased renal function, hypercalcemia,hyperphosphatemia, hypervitaminosis, malabsorptionsyndrome, vitamin D toxicityInteractionsDRUGSaluminum-containing antacids: Increasedblood aluminum level, especially in patientswith chronic renal failurebarbiturates, corticosteroids, hydantoin anticonvulsants,primidone: Decreased effects ofvitamin Dcalcitonin, etidronate, gallium nitrate, pamidronate,plicamycin: Decreased effects ofthese drugscalcium (high doses), thiazide diuretics:Increased risk of hypercalcemiacholestyramine, colestipol, mineral oil:Decreased vitamin D absorptiondigitalis glycosides: Increased risk ofarrhythmias from hypercalcemiamagnesium-containing antacids:Hypermagnesemia, especially in chronicrenal failurephosphorous-containing drugs: Increasedrisk of hyperphosphatemiaverapamil: Increased risk of atrial fibrillationvitamin D derivatives, such as calcitriol,dihydrotachysterol, ergocalciferol: Increasedrisk of vitamin D toxicityC

166calcitonincinosis, and other soft-tissue calcification.• If patient receives high-dose or long-termcalcifediol therapy, be alert for vitamin Dtoxicity. Early evidence includes bonepain, constipation, dry mouth, headache,metallic taste, myalgia, nausea, somnolence,vomiting, and weakness. Late evidenceincludes albuminuria, anorexia,arrhythmias, azotemia, conjunctivitis (calcific),decreased libido, elevated AST andALT levels, elevated BUN level, generalizedvascular calcification, hypercholeterolemia,hypertension, hyperthermia, irritability,mild acidosis, nephrocalcinosis,nocturia, pancreatitis, photophobia, polydipsia,polyuria, pruritus, rhinorrhea, andweight loss.PATIENT TEACHING• Instruct patient to swallow capsule wholeand not to crush or chew it.• Advise patient to consult prescriber beforetaking OTC drugs.• Instruct patient to store drug tightlycapped in a cool, dry place away fromdirect light.• Encourage patient to eat a balanced dietthat includes foods high in vitamin D andcalcium. Calcifediol is most effective witha high-calcium diet.• If patient takes vitamin supplements, warnhim not to exceed recommended amounts.• Tell patient to avoid calcium-, phosphate-,and magnesium-containing laxatives andantacids; mineral oil; and vitamin Dpreparations because they may increasethe risk of calcifediol’s toxic effects.• Advise patient to immediately report possibletoxicity, such as headache, irritability,nausea, photophobia, vomiting, weakness,and weight loss.• Stress need for follow-up care, includinglaboratory tests to evaluate progress andidentify signs of toxicity early.calcitonin, humanCibacalcincalcitonin, salmonCalcimar, MiacalcinClass and CategoryChemical class: Polypeptide hormoneTherapeutic class: Antihypercalcemic, boneresorption inhibitor, osteoporosis therapyadjunctPregnancy category: CIndications and Dosages To treat hypercalcemic emergencyI.M. OR SUBCUTANEOUS INJECTIONAdults. Initial: 4 international units/kgevery 12 hr. Increased after 1 or 2 days, ifneeded, to 8 international units/kg every12 hr. Maximum: 8 international units/kgevery 6 hr. To treat postmenopausal osteoporosisI.M. OR SUBCUTANEOUS INJECTION (CALCITONIN,SALMON)Adults. Initial: 100 international units daily,every other day, or 3 times weekly.Maximum: 100 international units daily.NASAL SPRAYAdults. 200 international units (1 spray)daily, alternating nostrils. To treat Paget’s disease of the boneI.M. OR SUBCUTANEOUS INJECTION (CALCITONIN,SALMON)Adults. Initial: 100 international units daily.Maintenance: 50 to 100 international unitsdaily or every other day. Maximum:100 international units daily.SUBCUTANEOUS INJECTION (CALCITONIN, HUMAN)Adults. 0.5 mg daily, 0.5 mg 2 or 3 times/wk, or 0.25 mg daily.Route Onset Peak DurationI.M., SubQ In 15 min* 2 hr† 6–8 hr †Mechanism of ActionDirectly inhibits bone resorption. Besidesreducing the serum calcium level, thisaction slows bone metabolism (a major factorin the development of Paget’s disease)and calcium loss from the bone (a majorfactor in the development of osteoporosis).ContraindicationsHypersensitivity to calcitonin, human; calcitonin,salmon; or their componentsInteractionsDRUGSlithium: Possibly decreased lithium level* For hypercalcemia; 6 to 24 mo for Paget’sdisease.† For hypercalcemia; unknown for otherindications.

Adverse ReactionsCNS: Agitation, anxiety, dizziness,headache, insomnia, neuralgia, paresthesia,stroke, vertigoCV: Bundle-branch block, hypertension,MI, palpitations, peripheral edema, tachycardia,thrombophlebitisEENT: Blurred vision; dry mouth; earache;epistaxis; eye pain; hearing loss; nasal irritation,lesions, or redness; pharyngitis; rhinitis;salty taste; sinusitis; taste perversion;tinnitus; vitreous floatersENDO: Goiter, hyperthyroidismGI: Abdominal pain, anorexia, cholelithiasis,diarrhea, epigastric discomfort, flatulence,gastritis, hepatitis, increased appetite,nausea, thirst, vomitingGU: Hematuria, nocturia, pyelonephritis,renal calculiHEME: AnemiaMS: Arthritis, arthrosis, back pain, jointstiffness, polymyalgia rheumaticaRESP: Bronchitis, bronchospasm, cough,dyspnea, pneumonia, upper respiratorytract infectionSKIN: Alopecia, diaphoresis, eczema, flushingof face or hands, pruritus of earlobes,rash, ulcerationOther: Anaphylaxis, anaphylactic shock,angioedema, antibody formation, feverishsensation, injection site inflammation,lymphadenopathy, mild tetanic symptomsNursing Considerations• If sensitivity to calcitonin, human; calcitonin,salmon; or their components is suspected,expect to perform a skin testbefore giving drug. Prepare a mixture of10 international units/ml by withdrawing0.05 ml from a 200–international unitssolution in a tuberculin syringe and fillingthe syringe to 1 ml with sodium chloridefor injection. Mix well, discard 0.9 ml, andinject 0.1 ml intradermally on the innerforearm. Observe the site for 15 minutesafter injection. If you detect evidence ofsensitivity, such as more than mild erythemaor a wheal, notify prescriber.• If patient receives calcitonin for hypercalcemia,monitor serum calcium level.During first several doses, keep parenteralcalcium available in case the calcium levelis inadvertently overcorrected.• If prescribed calcitonin dose exceeds 2 ml,expect to use I.M. route and multipleinjection sites.• For patient receiving calcitonin for postmenopausalosteoporosis, also expect togive 1.5 g supplemental calcium carbonateand at least 400 units vitamin D daily. Planto provide a balanced diet that includesfoods high in calcium and vitamin D.• Assess for nausea, especially with the firstdose. Nausea tends to decrease or disappearwith continued use.• If patient with Paget’s disease relapses aftertreatment, check for antibody formation,as ordered.PATIENT TEACHING• Tell patient to refrigerate injection orunopened nasal spray container.• Teach patient to self-administer injections.• If patient has postmenopausal osteoporosis,teach her about dietary needs, includingfoods rich in calcium and vitamin D.• For nasal spray, explain how to activatenasal pump by holding the bottle uprightand depressing two white side armstoward the bottle six times. When bottleemits a faint spray, pump is activated. Tellpatient to store activated nasal pumpupright at room temperature and to discardit after 30 days.• Instruct patient to place nozzle firmly intoone nostril while holding head upright.Tell him to then depress the pump towardthe bottle.• Remind patient that he doesn’t need toreactivate the pump before each dose.• Instruct patient to report nasal symptoms,such as redness, lesions, sinusitis, andrhinitis, to prescriber.calcitriol(1,25-dihydroxycholecalciferol)Calcijex, Rocaltrolcalcitriol 167Class and CategoryChemical class: Sterol derivative, vitamin DanalogueTherapeutic class: Antihypocalcemic,antihypoparathyroidPregnancy category: CIndications and Dosages To treat hypocalcemia in dialysis patientsC

168calciumCAPSULES, ORAL SOLUTIONAdults. Initial: 0.25 mcg daily. Increased by0.25 mcg daily every 4 to 8 wk, if needed toachieve normal serum calcium level.Maintenance: 0.5 to 3 mcg daily. To treat hypocalcemia in predialysispatientsCAPSULES, ORAL SOLUTIONAdults and children age 3 and over. Initial:0.25 mcg daily. Increased after 4 to 8 wk, ifneeded, to 0.5 mcg daily.ORAL SOLUTIONChildren up to age 3. 10 to 15 ng/kg daily. To treat hypoparathyroidismTABLETSAdults and children age 6 and over. Initial:0.25 mcg daily in the morning. Increasedevery 2 to 4 wk, if needed to achieve normalserum calcium level. Usual: 0.5 to2 mcg daily.Children ages 1 to 5. 0.25 to 0.75 mcg dailyin the morning.I.V. INJECTIONAdults. Initial: 1 to 2 mcg 3 times/wk givenevery other day. Each dose increased 0.5 to1 mcg at 2- to 4-wk intervals, if needed.Route Onset Peak DurationP.O. 2–6 hr 10 hr 3–5 daysMechanism of ActionBinds to specific receptors on intestinalmucosa to increase calcium absorptionfrom intestine. Drug also may regulate calciumion transfer from bone to blood andstimulate calcium reabsorption in the distalrenal tubules, making more calcium availablein the body.ContraindicationsHypercalcemia, vitamin D toxicityInteractionsDRUGScholestyramine: Decreased calcitriol absorptiondigitalis glycosides: Possibly arrhythmiasketoconazole: Decreased calcitriol levelmagnesium-containing antacids (I.V. form):Hypermagnesemiamineral oil: Decreased blood calcitriol level(with prolonged use of mineral oil)phenobarbital, phenytoin: Decreased synthesisand blood level of calcitriolthiazide diuretics: HypercalcemiaAdverse ReactionsSKIN: Erythema multiforme, lip swelling,pruritus, rash, urticariaOther: AnaphylaxisNursing Considerations• Make sure patient receives enough calcium.• Store drug at room temperature, and protectfrom heat and direct light.• In high-dose or long-term calcitriol therapy,be alert for vitamin D toxicity. Earlyevidence includes abdominal or bonepain, constipation, dry mouth, headache,metallic taste, myalgia, nausea, somnolence,vomiting, and weakness. Late evidenceincludes albuminuria, anorexia,arrhythmias, azotemia, conjunctivitis (calcific),decreased libido, elevated AST andALT levels, elevated BUN level, vascularcalcification, hypercholesterolemia, hypertension,hyperthermia, irritability, mildacidosis, nephrocalcinosis, nocturia, pancreatitis,photophobia, polydipsia, polyuria,pruritus, rhinorrhea, and weight loss.PATIENT TEACHING• Warn patient not to take other forms ofvitamin D while taking calcitriol.• Instruct patient to take a missed dose assoon as possible.• Advise patient to notify prescriber immediatelyabout possible toxicity, such asheadache, irritability, nausea, photophobia,vomiting, weakness, and weight loss.calcium acetatePhosLocalcium carbonateApo-Cal (CAN), Calci-Mix, Calsan (CAN),Liqui-Cal, Liquid Cal-600, Titralaccalcium chlorideCalciject (CAN)calcium citrateCitracal, Citracal Liquitabscalcium glubionateCalcionate, Calcium-Sandoz (CAN),Neo-Calglucon

calcium gluceptateCalcium Stanley (CAN)calcium gluconatecalcium lactateClass and CategoryChemical class: Elemental cationTherapeutic class: Antacid, antihypermagnesemic,antihyperphosphatemic, antihypocalcemic,calcium replacement, cardiotonicPregnancy category: C (Not rated for calciumcarbonate, citrate, and lactate)Indications and Dosages To treat hyperphosphatemiaTABLETS (CALCIUM ACETATE)Adults. Initial: 2 tablets (338 mg elementalcalcium, 1,334 mg calcium acetate) t.i.d.with meals. Dosage increased to reduceserum phosphorus level below 6 mg/dl aslong as hypercalcemia doesn’t develop.Maintenance: 3 or 4 tablets t.i.d. with eachmeal. To prevent hypocalcemiaCAPSULES, ORAL SUSPENSION, TABLETS (CALCIUMCARBONATE); EFFERVESCENT TABLETS, TABLETS(CALCIUM CITRATE); SYRUP (CALCIUM GLUBION-ATE); TABLETS (CALCIUM GLUCONATE OR LACTATE)Adults and children over age 10. 800 to1,200 mg daily.Pregnant and breast-feeding women.1,200 mg daily.Children ages 4 to 10. 800 mg daily.Children up to age 4. 400 to 800 mg daily. To provide antacid effectsCHEWABLE TABLETS, ORAL SUSPENSION, TABLETS(CALCIUM CARBONATE)Adults and children age 12 and over.350 to 1,500 mg 1 hr after meals and atbedtime, p.r.n. To replace calcium in hypocalcemiaI.V. INFUSION (CALCIUM CHLORIDE)Adults. 0.5 to 1 g every 1 to 3 days, infusedat less than 1 ml/min.Children. 25 mg/kg given over several minutes.I.V. OR I.M. INJECTION (CALCIUM GLUCEPTATE)Adults and children. 0.44 to 1.1 g I.M. or1.1 to 4.4 g I.V. at a rate of no more thancalcium 1692 ml (36 mg)/min.I.V. INJECTION (CALCIUM GLUCONATE)Adults. 970 mg given slowly, repeated ifneeded, until tetany is controlled.Children. 200 to 500 mg as a single dosegiven slowly, repeated if needed, untiltetany is controlled. As adjunct to treat magnesium intoxicationI.V. INJECTION (CALCIUM CHLORIDE)Adults. 500 mg promptly and repeatedp.r.n., based on response. As adjunct in cardiac resuscitationI.V. INJECTION (CALCIUM CHLORIDE)Adults. 0.5 to 1 g.Children. 0.2 ml/kg. As adjunct in exchange transfusionI.V. INJECTION (CALCIUM GLUCONATE)Adults. 1.35 mEq with each 100 ml of citratedblood exchanged.Neonates. 0.45 mEq after each 100 ml ofcitrated blood exchanged.I.V. INJECTION (CALCIUM GLUCEPTATE)Neonates. 110 mg after each 100 ml of citratedblood exchanged.Mechanism of ActionIncreases levels of intracellular and extracellularcalcium, which is needed to maintainhomeostasis, especially in the nervousand musculoskeletal systems. Also plays arole in normal cardiac and renal function,respiration, coagulation, and cell membraneand capillary permeability. Helps regulatethe release and storage of neurotransmittersand hormones. Oral forms also neutralizeor buffer stomach acid to relieve discomfortcaused by hyperacidity.ContraindicationsHypercalcemia, hypersensitivity to calciumsalts or their components, hypophosphatemia,renal calculiIncompatibilitiesTo avoid precipitation, don’t give I.V. calciumchloride, gluceptate, or gluconatethrough same I.V. line as bicarbonates, carbonates,phosphates, sulfates, or tartrates.InteractionsDRUGSaluminum-containing antacids: Enhancedaluminum absorption with use of calciumcitrateatenolol: Decreased blood atenolol level andC

170calciumbeta blockadecalcitonin: Possibly antagonized effects ofcalcitonin in hypercalcemia treatmentcalcium supplements, magnesium-containingpreparations: Increased serum calcium ormagnesium level, especially in patients withimpaired renal functioncellulose sodium phosphate: Decreased effectivenessof cellulose sodium phosphate inpreventing hypercalciuriadigitalis glycosides: Increased risk ofarrhythmiasestrogens, oral contraceptives (estrogen-containing):Increased calcium absorptionetidronate: Decreased etidronate absorptionfluoroquinolones: Reduced fluoroquinoloneabsorption by calcium carbonategallium nitrate: Antagonized effects of galliumnitrateiron salts: Decreased gastric iron absorptionmagnesium sulfate (parenteral): Neutralizedeffects of magnesium by parenteral calciumneuromuscular blockers (except succinylcholine):Possibly reversal of neuromuscularblockade by parenteral calcium salts;enhanced or prolonged neuromuscularblockade induced by tubocurarinenorfloxacin: Decreased norfloxacin bioavailabilityphenytoin: Decreased bioavailability ofphenytoin and calciumpotassium phosphates, potassium and sodiumphosphates: Increased risk of calcium depositionin soft tissuesodium bicarbonate: Possibly milk-alkalisyndromesodium fluoride: Reduced fluoride and calciumabsorptionsodium polystyrene sulfonate: Possibly metabolicalkalosis if patient has renal impairmenttetracyclines: Decreased tetracycline absorptionand blood level, leading to decreasedanti-infective responsethiazide diuretics: Possibly hypercalcemiaverapamil: Reversed verapamil effectsvitamin A (more than 25,000 units daily):Possibly stimulation of bone loss, decreasedeffects of calcium supplementation, andhypercalcemiavitamin D (high doses): Excessivelyincreased calcium absorptionFOODScaffeine, high-fiber food: Possibly decreasedcalcium absorptionACTIVITIESalcohol use (excessive), smoking: Possiblydecreased calcium absorptionAdverse ReactionsCNS: Paresthesia (parenteral form)CV: Hypotension, irregular heartbeat (parenteralform)GI: Nausea or vomiting (parenteral form)SKIN: Diaphoresis, flushing, or sensation ofwarmth (parenteral form)Other: Hypercalcemia; injection site burning,pain, rash, or redness (parenteral form)Nursing Considerations• Store at room temperature, and protectfrom heat, moisture, and direct light.Don’t freeze.• Warm solution to room temperaturebefore parenteral administration.• Keep patient in a recumbent position for30 minutes after parenteral administrationto prevent dizziness from hypotension.• Administer I.V. calcium through an infusingI.V. solution using a small-bore needleinserted into a large vein to minimize irritation.Give calcium slowly to preventexcess calcium from reaching the heartand causing adverse cardiovascular reactions.Adverse reactions often result fromtoo-rapid administration. If ECG tracingsare abnormal or patient reports injectionsite discomfort, expect to temporarily discontinueadministration.• Check regularly for infiltration becausecalcium causes necrosis. If infiltrationoccurs, stop infusion and tell prescriberimmediately.• Divide I.M. calcium gluceptate dose of5 ml or more in half and inject in glutealregion.• Regularly monitor serum calcium leveland evaluate therapeutic response byassessing for Chvostek’s and Trousseau’ssigns, which shouldn’t appear.• Be aware that calcium chloride injectioncontains three times as much calcium permilliliter as calcium gluconate injection.PATIENT TEACHING• For chewable tablets, urge patient to chewthoroughly before swallowing and to drinka glass of water afterward.• If suspension is prescribed, tell patient toshake bottle well before each use.• If calcium citrate effervescent tablets are

prescribed, tell patient to dissolve them inwater and drink immediately.• Instruct patient to take calcium carbonatetablets 1 to 2 hours after meals, calciumglubionate syrup before meals (diluted inwater or fruit juice, if desired, for an infantor a child), and other forms with meals.• Advise storing calcium at room temperatureaway from heat, moisture, and light.Warn against freezing suspension or syrup.• Instruct patient to avoid taking calciumwithin 2 hours of another oral drugbecause of risk of interactions.• Urge patient to ask prescriber before takingOTC drugs because of risk of interactions.• Tell patient to avoid excessive use of tobaccoand excessive consumption of alcoholicbeverages, caffeine-containing products,and high-fiber foods because these substancesmay decrease calcium absorption.candesartancilexetilAtacandClass and CategoryChemical class: Angiotensin II receptorantagonistTherapeutic class: AntihypertensivePregnancy category: C (first trimester), D(later trimesters)Indications and Dosages To manage, or as adjunct in managing,hypertensionTABLETSAdults. Initial: 16 mg daily. Maintenance:8 to 32 mg daily or 4 to 16 mg every 12 hr.Maximum: 32 mg daily.DOSAGE ADJUSTMENT Initial dosagedecreased to 2 mg for patients with moderateto severe hepatic impairment and to4 mg for those with renal impairment, needfor hemodialysis, or possibly a risk ofhypotension. To treat heart failure in patients with anejection fraction of 40% or less andNYHA class II–IV to reduce the risk ofdeath from cardiovascular causes andreduce hospitalizations for heart failureTABLETSAdults. Initial: 4 mg daily for 2 wk; thenNursing Considerations• If patient has known or suspected hypovolemia,expect to provide treatment, suchas I.V. normal saline solution, as prescribed,to correct it before starting candesartan.• Monitor patient closely during major surgeryand anesthesia because candesartanincreases risk of hypotension by blockingrenin-angiotensin system.• Watch for elevated BUN and serum creatininelevels, especially if patient has heartfailure or impaired renal function; drugmay cause acute renal failure. Report sigcandesartancilexetil 171doubled every 2 wk as tolerated until reachingtarget dose of 32 mg daily.Route Onset Peak DurationP.O. In 2 wk 4–5 wk UnknownMechanism of ActionSelectively blocks binding of angiotensin(AT) II to AT 1 receptor sites in many tissues,including vascular smooth muscle andadrenal glands. This inhibits vasoconstrictiveand aldosterone-secreting effects of ATII, which reduces blood pressure.ContraindicationsHypersensitivity to candesartan or its componentsInteractionsDRUGSdiuretics, other antihypertensives: Possiblyincreased risk of hypotensionheparin, potassium-sparing diuretics, potassiumsupplements, potassium-containing saltsubstitutes: Possibly increased risk of hyperkalemialithium: Increased blood lithium levelAdverse ReactionsCNS: Dizziness, headacheCV: HypotensionEENT: Pharyngitis, rhinitisGI: Elevated liver function test results,hepatitisGU: Elevated BUN and serum creatininelevelsHEME: Agranulocytosis, leukopenia, neutropeniaMS: Back pain, rhabdomyolysisRESP: Upper respiratory tract infectionOther: Hyperkalemia, hyponatremiaC

172capreomycin sulfatenificant or persistent increases immediately.• If blood pressure isn’t controlled with candesartanalone, expect to give a diuretic,such as hydrochlorothiazide, as prescribed.WARNING If patient receives a diuretic orantihypertensive with candesartan, hasheart failure, or is elderly, assess bloodpressure often because of added risk ofhypotension.• If patient develops hypotension, expect tostop drug temporarily. Immediately placepatient in supine position and prepare togive I.V. normal saline solution, as prescribed.Expect to resume therapy afterblood pressure stabilizes.• If patient receives a diuretic, providehydration, as ordered, to help preventhypovolemia. Watch for evidence, such ashypotension with dizziness and fainting. Ifpatient has heart failure and developshypotension, dosage of diuretic, candesartan,or both may be reduced when bloodpressure stablizes and therapy resumes.• Check CBC for decreases in hemoglobinand hematocrit. If they’re significant orpersistent, notify prescriber immediately.PATIENT TEACHING• Advise patient that full effects of candesartanmay not occur for 4 to 5 weeks.• Explain importance of lifestyle choices incontrolling hypertension.• Advise female patient to immediatelyreport known or suspected pregnancy.Explain that if she becomes pregnant, prescribermay replace candesartan withanother antihypertensive that’s safe to useduring pregnancy.capreomycin sulfateCapastatClass and CategoryChemical class: Polypeptide antibiotic isolatedfrom Streptomyces capreolusTherapeutic class: AntitubercularPregnancy category: CIndications and Dosages As adjunct to treat pulmonary tuberculosiscaused by Mycobacterium tuberculosisin which primary drugs are ineffectiveor can’t be used because of toxicityI.V. INFUSION, I.M. INJECTIONAdults. 1 g daily for 60 to 120 days followedby 1 g 2 or 3 times/wk for 12 to 24 mo.Maximum: 20 mg/kg daily.DOSAGE ADJUSTMENT For patient with renalimpairment, dosage reduced according topatient’s creatinine clearance.Mechanism of ActionMay interfere with lipid and nucleic acidbiosynthesis in actively growing tuberclebacilli.ContraindicationsHypersensitivity to capreomycin or its componentsInteractionsDRUGSaminoglycosides (parenteral): Increased riskof ototoxicity, nephrotoxicity, and neuromuscularblockadenephrotoxic drugs, such as amphotericin B:Increased risk of nephrotoxicitynondepolarizing neuromuscular blockers:Enhanced neuromuscular blockadeototoxic drugs, such as quinidine: Increasedrisk of ototoxicitypolymyxins (parenteral): Increased risk ofnephrotoxicity and neuromuscular blockadeAdverse ReactionsCNS: Dizziness, vertigoEENT: OtotoxicityGI: Elevated liver function test resultsGU: NephrotoxicityHEME: Leukocytosis, leukopeniaSKIN: Maculopapular rash, sterile abscess,urticariaOther: Hypocalcemia, hypokalemia, hypomagnesemia,injection site pain, induration,and bleedingNursing Considerations• Use capreomycin cautiously in patientswith renal insufficiency, impaired hearing,or a history of hypersensitivity, especiallyto other drugs.• Expect to obtain baseline renal functionstudies, as ordered, before starting capreomycinand weekly throughout therapybecause drug may alter renal function.• To reconstitute drug for I.V. injection, add100 ml normal saline solution. Administerover 60 minutes.• To reconstitute drug for I.M. injection,add 2 ml sodium chloride for injection or

sterile water for injection to each 1-g vial.Allow 2 to 3 minutes for complete dissolution.• Give I.M. injection deep into a large musclemass, such as the gluteus maximus.• Observe injection site for excessive bleedingor sterile abscess.• Make sure patient receives regular audiometricand vestibular function assessment.• Closely monitor patient for urticaria andmaculopapular rash.• Check serum electrolyte levels periodically,as ordered, because capreomycin maycause imbalances such as hypocalcemia,hypokalemia, and hypomagnesemia.PATIENT TEACHING• Advise patient to alert nurse or prescriberif injection site bleeds excessively.• Warn patient to contact prescriber immediatelyabout hearing loss or tinnitus.• Explain the need for frequent laboratorytests to monitor renal function.• Tell patient that tuberculosis therapy lastsfor 12 to 24 months.• Explain that noncompliance may decreaseeffectiveness and lengthen treatment.captoprilCapotenClass and CategoryChemical class: ACE inhibitorTherapeutic class: AntihypertensivePregnancy category: C (first trimester), D(later trimesters)Indications and Dosages To control hypertensionTABLETSAdults and adolescents. Initial: 25 mg b.i.d.or t.i.d. Increased to 50 mg b.i.d. or t.i.d.after 1 to 2 wk, if needed. If blood pressureisn’t well controlled at this dosage and withthe addition of a diuretic, dosage increasedto 100 mg b.i.d. or t.i.d. and then, if needed,to 150 mg b.i.d. or t.i.d. while continuingdiuretic. Maximum: 450 mg daily. To control accelerated or malignanthypertension when temporary discontinuationof current antihypertensive therapyisn’t practical or when prompt titrationof blood pressure is neededTABLETScaptopril 173Adults and adolescents. Initial: 25 mg b.i.d.or t.i.d while continuing diuretic but discontinuingcurrent antihypertensive drug.Increased every 24 hr as needed until satisfactoryresponse is obtained or maximumdosage is reached. Maximum: 450 mg daily. To treat heart failure that’s unresponsiveto conventional therapyTABLETSAdults and adolescents. Initial: 25 mg b.i.d.or t.i.d. Increased to 50 mg b.i.d. or t.i.d., asneeded. After 14 days, increased to 100 mgt.i.d. and then to 150 mg t.i.d, if needed.Maximum: 450 mg daily. To treat left-sided heart failure after MITABLETSAdults and adolescents. Initial: 6.25 mg assingle dose starting 3 days after MI andthen 12.5 mg t.i.d. Increased to 25 mg t.i.d.for several days and then again to maintenancedosage. Maintenance: 50 mg t.i.d. To treat diabetic nephropathyTABLETSAdults and adolescents. 25 mg t.i.d.DOSAGE ADJUSTMENT Starting dosagereduced to 6.25 mg b.i.d. or t.i.d. if patientwith hypertension also has heart failure, isundergoing dialysis, or is being vigorouslytreated with diuretics that result in hyponatremiaor hypovolemia.Route Onset Peak DurationP.O. 15–60 min 60–90 min 6–12 hrMechanism of ActionBy inhibiting angiotensin-convertingenzyme, captopril:• prevents conversion of angiotensin I toangiotensin II, a potent vasoconstrictorthat also stimulates the adrenal cortex tosecrete aldosterone. Inhibiting aldosteroneincreases sodium and water excretion,reducing blood pressure.• may inhibit renal and vascular productionof angiotensin II.• decreases serum angiotensin II level andincreases renin activity. This decreasesaldosterone secretion, slightly increasingserum potassium level and fluid loss.• decreases vascular tone and blood pressure.ContraindicationsHypersensitivity to captopril, other ACEinhibitors, or their componentsC

174carbamazepineInteractionsDRUGSallopurinol: Increased risk of hypersensitivityreactions, including Stevens-Johnsonsyndrome, skin eruptions, fever, arthralgiaantacids: Possibly impaired captoprilabsorptioncapsaicin: Possibly cause or worsening ofcough from ACE inhibitorcyclosporine, potassium-containing drugs,potassium-sparing diuretics, potassium supplements:Increased risk of hyperkalemiadigoxin: Increased blood digoxin leveldiuretics; hypotension-producing drugs, suchas hydralazine: Additive hypotensive effectsgold: Increased risk of nitritoid reaction,including facial flushing, nausea, vomiting,and hypotensionlithium: Increased risk of lithium toxicityNSAIDs: Decreased antihypertensiveresponse to ACE inhibitionprobenecid: Increased blood level anddecreased total clearance of captoprilACTIVITIESalcohol use: Additive hypotensive effectsAdverse ReactionsCNS: FeverCV: Chest pain, hypotension, orthostatichypotension, palpitations, tachycardiaEENT: Loss of tasteGU: Dysuria, impotence, nephrotic syndrome,nocturia, oliguria, polyuria,proteinuria, urinary frequencyHEME: EosinophiliaMS: ArthralgiaRESP: CoughSKIN: Photosensitivity, pruritus, rashOther: Angioedema, hyperkalemia,hyponatremia, positive ANA titerNursing Considerations• Closely monitor patient’s blood pressure,especially when therapy starts and dosageincreases. Keep patient supine if hypotensionoccurs.• Monitor renal function tests for signs ofnephrotic syndrome, such as proteinuriaand increased BUN and serum creatininelevels. Also watch for such renal evidenceas oliguria, polyuria, and urinary frequency.• Monitor WBC regularly, as ordered, especiallyif patient has collagen vascular diseaseor renal disease.PATIENT TEACHING• Instruct patient to take captopril 1 hourbefore meals.• Tell patient to rise slowly from sitting orlying to minimize orthostatic hypotension.• Tell patient to avoid sunlight or wear sunscreenin direct sunlight because photosensitivitymay occur.• Warn patient not to stop drug abruptly.• Urge patient not to use salt substitutes thatcontain potassium and to consult prescriberbefore increasing potassium intaketo avoid increasing risk of hyperkalemia.• Urge patient to tell prescriber about signsand symptoms of infection, such as sorethroat or fever.carbamazepineApo-Carbamazepine (CAN), Atretol,Carbatrol, Epitol, Equetro, Novo-Carbamaz (CAN), Tegretol, Tegretol-XRClass and CategoryChemical class: Tricyclic iminostilbenederivativeTherapeutic class: Analgesic, anticonvulsantPregnancy category: CIndications and Dosages To treat epilepsyE.R. CAPSULES (CARBATROL), E.R. TABLETS(TEGRETOL-XR)Adults and children age 12 and over.Initial: 200 mg b.i.d. Increased weekly by200 mg daily, if needed. Maximum:1,600 mg daily in adults, 1,200 mg daily inchildren age 16 and over, and 1,000 mgdaily in children ages 12 to 16.Children ages 6 to 12. Initial: 100 mg b.i.d.Increased weekly by 100 mg daily, if needed.Maximum: 1,000 mg daily.ORAL SUSPENSIONAdults and children age 12 and over.Initial: 100 mg q.i.d. Increased weekly by200 mg daily, if needed, given in divideddoses t.i.d or q.i.d. Maximum: 1,600 mgdaily in adults, 1,200 mg daily in childrenage 16 and over, and 1,000 mg daily in childrenages 12 to 16.Children ages 6 to 12. Initial: 50 mg q.i.d.Increased weekly by 100 mg daily, if needed,given in divided doses t.i.d or q.i.d.Maximum: 1,000 mg daily.Children up to age 6. Initial: 10 to 20 mg/

carbamazepine 175Mechanism of ActionNormally, sodium moves into a neuronalcell by passing through a gated sodiumchannel in the cell membrane.Carbamazepine may prevent or haltseizures by closing or blocking sodiumchannels, as shown below, thus preventingsodium from entering the cell.Keeping sodium out of the cell may slownerve impulse transmission, thus slowingthe rate at which neurons fire.CellexteriorNeuronalcellmembraneCellinteriorOpen sodiumchannelSodiumClosedsodiumchannelCarbamazepineCkg/day in divided doses q.i.d. Maximum:35 mg/kg daily.TABLETSAdults and children age 12 and over.Initial: 200 mg b.i.d. Increased weekly by200 mg/day, if needed, given in divideddoses t.i.d. or q.i.d. Maximum: 1,600 mgdaily in adults, 1,200 mg daily in childrenage 16 and over, and 1,000 mg daily in childrenages 12 to 16.Children ages 6 to 12. Initial: 100 mg b.i.d.Increased weekly by 100 mg daily, if needed,given in divided doses t.i.d. or q.i.d.Maximum: 1,000 mg daily.Children up to age 6. Initial: 10 to 20 mg/kg daily in divided doses b.i.d. or t.i.d.Increased weekly, if needed, divided andgiven t.i.d. or q.i.d. Maximum: 35 mg/kg/day. To relieve pain in trigeminal neuralgiaE.R. CAPSULES (CARBATROL), E.R. TABLETS(TEGRETOL-XR), TABLETSAdults. Initial: 100 mg b.i.d. Increased byup to 200 mg daily, if needed, in incrementsof 100 mg every 12 hr. Maintenance: 400 to800 mg/day. Maximum: 1,200 mg daily.ORAL SUSPENSION (100 MG/5 ML)Adults. 50 mg q.i.d. Increased by up to200 mg daily, if needed, in increments of50 mg q.i.d. Maintenance: 400 to 800 mgdaily. Maximum: 1,200 mg daily. To treat acute manic and mixed episodesin bipolar disorderE.R. CAPSULES (EQUETRO)Adults. Initial: 200 mg b.i.d., increased asneeded in 200-mg increments. Maximum:1,600 mg daily.ContraindicationsHistory of bone marrow depression; hypersensitivityto carbamazepine, tricyclic compounds,or their components; MAOinhibitor or nefazodone therapyRoute Onset Peak DurationP.O. (all In 1 mo* Unknown Unknownforms)InteractionsDRUGSacetaminophen (long-term use): Increasedmetabolism, leading to acetaminopheninducedhepatotoxicity or decreased acetaminopheneffectivenessacetazolamide, cimetidine, clarithromycin,danazol, diltiazem, erythromycin, fluconazole,fluoxetine, fluvoxamine, isoniazid, itraconazole,ketoconazole, loratadine, niacinamide,nicotinamide, propoxyphene, proteaseinhibitors, terfenadine, troleandomycin,valproate, verapamil: Increased blood carbamazepinelevelalprazolam, amitriptyline, bupropion, buspirone,citalopram, clobazam, clonazepam,clozapine, cyclosporine, delavirdine, desipramine,diazepam, dicumarol, doxycycline,ethosuximide, felodipine, glucocorticoids,haloperidol, itraconazole, lamotrigine, levothyroxine,lorazepam, methadone, methsuximide,midazolam, mirtazapine, nortriptyline,olanzapine, oral contraceptives, oxcarbazepine,phenytoin, praziquantel, proteaseinhibitors, quetiapine, risperidone, theophylline,tiagabine, topiramate, tramadol,triazolam, trazodone, valproate, warfarin,* For anticonvulsant use; 8 to 72 hr for usein trigeminal neuralgia.

176carbamazepineziprasidone, zonisamide: Decreased bloodlevels of these drugscisplatin, doxorubicin, felbamate, methsuximide,phenytoin, rifampin, theophylline:Decreased blood carbamazepine levelclomipramine, phenytoin, primidone:Increased blood levels of these drugsfelbamate: Decreased blood level of felbamateor carbamazepineisoniazid: Increased risk of carbamazepinetoxicity and isoniazid hepatotoxicitylamotrigine, phenobarbital, primidone, tricyclicantidepressants, valproic acid:Decreased blood levels of these drugs,increased blood level of carbamazepinelithium: Increased risk of CNS toxicitynefazodone: Decreased nefazodone effectivenessand increased carbamazepine levelnondepolarizing neuromuscular blockers:Possibly reduced duration or decreasedeffectiveness of neuromuscular blockeroral anticoagulants: Increased metabolismand decreased effectiveness of anticoagulantFOODSgrapefruit juice: Increased blood carbamazepinelevelACTIVITIESalcohol use: Increased sedative effectAdverse ReactionsCNS: Chills, confusion, dizziness, drowsiness,fatigue, fever, headache, suicidalideation, syncope, talkativeness, unsteadiness,visual hallucinationsCV: Arrhythmias, including AV block;edema; heart failure; hypertension;hypotension; thromboembolism; thrombophlebitis;worsened coronary artery diseaseEENT: Blurred vision, conjunctivitis, drymouth, glossitis, nystagmus, oculomotordisturbances, stomatitis, tinnitus, transientdiplopiaENDO: Syndrome of inappropriate ADHsecretion, water intoxicationGI: Abdominal pain, anorexia, constipation,diarrhea, dyspepsia, elevated liver functiontest results, hepatitis, nausea, pancreatitis,vomitingGU: Acute urine retention, albuminuria,azotemia, glycosuria, impotence, oliguria,renal failure, urinary frequencyHEME: Acute intermittent porphyria, agranulocytosis,aplastic anemia, bone marrowdepression, eosinophilia, leukocytosis, leukopenia,pancytopenia, thrombocytopeniaMS: Arthralgia, leg cramps, myalgiaRESP: Pulmonary hypersensitivity (dyspnea,fever, pneumonia, or pneumonitis)SKIN: Aggravation of disseminated lupuserythematosus, alopecia, altered skin pigmentation,diaphoresis, erythema multiforme,erythema nodosum, exfoliative dermatitis,jaundice, Lyell’s syndrome, photosensitivityreactions, pruritic and erythematousrash, purpura, Stevens-Johnson syndrome,urticariaOther: Adenopathy, lymphadenopathyNursing Considerations• Avoid using carbamazepine in patientswith a history of hepatic porphyriabecause it may prompt an acute attack.WARNING If patient has Asian ancestry,make sure he has been evaluated for thegenetic allelic variant HLA-B 1502 beforestarting carbamazepine therapy. Patientspositive for HLA-B 1502 shouldn’t takecarbamazepine because the risk of serious,sometimes fatal, dermatologic reactions isten times higher than in patients withoutthis variant.• Use carbamazepine cautiously in patientswith impaired hepatic function becauseit’s mainly metabolized in the liver.Monitor liver function tests, as directed.• Monitor patient closely for adverse reactionsbecause many are serious.• Periodically monitor blood carbamazepinelevel to assess for therapeutic and toxiclevels; a blood level of 6 to 12 mcg/ml isoptimal for anticonvulsant effects.WARNING Monitor WBC and plateletcounts monthly for first 2 months.Decreased counts may indicate bone marrowdepression.• Monitor patient closely for evidence ofsuicidal thinking or behavior, especiallywhen therapy starts or dosage changes.• Withdraw carbamazepine gradually tominimize risk of seizures.PATIENT TEACHING• Tell patient to take carbamazepine withfood (except the oral suspension form,which shouldn’t be taken with other liquiddrugs or diluents).• Warn patient about possible dizziness,blurred vision, and unsteadiness.• Inform patient that coating of E.R. tabletsisn’t absorbed and may appear in stool.

• Advise patient not to crush or chew E.R.capsules or tablets. If he can’t swallow capsuleswhole, have him open them andsprinkle contents on food.• Urge patient to wear sunscreen and protectiveclothing to reduce photosensitivity.• Tell patient to report unusual bleeding orbruising, fever, rash, or mouth ulcers.• Tell woman that drug decreases oral contraceptiveeffectiveness, and urge her touse different contraception. Because drugmay cause fetal harm, tell her to notifyprescriber about possible pregnancy.• If she becomes pregnant during therapy,urge her to enroll in the antiepileptic drugpregnancy registry by calling 1-888-233-2334. Explain that the registry is collectinginformation about the safety of antiepilepticdrugs during pregnancy.• Instruct caregivers to watch patient closelyfor evidence of suicidal tendencies, especiallywhen therapy starts or dosagechanges, and to report such tendencies toprescriber immediately.carisoprodolSoma, VanadomClass and CategoryChemical class: DicarbamateTherapeutic class: Skeletal muscle relaxantPregnancy category: CIndications and Dosages As adjunct to relieve acute musculoskeletalpain and stiffnessTABLETS (SOMA)Adults and children over age 16. 250 to350 mg t.i.d. and at bedtime.TABLETS (VANADOM)Children ages 5 to 12. 6.25 mg/kg t.i.d. andat bedtime.Route Onset Peak DurationP.O. 30 min Unknown 4–6 hrMechanism of ActionBlocks interneuronal activity in descendingreticular formation and spinal cord, producingmuscle relaxation and sedation.ContraindicationsHypersensitivity or idiosyncratic reactionscarisoprodol 177to carisoprodol, to its components, or tomeprobamate-related compounds; intermittentporphyriaInteractionsDRUGSCNS depressants, psychotropic drugs:Additive CNS depressionfluvoxamine, omeprazole: Increased bloodcarisoprodol levelrifampin, St. John’s wort: Decreased bloodcarisoprodol levelACTIVITIESalcohol use: Additive CNS depressionAdverse ReactionsCNS: Agitation, ataxia, depression, dizziness,drowsiness, fever, headache, insomnia,irritability, seizures, somnolence, syncope,tremor, vertigoCV: Orthostatic hypotension, tachycardiaEENT: Diplopia, transient vision lossGI: Epigastric discomfort, hiccups, nausea,vomitingHEME: EosinophiliaSKIN: Erythema multiforme, facial flushing,pruritus, rashOther: Drug dependence or withdrawalNursing Considerations• Use carisoprodol cautiously in patientswith history of drug addiction and inpatients taking other CNS depressants,including alcohol.• Carisoprodol therapy should last nolonger than 3 weeks.• Monitor patient closely for hypersensitivityor idiosyncratic reactions. They typicallyoccur before the fourth dose in patientswho have no previous carisoprodol exposure.• Provide rest and other pain-relief measures.• To avoid mild withdrawal symptoms,expect to taper therapy as prescribed,rather than stopping it abruptly.PATIENT TEACHING• Tell patient to take carisoprodol withmeals if GI distress occurs.• Caution patient that drug dependence andwithdrawal may occur, especially if therapylasts a long time or patient changesdosage without consulting prescriber.• Warn patient about possible dizziness,drowsiness, syncope, and vertigo.Discourage hazardous activities, such asdriving, until effects of drug are known.C

178Nursing ConsiderationsWARNING Be aware that stopping carteololabruptly in patients with angina maycause worsening of angina or MI; abruptcessation in patients with hyperthyroidismmay cause thyroid storm.• Carefully monitor blood glucose level indiabetic patient because carteolol canmask hypoglycemic symptoms. It also caninterfere with endogenous insulin releasein response to hyperglycemia, requiringadjustment of oral antidiabetic dosage.PATIENT TEACHING• Advise patient to complete dosing schedule,even if he feels better, and not to discontinuetherapy abruptly.• Instruct patient to report signs of heartfailure, such as fatigue, difficulty breathcarteololhydrochloride• Inform patient that abruptly stoppingdrug can cause headache, insomnia, nausea,and other adverse reactions.• Instruct patient to avoid alcohol and otherCNS depressants while taking drug.• Explain that saliva, urine, and sweat mayappear darker (red, brown, or black). Reassurehim that this discoloration is harmlessbut may stain garments.• Tell patient to store drug in a tightlycapped container at room temperature.• Tell patient not to store drug in bathroom,near kitchen sink, or in other damp placesto protect it from heat and moisture.carteololhydrochlorideCartrolClass and CategoryChemical class: Beta-adrenergic blockerTherapeutic class: AntihypertensivePregnancy category: CIndications and Dosages To control hypertensionTABLETSAdults. Initial: 2.5 mg daily. If response isinadequate, dosage increased to 5 mg andthen 10 mg daily, p.r.n. Maintenance: 2.5 or5 mg daily.DOSAGE ADJUSTMENT Interval increased toevery 48 hr for patients with creatinineclearance of 20 to 60 ml/min/1.73 m 2 or toevery 72 hr for clearance of less than 20 ml/min/1.73 m 2 .Route Onset Peak DurationP.O. Unknown 1–3 hr UnknownMechanism of ActionMay reduce blood pressure by competingwith beta-adrenergic receptor agonists,which helps reduce cardiac output, decreasesympathetic outflow to peripheral bloodvessels, and inhibit renin.ContraindicationsAsthma, bradycardia (less than 45 beats/min), cardiogenic shock, hypersensitivity tocarteolol or its components, second- orthird-degree heart blockInteractionsDRUGSallergen immunotherapy, allergenic extractsfor skin testing: Increased risk of serious systemicreaction or anaphylaxiscatecholamine-depleting drugs, such as reserpine:Additive effects, increased risk ofhypotension and bradycardiaclonidine: Increased risk of tachycardia andhypertension after clonidine discontinuationdiltiazem, nifedipine, verapamil: Potentiatedeffects of carteololgeneral anesthetics: Exaggeration of hypotensionNSAIDs: Reduced antihypertensive effect ofcarteololoral antidiabetic drugs: Reduced symptomaticresponses to hypoglycemiasympathomimetics with alpha- and betaadrenergiceffects, such as pseudoephedrine:Possibly hypertension and excessive bradycardiaor heart blockAdverse ReactionsCNS: Fatigue, insomnia, lassitude, paresthesia,tiredness, weaknessCV: Chest pain, heart failure, peripheraledemaEENT: Dry mouth, nasal congestion,pharyngitisGI: Abdominal pain, diarrhea, flatulence,nauseaMS: Arthralgia, back pain, leg pain, musclespasmsSKIN: Rash

ing, cough, and unusually fast heartbeat.• Tell diabetic patient to check his bloodglucose level often.• Advise patient to consult prescriber beforetaking OTC preparations, such as nasaldecongestants and cold preparations thatcontain sympathomimetics, because of therisk of serious drug interactions.carvedilolCoreg, Coreg CRClass and CategoryChemical class: Nonselective beta-adrenergicblocker with alpha 1 -adrenergic blockingactivityTherapeutic class: Antihypertensive, heartfailure treatment adjunctPregnancy category: CIndications and Dosages To control hypertensionTABLETSAdults. 6.25 mg b.i.d. for 7 to 14 days, iftolerated. Then dosage increased to 12.5 mgb.i.d. for 7 to 14 days, and up to 25 mg, iftolerated and needed. Maximum: 50 mgdaily.E.R. CAPSULESAdults. Initial: 20 mg once daily with food.After 7 to 14 days, increased to 40 mg oncedaily. After another 7 to 14 days, increasedto 80 mg once daily. Maximum: 80 mg oncedaily. As adjunct to treat mild to severe heartfailure of ischemic or cardiomyopathicoriginTABLETSAdults. 3.125 mg b.i.d. for 2 wk; thenincreased to 6.25, 12.5, and 25 mg b.i.d. atsuccessive 2-wk intervals, as tolerated.Maximum (for patients with mild to moderateheart failure): 50 mg b.i.d. if patientweighs more than 85 kg (187 lb).E.R. CAPSULESAdults. Initial: 10 mg once daily with foodfor 2 wk. Then increased to 20 mg oncedaily, as needed. Subsequent dosageincreased by 20 mg every 2 wk, as needed.Maximum: 80 mg once daily. To reduce CV mortality after acutephase of MI in patients with left ventricularejection fraction of 40% or lesscarvedilol 179TABLETSAdults. 6.25 mg b.i.d. for 3 to 10 days, iftolerated. Then dosage increased to 12.5 mgb.i.d. for 3 to 10 days and up to 25 mgb.i.d., if needed and tolerated.E.R. CAPSULESAdults. Initial: 10 to 20 mg once daily. After3 to 10 days, increased to 20 to 40 mg oncedaily. Increased again as needed every 3 to10 days until reaching tolerance or targetdose of 80 mg once daily. Maximum: 80 mgonce daily.DOSAGE ADJUSTMENT For patient with fluidretention or low blood pressure or heartrate, starting dosage may be decreased to3.125 mg b.i.d., increase may be slowed, orboth for tablet form. For patient with heartrate below 55 beats/min, extended-releasedosage decreased as clinical condition indicates.Route Onset Peak DurationP.O. In 30 min 1.5–7 hr UnknownMechanism of ActionReduces cardiac output and tachycardia,causes vasodilation, and decreases peripheralvascular resistance, which reduces bloodpressure and cardiac workload. When givenfor at least 4 weeks, carvedilol reduces plasmarenin activity.ContraindicationsAsthma or related bronchospastic conditions;cardiogenic shock; decompensatedheart failure that requires I.V. inotropics;history of serious hypersensitivity reactions,such as anaphylaxis, angioedema, orStevens-Johnson syndrome; hypersensitivityto carvedilol or its components; second- orthird-degree AV block, severe bradycardiaor hepatic impairment, or sick sinus syndromeunless pacemaker is in placeInteractionsDRUGSamiodarone; other CYP2C9 drugs, such asfluconazole: Increased risk of bradycardia orheart blockbeta blockers, digoxin: Increased risk ofbradycardiacalcium channel blockers (especially diltiazemand verapamil): Abnormal cardiacconduction and, possibly, increased adverseeffects of calcium channel blockersC

180caspofungin acetatecatecholamine-depleting drugs (such as reserpine,MAO inhibitors): Additive effects,increased risk of hypotension and bradycardiacimetidine: Increased blood carvedilol levelclonidine: Risk of tachycardia and hypertensionwhen clonidine is discontinuedcyclosporine, digoxin: Increased blood levelsof these drugsdigoxin: Possibly increased digoxin leveloral antidiabetics: Increased risk of hypoglycemiarifampin: Decreased blood carvedilol levelAdverse ReactionsCNS: Asthenia, depression, dizziness,fatigue, fever, headache, hypesthesia, hypotonia,insomnia, light-headedness, malaise,paresthesia, somnolence, stroke, syncope,vertigoCV: Angina, AV block, bradycardia, edema,heart failure, hypertension, hypertriglyceridemia,orthostatic hypotension, palpitations,peripheral vascular disorderEENT: Blurred vision, dry eyes, periodontitis,pharyngitis, rhinitisENDO: Hyperglycemia, hypoglycemiaGI: Abdominal pain, diarrhea, elevated liverfunction test results, melena, nausea, vomitingGU: Albuminuria, hematuria, elevatedBUN and creatinine levels, impotence, renalinsufficiency, UTIHEME: Aplastic anemia, decreased PT,thrombocytopenia, unusual bleeding orbruisingMS: Arthralgia, arthritis, back pain, musclecrampsRESP: Dyspnea, increased coughSKIN: Jaundice, pruritus, purpura, urticariaOther: Anaphylaxis, angioedema, fluidoverload, gout, hyperkalemia, hyperuricemia,hyponatremia, hypovolemia, viralinfection, weight gain or lossNursing Considerations• Use carvedilol cautiously in patients withperipheral vascular disease because it mayaggravate symptoms of arterial insufficiency.In patients with diabetes mellitus itmay mask signs of hypoglycemia, such astachycardia, and may delay recovery.• Monitor patient’s blood glucose level, asordered, during carvedilol therapy becausedrug may alter blood glucose level.WARNING Avoid stopping drug abruptly inpatients with hyperthyroidism becausethyroid storm may occur and in patientswith angina because it may worsen or MImay occur.• If patient has heart failure, expect to alsogive digoxin, a diuretic, and an ACEinhibitor.PATIENT TACHING• Instruct patient prescribed extendedreleasecapsules to swallow them whole. Ifswallowing capsules is difficult, tell patienthe may open capsule and sprinkle beadson a spoonful of cold applesauce and theneat the applesauce immediately withoutchewing.• Warn patient that drug may cause orthostatichypotension, light-headedness, anddizziness; advise him to take precautions.• Tell patient with heart failure to notifyprescriber if he gains 5 lb or more in2 days or if shortness of breath increases,which may signal worsening heart failure.• Alert patient with diabetes to monitor hisglycemic control closely because drug mayincrease blood glucose level or masksymptoms of hypoglycemia.• Stress the need to seek emergency care ifpatient develops hives or swelling of theface, lips, tongue, or throat that causestrouble swallowing or breathing.caspofungin acetateCancidasClass and CategoryChemical class: EchinocandinsTherapeutic class: AntifungalPregnancy category: CIndications and Dosages To treat invasive aspergillosis in patientsrefractory to or intolerant of other therapies;to treat candidemia and candidalinfections in intra-abdominal abscesses,peritonitis, and pleural space infectionsI.V. INFUSIONAdults. Initial: 70 mg on day 1, followed by50 mg daily. Maximum: 70 mg daily.Children ages 3 months to 17 years. Initial:70 mg/m 2 on day 1, followed by 50 mg/m 2daily. Maximum: 70 mg daily regardless of

caspofungin acetate 181Mechanism of ActionCaspofungin acetate interferes withfungal cell membrane synthesis byinhibiting the synthesis of (1,3)-Dglucan.A polypeptide, (1,3)-Dglucanis the essential component ofthe fungal cell membrane that makesit rigid and protective. Without it,fungal cells rupture and die. Thismechanism of action is most effectiveagainst susceptible filamentous fungi,such as Aspergillus.Fungal cell exteriorβ (1,3)-D-glucanCellmembraneCaspofunginFungal cell interiorInhibitedβ (1,3)-D-glucanCdose calculated based on patient’s body surfacearea. To treat presumed fungal infections infebrile, neutropenic patientsI.V. INFUSIONAdults. Initial: 70 mg on day 1, followed by50 mg daily for at least 14 days, including atleast 7 days after neutropenia and symptomshave resolved. Increased to 70 mgdaily as needed. Maximum: 70 mg daily.Children ages 3 months to 17 years. Initial:70 mg/m 2 on day 1, followed by 50 mg/m 2daily for at least 14 days, including at least7 days after neutropenia and symptomshave resolved. Maximum: 70 mg dailyregardless of dose calculated based onpatient’s body surface area.DOSAGE ADJUSTMENT Dosage reduced to35 mg daily after initial 70-mg loading dosein moderate hepatic insufficiency. To treat esophageal candidiasisI.V. INFUSIONAdults. 50 mg daily.Children ages 3 months to 17 years. Initial:70 mg/m 2 on day 1, followed by 50 mg/m 2daily. Maximum: 70 mg daily regardless ofdose calculated based on patient’s body surfacearea.DOSAGE ADJUSTMENT Dosage reduced to35 mg daily in moderate hepatic insufficiency.IncompatibilitiesDon’t mix or infuse with other drugs. Don’tadmix with diluents that contain dextrose.ContraindicationsHypersensitivity to caspofungin acetate orits componentsInteractionsDRUGScarbamazepine, dexamethasone, efavirenz,nelfinavir, nevirapine, phenytoin, rifampin:Possibly decreased blood caspofungin levelcyclosporine: Transient increases in ALT andAST levelstacrolimus: Possibly decreased blood tacrolimuslevelAdverse ReactionsCNS: Chills, dizziness, fever, headache,insomnia, paresthesia, tremorCV: Edema, hypertension, hypotension,phlebitis, tachycardia, thrombophlebitisEENT: Mucosal inflammationGI: Abdominal pain, diarrhea, elevated liverfunction test results, hepatic dysfunction,jaundice, nausea, vomitingGU: Elevated BUN or serum creatininelevel, proteinuria, renal insufficiencyHEME: Decreased hemoglobin and hematocritMS: Back pain, myalgiaRESP: Bronchospasm, cough, crackles, dyspnea,pleural effusion, pneumonia, respiratoryfailure, stridor, tachypneaSKIN: Diaphoresis, erythema, flushing,pruritus, rash, sensation of warmthOther: Anaphylaxis, decreased serum bicarbonatelevel, facial edema, hypercalcemia,hyperkalemia, hyperphosphatemia,hypokalemia, hypomagnesemia, infusionsite reaction, sepsis, septic shockNursing Considerations• To prepare 70-mg loading dose, let vial

182cefaclorreach room temperature. Reconstitute byadding 10.5 ml normal saline solution tovial. Dilute for administration by transferring10 ml of reconstituted drug to 250 mlnormal saline solution.• To prepare 70-mg loading dose from two50-mg vials, add 10.5 ml normal salinesolution to each vial; then transfer 14 mlof prepared solution to 250 ml normalsaline solution.• To prepare daily 50-mg infusion, let vialreach room temperature. Reconstitute byadding 10.5 ml normal saline solution tovial. Dilute for administration by transferringonly 10 ml of reconstituted drug to250 ml normal saline solution.• To prepare daily 50-mg infusion atreduced volume, add 10 ml of reconstituteddrug to 100 ml normal saline solution.• To prepare 35-mg daily dose for patientwith moderate hepatic insufficiency,reconstitute 50-mg vial with 10.5 ml normalsaline solution. To dilute, transfer only7 ml of reconstituted drug to 250 ml normalsaline solution or, if needed, to 100 mlnormal saline solution.• When preparing powder for reconstitution,mix gently to obtain clear solution.Don’t use if solution is cloudy or containsprecipitate. Discard unused solution after24 hours.• Infuse drug slowly over about 1 hour.• Expect to increase daily dose to 70 mg foradults and 70 mg/m 2 for children (not toexceed the adult dose of 70 mg regardlessof calculated dose), as prescribed, forpatients also receiving carbamazepine,dexamethasone, efavirenz, nelfinavir, nevirapine,phenytoin, or rifampin.• Watch for flushed skin, and assess patientoften for unexplained temperature elevation.• Assess for airway patency if patient developsexcessive facial edema or respiratorystridor. Provide emergency airway managementif complete obstruction occurs.• Monitor patient’s liver function testresults, as ordered, and report abnormalities.PATIENT TEACHING• Urge patient to notify prescriber immediatelyif he has difficulty talking, swallowing,or breathing during drug administration.cefaclorApo-Cefaclor (CAN), Ceclor, Ceclor CD,RaniclorClass and CategoryChemical class: Second-generationcephalosporin, 7-aminocephalosporanicacidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat otitis media caused by Haemophilusinfluenzae, staphylococci,Streptococcus pneumoniae, andStreptococcus pyogenes; lower respiratorytract infections, including pneumoniacaused by H. influenzae, S. pneumoniae,and S. pyogenes; pharyngitisand tonsillitis caused by S. pyogenes;UTI, including cystitis and pyelonephritis,caused by Escherichia coli,Klebsiella species, Proteus mirabilis,and coagulase-negative staphylococci;and skin and soft-tissue infectionscaused by S. pyogenes and StaphylococcusaureusCAPSULESAdults and adolescents. 250 mg every 8 hr.For severe infections, such as pneumonia,or those caused by less susceptible organisms,500 mg every 8 hr. Maximum: 4 gdaily.CHEWABLE TABLETS, ORAL SUSPENSIONAdults and adolescents. 250 mg every 8 hr.For severe infections, such as pneumonia,or those caused by less susceptible organisms,500 mg every 8 hr. Maximum: 4 gdaily.Children. 20 mg/kg daily in divided dosesevery 8 hr. For serious infections, such asotitis media, and infections caused by lesssusceptible organisms, 40 mg/kg daily individed doses every 8 hr. For otitis mediaand pharyngitis, total daily dosage dividedand given every 12 hr, if needed. Maximum:1 g daily. To treat acute bacterial infection inchronic bronchitis or secondary bacterialinfection in acute bronchitis (not causedby H. influenzae)E.R. TABLETSAdults and adolescents age 16 and over.

500 mg every 12 hr for 7 days. To treat pharyngitis and tonsillitis (notcaused by H. influenzae)E.R. TABLETSAdults and adolescents age 16 and over.375 mg every 12 hr for 10 days. To treat uncomplicated skin and soft-tissueinfections caused by S. aureusE.R. TABLETSAdults and adolescents age 16 and over.375 mg every 12 hr for 7 to 10 days.Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting cross-linking of peptidoglycanstrands, which stiffen cell membranes. As aresult, bacterial cells rupture.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityantacids: Decreased blood cefaclor level(E.R. tablets)oral anticoagulants: Increased anticoagulationAdverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, nausea, oral candidiasis,pseudomembranous colitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-JohnsonsyndromeOther: Anaphylaxis, superinfectionNursing Considerations• Use cefaclor cautiously in patients withimpaired renal function or a history of GIdisease, particularly colitis, and in patientswho are hypersensitive to penicillin; about10% of them have cross-sensitivity.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.• Monitor BUN and serum creatinine levelsfor early signs of nephrotoxicity. Alsomonitor fluid intake and output; decreasingurine output may indicate nephrotoxicity.• Be aware that an allergic reaction mayoccur a few days after therapy starts.• Assess bowel pattern daily; severe diarrheamay indicate pseudomembranous colitis.• Assess patient for superinfection: perinealitching, fever, malaise, redness, pain,swelling, rash, drainage, diarrhea, cough,sputum changes.PATIENT TEACHING• Instruct patient to complete the prescribedcourse of therapy, even if he feels better.• Tell patient to swallow E.R. tablets wholeand not to crush, break, or chew them.• Advise patient to take E.R. tablets withfood to enhance absorption.• Instruct patient to take capsules or E.R.tablets with a full glass of water.• Tell patient to shake oral suspension wellbefore measuring and to use a calibratedmeasuring device to ensure accurate dose.• Tell patient to refrigerate oral suspensionand to discard unused portion after14 days.• Instruct patient to immediately reportsevere diarrhea to prescriber.• Explain that yogurt and buttermilk protectintestinal flora and decrease diarrhea.• Urge patient to report evidence of superinfection.cefadroxilDuricefcefadroxil 183Class and CategoryChemical class: First-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat UTI caused by Escherichia coli,Klebsiella species, or Proteus mirabilisCAPSULES, TABLETSAdults. For uncomplicated lower UTI, 1 toC

184cefadroxil2 g daily or in divided doses every 12 hr.For all other UTIs, 2 g every 12 hr.ORAL SUSPENSIONAdults. For uncomplicated lower UTI, 1 to2 g daily or in divided doses every 12 hr.For all other UTIs, 2 g every 12 hr.Children. 30 mg/kg daily in divided dosesevery 12 hr. Maximum: Adult dosage. To treat skin and soft-tissue infectionscaused by staphylococci or streptococciCAPSULES, TABLETSAdults. 1 g daily or 500 mg every 12 hr.ORAL SUSPENSIONAdults. 1 g daily or 500 mg every 12 hr.Children. 30 mg/kg daily in divided dosesevery 12 hr. Maximum: Adult dosage. To treat pharyngitis and tonsillitiscaused by group A beta-hemolytic streptococciCAPSULES, TABLETSAdults. 1 g daily or 500 mg b.i.d for 10 days.ORAL SUSPENSIONAdults. 1 g daily or 500 mg b.i.d. for 10 days.Children. 30 mg/kg daily in divided dosesevery 12 hr for 10 days. Maximum: 1 g dailyor 500 mg b.i.d. for 10 days.DOSAGE ADJUSTMENT Initial dose of 1 g;then maintenance of 0.5 g every 12 hr ifcreatinine clearance is 25 to 50 ml/min/1.73 m 2 ; 0.5 g every 24 hr if creatinineclearance is 10 to 25 ml/min/1.73 m 2 ; and0.5 g every 36 hr if creatinine clearance is0 to 10 ml/min/1.73 m 2 .Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes cell membranes rigid andprotective. Without it, bacterial cells ruptureand die.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedtoxicity of these drugsAdverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, nausea, oral candidiasis,pseudomembranous colitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-JohnsonsyndromeOther: Anaphylaxis, superinfectionNursing Considerations• Use cefadroxil cautiously in patients withimpaired renal function or a history of GIdisease, particularly colitis. Also use drugcautiously in patients who are hypersensitiveto penicillin because cross-sensitivityhas occurred in about 10% of suchpatients.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.• Be aware that an allergic reaction mayoccur a few days after therapy starts.• Monitor BUN and serum creatinine levelsfor early signs of nephrotoxicity. Alsomonitor fluid intake and output; decreasingurine output may indicate nephrotoxicity.• Assess bowel pattern daily; severe diarrheamay indicate pseudomembranous colitis.• Assess for signs of superinfection, such asperineal itching, fever, malaise, redness,pain, swelling, drainage, rash, diarrhea,and cough or sputum changes.PATIENT TEACHING• Instruct patient to complete the prescribedcourse of therapy.• Tell patient to shake oral suspensionbefore measuring and to use a liquidmeasuringdevice to ensure accurate doses.• Tell patient to refrigerate oral suspensionand to discard the unused portion after14 days.• Urge patient to report watery, bloodystools to prescriber immediately, even upto 2 months after drug therapy has ended.• Inform patient that yogurt and buttermilkcan help maintain intestinal flora anddecrease diarrhea.• Teach patient to recognize and report evidenceof superinfection, such as furry

tongue, perineal itching, and loose, foulsmellingstools.cefazolin sodiumAncefClass and CategoryChemical class: First-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat respiratory tract infectionscaused by group A beta-hemolytic streptococci,Haemophilus influenzae,Klebsiella species, Staphylococcusaureus, and Streptococcus pneumoniae;skin and soft-tissue infections causedby S. aureus, group A beta-hemolyticand other strains of streptococci; biliarytract infections caused by Escherichiacoli, Klebsiella species, Proteusmirabilis, S. aureus, and various strainsof streptococci; bone and joint infectionscaused by S. aureus; genital infections,such as epididymitis and prostatitis,caused by E. coli, Klebsiella species, P.mirabilis, and some strains of enterococci;septicemia caused by E. coli,Klebsiella species, P. mirabilis, S.aureus, and S. pneumoniae; and endocarditiscaused by group A betahemolyticstreptococci and S. aureusI.V. INFUSION, I.V. OR I.M. INJECTIONAdults. For mild infections, 250 to 500 mgevery 8 hr; for moderate to severe infections,500 to 1,000 mg every 6 to 8 hr; andfor severe life-threatening infections, 1,000to 1,500 mg every 6 hr. Maximum: 6 g daily.Children: For mild to moderate infections,25 to 50 mg/kg daily divided equally andgiven t.i.d. or q.i.d.; for severe infections,100 mg/kg daily divided equally and givent.i.d. or q.i.d. To treat pneumococcal pneumoniaI.V. INFUSION, I.V. OR I.M. INJECTIONAdults. 500 mg every 12 hr. To treat acute uncomplicated UTIcaused by E. coli, Klebsiella species, P.mirabilis, and some strains ofEnterobacter and EnterococcusI.V. INFUSION, I.V. OR I.M. INJECTIONcefazolin sodium 185Adults. 1 g every 12 hr. To provide surgical prophylaxisI.V. INFUSION, I.V. OR I.M. INJECTIONAdults. 1 g 30 to 60 min before surgery;0.5 to 1 g during surgery if it lasts 2 hr orlonger; 0.5 to 1 g every 6 to 8 hr for 24 hrafter surgery.DOSAGE ADJUSTMENT After initial loadingdose appropriate to infection’s severity,dosage interval restricted to at least 8 hr foradults with creatinine clearance of 35 to54 ml/min/1.73 m 2 ; dosage reduced by 50%and given every 12 hr for adults with creatinineclearance of 11 to 34 ml/min/1.73 m 2 ;and dosage reduced by 50% and given every18 to 24 hr for adults with creatinine clearanceof 10 ml/min/1.73 m 2 or less. Dosagereduced to 60% and given every 12 hr forchildren with creatinine clearance of 40 to70 ml/min/1.73 m 2 ; dosage reduced to 25%and given every 12 hr for children with creatinineclearance of 20 to 40 ml/min/1.73 m 2 ; and dosage reduced to 10% andgiven every 24 hr for children with creatinineclearance of 5 to 20 ml/min/1.73 m 2 .Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes cell membranes rigid andprotective. Without it, bacterial cells ruptureand die.IncompatibilitiesTo prevent mutual inactivation, don’t mixcefazolin with aminoglycosides. Also avoidmixing cefazolin with other drugs, includingpentamidine isethionate.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Additivenephrotoxicityprobenecid: Increased and prolonged bloodcefazolin levelAdverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,C

186Indications and Dosages To treat community-acquired pneumoniacaused by Haemophilus influenzae(including beta-lactamase–producingstrains), Haemophilus parainfluenzae(including beta-lactamase–producingstrains), Streptococcus pneumoniae(penicillin-susceptible strains only), andMoraxella catarrhalis (including betalactamase–producingstrains)CAPSULESAdults and adolescents. 300 mg every 12 hrfor 10 days. Maximum: 600 mg daily. To treat pharyngitis or tonsillitis causedby Streptococcus pyogenes and acuteexacerbations of chronic bronchitiscaused by H. influenzae (includingbeta-lactamase–producing strains), H.parainfluenzae (including betalactamase–producingstrains), S. pneucefdinirhepatitis, hepatomegaly, nausea, oral candidiasis,pseudomembranous colitis, vomitingGU: Elevated BUN and serum creatininelevels, nephrotoxicity, renal failure, vaginalcandidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-JohnsonsyndromeOther: Anaphylaxis; injection site pain, redness,and swelling; superinfectionNursing Considerations• Use cefazolin cautiously in patients withimpaired renal function or a history of GIdisease, particularly colitis. Also use cautiouslyin patients hypersensitive to penicillinbecause cross-sensitivity hasoccurred in about 10% of such patients.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.WARNING To prevent unintentional overdose,cefazolin for injection USP and dextroseinjection USP shouldn’t be used inchildren who require less than the fulladult dose.• Reconstitute 500-mg drug vial with 2 mlof sterile water for injection (or 1-g vialwith 2.5 ml). Shake well until dissolved.• For direct I.V. injection, further dilutereconstituted solution with at least 5 mlsterile water for injection. Inject slowlyover 3 to 5 minutes through tubing of aflowing compatible I.V. solution.• For intermittent I.V. infusion, reconstitute500 to 1,000 mg in 50 to 100 ml normalsaline solution, D 5 W,D 10 W, dextrose 5%in lactated Ringer’s solutoin, dextrose 5%in quarter-normal (0.2) saline solution,dextrose 5% in half-normal (0.45) salinesolution, dextrose 5% in normal salinesolution, lactated Ringer’s injection, 5% or10% invert sugar in sterile water for injection,5% sodium bicarbonate (Ancef), orRinger’s injection.• Administer I.M injection deep into largemuscle mass, such as the gluteus maximus.• Store reconstituted drug up to 24 hours atroom temperature or 10 days refrigerated.• Monitor I.V. site for irritation, phlebitis,and extravasation.• Monitor BUN and serum creatinine forearly signs of nephrotoxicity. Also monitorfluid intake and output; decreasing urineoutput may indicate nephrotoxicity.• Be aware that an allergic reaction mayoccur a few days after therapy starts.• Assess bowel pattern daily; severe diarrheamay indicate pseudomembranous colitis.• Watch for evidence of superinfection:cough, diarrhea, drainage, fever, malaise,pain, perineal itching, rash, redness,swelling.• Assess for pharyngitis, ecchymosis, bleeding,and arthralgia; they may indicate ablood dyscrasia.PATIENT TEACHING• Instruct patient to complete the prescribedcourse of therapy.• Reassure patient that I.M. injection doesn’ttypically cause pain.• Tell patient to report watery, bloody stoolsto prescriber immediately, even up to2 months after drug therapy has ended.cefdinirOmnicefClass and CategoryChemical class: CephalosporinTherapeutic class: AntibioticPregnancy category: B

moniae (penicillin-susceptible strainsonly), and M. catarrhalis (includingbeta-lactamase–producing strains)CAPSULESAdults and adolescents. 300 mg every 12 hrfor 5 to 10 days or 600 mg every 24 hr for10 days. Maximum: 600 mg daily.ORAL SUSPENSIONChildren ages 6 months to 12 years. 7 mg/kg every 12 hr for 5 to 10 days or 14 mg/kgevery 24 hr for 10 days (for pharyngitis ortonsillitis). To treat acute maxillary sinusitis causedby H. influenzae (including betalactamase–producingstrains), S. pneumoniae(penicillin-susceptible strainsonly), and M. catarrhalis (includingbeta-lactamase–producing strains)CAPSULESAdults and adolescents. 300 mg every12 hr or 600 mg every 24 hr for 10 days.Maximum: 600 mg daily.ORAL SUSPENSIONChildren ages 6 months to 12 years. 7 mg/kg every 12 hr or 14 mg/kg every 24 hr for10 days. To treat uncomplicated skin and softtissueinfections caused byStaphylococcus aureus (including betalactamase–producingstrains) andStreptococcus pyogenesCAPSULESAdults and adolescents. 300 mg every 12 hrfor 10 days. Maximum: 600 mg daily.ORAL SUSPENSIONChildren ages 6 months to 12 years. 7 mg/kg every 12 hr for 10 days. To treat acute bacterial otitis mediacaused by H. influenzae (includingbeta-lactamase–producing strains), S.pneumoniae (penicillin-susceptiblestrains only), and M. catarrhalis(including beta-lactamase–producingstrains)ORAL SUSPENSIONChildren ages 6 months to 12 years. 7 mg/kg every 12 hr for 5 to 10 days or 14 mg/kgevery 24 hr for 10 days.DOSAGE ADJUSTMENT For adults with creatinineclearance less than 30 ml/min/1.73 m 2 ,expect to reduce cefdinir dosage to 300 mgdaily; for children with creatinine clearanceless than 30 ml/min/1.73 m 2 , dosage is7 mg/kg (up to 300 mg) daily. For patientscefdinir 187undergoing intermittent hemodialysis,dosage is 300 mg or 7 mg/kg every otherday, beginning at the end of each hemodialysissession, as prescribed.Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes cell membranes rigid andprotective. Without it, bacterial cells ruptureand die. Because cefdinir is notdegraded by some bacterial beta-lactamaseenzymes, it’s effective against many organismsthat are resistant to both penicillinsand some cephalosporins.ContraindicationsHypersensitivity to cefdinir, othercephalosporins, or their componentsInteractionsDRUGSantacids that contain aluminum or magnesium:Decreased cefdinir absorption if givenwithin 2 hours of antacidiron salts: Reduced cefdinir absorption ifgiven within 2 hours of ironprobenecid: Increased blood level and prolongedhalf-life of cefdinirAdverse ReactionsCNS: Asthenia, dizziness, drowsiness,headache, insomnia, somnolenceEENT: Dry mouth, pharyngitis, rhinitisGI: Abdominal pain, anorexia, constipation,diarrhea, flatulence, indigestion, nausea,pseudomembranous colitis, stool discoloration,vomitingGU: Leukorrhea, vaginal candidiasis, vaginitisHEME: LeukopeniaSKIN: Pruritus, rashOther: Anaphylaxis, serum sicknesslikereactionNursing Considerations• To reconstitute cefdinir powder for oralsuspension, tap bottle to loosen powder,and then dilute with water to 125 mg/5 ml. Shake well before each use. Discardany unused portion after 10 days. Keepsuspension bottle tightly closed, and storeit at room temperature.• Give antacids that contain aluminum ormagnesium and iron salts at least 2 hoursbefore or after cefdinir because they mayC

188Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidocefditorenpivoxilinterfere with cefdinir absorption.• Monitor patient allergic to penicillin forevidence of hypersensitivity reaction, froma mild rash to fatal anaphylaxis, becausecross-sensitivity can occur.• Monitor patient with a chronic GI condition,such as colitis, for signs and symptomsof a drug-related exacerbation.• Because all cephalosporins have the potentialto cause bleeding, monitor elderlypatients and patients with a preexistingcoagulopathy, including vitamin K deficiency,for elevated PT or APTT.• Monitor patient closely for diarrhea,which may indicate pseudomembranouscolitis caused by Clostridium difficile. Ifdiarrhea occurs, notify prescriber andexpect to withhold cefdinir and treat withfluids, electrolytes, protein, and an antibioticeffective against C. difficile.• Assess for other evidence of superinfection,including perineal itching; loose,foul-smelling stools; and vaginal drainage.PATIENT TEACHING• Advise patient taking cefdinir oral suspensionto shake bottle well before use and touse a liquid-measuring device to ensureaccurate dose.• Inform patient that tablet coating maycause stools to become a reddish color.• Instruct patient to complete entire courseof therapy, even if he feels better.• Advise patient to take iron salts and aluminum-or magnesium-containingantacids at least 2 hours before or aftertaking cefdinir.• Inform patient with history of colitis thatcefdinir may worsen it; urge him to notifyprescriber promptly if symptoms develop.• Inform patient with diabetes mellitus thatoral suspension contains 2.86 g of sucroseper teaspoon; advise him to monitor hisblood glucose levels as appropriate.• Teach patient to recognize and report evidenceof superinfection, such as perinealitching; loose, foul-smelling stools; andvaginal drainage.• Inform patient that yogurt and buttermilkcan help prevent superinfection and maydecrease diarrhea.• Urge patient to tell prescriber about diarrheathat’s severe or lasts longer than3 days. Remind patient that watery orbloody stools can occur 2 or more monthsafter antibiotic therapy and can be serious,requiring prompt treatment.cefditoren pivoxilSpectracefClass and CategoryChemical class: CephalosporinTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat mild to moderate acute bacterialexacerbation of chronic bronchitis orcommunity-acquired pneumonia causedby Haemophilus influenzae (includingbeta-lactamase–producing strains),Haemophilus parainfluenzae (includingbeta-lactamase–producing strains),Streptococcus pneumoniae (penicillinsusceptiblestrains), or Moraxellacatarrhalis (including betalactamase–producingstrains)TABLETSAdults and children age 12 and over.400 mg b.i.d. for 10 days or for 14 days forcommunity-acquired pneumonia. To treat mild to moderate pharyngitisand tonsillitis caused by StreptococcuspyogenesTABLETSAdults and children age 12 and over.200 mg b.i.d. for 10 days. To treat mild to moderate uncomplicatedskin and soft-tissue infections causedby Staphylococcus aureus (includingbeta-lactamase–producing strains) or S.pyogenesTABLETSAdults and children age 12 and over.200 mg b.i.d. for 10 days.DOSAGE ADJUSTMENT Inmoderate renalimpairment (creatinine clearance 30 to 49ml/min/1.73 m 2 ), maximum dosagereduced to 200 mg b.i.d. In severe renalimpairment (creatinine clearance less than30 ml/min/1.73 m 2 ), maximum dosagereduced to 200 mg daily.

glycan makes the cell membrane rigid andprotective. Without it, bacterial cells ruptureand die. This mechanism of action ismost effective against bacteria that dividerapidly, including many gram-positive andgram-negative bacteria. Cefditoren isn'tinactivated by beta lactamase produced bysome bacteria.ContraindicationsCarnitine deficiency or inborn metabolicdisorder that causes it; hypersensitivity tocephalosporins or their componentsInteractionsDRUGSaluminum- and magnesium-containingantacids, H 2 -receptor antagonists: Reducedcefditoren absorptionprobenecid: Increased and prolonged bloodcefditoren levelFOODSfood: Increased cefditoren absorptionAdverse ReactionsCNS: Headache, hyperactivity, hypertonia,seizuresGI: Abdominal pain, diarrhea, dyspepsia,hepatic dysfunction, nausea, pseudomembranouscolitis, vomitingGU: Acute renal failure, renal dysfunction,toxic nephropathyHEME: Aplastic anemia, hemolytic anemia,hemorrhage, thrombocytopeniaMS: ArthralgiaRESP: PneumoniaSKIN: Erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysisOther: Allergic reaction, anaphylaxis, carnitinedeficiency, drug fever, serum sicknesslikereaction, superinfectionNursing ConsiderationsWARNING Before starting cefditoren therapy,determine if patient is hypersensitiveto milk protein because cefditoren containssodium caseinate, a milk protein.Drug should not be given to patient withthis hypersensitivity. Also determine ifpatient has had a hypersensitivity reactionto cefditoren or other cephalosporins(because drug is contraindicated in thesepatients) or to penicillin (because crosssensitivityhas occurred in about 10% ofsuch patients).• Cefditoren shouldn’t be used for prolongedtreatment because of the risk ofcarnitine deficiency.• If possible, obtain culture and sensitivitytest results before giving cefditoren.• Assess patient for evidence of Clostridiumdifficile infection and pseudomembranouscolitis, such as profuse, watery diarrhea.For mild cases, expect to discontinuecefditoren. For moderate to severe cases,expect to also give fluids and electrolytes,protein supplementation, and an antibacterialdrug effective against C. difficile.• If an allergic reaction occurs, expect todiscontinue drug, as prescribed. For seriousacute hypersensitivity reactions,expect to also give epinephrine, oxygen,and I.V. fluids, antihistamines, corticosteroids,and vasopressors, as prescribed.• Monitor BUN and serum creatinine levelsto detect early signs of renal dysfunction.Also monitor fluid intake and output.• Watch for a decreased PT, as ordered, inat-risk patients, such as those with renal orhepatic impairment, those with a poornutritional state, and those receiving anticoagulantor prolonged antibiotic therapy.Notify prescriber if a decrease occurs, andgive vitamin K as ordered.PATIENT TEACHING• Urge patient to complete prescribedcourse of therapy.• Instruct patient to take cefditoren withmeals to enhance drug absorption.• Advise patient not to take cefditoren withaluminum- or magnesium-containingantacids or other drugs used to reducestomach acids because these drugs mayinterfere with cefditoren absorption.• Explain that yogurt and buttermilk helpmaintain normal intestinal flora and candecrease diarrhea during therapy.•Instruct patient to immediately reportsevere diarrhea to prescriber.cefepimehydrochlorideMaxipimeClass and CategoryChemical class: Fourth-generation cephalocefepimehydrochloride 189C

190cefepime hydrochloridesporin, 7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat mild to moderate UTI causedby Escherichia coli, Klebsiella pneumoniae,or Proteus mirabilisI.V. INFUSION, I.M. INJECTION (ONLY FOR UTICAUSED BY E. COLI)Adults and children age 12 and over. 500 to1,000 mg every 12 hr for 7 to 10 days. To treat severe UTI caused by E. coli orK. pneumoniae, moderate to severe skinand soft-tissue infections caused byStaphylococcus aureus orStreptococcus pyogenesI.V. INFUSIONAdults and children age 12 and over. 2 gevery 12 hr for 10 days. To treat moderate to severe pneumoniacaused by Enterobacter species, K.pneumoniae, Pseudomonas aeruginosa,or Streptococcus pneumoniaeI.V. INFUSIONAdults and children age 12 and over. 1 to2 g every 12 hr for 10 days. To treat febrile neutropeniaI.V. INFUSIONAdults and children age 12 and over. 2 gevery 8 hr for 7 days or until neutropeniaresolves. To treat complicated intra-abdominalinfections (together with metronidazole)caused by alpha-hemolytic streptococci,Bacteroides fragilis, E. coli,Enterobacter species, K. pneumoniae,or P. aeruginosaI.V. INFUSIONAdults and children age 12 and over. 2 gevery 12 hr for 7 to 10 days.DOSAGE ADJUSTMENT Dosing intervalincreased from 12 to 24 hr and from 8 to12 hr if creatinine clearance is 30 to 60 ml/min/1.73 m 2 . Interval increased from 8 or12 hr to 24 hr and dose decreased from 2 gevery 12 hr to 1 g every 24 hr (all otherdoses unchanged) if creatinine clearance is11 to 29 ml/min/1.73 m 2 . Dosage decreasedfrom 500 mg every 12 hr to 250 mg every24 hr, from 1,000 mg every 12 hr to 250 mgevery 24 hr, from 2,000 mg every 12 hr to500 mg every 24 hr, and from 2 g every 8 hrto 1 g every 24 hr if creatinine clearance isless than 11 ml/min/1.73 m 2 .Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes cell membranes rigid andprotective. Without it, bacterial cells ruptureand die.IncompatibilitiesDon’t add cefepime to solutions that containampicillin in a concentration of morethan 40 mg/ml. Don’t add drug to solutionsthat contain aminophylline, gentamycin,metronidazole, netilmicin sulfate,tobramycin, or vancomycin.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of renal failure in renal diseaseAdverse ReactionsCNS: Chills, coma, confusion, fever, hallucinations,headache, myoclonus, seizures, stuporCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, nausea, oral candidiasis,pseudomembranous colitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-JohnsonsyndromeOther: Anaphylaxis; injection site pain, redness,and swelling; superinfectionNursing Considerations• Use cefepime cautiously in patients withimpaired renal function or a history of GIdisease, particularly colitis. Also use cautiouslyin patients hypersensitive to penicillinbecause cross-sensitivity hasoccurred in about 10% of such patients.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.

• For I.V. infusion, reconstitute using manufacturer’sguidelines. Give over 30 minutes.• For I.M. injection, reconstitute 500-mgvial of drug with 1.3 ml of diluent, such assterile water for injection (or 1-g vial with2.4 ml of diluent). See drug guidelines forcomplete list of appropriate diluents.• Be aware that an allergic reaction mayoccur a few days after therapy starts.• Monitor BUN and serum creatinine levelsfor early signs of nephrotoxicity. Alsomonitor fluid intake and output; decreasingurine output may indicate nephrotoxicity.Be aware that unadjusted dosages ofcefepime in renally impaired patients maycause myoclonus and seizures.• Assess bowel pattern daily; severe diarrheamay indicate pseudomembranous colitis.• Assess for signs of superinfection, such asperineal itching, fever, malaise, redness,pain, swelling, drainage, rash, diarrhea,and cough or sputum changes.• Assess for pharyngitis, ecchymosis, bleeding,and arthralgia; they may indicate ablood dyscrasia.• Monitor patient for evidence ofencepalopathy, such as changes in level ofconsciousness, myoclonus, and seizures.Patient will need immediate treatment,and the cefepime dosage will need to beadjusted or the drug discontinued.PATIENT TEACHING• Tell patient to immediately report severediarrhea to prescriber.• Instruct patient and caregiver to immediatelyseek emergency care for any changein mental status, such as coma, hallucinations,decreased responsiveness, abnormalmovements, or seizures. Cefepime shouldbe stopped until patient is evaluated.cefiximeSupraxClass and CategoryChemical class: Third-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat uncomplicated UTI caused byEscherichia coli and Proteus mirabilis;cefixime 191otitis media caused by Haemophilusinfluenzae, Moraxella catarrhalis, orStreptococcus pyogenes; pharyngitisand tonsillitis caused by S. pyogenes;acute bronchitis and acute exacerbationsof chronic bronchitis caused by H.influenzae and Streptococcus pneumoniaeORAL SUSPENSIONChildren. 8 mg/kg daily or 4 mg/kg every12 hr.TABLETSAdults and children over 50 kg (110 lb) orage 12. 400 mg daily or 200 mg every 12 hr. To treat uncomplicated gonorrheacaused by Neisseria gonorrhoeaeTABLETSAdults and children over 50 kg or age 12.400 mg daily.DOSAGE ADJUSTMENT Dosage reduced to75% for patients who have creatinine clearanceof 21 to 60 ml/min/1.73 m 2 or receivehemodialysis. Dosage reduced to 50% forpatients who have creatinine clearance of20 ml/min/1.73 m 2 or less.Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes cell membranes rigid andprotective. Without it, bacterial cells ruptureand die.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicitycarbamazepine: Increased blood carbamazepinelevelAdverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatitis, hepatomegaly, jaundice, nausea,oral candidiasis, pseudomembranous colitis,vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisC

192cefmetazole sodiumHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-Johnsonsyndrome, toxic epidermal necrolysisOther: Anaphylaxis, angioedema, facialedema, superinfectionNursing Considerations• Use cefixime cautiously in patients withimpaired renal function or a history of GIdisease, especially colitis. Also use cautiouslyin patients hypersensitive to penicillinbecause cross-sensitivity hasoccurred in about 10% of such patients.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.• Tablets shouldn’t be substituted for oralsuspension to treat otitis media becausecefixime suspension produces a higherpeak blood level than do tablets whenadministered at the same dose.• Monitor BUN and serum creatinine forearly signs of nephrotoxicity. Also monitorfluid intake and output; decreasing urineoutput may indicate nephrotoxicity.• Be aware that an allergic reaction mayoccur a few days after therapy starts.• Assess bowel pattern daily; severe diarrheamay indicate pseudomembranous colitis.• Assess for signs of superinfection, such asperineal itching, fever, malaise, redness,pain, swelling, drainage, rash, diarrhea,and cough or sputum changes.• Assess for pharyngitis, ecchymosis, bleeding,and arthralgia; they may indicate ablood dyscrasia.PATIENT TEACHING• Instruct patient to complete the prescribedcourse of therapy.• Advise patient to shake oral suspensionwell before pouring dose and to use a calibrateddevice to obtain an accurate dose.• Instruct patient to store oral suspension atroom temperature and to discard unusedportion after 14 days.• Tell patient to immediately report severediarrhea to prescriber.• Inform patient that yogurt and buttermilkcan help maintain intestinal flora anddecrease diarrhea.• Teach patient to recognize and reportsigns of superinfection, such as furrytongue, perineal itching, and loose, foulsmellingstools.cefmetazole sodiumZefazoneClass and CategoryChemical class: Second-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat UTI caused by Escherichia coli;lower respiratory tract infections, such asbronchitis and pneumonia, caused by E.coli, Haemophilus influenzae, Staphylococcusaureus, and Streptococcuspneumoniae; skin and soft-tissue infectionscaused by Bacteroides fragilis,Bacteroides melaninogenicus, E. coli,Klebsiella oxytoca, Klebsiella pneumoniae,Morganella morganii, Proteusmirabilis, Proteus vulgaris, S. aureus,Staphylococcus epidermidis, Streptococcusagalactiae, and Streptococcuspyogenes; intra-abdominal infectionscaused by B. fragilis, Clostridium perfringens,E. coli, K. oxytoca, and K.pneumoniaeI.V. INFUSIONAdults. 2 g every 6 to 12 hr for 5 to 14 days.DOSAGE ADJUSTMENT Dosage reduced to1 to 2 g every 12 hr if creatinine clearance is50 to 90 ml/min/1.73 m 2 ; 1 to 2 g every16 hr if creatinine clearance is 30 to 49 ml/min/1.73 m 2 ; 1 to 2 g every 24 hr if creatinineclearance is 10 to 29 ml/min/1.73 m 2 ;and 1 to 2 g every 48 hr if creatinine clearanceis less than 10 ml/min/1.73 m 2 . To provide surgical prophylaxis for vaginalhysterectomyI.V. INFUSIONAdults. 2 g as a single dose 30 to 90 minbefore surgery or 1 g 30 to 90 min beforesurgery and repeated 8 and 16 hr later. To provide surgical prophylaxis forabdominal hysterectomy and for highriskcholecystectomyI.V. INFUSION

Adults. 1 g 30 to 90 min before surgery andrepeated 8 and 16 hr later. To provide surgical prophylaxis forcesarean sectionI.V. INFUSIONAdults. 2 g as a single dose after cord isclamped or 1 g after cord is clamped andthen repeated 8 and 16 hr later. To provide surgical prophylaxis for colorectalsurgeryI.V. INFUSIONAdults. 2 g as a single dose 30 to 90 minbefore surgery or 2 g 30 to 90 min beforesurgery and repeated 8 and 16 hr later.Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes cell membranes rigid andprotective. Without it, bacterial cells ruptureand die.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityanticoagulants: Possibly increased anticoagulanteffectprobenecid: Increased and prolonged bloodcefmetazole levelACTIVITIESalcohol use: Possibly disulfiram-like reactionAdverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, nausea, oral candidiasis,pseudomembranous colitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-Johnsonsyndromecefonicid sodium 193Other: Anaphylaxis; injection site pain, redness,and swelling; superinfectionNursing Considerations• Use cefmetazole cautiously in patientshypersensitive to penicillin; cross-sensitivityhas occurred in about 10% of suchpatients.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.• Reconstitute drug with sterile or bacteriostaticwater for injection or sodium chloridefor injection.• Dilute primary solution as needed to 1 to20 mg/ml in D 5 W, normal saline solution,lactated Ringer’s solution, or 1% lidocainesolution without epinephrine.• Store reconstituted solution for up to24 hours at room temperature or 7 daysrefrigerated.• Monitor BUN and serum creatinine levelsand fluid intake and output to detect earlysigns of nephrotoxicity.• Assess bowel pattern daily; severe diarrheamay indicate pseudomembranous colitis.• Assess for signs of superinfection, such asperineal itching, fever, malaise, redness,rash, diarrhea, and cough or sputumchanges.• Assess for pharyngitis, bleeding, and arthralgia,which may indicate blood dyscrasia.Monitor PT and bleeding time, asordered.PATIENT TEACHING• Advise patient to immediately reportsevere diarrhea to prescriber.• Instruct patient to avoid alcohol duringtherapy and for at least 3 days after lastdose.cefonicid sodiumMonocidClass and CategoryChemical class: Second-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat lower respiratory tract infectionscaused by Escherichia coli,Haemophilus influenzae, KlebsiellaC

194Nursing Considerations• Use cefonicid cautiously in patients withimpaired renal function. Also use cautiouslyin patients hypersensitive to penicillinbecause cross-sensitivity hasoccurred in about 10% of such patients.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.• Reconstitute each 500-mg vial of drugwith 2 ml sterile water for injection (oreach 1-g vial with 2.5 ml).• For I.V. infusion, dilute further in 50 to100 ml compatible solution, such as D 5 W,D 10 W, dextrose 5% in quarter-normal(0.2) saline solution, dextrose 5% in halfnormal(0.45) saline solution, or dextrose5% in normal saline solution.• Give I.V. injection slowly over 3 to 5 minutesthrough tubing of a flowing compatibleI.V. solution.• For I.M. dose larger than 1 g, divide dosein half and give into large muscle mass,such as the gluteus maximus, at two differentsites.• Reconstituted solution may be stored24 hours at room temperature, 72 hoursrefrigerated.• Monitor patient’s BUN and serum creatininelevels to detect early signs of nephrocefonicidsodiumpneumoniae, and Streptococcus pneumoniae;UTI caused by E. coli, K.pneumoniae, Morganella morganii,Proteus mirabilis, Proteus vulgaris, andProvidencia rettgeri; skin and soft-tissueinfections caused by Staphylococcusaureus, Staphylococcus epidermidis,Streptococcus agalactiae, andStreptococcus pyogenes; septicemiacaused by E. coli and S. pneumoniae;and bone and joint infections caused byS. aureusI.V. INFUSION, I.V. OR I.M. INJECTIONAdults. For mild to moderate infections,1 g every 24 hr. For severe or life-threateninginfections, 2 g every 24 hr. To treat uncomplicated UTII.V. INFUSION, I.V. OR I.M. INJECTIONAdults. 500 mg every 24 hr.DOSAGE ADJUSTMENT Initial dose reducedto 75 mg/kg I.V. or I.M. in patients withimpaired renal function. Then reduced to10 to 25 mg/kg every 24 hr if creatinineclearance is 60 to 79 ml/min/1.73 m 2 ;8to20 mg/kg every 24 hr if creatinine clearanceis 40 to 59 ml/min/1.73 m 2 ; 4 to 15 mg/kgevery 24 hr if creatinine clearance is 20 to39 ml/min/1.73 m 2 ; 4 to 15 mg/kg every48 hr if creatinine clearance is 10 to 19 ml/min/1.73 m 2 ; 4 to 15 mg/kg every 3 to5 days if creatinine clearance is 5 to 9 ml/min/1.73 m 2 ; and 3 to 4 mg/kg every 3 to5 days if creatinine clearance is less than5 ml/min/1.73 m 2 . To provide surgical prophylaxisI.V. INFUSION, I.V. OR I.M. INJECTIONAdults. 1 g 60 min before surgery. Doserepeated once daily, if needed, for 2 daysafter prosthetic arthroplasty or open-heartsurgery.Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes cell membranes rigid andprotective. Without it, bacterial cells ruptureand die.IncompatibilitiesTo prevent mutual inactivation, don’t mixcefonicid with aminoglycosides.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityAdverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, nausea, oral candidiasis,pseudomembranous colitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-JohnsonsyndromeOther: Anaphylaxis; injection site pain, redness,and swelling; superinfection

toxicity. Also monitor fluid intake andoutput; decreasing urine output may indicatenephrotoxicity.• Assess patient’s bowel pattern daily; severediarrhea may indicate pseudomembranouscolitis.• Watch for evidence of superinfection, suchas perineal itching, fever, malaise, redness,pain, swelling, drainage, rash, diarrhea,and cough or sputum changes.• Assess patient for pharyngitis, ecchymosis,bleeding, and arthralgia; they may indicatea blood dyscrasia.PATIENT TEACHING• Warn patient that I.M. injection may bepainful.• Tell patient to immediately report severediarrhea to prescriber.cefoperazonesodiumCefobidClass and CategoryChemical class: Third-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: Bcefoperazone sodium 195Indications and Dosages To treat respiratory tract infectionscaused by Enterobacter species,Escherichia coli, Haemophilus influenzae,Klebsiella pneumoniae, Proteusmirabilis, Pseudomonas aeruginosa,Staphylococcus aureus, Streptococcuspneumoniae, Streptococcus pyogenes,and other streptococci (excluding enterococci);UTI caused by E. coli and P.aeruginosa; uncomplicated gonorrheacaused by Neisseria gonorrhoeae; gynecologicinfections caused by anaerobicgram-positive cocci, Bacteroides species,Clostridium species, E. coli,Staphylococcus epidermidis, andStreptococcus agalactiae; bacterial septicemiacaused by E. coli, Klebsiellaspecies, S. aureus, Serratia marcescens,and streptococci; skin and soft-tissueinfections caused by P. aeruginosa, S.aureus, and S. pyogenes; and intraabdominalinfections caused by anaerobicgram-negative bacilli, E. coli, and P.aeruginosaI.V. INFUSION,I.M. INJECTIONAdults. 1 to 2 g every 12 hr. For severeinfections or those caused by less sensitiveorganisms, 6 to 12 g daily divided intoequal doses and given b.i.d., t.i.d., or q.i.d.Maximum: 12 g daily.Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes cell membranes rigid andprotective. Without it, bacterial cells ruptureand die.IncompatibilitiesTo prevent mutual inactivation, don’t mixcefoperazone with aminoglycosides. Alsoavoid mixing cefoperazone with otherdrugs, including pentamidine isethionate.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityoral anticoagulants, other drugs that affectblood clotting: Increased anticoagulant effectACTIVITIESalcohol use: Disulfiram-like reactionAdverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, nausea, oral candidiasis,pseudomembranous colitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-JohnsonsyndromeOther: Anaphylaxis; injection site pain, redness,and swelling; superinfectionC

196cefotaxime sodiumNursing Considerations• Use cefoperazone cautiously in patientswith a history of bleeding problems, GIdisease (especially colitis), or severelyimpaired hepatic or renal function. Alsouse cautiously in patients hypersensitive topenicillin because cross-sensitivity hasoccurred in about 10% of such patients.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.• For I.V. use, reconstitute with requiredamount of diluent. Then further dilute incompatible solution, such as D 5 W, D 10 W,dextrose 5% in lactated Ringer’s solution,dextrose 5% in quarter-normal (0.2) salinesolution, dextrose 5% in normal salinesolution, lactated Ringer’s injection, normalsaline solution, Normosol M andD 5 W, or Normosol R. (See manufacturer’sguidelines for details.)• Give I.V. drug as intermittent infusionover 15 to 30 minutes or as continuousinfusion. Direct bolus injection isn’t recommended.• For I.M. injection, reconstitute drug withbacteriostatic water for injection (thatcontains benzyl alcohol or parabens) orsterile water for injection.• After reconstitution, let foam dissipate,and inspect the solution to ensure completedissolution.• Store reconstituted solution at room temperaturefor 24 hours.• Monitor BUN and serum creatinine levelsto detect early signs of nephrotoxicity.Also monitor fluid intake and output;decreasing urine output may indicatenephrotoxicity.• Assess bowel pattern daily; severe diarrheamay indicate pseudomembranous colitis.• Assess for pharyngitis, ecchymosis, bleeding,and arthralgia; they may indicate ablood dyscrasia.• Assess for evidence of superinfection, suchas perineal itching, fever, malaise, redness,pain, swelling, drainage, rash, diarrhea,and cough or sputum changes.PATIENT TEACHING• Advise patient to avoid alcohol duringtherapy and for at least 3 days after lastdose.• Explain that I.M. injection may hurt.• Tell patient to immediately report severediarrhea to prescriber.cefotaxime sodiumClaforanClass and CategoryChemical class: Third-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To provide perioperative prophylaxisI.V. INFUSION, I.V. OR I.M. INJECTIONAdults and children weighing more than50 kg (110 lb). 1 g 30 to 90 min before surgery. To provide perioperative prophylaxisrelated to cesarean sectionI.V. INFUSION, I.V. OR I.M. INJECTIONAdults. 1 g as soon as cord is clamped, then1 g every 6 hr for up to two doses. To treat gonococcal urethritis and cervicitisin men and womenI.M. INJECTIONAdults weighing more than 50 kg. 500 mgas a single dose. To treat rectal gonorrhea in womenI.M. INJECTIONAdults weighing more than 50 kg. 500 mgas a single dose. To treat rectal gonorrhea in menI.M. INJECTIONAdults weighing more than 50 kg. 1 g as asingle dose. To treat disseminated gonorrheaI.V. INFUSION OR INJECTIONAdults and children weighing more than50 kg. 1 g every 8 hr. To treat uncomplicated infections causedby susceptible organismsI.V. INFUSION, I.V. OR I.M. INJECTIONAdults and children weighing more than50 kg. 1 g every 12 hr.Children ages 1 month to 12 years weighingless than 50 kg. 50 to 180 mg/kg dailyin four to six divided doses.Children ages 1 to 4 weeks. 50 mg/kg I.V.every 8 hr.Children age 1 week and under. 50 mg/kgI.V. every 12 hr. To treat moderate to severe infectionscaused by susceptible organismsI.V. INFUSION, I.V. OR I.M. INJECTIONAdults and children weighing more than

50 kg. 1 to 2 g every 8 hr.Children ages 1 month to 12 years weighingless than 50 kg. 50 to 180 mg/kg dailyin four to six divided doses. For more seriousinfections, including meningitis, higherdosages are used.Children ages 1 to 4 weeks. 50 mg/kg I.V.every 8 hr.Children age 1 week and younger. 50 mg/kg I.V. every 12 hr. To treat septicemia and other infectionsthat commonly require antibiotics inhigher doses than those used to treatmoderate to severe infectionsI.V. INFUSION OR INJECTIONAdults and children weighing more than50 kg. 2 g every 6 to 8 hr. To treat life-threatening infectionscaused by susceptible organismsI.V. INFUSION OR INJECTIONAdults and children weighing more than50 kg. 2 g every 4 hr. Maximum: 12 g daily.Children ages 1 month to 12 years weighingless than 50 kg. 50 to 180 mg/kg dailyin four to six divided doses.Children ages 1 to 4 weeks. 50 mg/kg every8hr.Children age 1 week and younger. 50 mg/kg every 12 hr.DOSAGE ADJUSTMENT Dosage reduced by50% for patients with estimated creatinineclearance below 20 ml/min/1.73 m 2 .Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting cross-linking of peptidoglycanstrands. Peptidoglycan makes cell membranesrigid and protective. Without it, bacterialcells rupture and die.IncompatibilitiesTo prevent mutual inactivation, don’t mixcefotaxime with aminoglycosides. Alsoavoid mixing cefotaxime with other drugs,including pentamidine isethionate.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityprobenecid: Increased and prolonged bloodcefotaxime levelcefotaxime sodium 197Adverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, cholestasis, diarrhea,elevated liver function test results,hepatic failure, hepatitis, hepatomegaly,jaundice, nausea, oral candidiasis, pseudomembranouscolitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-Johnsonsyndrome, toxic epidermal necrolysisOther: Anaphylaxis; injection site pain, redness,and swelling; superinfectionNursing Considerations• Use cefotaxime cautiously in patients withimpaired renal function, a history of GIdisease (especially colitis), or hypersensitivityto penicillin because cross-sensitivityhas occurred in about 10% of suchpatients.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.• For I.V. use, reconstitute each 0.5-, 1-, or2-g vial with 10 ml of sterile water forinjection. Shake to dissolve.• For intermittent I.V. infusion, furtherdilute in 50 to 100 ml of D 5 W or normalsaline solution.• For I.M. use, reconstitute each 500-mg vialwith 2 ml sterile water for injection orbacteriostatic water for injection; each 1-gvial with 3 ml diluent; and each 2-g vialwith 5 ml diluent. Shake to dissolve.WARNING When preparing drug for aneonate, don’t use diluent that containsbenzyl alcohol; it could cause a fatal toxicsyndrome.• Give cefotaxime by I.V. injection over 3 to5 minutes through tubing of a free-flowingcompatible I.V. solution. Temporarilystop other solutions being given throughsame I.V. site.• Discard unused drug after 24 hours ifstored at room temperature, 5 days ifrefrigerated.C

198cefotetan disodium• Protect cefotaxime powder and solutionfrom light and heat.• Monitor I.V. sites for signs of phlebitis orextravasation. Rotate I.V. sites every72 hours.• Monitor BUN and serum creatinine levelsand fluid intake and output for signs ofnephrotoxicity.• Be aware that allergic reaction may occur afew days after cefotaxime therapy starts.• Assess bowel pattern daily; severe diarrheamay indicate pseudomembranous colitiscaused by Clostridium difficile. If diarrheaoccurs, notify prescriber and expect towithhold cefotaxime and treat with fluids,electrolytes, protein, and an antibioticeffective against C. difficile.• Assess patient for pharyngitis, ecchymosis,bleeding, and arthralgia, which may indicatea blood dyscrasia. Monitor CBC, PT,and bleeding time, as ordered.• Monitor patient closely for superinfection.If evidence appears, notify prescriber andexpect to stop drug and provide care.PATIENT TEACHING• Explain that I.M. injection may be painful.• Instruct patient to report watery, bloodystools to prescriber immediately, even upto 2 months after drug therapy has ended.cefotetan disodiumCefotanClass and CategoryChemical class: Second-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To provide surgical prophylaxisI.V. INJECTIONAdults. 1 to 2 g 30 to 60 min before surgeryor, in cesarean section, as soon as cord isclamped. To treat lower respiratory tract infectionscaused by Escherichia coli,Haemophilus influenzae, Klebsiellaspecies, Proteus mirabilis, Serratiamarcescens, Staphylococcus aureus,and Streptococcus pneumoniae; gynecologicinfections caused by Bacteroidesspecies (excluding B. distasonis, B. ovatus,and B. thetaiotaomicron), E. coli,Fusobacterium species, gram-positiveanaerobic cocci, Neisseria gonorrhoeae,P. mirabilis, S. aureus, Staphylococcusepidermidis, and Streptococcus species(excluding enterococci); intra-abdominalinfections caused by Bacteroidesspecies (excluding B. distasonis, B. ovatus,and B. thetaiotaomicron),Clostridium species, E. coli, Klebsiellaspecies, and Streptococcus species(excluding enterococci); and bone andjoint infections caused by S. aureusI.V. INFUSION, I.V. OR I.M. INJECTIONAdults. For mild to moderate infections,1 to 2 g every 12 hr.I.V. INFUSION OR INJECTIONAdults. For severe infections, 2 g every12 hr; for life-threatening infections, 3 gevery 12 hr. To treat UTI caused by E. coli,Klebsiella species, or Proteus speciesI.V. INFUSION, I.V. OR I.M. INJECTIONAdults. 0.5 to 2 g every 12 hr or 1 to 2 gevery 24 hr. To treat skin and soft-tissue infectionscaused by E. coli, Klebsiella pneumoniae,Peptostreptococcus species, S.aureus, S. epidermidis, Streptococcuspyogenes, and Streptococcus species(excluding enterococci)I.V. INFUSION, I.V. OR I.M. INJECTIONAdults. For mild to moderate infectionsdue to K. pneumoniae, 1 or 2 g every 12 hr.For mild to moderate infections caused byother organisms, 1 g I.M. or I.V. every 12 hror 2 g I.V. every 24 hr; for severe infections,2 g I.V. every 12 hr.DOSAGE ADJUSTMENT Dosing intervalreduced to 24 hr if creatinine clearance is10 to 30 ml/min/1.73 m 2 and to 48 hr ifcreatinine clearance is less than 10 ml/min/1.73 m 2 .Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes cell membranes rigid andprotective. Without it, bacterial cells ruptureand die.IncompatibilitiesTo prevent mutual inactivation, don’t mixcefotetan with aminoglycosides.

ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityoral anticoagulants, other drugs that affectblood clotting: Enhanced anticoagulanteffectprobenecid: Increased and prolonged bloodcefotetan levelACTIVITIESalcohol use: Disulfiram-like reactionAdverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, nausea, oral candidiasis,pseudomembranous colitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-JohnsonsyndromeOther: Anaphylaxis; injection site pain, redness,and swelling; superinfectionNursing Considerations• Use cefotetan cautiously in patients withimpaired renal function or a history of GIdisease, especially colitis. Also use cautiouslyin patients hypersensitive to penicillinbecause cross-sensitivity hasoccurred in about 10% of such patients.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.• For I.V. use, reconstitute each 1-g vial ofdrug with 10 ml sterile water for injection.For each 2-g vial, use 10 to 20 ml diluent.For I.V. infusion, further dilute solution in50 to 100 ml D 5 W or normal saline solution.• For direct I.V. injection, give drug slowlyover 3 to 5 minutes through tubing of aflowing compatible I.V. solution.cefoxitin sodium 199• For I.M. use, reconstitute each 1-g vial ofdrug with 2 ml of sterile or bacteriostaticwater for injection, or sodium chloride forinjection. For a 2-g vial, use 3 ml diluent.• Monitor I.V. site for signs and symptomsof phlebitis and extravasation; rotate sitesevery 72 hours.• Protect reconstituted solution from light,and store for up to 24 hours at room temperatureor 96 hours under refrigeration.• Be aware than an allergic reaction mayoccur a few days after therapy starts.• Monitor BUN and serum creatinine levelsand fluid intake and output for signs ofnephrotoxicity.• Monitor patient receiving even short-termcefotetan therapy for signs and symptomsof hemolytic anemia, such as marked pallorand fatigue.• If patient receives long-term therapy,monitor CBC and serum AST, ALT, bilirubin,LD, and alkaline phosphatase levels.• Assess patient’s bowel pattern daily; severediarrhea may indicate pseudomembranouscolitis.• Watch for pharyngitis, ecchymosis, bleeding,and arthralgia, which may indicate ablood dyscrasia. Monitor PT and bleedingtime, as ordered. Be prepared to give vitaminK, if ordered, to treat hypoprothrombinemia.PATIENT TEACHING• Explain that I.M. injection may be painful.• Tell patient to immediately report severediarrhea to prescriber.• Urge patient to avoid alcohol during andfor at least 3 days after cefotetan therapy.cefoxitin sodiumMefoxinClass and CategoryChemical class: Second-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To provide surgical prophylaxisI.V. INFUSION OR INJECTIONAdults. 2 g 30 to 60 min before surgery andthen 2 g every 6 hr after first dose for up to24 hr.C

200cefoxitin sodiumChildren age 3 months or over. 30 to40 mg/kg 30 to 60 min before surgery andevery 6 hr after first dose for up to 24 hr. To provide surgical prophylaxis forcesarean sectionI.V. INFUSION OR INJECTIONAdults. 2 g as a single dose as soon as cordis clamped or 2 g as soon as cord isclamped followed by 2 g 4 and 8 hr afterinitial dose. To provide surgical prophylaxis fortransurethral prostatectomyI.V. INFUSION OR INJECTIONAdults. 1 g 30 to 60 min before surgery andthen 1 g every 8 hr for up to 5 days. To treat infections, including septicemia,gynecologic infections, intra-abdominalinfections, UTI, and infections of thelower respiratory tract, skin, soft tissue,bones, and joints caused by anaerobes(including Bacteroides species,Clostridium species, Fusobacteriumspecies, Peptococcus niger, andPeptostreptococcus species), gramnegativeorganisms (including Escherichiacoli, Haemophilus influenzae[also ampicillin-resistant strains],Klebsiella, and Proteus species), andgram-positive organisms (includingStaphylococcus aureus [penicillinaseandnon–penicillinase-producingstrains], Staphylococcus epidermidis,Streptococcus agalactiae, Streptococcuspneumoniae, and Streptococcus pyogenes)I.V. INFUSION OR INJECTIONAdults. For uncomplicated infections, 1 gevery 6 to 8 hr; for moderate to severeinfections, 1 g every 4 hr or 2 g every 6 to8 hr. For infections that commonly requirehigh-dose antibiotics (such as gas gangrene),2 g every 4 hr or 3 g every 6 hr.Children age 3 months or over. 80 to160 mg/kg daily in equal doses given every4 to 6 hr (higher dosages used for moresevere infections). Maximum: 12 g daily. To treat uncomplicated gonorrheaI.M. INJECTIONAdults. 2 g as a single dose along with 1 goral probenecid concurrently or within30 min of cefoxitin.DOSAGE ADJUSTMENT Dosage reduced to1 to 2 g every 8 to 12 hr if creatinine clearanceis 30 to 50 ml/min/1.73 m 2 ; 1 to 2 gevery 12 to 24 hr if clearance is 10 to 29 ml/min/1.73 m 2 ; 0.5 to 1 g every 12 to 24 hr ifclearance is 5 to 9 ml/min/1.73 m 2 ; and0.5 to 1 g every 24 to 48 hr if clearance isless than 5 ml/min/1.73 m 2 .Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes cell membranes rigid andprotective. Without it, bacterial cells ruptureand die.IncompatibilitiesTo prevent mutual inactivation, don’t mixcefoxitin with aminoglycosides. Also avoidmixing cefoxitin with other drugs, includingpentamidine isethionate.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityAdverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, nausea, oral candidiasis,pseudomembranous colitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, flushing, pruritus, rash,Stevens-Johnson syndrome, urticariaOther: Anaphylaxis; injection site pain, redness,and swelling; superinfectionNursing Considerations• Use cefoxitin cautiously in patients hypersensitiveto penicillin; cross-sensitivity hasoccurred in about 10% of such patients.• Also use cautiously in patients with a historyof GI disease, particularly colitis,because of an increased risk of

pseudomembranous colitis.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.• For I.V. use, reconstitute 1 g with 10 mlsterile water for injection or 2 g with 10 to20 ml diluent.• For I.V. injection, give slowly over 3 to5 minutes through tubing of a flowingcompatible I.V. solution.• For intermittent infusion, further dilutewith 50 to 100 ml D 5 W or normal salinesolution.• For continuous high-dose infusion, addcefoxitin to I.V. solutions of D 5 W, normalsaline solution, or dextrose 5% in normalsaline solution.• For I.M. use, reconstitute each 1 g with2 ml sterile water for injection.• Discard unused drug after 24 hours ifstored at room temperature or after1 week if refrigerated.• Be aware that powder or solution maydarken during storage, which doesn’treflect altered potency.• Be aware that an allergic reaction mayoccur a few days after therapy starts.• Monitor BUN and serum creatinine forearly signs of nephrotoxicity. Also monitorfluid intake and output; decreasing urineoutput may indicate nephrotoxicity.• Assess patient’s bowel pattern daily; severediarrhea may indicate pseudomembranouscolitis.• Assess for pharyngitis, ecchymosis, bleeding,and arthralgia; they may indicate ablood dyscrasia.PATIENT TEACHING• Tell patient to immediately report severediarrhea to prescriber.• Instruct patient to complete the course oftherapy as prescribed.cefpodoximeproxetilVantinClass and CategoryChemical class: Third-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: Bcefpodoxime proxetil 201Indications and Dosages To treat acute community-acquiredpneumonia caused by Haemophilus influenzaeor Streptococcus pneumoniaeORAL SUSPENSION, TABLETSAdults and adolescents over age 13.200 mg every 12 hr for 14 days. To treat acute bacterial exacerbation ofchronic bronchitis caused by H. influenzae,Moraxella catarrhalis, or S. pneumoniaeTABLETSAdults and adolescents over age 13.200 mg every 12 hr for 10 days. To treat uncomplicated gonorrhea inmen and women and rectal gonococcalinfections in women caused by NeisseriagonorrhoeaeORAL SUSPENSION, TABLETSAdults. 200 mg as a single dose. To treat uncomplicated UTI caused byEscherichia coli, Klebsiella pneumoniae,Proteus mirabilis, orStaphylococcus saprophyticusORAL SUSPENSION, TABLETSAdults. 100 mg every 12 hr for 7 days. To treat skin and soft-tissue infectionscaused by Staphylococcus aureus orStaphylococcus pyogenesORAL SUSPENSION, TABLETSAdults and adolescents over age 13.400 mg every 12 hr for 7 to 14 days. To treat acute otitis media caused by H.influenzae, M. catarrhalis, or S. pneumoniaeORAL SUSPENSION, TABLETSChildren ages 5 months through 12 years.5 mg/kg every 12 hr (maximum: 200 mg/dose) or 10 mg/kg every 24 hr (maximum:400 mg/dose) for 10 days. To treat pharyngitis and tonsillitiscaused by S. pyogenesORAL SUSPENSION, TABLETSAdults and adolescents over age 13.100 mg every 12 hr for 5 to 10 days.Children ages 2 months through 12 years.5 mg/kg every 12 hr for 5 to 10 days.Maximum: 100 mg/dose.DOSAGE ADJUSTMENT Dosing intervalincreased to 24 hr in patients with creatinineclearance less than 30 ml/min/1.73 m 2 .Mechanism of ActionInterferes with bacterial cell wall synthesisC

202cefprozilby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes cell membranes rigid andprotective. Without it, bacterial cells ruptureand die.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityantacids, H 2 -receptor antagonists: Reducedbioavailability and blood level of cefpodoximeoral anticholinergics: Delayed peak bloodlevel of cefpodoximeprobenecid: Possibly increased and prolongedblood cefpodoxime levelAdverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, nausea, oral candidiasis,pseudomembranous colitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-JohnsonsyndromeOther: Anaphylaxis, superinfectionNursing Considerations• Use cefpodoxime cautiously in patientswho have impaired renal function or arereceiving potent diuretics. Also use drugcautiously in patients hypersensitive topenicillin because cross-sensitivity hasoccurred in about 10% of such patients.• If possible, obtain culture and sensitivitytest results, as ordered, before giving cefpodoxime.• Assess patient’s bowel pattern daily; severediarrhea may indicate pseudomembranouscolitis.• Be aware that an allergic reaction mayoccur a few days after therapy starts.PATIENT TEACHING• Urge patient to complete the prescribedcourse of therapy.• Tell patient to take tablets with food toenhance absorption.• Advise patient to refrigerate oral suspensionand discard after 14 days.• Instruct patient to shake oral suspensionbottle well before pouring dose and to usea calibrated liquid-measuring device toensure accurate doses.• Inform patient that yogurt and buttermilkcan help maintain intestinal flora anddecrease diarrhea.• Warn patient not to take an antacid within2 hours before or after taking cefpodoxime.• Tell patient to report watery, bloody stoolsto prescriber immediately, even up to2 months after drug therapy has ended.cefprozilCefzilClass and CategoryChemical class: Second-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat secondary bacterial infections inpatients with acute bronchitis and acutebacterial exacerbations of acute bronchitiscaused by Haemophilus influenzae,Moraxella catarrhalis, and StreptococcuspneumoniaeORAL SUSPENSION, TABLETSAdults and adolescents. 500 mg every 12hr for 10 days. To treat uncomplicated skin and softtissueinfections caused by Staphylococcusaureus and Streptococcus pyogenesORAL SUSPENSION, TABLETSAdults and adolescents. 250 mg every 12 hror 500 mg every 12 to 24 hr for 10 days.Children ages 2 to 12. 20 mg/kg every 24 hrfor 10 days. To treat pharyngitis and tonsillitiscaused by S. pyogenes

ORAL SUSPENSION, TABLETSAdults and adolescents. 500 mg every 24 hrfor 10 days.Children ages 2 to 12. 7.5 mg/kg every12 hr for 10 days. To treat otitis media caused by H. influenzae,M. catarrhalis, and S. pneumoniaeORAL SUSPENSION, TABLETSChildren ages 6 months to 12 years.15 mg/kg every 12 hr for 10 days. To treat acute sinusitis caused by H.influenzae, M. catarrhalis, and S. pneumoniaeORAL SUSPENSION, TABLETSAdults and adolescents. 250 to 500 mgevery 12 hr for 10 days.Children ages 6 months to 12 years. 7.5 or15 mg/kg every 12 hr for 10 days.DOSAGE ADJUSTMENT Dosage reduced byhalf and given at usual intervals in patientswith creatinine clearance less than 30 ml/min/1.73 m 2 .Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes the cell membrane rigid andprotective. Without it, bacterial cells ruptureand die.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityprobenecid: Increased blood cefprozil levelAdverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, nausea, oral candidiasis,pseudomembranous colitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-JohnsonsyndromeOther: Anaphylaxis, superinfectionNursing Considerations• Use cefprozil cautiously in patients whohave impaired renal function or a historyof GI disease, especially colitis. Also usedrug cautiously in patients who are hypersensitiveto penicillin because crosssensitivityhas occurred in about 10% ofsuch patients.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.WARNING Don’t administer oral suspensionto patients with phenylketonuria becauseit contains phenylalanine 28 mg/5 ml.• Monitor BUN and serum creatinine levelsto detect early signs of nephrotoxicity.Also monitor fluid intake and output;decreasing urine output may indicatenephrotoxicity.• Be aware that an allergic reaction mayoccur a few days after therapy starts.• Assess patient’s bowel pattern daily; severediarrhea may indicate pseudomembranouscolitis.PATIENT TEACHING• Urge patient to complete the prescribedcourse of therapy.• Tell patient to refrigerate oral suspensionand discard after 14 days.• Instruct patient to shake oral suspensionwell before pouring and to use a calibratedmeasuring device to ensure accurate doses.• Inform patient that yogurt and buttermilkcan help maintain intestinal flora anddecrease diarrhea.• Tell patient to report watery, bloody stoolsto prescriber immediately, even up to2 months after drug therapy has ended.ceftazidimeceftazidime 203Ceptaz, Fortaz, Tazicef, TazidimeClass and CategoryChemical class: Third-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BC

204ceftazidimeIndications and Dosages To treat infections caused by gramnegativeorganisms (including Acinetobacter,Citrobacter, Enterobacter,Escherichia coli, Haemophilus influenzae,Klebsiella, Neisseria, Proteusmirabilis, Proteus vulgaris, Pseudomonasaeruginosa, Salmonella,Serratia, and Shigella), gram-positiveorganisms (including Streptococcusagalactiae, Streptococcus pneumoniae,and Streptococcus pyogenes [group Bstreptococci]), as well as Staphylococcusaureus (penicillinase- and non–penicillinase-producing strains)I.V. INFUSION, I.M. INJECTIONAdults and children age 12 and over. 1 gevery 8 to 12 hr.I.V. INFUSIONChildren ages 1 month to 12 years. 30 to50 mg/kg every 8 hr.Neonates up to age 1 month. 30 mg/kgevery 12 hr. Maximum: 6 g daily. To treat uncomplicated UTII.V. INFUSION, I.M. INJECTIONAdults and children age 12 and over.250 mg every 12 hr. To treat complicated UTII.V. INFUSION, I.M. INJECTIONAdults and children age 12 and over.500 mg every 8 to 12 hr. To treat uncomplicated pneumonia andmild skin and soft-tissue infectionsI.V. INFUSION, I.M. INJECTIONAdults and children age 12 and over. 0.5 to1 g every 8 hr. To treat bone and joint infectionsI.V. INFUSIONAdults and children age 12 and over. 2 gevery 12 hr. To treat serious gynecologic and intraabdominalinfections, meningitis, andlife-threatening infections, especially inimmunocompromised patientsI.V. INFUSIONAdults and children age 12 and over. 2 gevery 8 hr. To treat pseudomonal lung infection inpatients with cystic fibrosis and normalrenal functionI.V. INFUSIONAdults and children age 1 month and over.30 to 50 mg/kg every 8 hr. Maximum: 6 gdaily.Neonates up to age 1 month. 30 mg/kgevery 12 hr.DOSAGE ADJUSTMENT Dosage reduced to 1 gevery 12 hr if creatinine clearance is 31 to50 ml/min/1.73 m 2 ; to 1 g every 24 hr if16 to 30 ml/min/1.73 m 2 ; to 0.5 g every24 hr if 6 to 15 ml/min/1.73 m 2 ; and to0.5 g every 48 hr if less than 6 ml/min/1.73 m 2 .Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the cross-linking of peptidoglycanstrands. Peptidoglycan makes the cellmembrane rigid and protective. Without it,bacterial cells rupture and die.IncompatibilitiesDon’t mix ceftazidime with aminoglycosidesto prevent mutual inactivation.Vancomycin is physically incompatible withceftazidime (precipitate may form); flushI.V. line between these drugs if giventhrough same tubing. Avoid mixing ceftazidimewith other drugs, including pentamidineisethionate.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityoral combined estrogen-progesterone contraceptives:Decreased effectiveness of oralcontraceptiveAdverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, nausea, oral candidiasis,pseudomembranous colitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-Johnsonsyndrome

Other: Anaphylaxis; injection site pain, redness,and swelling; superinfectionNursing Considerations• Use ceftazidime cautiously in patientshypersensitive to penicillin because crosssensitivityoccurs in about 10% of suchpatients. Watch for allergic reactions a fewdays after therapy starts.• Use cautiously in patients with a history ofGI disease, particularly colitis, because riskof pseudomembranous colitis is increased.• Ceftazidime l-arginine (Ceptaz) is not recommendedfor children under age 12.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.• Protect ceftazidime powder and reconstituteddrug from heat and light; both tendto darken during storage.• If pharmacy delivers frozen solution, thawit at room temperature, not in water bathor microwave. Store thawed solution forup to 12 hours at room temperature or7 days in refrigerator; don’t refreeze.WARNING When preparing drug forneonates or immature infants, don’t usediluents containing benzyl alcohol becausethey are linked to a fatal toxic syndrome.• For I.V. bolus, reconstitute 1 to 2 g with10 ml sterile water for injection, D 5 W, orsodium chloride for injection. Shake todissolve. Administer I.V. injection slowlyover 3 to 5 minutes through tubing of aflowing compatible I.V. fluid.• For intermittent infusion, further dilute in50 to 100 ml D 5 W or normal saline solution.Avoid using sodium bicarbonateinjection as a diluent because drug is leaststable in it. During ceftazidime administration,temporarily stop other solutionsbeing given at the same I.V. site.• For I.M. use, reconstitute each gram with3 ml sterile water for injection or bacteriostaticwater for injection.• Give I.M. injection deep into large musclemass, such as gluteus maximus.• Rotate I.V. sites every 72 hours. Assess forphlebitis and extravasation.• Assess patient’s bowel pattern daily; severediarrhea may indicate pseudomembranouscolitis.• Monitor CBC, hematocrit, and serumAST, ALT, bilirubin, LD, and alkaline phosphataselevels during long-term therapy.• Monitor PT, as ordered, in at-risk patients,such as those with renal or hepatic impairmentor poor nutritional state and thosereceiving anticoagulant or prolongedantibiotic therapy. Notify prescriber if PTdecreases, and expect to give vitamin K.• Assess patient for perineal itching, fever,malaise, redness, swelling, rash, andchange in cough or sputum; they mayindicate a superinfection.• Watch for pharyngitis, ecchymosis, bleeding,and arthralgia (possible blood dyscrasia).Monitor PT and bleeding time.PATIENT TEACHING• Tell patient to take ceftazidine exactly asprescribed.• Tell patient to immediately report evidenceof blood dyscrasia or superinfectionto prescriber.• Urge patient to report watery, bloodystools to prescriber immediately, even upto 2 months after drug therapy has ended.ceftibutenCedaxceftibuten 205Class and CategoryChemical class: Third-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat acute bacterial exacerbations ofchronic bronchitis caused by Haemophilusinfluenzae, Moraxella catarrhalis,or Streptococcus pneumoniae; pharyngitisand tonsillitis caused by Streptococcuspyogenes; and acute bacterialotitis media caused by H. influenzae, M.catarrhalis, or S. pneumoniaeCAPSULES, ORAL SUSPENSIONAdults and children age 12 and over.400 mg daily for 10 days. To treat pharyngitis and tonsillitiscaused by S. pyogenes and acute bacterialotitis media caused by H. influenzae,M. catarrhalis, or S. pneumoniaeORAL SUSPENSIONChildren under age 12. 9 mg/kg daily for10 days. Maximum: 400 mg daily.DOSAGE ADJUSTMENT Dosage reduced to4.5 mg/kg or 200 mg every 24 hr if creatinineclearance is 30 to 49 ml/min/1.73 m 2 ;C

206ceftizoxime sodiumto 2.25 mg/kg or 100 mg every 24 hr if it’s 5to 29 ml/min/1.73 m 2 .Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the cross-linking of peptidoglycanstrands. Peptidoglycan makes the cellmembrane rigid and protective. Without it,bacterial cells rupture and die.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityAdverse ReactionsCNS: Aphasia, chills, fever, headache, psychosis,seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, jaundice, melena, nausea,oral candidiasis, pseudomembranous colitis,vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-Johnsonsyndrome, toxic epidermal necrolysisOther: Anaphylaxis, serum sickness, superinfectionNursing Considerations• Use ceftibuten cautiously in patientshypersensitive to penicillins because crosssensitivityoccurs in up to 10% of suchpatients.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.• Refrigerate oral suspension; shake wellbefore using. Discard after 14 days.• Monitor BUN and serum creatinine levelsto detect early signs of nephrotoxicity.Also monitor fluid intake and output;decreasing urine output may indicatenephrotoxicity.• Be aware that an allergic reaction mayoccur a few days after therapy starts.• Assess bowel pattern daily; severe diarrheamay indicate pseudomembranous colitis.• Assess patient for perineal itching, fever,malaise, redness, swelling, rash, andchange in cough or sputum; they mayindicate a superinfection.• Assess for pharyngitis, ecchymosis, bleeding,and arthralgia; they may indicate ablood dyscrasia.PATIENT TEACHING• Urge patient to complete the drug therapyas prescribed.• Instruct patient to take drug on an emptystomach at least 2 hours before or 1 hourafter meals.• Inform patient that unflavored oral suspensionhas a bitter taste. Suggest having aflavor added when prescription is filled.• Advise patient that yogurt and buttermilkcan help maintain intestinal flora anddecrease diarrhea during therapy.• Tell patient to immediately report hypersensitivityreactions, severe diarrhea, andevidence of blood dyscrasia or superinfection.ceftizoxime sodiumCefizoxClass and CategoryChemical class: Third-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat mild to moderate infections ofthe lower respiratory tract, skin, soft tissue,bones, and joints; septicemia;meningitis; and intra-abdominal infectionscaused by anaerobes (such asBacteroides species, Peptococcus, andPeptostreptococcus), gram-negativeorganisms (including Escherichia coli,Haemophilus influenzae, Klebsiella,and Proteus mirabilis), and grampositiveorganisms (including Enterobacterspecies, Serratia species, Staphylococcusaureus, Staphylococcus epidermidis,Streptococcus agalactiae,Streptococcus pneumoniae, andStreptococcus pyogenes)

I.V. INFUSION, I.V. OR I.M. INJECTIONAdults and children age 12 and over. 1 to2 g every 8 to 12 hr. To treat severe or refractory infections ofthe type listed aboveI.V. INFUSION OR INJECTIONAdults and children age 12 and over. 1 gevery 8 hr or 2 g every 8 to 12 hr. To treat life-threatening infections of thetype listed aboveI.V. INFUSION OR INJECTIONAdults and children age 12 and over. 3 to4 g every 8 hr or, if required, up to 2 g every4 hr. To treat bacterial infections in childrenI.V. INFUSION, I.V. ORI.M. INJECTIONChildren age 6 months and over. 50 mg/kgevery 6 to 8 hr. To treat uncomplicated UTII.V. INFUSION, I.V. OR I.M. INJECTIONAdults. 500 mg every 12 hr. To treat pelvic inflammatory diseaseI.V. INFUSION OR INJECTIONAdults. 2 g every 8 hr. To treat uncomplicated gonococcal infectionsI.M. INJECTIONAdults. 1 g as a single dose.DOSAGE ADJUSTMENT Dosage reduced to0.5 g every 8 hr for less severe infectionsand 0.75 to 1.5 g every 8 hr for life-threateninginfections if creatinine clearance is50 to 79 ml/min/1.73 m 2 ; to 0.25 to 0.5 gevery 12 hr for less severe infections and0.5 to 1 g every 12 hr for life-threateninginfections if creatinine clearance is 5 to49 ml/min/1.73 m 2 ; and to 0.5 g every 48 hror 0.25 g every 24 hr for less severe infectionsand 0.5 to 1 g every 48 hr or 0.5 gevery 24 hr for life-threatening infections ifcreatinine clearance is 4 ml/min/1.73 m 2 orless.Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes the cell membrane rigid andprotective. Without it, bacterial cells ruptureand die.ContraindicationsHypersensitivity to cephalosporins or theircomponentsceftizoxime sodium 207InteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityAdverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, nausea, oral candidiasis,pseudomembranous colitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-JohnsonsyndromeOther: Anaphylaxis; injection site pain, redness,and swelling; superinfectionNursing Considerations• Use ceftizoxime cautiously in patientshypersensitive to penicillin because crosssensitivityhas occurred in about 10% ofsuch patients.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.• For I.V. administration, reconstitute withsterile water for injection as follows: for500-mg vial, add 5 ml; for 1-g vial, add10 ml; and for 2-g vial, add 20 ml. Shakewell. Dilute reconstituted solution furtherwith 50 to 100 ml of a compatible solution,such as normal saline solution orD 5 W, before administration. Give I.V.injection slowly over 3 to 5 minutesthrough tubing of a flowing compatibleI.V. fluid.• For I.M. administration, reconstitute withsterile water for injection as follows: for500-mg vial, add 1.5 ml; for 1-g vial, add3 ml; and for 2-g vial, add 6 ml. Shakewell. Divide 2-g doses and administer indifferent sites. Inject deep in large musclemass, such as the gluteus maximus.• Reconstituted drug may be stored24 hours at room temperature or 96 hoursif refrigerated.• Assess I.V. site for extravasation andC

208ContraindicationsCalcium-containing I.V. solutions; hyperceftriaxonesodiumphlebitis.• Monitor BUN and serum creatinine levelsto detect early signs of nephrotoxicity.Also monitor fluid intake and output;decreasing urine output may indicatenephrotoxicity.• Assess patient’s bowel pattern daily; severediarrhea may indicate pseudomembranouscolitis.• Monitor patient for allergic reactions a fewdays after therapy starts.• Assess CBC, hematocrit, and serum AST,ALT, bilirubin, LD, and alkaline phosphataselevels during long-term therapy.• Assess patient for pharyngitis, ecchymosis,bleeding, and arthralgia; they may indicatea blood dyscrasia.PATIENT TEACHING• Advise patient to immediately reportsevere or persistent diarrhea or evidence ofblood dyscrasia to prescriber.ceftriaxone sodiumRocephinClass and CategoryChemical class: Third-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat infections of the lower respiratorytract, skin, soft tissue, urinary tract,bones, and joints; sinusitis; intraabdominalinfections; and septicemiacaused by anaerobes (including Bacteroidesbivius, Bacteroides fragilis,Bacteroides melaninogenicus, andPeptostreptococcus species), gramnegativeorganisms (including Citrobacterspecies, Enterobacter aerogenes,Escherichia coli, Haemophilus influenzae,Klebsiella species, Neisseria species,Proteus mirabilis, Proteus vulgaris,Providencia species, Salmonella species,Serratia marcescens, Shigella, and somestrains of Pseudomonas aeruginosa),and gram-positive organisms (includingStaphylococcus aureus, Streptococcuspneumoniae, and Streptococcus pyogenes)I.V. INFUSION, I.M. INJECTIONAdults. 1 to 2 g daily or in equally divideddoses b.i.d. Maximum: 4 g daily.Children. 50 to 75 mg/kg daily in divideddoses every 12 hr. Maximum: 2 g daily. To treat meningitisI.V. INFUSIONChildren. Initial: 100 mg/kg on first day,then 100 mg/kg daily or in divided dosesevery 12 hr for 7 to 14 days. Maximum: 4 gdaily. To treat acute bacterial otitis mediaI.M. INJECTIONChildren. 50 mg/kg as a single dose.Maximum: 1 g. To treat chancroid (Haemophilusducreyi infection) and uncomplicatedgonorrheaI.M. INJECTIONAdults. 250 mg as a single dose. To treat gonococcal conjunctivitisI.M. INJECTIONAdults. 1 g as a single dose. To treat disseminated gonoccocal infectionand pelvic inflammatory diseaseI.V. INFUSION, I.M. INJECTIONAdults. 1 g every 24 hr. To treat gonococcal meningitis andendocarditisI.V. INFUSIONAdults. 1 to 2 g every 12 hr for 10 to14 days (meningitis) or for 4 wk or longer(endocarditis). To provide surgical prophylaxisI.V. INFUSIONAdults. 1 g 30 min to 2 hr before surgery.Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting cross-linking of peptidoglycanstrands. Peptidoglycan makes the cell membranerigid and protective. Without it, bacterialcells rupture and die.IncompatibilitiesDon’t admix ceftriaxone with pentamidineisethionate, labetalol, or other antibiotics,such as aminoglycosides, because of potentialfor incompatibility, such as substantialmutual inactivation. Also don’t mix withcalcium-containing solutions or productsbecause a ceftriaxone-calcium salt may precipitatein the lungs and kidneys and maybe fatal, especially in newborns.

ilirubinemic neonates 28 days old or less ifthey’re expected to need calcium-containingsolutions, including parenteral nutrition;hypersensitivity to ceftriaxone, othercephalosporins, or their componentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityAdverse ReactionsCNS: Chills, fever, headache, hypertonia,reversible hyperactivity, seizuresCV: EdemaEENT: Glossitis, hearing loss, stomatitisGI: Abdominal cramps, cholestasis, diarrhea,elevated liver function test results,gallbladder dysfunction, hepatic failure,hepatomegaly, nausea, oral candidiasis,pancreatitis, pseudolithiasis, pseudomembranouscolitis, vomitingGU: Elevated BUN level, nephrotoxicity,oliguria, renal failure, vaginal candidiasisHEME: Aplastic anemia, eosinophilia,hemolytic anemia, hemorrhage, hypoprothrombinemia,neutropenia, thrombocytopenia,unusual bleedingMS: ArthralgiaRESP: Allergic pneumonitis, dyspneaSKIN: Allergic dermatitis, ecchymosis, erythema,erythema multiforme, exanthema,pruritus, rash, Stevens-Johnson syndrome,toxic epidermal necrolysis, urticariaOther: Anaphylaxis; drug fever; injectionsite pain, redness, and swelling; serum sickness;superinfectionNursing ConsiderationsWARNING Calcium-containing productsmust not be given I.V. within 48 hours ofceftriaxone, including solutions giventhrough a different I.V. line and at a differentsite, because a ceftriaxone-calcium saltmay precipitate in the lungs and kidneysand could be fatal.• Use ceftriaxone cautiously in patients whoare hypersensitive to penicillins becausecross-sensitivity has occurred in about10% of such patients.• If possible, obtain culture and sensitivityresults, as ordered, before giving drug.• Protect powder from light.• For I.V. use, reconstitute with an appropriatediluent, such as sterile water for injectionor sodium chloride for injection, asceftriaxone sodium 209follows: for 250-mg vial, add 2.4 ml; for500-mg vial, add 4.8 ml; for 1-g vial, add9.6 ml; and for 2-g vial, add 19.2 ml toyield 100 mg/ml. For piggyback bottles,reconstitute with 10 ml of diluent indicatedabove for 1-g bottle and 20 ml for 2-gbottle. After reconstitution, further diluteto 50 to 100 ml with diluent indicatedabove and infuse over 30 minutes.WARNING Never give ceftriaxone by I.V.infusion and calcium-containing IV solutionsat the same time, including suchcontinuous calcium-containing infusionsas parenteral nutrition via Y-site. Forpatients other than neonates, ceftriaxoneand calcium-containing solutions may begiven sequentially if infusion lines arethoroughly flushed with a compatiblefluid between infusions.• For I.M. administration, reconstitute withan appropriate diluent, such as sterilewater for injection or sodium chloride forinjection, as follows: for 250-mg vial, add0.9 ml; for 500-mg vial, add 1.8 ml; for 1-gvial, add 3.6 ml; and for 2-g vial, add7.2 ml to make a 250-mg/ml concentration.Shake well. Inject deep into largemuscle mass, such as the gluteus maximus.• Monitor BUN and serum creatinine levelsto detect early signs of nephrotoxicity.Also monitor fluid intake and output;decreasing urine output may indicatenephrotoxicity.• Monitor patient for allergic reactions a fewdays after therapy starts.• Assess CBC, hematocrit, and serum AST,ALT, bilirubin, LD, and alkaline phosphataselevels during long-term therapy. Ifabnormalities occur, notify prescriber.Drug may need to be discontinued.• Assess bowel pattern daily; severe diarrheamay indicate pseudomembranous colitiscaused by Clostridium difficile. If diarrheaoccurs, notify prescriber and expect towithhold cefotaxime and treat with fluids,electrolytes, protein, and an antibioticeffective against C. difficile.• Monitor patient for evidence of gallbladderdisease (abdominal pain, nausea, vomiting)because drug may cause ceftriaxonecalciumsalt to deposit in the gallbladder,which may mimic gallstones. Expect drugto be discontinued if gallbladder disordersarise.C

210cefuroxime• Assess for perineal itching, fever, malaise,redness, swelling, rash, and change incough or sputum; they may indicate asuperinfection.• Assess for pharyngitis, ecchymosis, bleeding,and arthralgia; they may indicate ablood dyscrasia.PATIENT TEACHING• Tell patient to immediately report evidenceof blood dyscrasia or superinfectionto prescriber.• Urge patient to report watery, bloodystools to prescriber immediately, even upto 2 months after drug therapy has ended.cefuroxime axetilCeftincefuroxime sodiumZinacefClass and CategoryChemical class: Second-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat pharyngitis and tonsillitisORAL SUSPENSIONChildren ages 3 months to 12 years.10 mg/kg daily in equally divided dosesb.i.d. for 10 days. Maximum: 500 mg daily.TABLETSAdults and children age 13 and over.250 mg b.i.d. for 10 days.Children under age 13 who can swallowtablets. 125 mg b.i.d. for 10 days. To treat acute otitis mediaORAL SUSPENSIONChildren ages 3 months to 12 years.30 mg/kg daily in equally divided dosesb.i.d. for 10 days. Maximum: 1,000 mgdaily.TABLETSChildren under age 13 who can swallowtablets. 250 mg b.i.d. for 10 days. To treat impetigoORAL SUSPENSIONChildren ages 3 months to 12 years. 30 mg/kg daily in equally divided doses b.i.d. for10 days. Maximum: 1,000 mg daily. To treat acute bacterial maxillarysinusitisORAL SUSPENSIONChildren ages 3 months to 12 years. 30 mg/kg daily in equally divided doses b.i.d. for10 days. Maximum: 1,000 mg daily.TABLETSAdults and children age 13 and over andchildren under age 13 who can swallowtablets. 250 mg b.i.d. for 10 days. To treat acute bacterial exacerbations ofchronic bronchitis and uncomplicatedskin and soft-tissue infectionsTABLETSAdults and children age 13 and over.250 to 500 mg b.i.d. for 10 days.I.V. INFUSION, I.V. OR I.M. INJECTIONAdults. 750 mg every 8 hr. To treat secondary bacterial infection inpatients with acute bronchitisAdults and children age 13 and over.250 to 500 mg b.i.d. for 5 to 10 days. To treat early Lyme diseaseTABLETSAdults and children age 13 and over.500 mg b.i.d. for 20 days. To treat uncomplicated UTITABLETSAdults. 125 to 250 mg b.i.d. for 7 to10 days.I.V. INFUSION, I.V. ORI.M. INJECTIONAdults. 750 mg every 8 hr. To treat uncomplicated gonorrheaTABLETSAdults. 1 g as a single dose.I.V. INJECTIONAdults. 1.5 g as a single dose divided equallyand injected into two different sites;given with oral probenecid 1 g. To treat disseminated gonococcal infectionand uncomplicated pneumoniaI.V. INFUSION, I.V. OR I.M. INJECTIONAdults. 750 mg every 8 hr. To treat bone and joint infectionsI.V. INFUSION, I.V. OR I.M. INJECTIONAdults. 1.5 g every 8 hr.Children over age 3 months. 50 to 150 mg/kg daily in divided doses every 8 hr.Maximum: Adult dose. To treat bacterial meningitisI.V. INFUSIONAdults. 1.5 to 3 g every 8 hr.Children over age 1 month. 50 to 80 mg/kgevery 6 to 8 hr.

Neonates up to age 1 month. 33.3 to 50 mg/kg every 8 to 12 hr. To treat moderate infections other thanthose listed aboveI.V. INFUSION, I.V. OR I.M. INJECTIONAdults. 750 mg every 8 hr for 5 to 10 days.I.V. INFUSION OR INJECTIONChildren over age 3 months. 50 mg/kg dailyin equally divided doses every 6 to 8 hr. To treat severe or complicated infectionsother than those listed aboveI.V. INFUSION OR INJECTIONAdults. 1.5 g every 8 hr.Children over age 3 months. 100 mg/kgdaily in equally divided doses every 6 to 8 hr. To treat life-threatening infections otherthan those listed aboveI.V. INFUSION OR INJECTIONAdults. 1.5 g every 6 hr. To provide perioperative prophylaxisI.V. INFUSION OR INJECTIONAdults. 1.5 g 30 to 60 min before surgery(at induction of anesthesia for open-heartsurgery), and then 0.75 g every 8 hr thereafter(1.5 g every 12 hr for total of 6 g withopen-heart surgery).DOSAGE ADJUSTMENT Parenteral dosagereduced to 0.75 g every 12 hr if creatinineclearance is 10 to 20 ml/min/1.73 m 2 or to0.75 g every 24 hr if creatinine clearanceless than 10 ml/min/1.73 m 2 .Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes the cell membrane rigid andprotective. Without it, bacterial cells ruptureand die.IncompatibilitiesDon’t admix parenteral cefuroxime withother antibiotics, such as aminoglycosides,because of potential for incompatibility,such as substantial mutual inactivation. Ifthey’re administered concurrently, don’tmix them in the same I.V. bag or bottle.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityNursing Considerations• Use cefuroxime cautiously in patientshypersensitive to penicillin because crosssensitivityhas occurred in about 10% ofsuch patients.• If possible, obtain culture and sensitivityresults, as ordered, before giving drug.• Give oral form with food to decrease GIdistress, as needed.• Remember that oral forms—tablets andsuspension—aren’t bioequivalent.• For I.V. use, reconstitute using manufacturer’sinstructions according to type ofpreparation available. Solution ranges incolor from light yellow to amber.• For I.M. use, add 3 or 3.6 ml sterile waterfor injection to each 750-mg vial to yield220 mg/ml.• If using a container of frozen parenteralsolution, thaw at room temperature orunder refrigeration before administration;make sure all ice crystals have melted.Don’t force thawing by microwaving.• Store reconstituted parenteral drug for upto 24 hours at room temperature or 96hours in refrigerator. (Thawed solutionsmay be stable 24 hours at room temperatureor 28 days if refrigerated.) Storereconstituted oral suspension in refrigeracefuroxime211antacids, H 2 -receptor antagonists, omeprazole:Decreased cefuroxime axetil absorptionprobenecid: Increased and prolonged bloodcefuroxime levelAdverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing loss, oral candidiasisGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, nausea, pseudomembranouscolitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-JohnsonsyndromeOther: Anaphylaxis; injection site edema,pain, and redness; superinfectionC

212celecoxibtor or at room temperature up to 10 days.• Give I.V. injection over 3 to 5 minutesthrough tubing of a flowing compatibleI.V. fluid.• Monitor I.V. site for extravasation andphlebitis.• Monitor BUN and serum creatinine levelsand fluid intake and output to detect signsof nephrotoxicity. Monitor patients withrenal impairment closely because theymay have greater toxic reactions tocefuroxime.• Monitor patient for allergic reactions continuingup to a few days after therapystarts. Patients with a history of someform of allergy, especially to drugs, are atincreased risk for an allergic reaction.• Assess bowel pattern daily; severe diarrheamay indicate pseudomembranous colitis.If it’s suspected, stop drug, as ordered, andprovide treatment as prescribed.• Assess patient for pharyngitis, ecchymosis,bleeding, and arthralgia, which may indicatea blood dyscrasia.• Monitor PT and bleeding time, as ordered.Be prepared to administer vitamin K, ifordered, to treat hypothrombinemia.PATIENT TEACHING• Instruct patient to shake oral suspensionwell before measuring each dose and touse a calibrated liquid-measuring device.• Advise patient using single-dose packets oforal suspension to empty contents of onepacket into a glass and add at least 10 ml(2 tsp) of cold water; apple, grape, ororange juice; or lemonade. Tell him to stirwell and consume entire mixture at once.• Inform patient that yogurt and buttermilkhelp maintain intestinal flora and candecrease diarrhea during therapy.• Instruct patient to report evidence ofblood dyscrasia to prescriber immediately.• Urge patient to report watery, bloodystools to prescriber immediately, even upto 2 months after drug therapy has ended.celecoxibCelebrexClass and CategoryChemical class: Diaryl-substituted pyrazolederivativeTherapeutic class: Anti-inflammatory, antirheumaticPregnancy category: CIndications and Dosages To relieve signs and symptoms of osteoarthritisCAPSULESAdults. 200 mg daily or 100 mg b.i.d. To relieve signs and symptoms ofrheumatoid arthritisCAPSULESAdults. 100 to 200 mg b.i.d. To relieve signs and symptoms of juvenilerheumatoid arthritisCAPSULESChildren age 2 and older weighing 10 to25 kg (22 to 55 lb). 50 mg b.i.d.Children age 2 and older weighing morethan 25 kg. 100 mg b.i.d. To relieve pain from ankylosingspondylitisCAPSULESAdults. 200 mg daily or 100 mg b.i.d.Dosage increased to 400 mg daily or200 mg b.i.d. after 6 weeks if needed. As adjunct to reduce adenomatous colorectalpolyps in patients with familialadenomatous polyposisCAPSULESAdults. 400 mg b.i.d. To manage acute pain, to treat primarydysmenorrheaCAPSULESAdults. 400 mg, followed by 200 mg ifneeded, on 1st day. On subsequent days,200 mg b.i.d. as needed.DOSAGE ADJUSTMENT Daily dosage reducedfor patients with hepatic impairment. Forthose weighing less than 50 kg (110 lb),expect to start with lowest recommendeddose. For patients who are poor CYP2C9metabolizers, starting dosage should be halfthe lowest recommended dose.Mechanism of ActionSelectively inhibits the enzymatic activity ofcyclooxygenase-2 (COX-2), the enzymeneeded to convert arachidonic acid toprostaglandin. Prostaglandins are responsiblefor mediating the inflammatoryresponse and causing local vasodilation,swelling, and pain. Prostaglandins also playa role in peripheral pain transmission to thespinal cord. By inhibiting COX-2 activity

and prostaglandin production, this NSAIDreduces inflammatory symptoms andrelieves pain. Celecoxib’s mechanism ofaction in reducing the number of colorectalpolyps is unknown.ContraindicationsAllergic reaction (such as anaphylaxis orangioedema) to aspirin, other NSAIDs, orsulfonamide derivatives or history ofaspirin-induced nasal polyps with bronchospasm;hypersensitivity to celecoxib orits components; treatment of perioperativepain after coronary artery bypass graft surgeryInteractionsDRUGSACE inhibitors, angiotensin II receptorantagonists: Decreased antihypertensiveeffect of ACE inhibitors and angiotensin IIreceptor antagonists, increased risk of renalfailureaspirin: Increased risk of GI ulceration andother GI complicationsfluconazole: Increased blood celecoxib levelfurosemide, thiazide diuretics: Reduceddiuretic effects of these drugs, increasedrisk of renal failurelithium: Possibly elevated blood lithiumlevelwarfarin: Possibly increased PT and risk ofbleedingAdverse ReactionsCNS: Asceptic meningitis, cerebral hemorrhage,depression, dizziness, fever,headache, insomnia, ischemic stroke,stroke, suicidal ideation, syncope, transientischemic attacks, vertigoCV: Aortic valve incompetence, chest pain,congestive heart failure, deep vein thrombosis,fluid retention, hypertension, MI,palpitations, peripheral edema or gangrene,sinus bradycardia, tachycardia, thrombosis,unstable angina, vasculitis, ventricular fibrillation,ventricular hypertrophyEENT: Conjunctival hemorrhage, deafness,labyrinthitis, nasopharyngitis, pharyngitis,rhinitis, sinusitis, vitreous floatersENDO: Hyperglycemia, hypoglycemiaGI: Abdominal pain, diarrhea, elevated liverfunction test results, esophageal perforation,flatulence, GI bleeding or ulceration,hepatic failure, ileus, indigestion, jaundice,nausea, pancreatitis, perforation of stomachcelecoxib 213or intestine, vomitingGU: Acute renal failure, interstitial nephritis,ovarian cyst, proteinuria, UTI, urinaryincontinenceHEME: Agranulocytosis, aplastic anemia,decreased hematocrit and hemoglobin,leukopenia, pancytopenia, prolonged APTT,thrombocytopeniaMS: Arthralgia, back pain, elevated serumCK level, epicondylitis, tendon ruptureRESP: Bronchospasm, cough, dyspnea,pneumonia, pulmonary embolism, upperrespiratory tract infectionSKIN: Erythema multiforme, exfoliativedermatitis, phototoxicity, rash, Stevens-Johnson syndrome, toxic epidermal necrolysis,urticariaOther: Anaphylaxis, angioedema, hyperkalemia,hypernatremia, hyponatremia, sepsisNursing Considerations• Use celecoxib with extreme caution inpatients who have a history of ulcer diseaseor GI bleeding because NSAIDs, suchas celecoxib, increase the risk of GI bleedingand ulceration. In these patients, drugshould be used for shortest time possible.• Be aware that serious GI tract ulcerationand bleeding, as well as perforation ofstomach or intestine, can occur withoutwarning or symptoms. Elderly patients areat greatest risk. To minimize risk, givecelecoxib with food. If patient develops GIdistress, withhold celecoxib and notifyprescriber immediately.• Use celecoxib cautiously in patients withhypertension, and monitor blood pressureclosely throughout therapy because drugcan start or worsen hypertension.• Use celecoxib cautiously in children withsystemic onset juvenile rheumatoid arthritisbecause serious adverse reactions canoccur, including disseminated intravascularcoagulation.• Use celecoxib cautiously in patients knownto be poor CYP2C9 metabolizers based onhistory or experience with other CYP2C9substrates, such as warfarin or phenytoin.Dosage should start at half the lowest recommendedamount. For patients withjuvenile rheumatoid arthritis who are alsopoor CYP2C9 metabolizers, alternativemanagement should be considered.WARNING Monitor patient closely forC

214cephalexinthrombotic events, including MI andstroke, because use (especially long-termuse) of NSAIDs such as celecoxib increasesthe risk.WARNING In patient who has bone marrowsuppression or is receiving antineoplastictherapy, monitor laboratory results(including WBC) and assess for infectionbecause celecoxib’ anti-inflammatory andantipyretic actions may mask signs andsymptoms, such as fever and pain.• Monitor patient—especially if elderly orreceiving long-term celecoxib therapy—for less common but serious adverse GIreactions, including anorexia, constipation,diverticulitis, dysphagia, esophagitis,gastritis, gastroenteritis, gastroesophagealreflux disease, hemorrhoids, hiatal hernia,melena, stomatitis, and vomiting.• Monitor liver function test results because,in rare cases, elevation may progress tosevere hepatic reaction, including fatalhepatitis, hepatic necrosis, and hepaticfailure.• Monitor BUN and serum creatinine levelsin elderly patients; patients taking diuretics,ACE inhibitors, or angiotensin IIreceptor antagonists; and patients withheart failure, impaired renal function, orhepatic dysfunction because drug maycause renal failure.• Monitor CBC for decreased hemoglobinlevel and hematocrit because drug mayworsen anemia.• Assess patient’s skin regularly for signs ofrash or other hypersensitivity reactionbecause celecoxib is a sulfur drug and maycause serious skin reactions without warning,even in patients with no history ofsensivitity to sulfur. At first sign of reaction,stop drug and notify prescriber.• Avoid using celecoxib with a non-aspirinNSAID, regardless of the dose, becausecelecoxib reduces inflammation and fever,which may mask signs of infection.PATIENT TEACHING• Instruct patient to swallow celecoxib capsuleswhole with a full glass of water andwith food or milk to prevent stomachupset.• Tell patient to take celecoxib exactly asprescribed and not to increase dosage ortake drug longer than prescribed becauseserious adverse reactions can occur.• Advise patient to notify prescriber if paincontinues or is poorly controlled.• Explain that celecoxib may increase therisk of serious adverse CV events; urgepatient to seek immediate medical attentionif signs or symptoms arise, such aschest pain, shortness of breath, slurredspeech, and weakness.• Tell patient that celecoxib may increase therisk of serious adverse GI reactions. Stressthe need to seek immediate medical attentionif signs or symptoms develop, such asepigastric or abdominal pain, indigestion,black or tarry stools, and vomiting bloodor material that resembles coffee grounds.• Alert patient that celecoxib may cause seriousskin reactions. Advise immediatemedical attention if signs or symptomsdevelop, such as rash, blisters, fever, itching,or other evidence of hypersensitivity.• Urge patient to avoid smoking and alcoholconsumption during celecoxib therapybecause they may increase the risk ofadverse GI reactions.cephalexinhydrochlorideKeftabcephalexinmonohydrateApo-Cephalex (CAN), Keflex, Novo-Lexin (CAN), Nu-Cephalex (CAN), PMS-Cephalexin (CAN)Class and CategoryChemical class: First-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat streptococcal tonsillitis, pharyngitis,and skin and soft-tissue infectionsCAPSULES, ORAL SUSPENSION, TABLETSAdults and adolescents age 15 and over.500 mg every 12 hr. Maximum: 4 g daily.Children and adolescents ages 2 to 15.25 to 50 mg/kg daily divided into two equaldoses and given every 12 hr. If infection issevere, dose may be doubled.

cephalexin 215Mechanism of ActionLike all cephalosporins, cephalexin interfereswith bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes the cell membranerigid and protective. Without it, bacterialcells rupture and die. This mechanismof action is most effective against bacteriathat divide rapidly, including manygram-positive and gram-negative bacteria.PeptidoglycanstrandBacterial cell exteriorCephalexinBacterialcell interiorC To treat mild to moderate respiratorytract, skin, soft-tissue, bone, and GUinfections caused by susceptible organismsother than streptococciCAPSULES, ORAL SUSPENSION, TABLETSAdults. 250 mg every 6 hr.ORAL SUSPENSIONChildren. 25 to 50 mg/kg daily in equallydivided doses b.i.d. or q.i.d. To treat severe respiratory tract, skin,soft-tissue, bone, and GU infectionsCAPSULES, ORAL SUSPENSION, TABLETSAdults. 0.5 to 1 g every 6 hr. Maximum: 4 gdaily.Children. 50 to 100 mg/kg daily in equallydivided doses q.i.d. To treat otitis mediaORAL SUSPENSIONChildren. 75 to 100 mg/kg daily in equallydivided doses q.i.d. To treat uncomplicated cystitisCAPSULES, ORAL SUSPENSION, TABLETSAdults and adolescents age 15 and over.500 mg every 12 hr.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityprobenecid: Increased and prolonged bloodcephalexin levelAdverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, nausea, oral candidiasis,pseudomembranous colitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-JohnsonsyndromeOther: Anaphylaxis, superinfectionNursing Considerations• Use cephalexin cautiously in patientshypersensitive to penicillin because crosssensitivityoccurs in about 10% of them.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.• Monitor patient’s BUN and serum creatininelevels to detect early signs of nephrotoxicity.Also monitor fluid intake andoutput; decreasing urine output may indicatenephrotoxicity.• Monitor for allergic reactions a few daysafter therapy starts.• Assess CBC, hematocrit, and serum AST,ALT, bilirubin, LD, and alkaline phosphataselevels during long-term therapy.• Assess patient’s bowel pattern daily; severediarrhea may indicate pseudomembranouscolitis caused by Clostridium difficile. Ifdiarrhea occurs, notify prescriber andexpect to withhold cefotaxime and treat

216cephapirin sodiumwith fluids, electrolytes, protein, and anantibiotic effective against C. difficile.• Assess patient for pharyngitis, ecchymosis,bleeding, and arthralgia; they may indicatea blood dyscrasia.PATIENT TEACHING• Advise patient to complete prescribedcourse of therapy.• Instruct patient to shake oral suspensionwell before measuring each dose and touse a calibrated liquid-measuring deviceto ensure an accurate dose.• Tell patient that yogurt and buttermilk canhelp maintain intestinal flora and decreasediarrhea during therapy.• Urge patient to immediately report watery,bloody stools to prescriber, even if theyoccur up to 2 months after cephalexintherapy has ended.cephapirin sodiumCefadylClass and CategoryChemical class: First-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat respiratory tract infection, skinand soft-tissue infections, UTI, septicemia,endocarditis, and osteomyelitiscaused by gram-negative organisms(including Escherichia coli, Haemophilusinfluenzae, Klebsiella species,and Proteus mirabilis) and grampositiveorganisms (including group Abeta-hemolytic streptococci, Streptococcuspneumoniae, and staphylococci,including coagulase-positive, coagulasenegative,and penicillinase-producingstrains but not methicillin-resistantStaphylococcus aureus)I.V. INFUSION, I.V. OR I.M. INJECTIONAdults. 0.5 to 1 g every 4 to 6 hr.Maximum: 12 g daily. For serious infections,higher doses are given by I.V. route.Children over age 3 months. 40 to 80 mg/kg daily divided into four equal doses andgiven every 6 hr. Maximum: 12 g daily. To provide surgical prophylaxisI.V. INFUSION, I.V. OR I.M. INJECTIONAdults. 1 to 2 g 30 to 60 min before surgery,1 to 2 g during long procedure, and1 to 2 g every 6 hr after surgery for 24 hr.DOSAGE ADJUSTMENT For open-heart surgeryor prosthetic arthroplasty, prophylaxiscontinued 3 to 5 days after procedure, ifneeded.Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes the cell membrane rigid andprotective. Without it, bacterial cells ruptureand die.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityprobenecid: Increased and prolonged bloodcephapirin levelAdverse ReactionsCNS: Chills, fever, headache, seizuresCV: EdemaEENT: Hearing lossGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, nausea, oral candidiasis,pseudomembranous colitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-JohnsonsyndromeOther: Anaphylaxis; injection site pain, redness,and swelling; superinfectionNursing Considerations• Use cephapirin cautiously in patientshypersensitive to penicillins because crosssensitivityhas occurred in about 10% ofsuch patients.• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.• For I.V. injection, reconstitute 1 g with10 ml or more of appropriate diluent, such

as sterile water for injection. AdministerI.V. injection slowly over 3 to 5 minutesthrough tubing of a flowing compatibleI.V. fluid.• For I.V. infusion, dilute further in 50 ml ofD 5 W or normal saline solution and infuseover 15 to 30 minutes. Stop primary I.V.solution during cephapirin delivery.• For I.M. injection, reconstitute 1-g vialwith 2 ml sterile water for injection orbacteriostatic water for injection. Injectdeep into large muscle mass, such as thegluteus maximus.• Store reconstituted drug up to 24 hours atroom temperature or 10 days refrigerated.• Don’t give cloudy solution.• Assess I.V. site for extravasation andphlebitis.• Monitor BUN and serum creatinine levelsto detect early signs of nephrotoxicity.Also, monitor fluid intake and output;decreasing urine output may indicatenephrotoxicity.• Monitor patient for allergic reactions a fewdays after therapy starts.• Assess CBC, hematocrit, and serum AST,ALT, bilirubin, LD, and alkaline phosphataselevels during long-term therapy.• Assess patient’s bowel pattern daily; severediarrhea may indicate pseudomembranouscolitis.• Assess patient for pharyngitis, ecchymosis,bleeding, and arthralgia; they may indicatea blood dyscrasia.• Assess patient for furry tongue, perinealitching, and loose, foul-smelling stool;they may indicate superinfection.PATIENT TEACHING• Instruct patient to immediately reportsevere diarrhea or evidence of blooddyscrasia or superinfection to prescriber.cephradineVelosefClass and CategoryChemical class: First-generation cephalosporin,7-aminocephalosporanic acidTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat respiratory tract infectionscephradine 217(other than lobar pneumonia) and skinand soft-tissue infectionsCAPSULES, ORAL SUSPENSIONAdults. 250 mg every 6 hr or 500 mg every12 hr. Maximum: 4 g daily.ORAL SUSPENSIONChildren age 9 months and over. 25 to50 mg/kg daily in equally divided dosesevery 6 or 12 hr. Maximum: 4 g daily. To treat lobar pneumoniaCAPSULES, ORAL SUSPENSIONAdults. 0.5 g every 6 hr or 1 g every 12 hr.Maximum: 4 g daily.ORAL SUSPENSIONChildren age 9 months and over. 25 to50 mg/kg daily in equally divided dosesevery 6 or 12 hr. Maximum: 4 g daily. To treat uncomplicated UTICAPSULES, ORAL SUSPENSIONAdults. 500 mg every 12 hr. For more seriousinfections, 500 mg every 6 hr or1,000 mg every 12 hr. Maximum: 4 g daily. To treat otitis media caused by HaemophilusinfluenzaeORAL SUSPENSIONChildren. 75 to 100 mg/kg daily in equallydivided doses every 6 to 12 hr. Maximum:4 g daily.DOSAGE ADJUSTMENT Dosage reduced to500 mg every 6 hr if creatinine clearanceexceeds 20 ml/min/1.73 m 2 ; 250 mg every6 hr if clearance is 5 to 20 ml/min/1.73 m 2 ;and 250 mg every 12 hr if clearance is lessthan 5 ml/min/1.73 m 2 .Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting the final step in the crosslinkingof peptidoglycan strands. Peptidoglycanmakes the cell membrane rigid andprotective. Without it, bacterial cells ruptureand die.ContraindicationsHypersensitivity to cephalosporins or theircomponentsInteractionsDRUGSaminoglycosides, loop diuretics: Increasedrisk of nephrotoxicityprobenecid: Increased and prolonged bloodcephradine levelAdverse ReactionsCNS: Chills, fever, headache, seizuresC

218certolizumab pegolCV: EdemaEENT: Hearing loss, oral candidiasisGI: Abdominal cramps, diarrhea, elevatedliver function test results, hepatic failure,hepatomegaly, nausea, pseudomembranouscolitis, vomitingGU: Elevated BUN level, nephrotoxicity,renal failure, vaginal candidiasisHEME: Eosinophilia, hemolytic anemia,hypoprothrombinemia, neutropenia,thrombocytopenia, unusual bleedingMS: ArthralgiaRESP: DyspneaSKIN: Ecchymosis, erythema, erythemamultiforme, pruritus, rash, Stevens-JohnsonsyndromeOther: Anaphylaxis, superinfectionNursing Considerations• If possible, obtain culture and sensitivitytest results, as ordered, before giving drug.• Monitor patients hypersensitive to penicillinfor evidence of hypersensitivity reactionbecause cross-sensitivity has occurredin about 10% of such patients.• Store oral suspension for 7 days at roomtemperature or for 14 days if refrigerated.• Monitor BUN and serum creatinine levelsto detect early signs of nephrotoxicity.Also monitor fluid intake and output;decreasing urine output may indicatenephrotoxicity.• Monitor patient for allergic reactions a fewdays after therapy starts. If hypersensitivitydevelops, be prepared to stop drug andadminister antihistamines, corticosteroids,and vasopressors, as ordered. Also prepareto administer oxygen, maintain an openairway, and assist with endotracheal intubation,as appropriate.• Assess CBC, hematocrit, and serum AST,ALT, bilirubin, LD, and alkaline phosphataselevels during long-term therapy.• Assess patient’s bowel pattern daily; severediarrhea may indicate pseudomembranouscolitis. Obtain a stool specimen to test forClostridium difficile. Keep in mind thatthis serious adverse reaction can occurduring therapy or up to several weeks aftertherapy ends. Also avoid giving antiperistalticantidiarrheals, such as atropine anddiphenoxylate or loperamide, because theymay delay elimination of toxins from thebowel and damage the colon from toxinretention. Mild cases may respond aftercephradine is discontinued. For moderateor severe cases, be prepared to administerfluids, electrolytes, and protein replacementas ordered.• If patient has a history of GI disease, especiallyulcerative colitis, regional enteritis,or antibiotic-associated colitis, assess himoften for diarrhea because he is at risk forpseudomembranous colitis.• Assess patient for pharyngitis, ecchymosis,bleeding, and arthralgia; these may indicatea blood dyscrasia.• If patient has a seizure, notify prescriberimmediately and expect to discontinuedrug. Institute seizure precautions accordingto facility policy.PATIENT TEACHING• If patient develops GI distress, advise himto take cephradine with food.• Advise patient to complete prescribedcourse of therapy.• Urge patient to avoid missing doses and totake the drug at evenly spaced intervals. Ifpatient misses a dose, instruct him to takeit as soon as possible unless it’s almosttime for the next dose. Emphasize that heshouldn’t double the dose.• Tell patient that yogurt and buttermilkhelp maintain intestinal flora and candecrease diarrhea during therapy.• Instruct patient to immediately report toprescriber severe diarrhea or evidence ofblood dyscrasia or superinfection. Warnpatient not to take any OTC antidiarrhealsbefore consulting prescriber.• Tell patient to notify prescriber if symptomsdon’t improve within a few days.certolizumab pegolCimziaClass and CategoryChemical class: Recombinant, humanizedantibody Fab fragmentTherapeutic class: Disease modifying antiinflammatoryPregnancy category: BIndications and Dosages To reduce signs and symptoms ofCrohn’s disease and maintain clinicalresponse in patients with moderately toseverely active disease who have had an

inadequate response to conventionaltherapySUBCUTANEOUS INJECTIONAdults. Initial: 400 mg (given as two 200-mg injections) and repeated at wk 2 and 4.Maintenance: 400 mg (given as two 200-mginjections) every 4 wk if clinical responseoccurs. To treat moderate to severe activerheumatoid arthritisSUBCUTANEOUS INJECTIONAdults. Initial: 400 mg (given as two 200-mg injections) and repeated at wk 2 and 4.Maintenance: 200 mg every other wk or400 mg (given as two 200-mg injections)every 4 wk if clinical response occurs.Route Onset Peak DurationSubQ Unknown 54–171 hr UnknownMechanism of ActionBinds to human tumor necrosis factor(TNF) alpha, inhibiting it. TNF alpha stimulatesproduction of inflammatory mediators,including interleukin-1, prostaglandins,platelet activating factor, andnitric oxide. TNF alpha level is increased inpatients with Crohn’s disease. Inhibition ofTNF alpha causes C-reactive protein levelto decline in patients with Crohn’s disease,and the disease improves.ContraindicationsActive infection, hypersensitivity tocetolizu-mab or its components, I.V.administrationInteractionsDRUGSanakinra: Possibly increased risk of seriousinfection and neutropeniaimmunosuppressants: Possibly increased riskof infectionlive-virus vaccines: Increased risk of adversevaccine effectsAdverse ReactionsCNS: Anxiety, bipolar disorder, dizziness,fever, malaise, suicidal ideation, syncopeCV: Angina, arrhythmias, heart failure,hypertension, hypotension, MI, pericardialeffusion, pericarditis, peripheral edema,vasculitisEENT: Optic neuritis, retinal hemorrhage,uveitiscertolizumab pegol 219ENDO: Hot flashesGI: Abdominal pain, diarrhea, elevated liverenzymes, hepatitis, intestinal obstructionGU: Menstrual dysfunction, nephrotic syndrome,pyelonephritis, renal failure, UTIHEME: Anemia, leukopenia, lyphadenopathy,pancytopenia, thrombophiliaMS: Arthralgia, extremity painRESP: Dyspnea, pneumonia, upper respiratoryinfectionSKIN: Allergic dermatitis, alopecia, erythemamultiforme, erythema nodosum, new orworsening psoriasis, rash, Stevens-Johnsonsydrome, toxic epidermal necrolysisOther: Angioedema; bacterial and viralinfections; injection site reactions (redness,pain); leukemia, lymphomas, and othermalignancies; lupus-like syndrome; serumsickness; tuberculosisNursing Considerations• Use certolizumab cautiously in patientswith recurrent or increased risk of infection,patients who live in regions wheretuberculosis and histoplasmosis areendemic, and patients with a history ofCNS demyelinating disorders because anyof these disorders can occur, rarely, duringcertolizumab therapy.• Use cautiously in patients who are chroniccarriers of hepatitis B virus because drugmay reactivate the virus. Assess patient forevidence of hepatitis B viral infectionbefore starting and periodically throughoutcertolizumab therapy. If HBV reactivationoccurs, notify prescriber, stop drug,and start appropriate therapy, as ordered.WARNING If patient has evidence of anactive infection when drug is prescribed,therapy shouldn’t begin until infection hasbeen treated. Monitor all patients forinfection during therapy, especially thosereceiving immunosuppressants. If seriousinfection develops, expect prescriber tostop drug.• Make sure patient has a tuberculin skintest before therapy starts. If skin test ispositive, treatment of latent tuberculosismust start before certolizumab is given, asprescribed.• Reconstitute two 200-mg certolizumabvials for each dose after drug has reachedroom temperature. Inject 1 ml sterilewater for injection using a 20G needle intoeach vial. Gently swirl each vial withoutC

220cevimeline hydrochlorideshaking. Then leave vials undisturbed forup to 30 minutes to allow time for powderto completely dissolve. Do not leave atroom temperature, once reconstituted, formore than 2 hours before administration.If administration will be delayed, reconstituteddrug can be refrigerated up to24 hours. Do not let drug freeze.• Administer drug only when solution hasreached room temperature. Using a 20Gneedle, withdraw drug from vial using aseparate syringe and needle for each vial.Switch to a 23G needle and administersubcutaneously into two separate areas onpatient’s abdomen or thigh.WARNING Stop drug immediately and notifyprescriber if patient has an allergic reaction.Expect to provide supportive care.• Monitor patient closely for evidence ofcongestive heart failure (sudden, unexplainedweight gain; dyspnea; crackles;anxiety), and notify prescriber if theyoccur.• Monitor patient’s CBC, as ordered,because certolizumab may have adversehematologic effects. Notify prescriberabout persistent fever, bruising, bleeding,or pallor.• Certolizumab is a TNF inhibitor. Althoughrare, malignancies (especially lymphomasand leukemias) have been reported inpatients receiving these drugs, includingchildren. Patients with rheumatoid arthritis,especially those with very active disease,are at greatest risk. Monitor themclosely.PATIENT TEACHING• Review signs and symptoms of allergicreaction (rash, swollen face, troublebreathing), and tell patient to seek emergencycare immediately if these occur.• Inform patient that injection site reactionssuch as redness or pain may occur andusually are mild and transient. Instructhim to apply a towel soaked in cold waterto the site if it hurts. Tell patient to callprescriber if reaction persists or worsens.• Inform patient that tuberculosis mayoccur during theray. Instruct him toreport persistent cough, wasting or weightloss, and low-grade fever to prescriber.• Tell patient to report evidence of infectionsand bleeding disorders to prescriber;drug may need to be stopped. Advisepatient to avoid people with infectionsand to comply with all prescribed tests.• Inform patient that certain kinds of cancer,especially lymphomas and leukemias,are more likely in patients taking certolizumabbut still rare. Stress need tokeep follow-up visits and report unusualor sudden signs or symptoms.• Caution against receiving live-virus vaccineswhile taking certolizumab; doing somay adversely effect the immune system.• Instruct patient to report lupus-like signsand symptoms that, although rare, mayoccur during therapy, such as chest painthat doesn’t go away, shortness of breath,joint pain, or rash on cheeks or arms that’ssensitive to the sun. Explain that drug mayneed to be discontinued if these occur.• Advise patient to inform all health careproviders about certolizumab use and toinform prescriber about any OTC medications,herbal remedies, and vitamin andmineral supplements being taken.cevimelinehydrochlorideEvoxacClass and CategoryChemical class: Quinuclidine derivative ofacetylcholineTherapeutic class: Cholinergic enhancer, drymouth relieverPregnancy category: CIndications and Dosages To treat dry mouth associated withSjögren’s syndromeCAPSULESAdults. 30 mg t.i.d. Maximum: 90 mg daily.Mechanism of ActionAs a cholinergic agonist, binds to and activatesmuscarinic receptors of the parasympatheticnervous system and increasessecretions of the exocrine glands, such assalivary glands.ContraindicationsAcute iritis, angle-closure glaucoma, hypersensitivityto cevimeline or its components,uncontrolled asthma

InteractionsDRUGSamiodarone, cimetidine, clarithromycin,diltiazem, erythromycin, fluconazole,haloperidol, itraconazole, ketoconazole,metoclopramide, mibefradil, nefazodone,propafenone, quinidine, ritonavir, selectiveserotonin reuptake inhibitors, thioridazine,tricyclic antidepressants, troleandomycin, verapamil:Possibly inhibited metabolism andincreased blood level of cevimelineanticholinergics: Decreased effectiveness ofanticholinergicsantimuscarinics: Altered effects of antimuscarinicsand decreased therapeutic action ofcevimelinebeta blockers: Possibly cardiac conductiondisturbancesparasympathomimetics: Additive effects ofeither drugAdverse ReactionsCNS: Depression, fatigue, fever, hypoesthesia,insomnia, migraine headache, tremorCV: Edema, palpitationsEENT: Abnormal vision, conjunctivitis, drymouth, earache, epistaxis, excessive salivation,eye pain, rhinitis, salivary gland painGI: Abdominal pain, anorexia, cholecystitis,constipation, eructation, heartburn, hiccups,nausea, vomitingHEME: AnemiaMS: Arthralgia, leg cramps, myalgiaRESP: Cough, dyspneaSKIN: Diaphoresis, pruritusOther: Flulike symptoms, hot flashesNursing Considerations• Give cevimeline on an empty stomachbecause food may decrease rate and extentof absorption, delaying peak concentration.• Assess patient with a pulmonary disorderfor wheezing and increased respiratorysecretions because drug may causeincreased bronchiolar smooth-musclecontractions, airway resistance, and respiratorysecretions.• Monitor patient with known or suspectedgallbladder disease for abdominal painand other warnings of biliary obstruction,cholecystitis, or cholangitis; each of theseconditions may be precipitated by cevimeline.PATIENT TEACHING• Instruct patient to take cevimeline on anchloral hydrate 221empty stomach.• Inform patient that cevimeline may causevision changes; advise him to avoid drivingat night or performing hazardousactivities until drug’s adverse effects areknown.• Urge patient to drink plenty of fluids duringhot weather and while exercisingbecause drug may cause excessive sweatingand dehydration.chloral hydrateAquachloral Supprettes, Novo-Chlorhydrate (CAN), PMS-ChloralHydrate (CAN)Class, Category, and ScheduleChemical class: Chloral derivativeTherapeutic class: Sedative-hypnoticPregnancy category: CControlled substance schedule: IVIndications and Dosages To prevent or suppress alcohol withdrawalsymptoms, act as an adjunct toopioids and analgesics to control postoperativepainCAPSULES, SYRUP, SUPPOSITORIESAdults. 250 mg t.i.d. after meals. Maximum:2,000 mg. To produce nocturnal sedationCAPSULES, SYRUP, SUPPOSITORIESAdults. 0.5 to 1 g 30 min before bedtime.Maximum: 2 g. To produce preoperative sedationCAPSULES, SYRUP, SUPPOSITORIESAdults. 0.5 to 1 g 30 min before surgery. To provide sedation before dental ormedical procedureSYRUP, SUPPOSITORIESChildren. 25 mg/kg up to 500 mg/singledose; up to 75 mg/kg for dental proceduresupplemented by nitrous oxide.Route Onset Peak DurationP.O. 30–60 min Unknown 4–8 hrP.R. Unknown Unknown 4–8 hrMechanism of ActionProduces CNS depression by an unknownmechanism involving trichloroethanol, thedrug’s active metabolite.C

222chloramphenicolContraindicationsGastritis; hypersensitivity or idiosyncrasy tochloral hydrate or its components; severecardiac, hepatic, or renal diseaseInteractionsDRUGSCNS depressants: Increased CNS effects ofchloral hydratefurosemide (I.V.): Increased adverse effectswhen given after chloral hydratephenytoin: Increased excretion anddecreased effectiveness of phenytoinwarfarin: Transient increase in anticoagulanteffectACTIVITIESalcohol use: Increased CNS effects of chloralhydrateAdverse ReactionsCNS: Ataxia, disorientation, hangover, incoherence,paranoia, somnolenceGI: Gastric irritation, nausea, vomitingSKIN: Rash, urticariaOther: Drug dependenceNursing Considerations• Administer with full glass of water or juiceto minimize GI distress from chloralhydrate capsules. Dilute syrup in a halfglassof water, ginger ale, or fruit juice.WARNING Monitor carefully for hypersensitivityreaction in patients with a history oftartrazine sensitivity.• Suspect physical or psychological dependenceif withdrawal of chloral hydrateproduces confusion, hallucinations, nausea,nervousness, restlessness, stomachpain, tremor, unusual excitement, or vomiting.PATIENT TEACHING• Instruct patient to take capsules with a fullglass of water or juice or to mix syrup in ahalf-glass of water, ginger ale, or fruitjuice.• Advise patient to avoid hazardous activitiesuntil CNS effects of chloral hydrateare known.• Caution patient that drug may be habitforming.Advise taking it exactly as prescribedand not to stop taking it abruptlybecause withdrawal symptoms couldoccur.• Instruct patient to notify prescriber rightaway about stomach pains or tarry stools.chloramphenicolChloromycetin, Novochlorocap (CAN)chloramphenicolpalmitateChloromycetinchloramphenicolsodium succinateChloromycetinClass and CategoryChemical class: Dichloroacetic acidderivativeTherapeutic class: AntibioticPregnancy category: Not ratedIndications and Dosages To treat serious infections for which lesspotentially dangerous drugs are ineffectiveor contraindicatedI.V. INFUSIONAdults. 12.5 mg/kg every 6 hr. Maximum:4 g daily.Children. 50 to 75 mg/kg daily in divideddoses every 6 hr.Full-term infants age 2 weeks and over.12.5 mg/kg every 6 hr or 25 mg/kg every12 hr.Preterm and full-term infants up to age2 weeks. 6.25 mg/kg every 6 hr. To treat bacteremia or meningitisI.V. INFUSIONChildren. 50 to 100 mg/kg daily in divideddoses every 6 hr.DOSAGE ADJUSTMENT Dosage limited to25 mg/kg daily for infants and childrenwith immature metabolic processes.Mechanism of ActionProduces a bacteriostatic effect on susceptibleorganisms by inhibiting protein synthesis,thus preventing amino acids from beingtransferred to growing polypetide chains.ContraindicationsHypersensitivity to chloramphenicol or itscomponentsInteractionsDRUGSalfentanil: Prolonged alfentanil effect

arbiturates: Increased blood barbituratelevel; decreased chloramphenicol levelblood-dyscrasia–causing drugs (such ascaptopril and cephalosporins), bone marrowdepressants (including colchicine and methotrexate):Increased bone marrow depressionchlorpropamide, tolbutamide: Increasedhypoglycemic effectsclindamycin, erythromycin, lincomycin:Decreased antibacterial effects of thesedrugscyclophosphamide: Decreased or delayedactivation of cyclophosphamide, increasedbone marrow depressionhepatic enzyme inducers (including rifampin):Decreased chloramphenicol levelhydantoins: Increased blood hydantoinlevel, possibly resulting in toxicity;increased or decreased blood chloramphenicolleveliron salts: Increased serum iron leveloral anticoagulants: Enhanced anticoagulantactionoral contraceptives containing estrogen:Decreased contraceptive effect with prolongedchloramphenicol usepenicillins: Decreased penicillin activity;synergistic effects with treatment of certainmicroorganismsvitamin B 12 : Antagonized hematopoieticresponse to vitamin B 12Adverse ReactionsCNS: Confusion, delirium, depression,fever, headache, peripheral neuropathyCV: Gray syndrome in neonatesEENT: Optic neuritisGI: Diarrhea, nausea, vomitingHEME: Aplastic anemia, bone marrowdepression, granulocytopenia, hypoplasticanemia, leukopenia, reticulocytopenia,thrombocytopeniaSKIN: RashOther: Anaphylaxis, angioedemaNursing Considerations• As appropriate and ordered, obtain specimenfor culture and sensitivity testingbefore starting chloramphenicol therapy.• Keep in mind that chloramphenicolshould never be used to treat minor infectionsor as prophylaxis because of its manyserious toxicities.• Repeated courses of therapy should beavoided because of the risk of seriouschlordiazepoxide hydrochloride 223adverse reactions.• For I.V. use, prepare a 10% solution byadding 10 ml sterile water for injection orD 5 W to each 1-g vial. Administer over atleast 1 minute.• Know that diluted I.V. solution is stablefor 24 to 48 hours when stored at roomtemperature or refrigerated. Don’t use ifcloudy.• Assess patient for fever, sore throat, tiredness,unusual bleeding, or ecchymosis;these may indicate a blood dyscrasia.• Perform neurologic assessments regularly,looking for signs of peripheral neuropathy.WARNING If early signs of gray syndromeappear (failure to eat, pallor, cyanosis,abdominal distention, irregular respirations,and vasomotor collapse), notify prescriberand be prepared to stop drugimmediately.• Monitor blood chloramphenicol level asappropriate. Keep in mind that therapeuticpeak levels are 10 to 20 mcg/ml andtrough levels are 5 to 10 mcg/ml.• Monitor CBC and platelet and reticulocytecounts as ordered to detect signs of blooddyscrasia. Notify prescriber immediatelyabout abnormal results.PATIENT TEACHING• Instruct patient to immediately report toprescriber signs of blood dyscrasia.WARNING Tell patient to stay alert for signsof potentially fatal, irreversible bone marrowdepression that leads to aplastic anemiaand is characterized by fever, pallor,pharyngitis, severe fatigue and weakness,and unusual bleeding or bruising. Bonemarrow depression may occur weeks tomonths after therapy stops. Stress the needfor follow-up care.chlordiazepoxidehydrochlorideApo-Chlordiazepoxide (CAN), Librium,Novo-Poxide (CAN)Class, Category, and ScheduleChemical class: BenzodiazepineTherapeutic class: AntianxietyPregnancy category: Not ratedControlled substance schedule: IVC

224chlordiazepoxide hydrochlorideIndications and Dosages To provide short-term management ofmild anxietyCAPSULES, TABLETSAdults. 5 to 10 mg t.i.d. or q.i.d.Children over age 6. 5 mg b.i.d. to q.i.d.increased as needed to 10 mg b.i.d. or t.i.d.,or 0.5 mg/kg daily in equally divided dosesevery 6 to 8 hr. To provide short-term management ofsevere anxietyCAPSULES, TABLETSAdults. 20 to 25 mg t.i.d. or q.i.d.I.V. OR I.M. INJECTIONAdults. Initial: 50 to 100 mg. Then, 25 to50 mg t.i.d. or q.i.d., p.r.n. Maximum:300 mg daily.I.M. INJECTIONChildren age 12 and over. 0.5 mg/kgdaily in equally divided doses every 6 to8hr. To provide short-term treatment ofacute alcohol withdrawalCAPSULES, TABLETS, I.V. OR I.M. INJECTIONAdults. Initial: 50 to 100 mg, usually givenI.V. or I.M. Repeated in 2 to 4 hr followedby individualized oral dosage if needed tocontrol symptoms. Maximum: 300 mgdaily. To provide perioperative relaxationand reduce apprehension and anxietyCAPSULES, TABLETS, I.M. INJECTIONAdults. 5 to 10 mg P.O. t.i.d. or q.i.d. severaldays before surgery; 50 to 100 mg I.M.1 hr before surgery.DOSAGE ADJUSTMENT Dosage reduced to5 mg P.O. b.i.d. to q.i.d., p.r.n., for elderly ordebilitated patients.Mechanism of ActionMay potentiate the effects of gammaaminobutyricacid (GABA) and otherinhibitory neurotransmitters by binding tospecific benzodiazepine receptors in limbicand cortical areas of the CNS. By binding tothese receptors, chlordiazepoxide increasesGABA’s inhibitory effects and blocks corticaland limbic arousal, which helps controlemotional behavior. It also helps relievesymptoms of alcohol withdrawal by causingCNS depression.ContraindicationsHypersensitivity to chlordiazepoxide or itscomponentsInteractionsDRUGSantacids: Altered rate of chlordiazepoxideabsorptioncimetidine, disulfiram, fluoxetine, isoniazid,ketoconazole, metoprolol, oral contraceptives,propoxyphene, propranolol, valproic acid:Increased blood chlordiazepoxide levelCNS depressants: Increased CNS effectsdigoxin: Increased blood digoxin level andrisk of digitalis toxicitylevodopa: Decreased efficacy of levodopa’santiparkinsonian effectsneuromuscular blockers: Potentiated, counteracted,or diminished effects of neuromuscularblockersphenytoin: Possibly increased phenytointoxicityprobenecid: Shortened onset of action orprolonged effect of chlordiazepoxiderifampin: Decreased chlordiazepoxide effecttheophyllines: Antagonized sedative effectsof chlordiazepoxideACTIVITIESalcohol use: Increased CNS effectsAdverse ReactionsCNS: Ataxia, confusion, depression, drowsiness,suicidal ideationCV: ECG changes, hypotension, tachycardiaGI: Hepatic dysfunctionHEME: AgranulocytosisSKIN: JaundiceOther: Injection site pain, redness, andswellingNursing Considerations• Use chlordiazepoxide cautiously inpatients with renal or hepatic impairmentor porphyria.WARNING Be aware that prolonged use ofchlordiazepoxide at therapeutic doses canlead to dependence.• For I.V. use, reconstitute ampule contentswith 5 ml sterile water for injection orsodium chloride for injection. Agitate gentlyuntil completely dissolved. Give slowlyover 1 minute.• For I.M. use, reconstitute only with diluentprovided by manufacturer.WARNING Don’t use supplied diluent toprepare drug for I.V. use because air bubblesform on the surface.• Don’t give opalescent or hazy solution.• Monitor patient for evidence of phlebitis

or thrombophlebitis after I.V. chlordiazepoxideadministration.• Monitor liver function test results duringtherapy.• If patient is a hyperactive, aggressive childor has a history of psychiatric disorders,watch for paradoxical reactions, such asexcitement, stimulation, and acute rage,during first 2 weeks of therapy.• Watch patients closely (especially children,adolescents, and young adults) for suicidaltendencies, particularly when chlordiazepoxidetherapy starts and dosage changes.PATIENT TEACHING• Warn that drug may cause drowsiness.• Advise patient to avoid other CNS depressantsduring therapy.• Warn patient not to take antacids withchlordiazepoxide.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes andparticularly if patient is a child, teenager,or young adult.chlorothiazideDiurilchlorothiazidesodiumDiurilClass and CategoryChemical class: Sulfonamide derivativeTherapeutic class: Antihypertensive, diureticPregnancy category: BIndications and Dosages To treat hypertensionORAL SUSPENSION, TABLETSAdults. 250 to 1,000 mg daily in a singledose or divided doses b.i.d. Maximum:2,000 mg daily in divided doses.Children age 6 months and over. 10 to20 mg/kg daily in a single dose or divideddoses b.i.d. Maximum: 1,000 mg dailyfor ages 2 to 12; 375 mg daily for ages6 months to 2 years.Children under age 6 months. Up to30 mg/kg daily in divided doses given b.i.d. To produce diuresisORAL SUSPENSION, TABLETSchlorothiazide 225Adults. 250 mg every 6 to 12 hr.Administered on an intermittent schedule,if needed, such as alternate days or 3 to5 days/wk.Children age 6 months and over. 10 to20 mg/kg daily in a single dose or divideddoses b.i.d. Maximum: 1,000 mg daily forchildren ages 2 to 12; 375 mg daily for childrenages 6 months to 2 years.Children under age 6 months. Up to33 mg/kg daily in divided doses b.i.d.I.V. INFUSION OR INJECTIONAdults. 250 mg every 6 to 12 hr.Route Onset Peak DurationP.O. 2 hr 4 hr 6–12 hrI.V. 15 min 4 hr 6–12 hrMechanism of ActionMay promote sodium, chloride, and waterexcretion by inhibiting sodium reabsorptionin the kidneys’ distal tubules. Initially,chlorothiazide may reduce blood pressureby decreasing extracellular fluid volume,plasma volume, and cardiac output. It alsomay dilate arteries directly, reducingperipheral vascular resistance. After severalweeks, extracellular fluid and plasma volumeand cardiac output return to normal,but peripheral vascular resistance remainsdecreased.ContraindicationsAnuria; hepatic coma; hypersensitivity tochlorothiazide or its components, sulfonamides,or related thiazide diuretics; renalfailureInteractionsDRUGSallopurinol: Increased risk of allopurinolhypersensitivityamiodarone: Increased risk of arrhythmiasfrom hypokalemiaamphotericin B, glucocorticoids: Intensifiedelectrolyte depletionanesthetics: Potentiated effects of anestheticsanticholinergics: Increased chlorothiazideabsorptionanticoagulants, methenamines, sulfonylureas:Decreased effects of these drugsantihypertensives: Increased antihypertensiveeffectantineoplastics: Prolonged antineoplasticinducedleukopeniaC

226chlorphenesin carbamatecalcium: Possibly increased blood calciumlevelcholestyramine, colestipol: Decreased chlorothiazideabsorptiondiazoxide: Hyperglycemia, hypotensiondigitalis glycosides: Increased risk of digitalisinducedarrhythmiasdopamine: Increased diuretic effectlithium: Increased risk of lithium toxicityloop diuretics: Synergistic effects, resultingin profound diuresis and serious electrolyteimbalancesmethyldopa: Potential development ofhemolytic anemianeuromuscular blockers: Increased neuromuscularblockadeNSAIDs: Possibly reduced diuretic effect ofchlorothiazide; increased risk of renal failureif patient has compromised renal functionsympathomimetics: Possibly inhibited antihypertensiveeffect of chlorothiazidevitamin D: Enhanced vitamin D actionAdverse ReactionsCNS: Dizziness, headache, paresthesia, restlessness,vertigo, weaknessCV: Orthostatic hypotensionENDO: HyperglycemiaGI: Abdominal cramps, anorexia, constipation,diarrhea, gastric irritation, nausea,pancreatitis, vomitingGU: Glycosuria, hematuria (I.V. form),impotence, interstitial nephritis, renal dysfunctionor failureHEME: Agranulocytosis, aplastic anemia,hemolytic anemia, leukopenia, thrombocytopeniaMS: Muscle spasmsSKIN: Jaundice, photosensitivity, purpura,rash, urticariaOther: Anaphylactic reactions, hypercalcemia,hyperuricemia, hypochloremic alkalosis,hypokalemia, hypomagnesemia, hyponatremia,hypovolemiaNursing Considerations• Don’t give parenteral form of chlorothiazideby I.M. or subcutaneous route.• For I.V. use, reconstitute with at least18 ml of sterile water for injection.Discard unused solution after 24 hours.Reconstituted solution is compatible withdextrose solution or normal saline solutionfor infusion.• Watch I.V. site closely. If extravasationoccurs, stop infusion and tell prescriber atonce.• Weigh patient daily to assess fluid loss anddrug effectiveness. If used to treat hypertension,check blood pressure often; antihypertensiveeffect may not appear fordays.• Assess patient for electrolyte imbalances.• Monitor renal function closely, especiallyin elderly patients, because risk of toxicityincreases with renal impairment.PATIENT TEACHING• Tell patient to take chlorothiazide early inthe day to avoid nocturia and to take itwith food or milk if GI distress occurs.• Urge patient to eat a high-potassium diet.• Instruct patient to rise slowly to minimizeeffects of orthostatic hypotension.• Urge patient to weigh himself at leastweekly and to notify prescriber if weightrises or falls by 5 lb (2.25 kg) or more in2 days.• Tell patient to immediately notify prescriberif he develops weakness, cramps,nausea, vomiting, restlessness, excessivethirst, drowsiness, tiredness, increasedheart rate, diarrhea, sudden joint pain, ordizziness.• If patient has diabetes mellitus, tell him tocheck blood glucose level often. Oralantidiabetic dosage may need to beincreased.• Tell patient to avoid prolonged exposureto sun, use sunscreen, and wear protectiveclothing.• Advise patient to consult prescriber orpharmacist before using alcohol and suchOTC drugs as those used for appetite control,colds, cough, hay fever, and sinusproblems.chlorphenesincarbamateMaolateClass and CategoryChemical class: Chemically related tomephenesinTherapeutic class: Skeletal muscle relaxantPregnancy category: Not rated

Indications and Dosages As adjunct to relieve pain in acute musculoskeletalconditionsTABLETSAdults. 800 mg t.i.d. until desired effectoccurs. Maintenance: 400 mg q.i.d or less,p.r.n.Mechanism of ActionMay act on the CNS, rather than directly onskeletal muscle, producing a sedative effectthat aids in muscle relaxation.ContraindicationsHypersensitivity to chlorphenesin or itscomponentsInteractionsDRUGSCNS depressants: Increased adverse CNSeffectsACTIVITIESalcohol use: Increased adverse CNS effectsAdverse ReactionsCNS: Confusion, dizziness, drowsiness,headache, insomnia, nervousness, paradoxicalstimulationEENT: Diplopia, transient vision lossGI: Epigastric discomfort, nauseaOther: Anaphylaxis, drug-induced feverNursing ConsiderationsWARNING Use chlorphenesin cautiously inpatients hypersensitive to aspirin; it containstartrazine, which may cause hypersensitivity.• Expect drug therapy to last for no morethan 8 weeks because safety beyond thispoint is unknown.• Provide rest and other pain-relief measures.PATIENT TEACHING• Because of possible reduced alertness,advise patient to avoid potentially hazardousactivities until drug’s CNS effectsare known.• Instruct patient to notify prescriber ifthese symptoms occur: confusion, dizziness,drowsiness, insomnia, nervousness,or paradoxical stimulation.• Tell patient to immediately notify prescriberif he develops a fever or any signsor symptoms of an allergic reaction, suchas rash, hives, itching, facial swelling, ordifficulty breathing.chlorpromazine 227chlorpromazineLargactil (CAN), ThorazinechlorpromazinehydrochlorideChlorpromanyl (CAN), Novo-Chlorpromazine (CAN), Thorazine,Thorazine SpansuleClass and CategoryChemical class: Propylamine derivative ofphenothiazineTherapeutic class: Antiemetic, antipsychotic,tranquilizerPregnancy category: Not ratedIndications and Dosages To manage symptoms of psychotic disordersor control manic manifestations ofmanic-depression in outpatientsE.R. CAPSULESAdults. 30 to 300 mg 1 to 3 times daily,with dosage adjusted as needed. Maximum:1 g daily.ORAL CONCENTRATE, SYRUP, TABLETSAdults. 10 mg t.i.d. or q.i.d., or 25 mg b.i.d.or t.i.d. After 1 or 2 days, dose increased by20 to 50 mg semiweekly until patient iscalm. After 2 wk of calmness, dosage graduallyreduced to maintenance level of 200 to800 mg daily in equally divided doses. To control acutely disturbed or manichospitalized patientsI.M. INJECTIONAdults. 25 mg. Repeated 25 to 50 mg in1 hr, if needed. Increased gradually overseveral days up to 400 mg every 4 to 6 hrfor severe cases until behavior is controlled.Then, regimen switched to oral form andoutpatient dosage. To treat severe behavioral problems inchildrenORAL CONCENTRATE, SYRUP, TABLETSChildren ages 6 months to 12 years.0.55 mg/kg every 4 to 6 hr, p.r.n.SUPPOSITORIESChildren ages 6 months to 12 years. 1 mg/kg every 6 to 8 hr, p.r.n.I.M. INJECTIONChildren ages 6 months to 12 years.0.55 mg/kg every 6 to 8 hr. Maximum:75 mg daily for children ages 5 to 12 yearsC

228chlorpromazineor weighing 50 to 100 lb (23 to 45 kg),except in unmanageable cases; 40 mg dailyfor children up to age 5 or weighing up to50 lb. To treat nausea and vomitingORAL CONCENTRATE, SYRUP, TABLETSAdults and adolescents. 10 to 25 mg every4 to 6 hr, p.r.n.Children ages 6 months to 12 years.0.55 mg/kg every 4 to 6 hr, p.r.n.I.M. INJECTIONAdults. 25 mg. If no hypotension occurs,25 to 50 mg every 3 to 4 hr, p.r.n., untilvomiting stops; then drug switched to oralform.Children age 6 months and over. 0.55 mg/kg every 6 to 8 hr, p.r.n. Maximum: 75 mgdaily for children ages 5 to 12 or weighing50 to 100 lb; 40 mg daily for children up toage 5 or weighing up to 50 lb.SUPPOSITORIESAdults and adolescents. 50 to 100 mg every6 to 8 hr, p.r.n.Children ages 6 months to 12 years. 1 mg/kg every 6 to 8 hr, p.r.n. To provide intraoperative control ofnausea and vomitingI.V. INJECTIONAdults. 25 mg diluted to 1 mg/ml withsodium chloride for injection and given atno more than 2 mg every 2 min. Maximum:25 mg.Children age 6 months and over. 0.275 mg/kg diluted to at least 1 mg/ml with sodiumchloride for injection and given at no morethan 1 mg every 2 min. Maximum: 75 mg/day for children ages 5 to 12 or weighing50 to 100 lb; 40 mg daily for children up toage 5 years or weighing up to 50 lb.I.M. INJECTIONAdults. 12.5 mg. Repeated in 30 min ifneeded and no hypotension occurs.Children age 6 months and over. 0.275 mg/kg. Repeated in 30 min if needed and tolerated. To treat intractable hiccupsTABLETSAdults. 25 to 50 mg t.i.d. or q.i.d. If hiccupslast longer than 2 days, route switched toI.M., as prescribed.I.V. INFUSIONAdults. 25 to 50 mg diluted in 500 to1,000 ml of normal saline solution andgiven at 1 mg/min with patient supine.I.M. INJECTIONAdults. 25 to 50 mg given only if oral routeis ineffective. If symptoms persist, routeswitched to I.V., as prescribed. To provide preoperative relaxationORAL CONCENTRATE, SYRUP, TABLETSAdults and adolescents. 25 to 50 mg 2 to3 hr before surgery.Children ages 6 months to 12 years.0.55 mg/kg 2 to 3 hr before surgery.I.M. INJECTIONAdults. 12.5 to 25 mg 1 to 2 hr before surgery.Children age 6 months and over. 0.55 mg/kg 1 to 2 hr before surgery. To treat acute intermittent porphyriaORAL CONCENTRATE, SYRUP, TABLETSAdults and adolescents. 25 to 50 mg t.i.d.or q.i.d.I.M. INJECTIONAdults. 25 mg t.i.d. or q.i.d. until oral routeis possible. To treat tetanus (usually as adjunct withbarbiturates)I.V. INFUSIONAdults. 25 to 50 mg diluted to at least1 mg/ml and given at no more than 1 mg/min.Children age 6 months and over. 0.55 mg/kg every 6 to 8 hr, diluted to at least 1 mg/ml and given at no more than 1 mg/2 min.Maximum: 75 mg daily for children ages5 to 12 years or weighing 50 to 100 lb;40 mg daily for children up to age 5 yearsor weighing up to 50 lb.I.M. INJECTIONAdults. 25 to 50 mg t.i.d. or q.i.d.Children age 6 months and over. 0.55 mg/kg every 6 to 8 hr. Maximum: 75 mg dailyfor children ages 5 to 12 or weighing 50 to100 lb; 40 mg daily for children up to age5 years or weighing up to 50 lb.DOSAGE ADJUSTMENT Dosage possiblyreduced for patients with hepatic dysfunction.Dosage reduced to one-third to onehalfthe normal adult dosage for elderly ordebilitated patients.Mechanism of ActionDepresses brain areas that control activityand aggression, including the cerebral cortex,hypothalamus, and limbic system, byan unknown mechanism. Prevents nauseaand vomiting by inhibiting or blockingdopamine receptors in the medullary

chemoreceptor trigger zone and peripherallyby blocking the vagus nerve in the GItract. May relieve anxiety by indirect reductionin arousal and increased filtering ofinternal stimuli to the reticular activatingsystem in the brain stem.IncompatibilitiesDon’t mix chlorpromazine with thiopental,atropine, or solutions that don’t have a pHof 4 to 5 because a precipitate will form.Don’t mix chlorpromazine injection withother drugs in a syringe.ContraindicationsComatose states; hypersensitivity to chlorpromazine,phenothiazines, or their components;use of large amounts of CNSdepressantsInteractionsDRUGSamphetamines: Decreased amphetamineeffectiveness, decreased antipsychotic effectivenessof chlorpromazineantacids (aluminum hydroxide or magnesiumtrisilicate gel): Decreased chlorpromazineabsorption and effectivenessbarbiturates: Decreased plasma level and,possibly, effectiveness of chlorpromazineCNS depressants: Prolonged and intensifiedCNS depressionmetrizamide: Possibly lowered seizurethresholdoral anticoagulants: Decreased anticoagulationphenytoin: Interference with phenytoinmetabolism, increased risk of phenytointoxicitypropranolol: Increased plasma levels of bothdrugsthiazide diuretics: Possibly increased orthostatichypotensionACTIVITIESalcohol use: Prolonged and intensified CNSdepressionAdverse ReactionsCNS: Drowsiness, extrapyramidal reactions(such as dystonia, fever, motor restlessness,pseudoparkinsonism, and tardive dyskinesia),neuroleptic malignant syndrome,seizuresCV: ECG changes, such as nonspecific, usuallyreversible Q- and T-wave changes;orthostatic hypotension; tachycardiachlorpromazine 229EENT: Blurred vision, dry mouth, nasalcongestion, ocular changes (fine particledeposits in lens and cornea) with long-termtherapyENDO: Gynecomastia, hyperglycemia,hypoglycemia, lactation, moderate breastengorgementGI: Constipation, ileus, nauseaGU: Amenorrhea, ejaculation disorders,impotence, priapism, urine retentionHEME: Agranulocytosis, aplastic anemia,eosinophilia, hemolytic anemia, leukopenia,pancytopenia, thrombocytopenic purpuraSKIN: Exfoliative dermatitis, jaundice, photosensitivity,tissue necrosis, urticariaNursing Considerations• Don’t open or crush E.R. capsules.• Chlorpromazine shouldn’t be used to treatdementia-related psychosis in the elderlybecause of an increased risk of death.• Use chlorpromazine cautiously in patients(especially children) with chronic respiratorydisorders (such as severe asthma oremphysema) or acute respiratory tractinfections because drug has CNS depressanteffect. Also use cautiously in patientswith cardiovascular, hepatic, or renal diseasebecause of increased risk of developinghypotension, heart failure, andarrhythmias.• Because of chlorpromazine’s anticholinergiceffects, use it cautiously in patientswith glaucoma. Also use it cautiously inthose who are exposed to extreme heat ororganophosphate insecticides and thosereceiving atropine or related drugs.• Protect concentrate from light.Refrigeration isn’t required.• Dilute concentrate in at least 60 ml ofdiluent just before administering it. Usetomato or fruit juice, milk, simple syrup,orange syrup, a carbonated beverage, coffee,tea, water, or semisolid food, such aspudding and soup.• Protect parenteral solution from light.Solution should be clear and colorless topale yellow. Discard markedly discoloredsolution.• Don’t inject drug by subcutaneous routebecause it can cause severe tissue necrosis.• Wear gloves when working with liquid orinjectable form because parenteral solutionmay cause contact dermatitis.C

230chlorpropamide• For I.V. injection, dilute chlorpromazinewith sodium chloride to a concentrationof 1 mg/ml.• Give I.M. injection slowly and deep intoupper outer quadrant of buttocks, such asin the gluteus maximus. To minimizehypotensive effects, keep patient lying flatand monitor blood pressure for 30 minutesafter injection.WARNING Stay alert for possible suppressedcough reflex, which increases the risk ofthe patient’s aspirating vomitus.• Monitor patient for increased sensitivity todrug’s CNS effects if patient has a historyof hepatic encephalopathy from cirrhosis.WARNING If neuroleptic malignant syndrome(hyperpyrexia, muscle rigidity,altered mental status, autonomic instability)develops, notify prescriber immediatelyand expect to stop drug and start intensivetreatment. Watch for recurrence if patientresumes antipsychotic therapy.PATIENT TEACHING• Instruct patient to swallow E.R. capsuleswhole and not to crush, break, or chewthem.• Tell patient not to take drug within2 hours of an antacid. Allow him to takedrug with food or a full glass of milk orwater.• If patient uses suppository form, tell himto chill the suppository, moisten it withcold water, and insert it well into rectum.• Tell patient to store oral concentrate atroom temperature, away from light, tomeasure it with the dropper provided, andto dilute it in 4 oz of fluid just before use.• Because of possible drowsiness, dizziness,and blurred vision (especially during thefirst few days of therapy), advise patient toavoid hazardous activities until drug’sCNS effects are known.• Tell patient to avoid alcohol because ofpossible additive effects and hypotension.• Advise patient, especially if elderly, to riseslowly from a supine or seated position toavoid dizziness, light-headedness, andfainting.• Tell patient to inform doctors and dentiststhat he’s taking chlorpromazine before hehas surgery, medical tests, or dental work.• Explain that drug may reduce the body’sresponse to heat and cold; tell patient toavoid temperature extremes, as in a sauna,hot tub, or very cold or hot shower.Remind patient to dress warmly in coldweather.• Warn patient not to take OTC drugs for acold or an allergy because they canincrease the risk of heatstroke and otherunwanted effects.• Inform patient that drug increases sensitivityto sunlight; tell him to stay out ofthe sun as much as possible and to protecthis skin.• If patient has dry mouth, suggest sugarlesschewing gum, hard candy, and fluids.• Urge patient to report sudden sore throator other signs of infection.chlorpropamideApo-Chlorpropamide (CAN), Diabinese,Novo-Propamide (CAN)Class and CategoryChemical class: SulfonylureaTherapeutic class: AntidiabeticPregnancy category: CIndications and Dosages As adjunct to manage non–insulindependentdiabetes when diet alone failsto lower blood glucose levelTABLETSAdults. Initial: 250 mg daily for 5 to 7 days.After therapy begins, dosage may be adjustedup or down in increments of 50 to125 mg at intervals of 3 to 5 days to obtainoptimal control. Maintenance: 100 to500 mg daily. Maximum: 750 mg daily.DOSAGE ADJUSTMENT If patient takes morethan 40 units of insulin daily, dosagereduced to half usual insulin dose for firstfew days of chlorpropamide therapy.Insulin dose can be reduced, depending onresponse. If patient takes oral antidiabeticdrug or less than 40 units of insulin daily, itmay be stopped abruptly when chlorpropamidestarts.Dosage reduced to half usual dose ifpatient has mild renal failure becausemetabolites and unchanged drug are excretedin urine. To avoid hypoglycemic reactions,initial dosage reduced to 100 to125 mg daily for elderly, debilitated, or malnourishedpatients and patients withimpaired hepatic function.

Mechanism of ActionLowers blood glucose level by stimulatingrelease of insulin from the pancreas inpatients who have functioning beta cells. Italso may increase insulin sensitivity in targettissues, which may result in a decreasein liver breakdown of glycogen to glucoseor the liver’s production of new glucose.Route Onset Peak DurationP.O. 1 hr 3–6 hr 24–72 hrContraindicationsDiabetic ketoacidosis (with or withoutcoma), hypersensitivity to chlorpropamideor its components, type I diabetes mellitusInteractionsDRUGSandrogens, anticoagulants, azole antifungals,chloramphenicol, clofibrate, fenfluramine,fluconazole, gemfibrozil, H 2 -receptor antagonists,magnesium salts, MAO inhibitors,methyldopa, probenecid, salicylates, sulfinpyrazone,sulfonamides, tricyclic antidepressants,urinary acidifiers: Increased hypoglycemiceffectbarbiturates: Prolonged barbiturate actionbeta blockers, calcium channel blockers,cholestyramine, corticosteroids, diazoxide,estrogens, hydantoins, isoniazid, nicotinicacid, oral contraceptives, phenothiazines,rifampin, sympathomimetics, thiazide diuretics,thyroid drugs, urinary alkalinizers:Decreased hypoglycemic effectdigitalis glycosides: Increased blood digitalisleveloral miconazole: Risk of severe hypoglycemiaACTIVITIESalcohol use: Disulfiram-like reactionAdverse ReactionsENDO: HypoglycemiaGI: Anorexia, diarrhea, hunger, nausea,vomitingHEME: Hemolytic anemiaSKIN: Maculopapular eruptions, photosensitivity,pruritus, urticariaOther: Disulfiram-like reactionNursing Considerations• Use chlorpropamide cautiously in patientswith renal or hepatic dysfunction; in elderly,debilitated, or malnourished patients;and in those with adrenal or pituitarychlorpropamide 231insufficiency because of increased susceptibilityto drug’s hypoglycemic action.• Use chlorpropamide cautiously in patientswith glucose 6-phosphate dehydrogenasedeficiency because sulfonylureas, such aschlorpropamide, can cause hemolytic anemia.• Monitor patient’s blood glucose level oftenat start of therapy and during dosageadjustments or changes in patient’s life,such as during stress and illness. Hypoglycemiamay be difficult to recognize inelderly patients and those who take betaadrenergicblockers.• Assess patient for hypoglycemia—themost common adverse reaction to chlorpropamide—especiallyin patients whosecaloric intake is deficient, who have justengaged in strenuous or prolonged exercise,who have ingested alcohol, or whotake more than one glucose-loweringdrug.• Treat hypoglycemia promptly by giving15 g of simple carbohydrate, such as 4 ozof orange juice or soda or 8 oz of milk.Repeat in 15 minutes, if needed. Becauseof drug’s long half-life, careful monitoringand frequent feedings are required for 3 to5 days after a hypoglycemic episode.Hospitalization and I.V. glucose may beneeded.• Monitor patients receiving long-termchlorpropamide therapy for secondaryfailure, which causes loss of blood glucosecontrol despite adherence to prescribeddrug therapy and diet and exercise guidelines.If secondary failure occurs, therapyshould be discontinued and a differentantidiabetic drug substituted.PATIENT TEACHING• Instruct patient to store chlorpropamidein a sealed container, protected from heatand light.• Tell patient to take chlorpropamide withbreakfast.• Stress that drug works with diet and exerciseto help control blood glucose leveland isn’t a substitute for them.• Tell patient to monitor blood glucose levelas instructed.• Instruct patient not to skip meals or exerciseexcessively.• Teach patient how to recognize and treathypoglycemia. Tell him to report frequentC

232chlorthalidoneor severe hypoglycemia to prescriber.• Caution patient with confirmed or suspectedhypoglycemia not to drive or operatemachinery until blood glucose levelsreturn to normal.• Tell patient to take a missed dose as soonas he remembers it unless it’s almost timefor the next scheduled dose.• Urge patient to wear or carry medicalidentification showing that he has diabetesand listing his drugs.• Advise the patient to protect his skin fromthe sun.• Instruct patient to report about fever, sorethroat, dark yellow or brown urine, yellowskin and eyes, bleeding, and bruising.chlorthalidoneApo-Chlorthalidone (CAN), Hygroton,Novo-Thalidone (CAN), Thalitone,Uridon (CAN)Class and CategoryChemical class: Phthalimidine derivative ofbenzenesulfonamide (thiazide-like diuretic)Therapeutic class: Antihypertensive, diureticPregnancy category: BIndications and Dosages To reduce edema caused by heart failure,hepatic cirrhosis, corticosteroid or estrogentherapy, or renal dysfunctionTABLETSAdults. Initial: 50 to 100 mg (Thalitone,30 to 60 mg) daily, 100 mg (Thalitone,60 mg) every other day, or 150 to 200 mg(Thalitone, 90 to 120 mg) daily or everyother day. Maintenance: Individualized; maybe lower than initial dosage. To treat hypertensionTABLETSAdults. Initial: 25 mg daily (Thalitone,15 mg daily). If response is insufficient,dosage increased to 50 mg daily (Thalitone,30 to 50 mg daily). If additional control isrequired, dosage increased to 100 mg daily(except Thalitone) or a second antihypertensiveadded. Maintenance: Individualized;may be lower than initial dosage.Mechanism of ActionMay promote sodium, chloride, and waterexcretion by inhibiting sodium reabsorptionin the distal tubules of the kidneys.Initially, chlorthalidone may decrease extracellularfluid volume, plasma volume, andcardiac output, which helps explain how itreduces blood pressure. It also may dilatearteries directly, which helps reduce peripheralvascular resistance and blood pressure.After several weeks, extracellular fluid andplasma volume and cardiac output returnto normal, but peripheral vascular resistanceremains decreased.Route Onset Peak DurationP.O. 2–3 hr 2–6 hr 24–72 hrContraindicationsAnuria; hypersensitivity to chlorthalidone,other sulfonamides, or their components;renal decompensationInteractionsDRUGSallopurinol: Increased risk of allopurinolhypersensitivityamphotericin B, glucocorticoids: Intensifiedelectrolyte depletionanesthetics: Potentiated effects of anestheticsanticholinergics: Increased chlorthalidoneabsorptionantidiabetics, methenamines, oral anticoagulants,sulfonylureas: Decreased effects ofthese drugsantihypertensives: Potentiated action ofantihypertensives and chlorthalidoneantineoplastics: Prolonged antineoplasticinducedleukopeniacholestyramine, colestipol: Decreased chlorthalidoneabsorptiondiazoxide: Increased risk of hyperglycemiaand hypotensiondigitalis glycosides: Increased risk of digitalis-inducedarrhythmiaslithium: Decreased renal lithium clearanceand increased risk of lithium toxicityloop diuretics: Increased synergistic effects,resulting in profound diuresis and seriouselectrolyte imbalancesmethyldopa: Potential development ofhemolytic anemianeuromuscular blockers: Increased neuromuscularblockadeNSAIDs: Possibly reduced diuretic effect ofchlorthalidonevitamin D: Enhanced vitamin D action

Adverse ReactionsCNS: Dizziness, headache, insomnia, lightheadedness,paresthesia, restlessness, vertigo,weaknessCV: Orthostatic hypotension, vasculitisEENT: Yellow visionENDO: HyperglycemiaGI: Abdominal cramps or pain, anorexia,bloating, constipation, diarrhea, gastric irritation,nausea, pancreatitis, vomitingGU: Decreased libido, impotenceHEME: Agranulocytosis, aplastic anemia,hypoplastic anemia, leukopenia, thrombocytopeniaMS: Gout attacks, muscle spasmsSKIN: Cutaneous vasculitis, exfoliative dermatitis,jaundice, necrotizing vasculitis,photosensitivity, purpura, rash, urticariaOther: HyperuricemiaNursing Considerations• Use chlorthalidone cautiously in patientswith impaired hepatic function or progressivehepatic disease because minorchanges in fluid and electrolyte balancemay cause hepatic coma.• Assess BUN, serum electrolyte, uric acid,and blood glucose levels before therapyand periodically throughout therapy.Monitor patient for signs of fluid andelectrolyte imbalance.WARNING Monitor renal function periodicallyto detect cumulative drug effects,which may cause azotemia in patients withimpaired renal function.PATIENT TEACHING• Stress the importance of taking chlorthalidoneeven when feeling well.• Tell patient to store drug at room temperaturein tightly closed container.• Tell patient to take drug in the morningwith food or milk.• To minimize effects of orthostatic hypotension,instruct patient to rise slowlyfrom a seated or lying position.• Advise patient to check blood pressureregularly.• Instruct patient to report signs of low potassiumlevel, such as muscle weaknessand fatigue.• Advise patient to protect his skin from thesun.• Urge patient to immediately report suddenjoint pain to prescriber because drugcan cause sudden gout attacks.chlorzoxazone 233• Instruct patient to take a missed dose assoon as he remembers it. If he misses oneday in an every-other-day schedule, tellhim to take the dose on the off day andthen resume usual dosing schedule. Warnagainst taking double or extra doses.chlorzoxazoneEZE-DS, Paraflex, Parafon Forte DSC,Relaxazone, Remular, Remular-S,Strifon Forte DSCClass and CategoryChemical class: Benzoxazole derivativeTherapeutic class: Skeletal muscle relaxantPregnancy category: C (Parafon Forte DSC,not rated)Indications and Dosages As adjunct to relieve acute musculoskeletalpain and stiffnessTABLETSAdults. 250 to 750 mg t.i.d. or q.i.d., usually500 mg t.i.d. or q.i.d., increased ordecreased according to patient response.Route Onset Peak DurationP.O. In 1 hr Unknown 3–4 hrMechanism of ActionReduces muscle spasm by inhibiting multisynapticreflex arcs at the level of the spinalcord and subcortical areas of the brain thatare active in producing and maintainingskeletal muscle spasm.ContraindicationsHypersensitivity or known intolerance tochlorzoxazone or any of its componentsInteractionsDRUGSCNS depressants: Additive CNS depressionACTIVITIESalcohol use: Additive CNS depressionAdverse ReactionsCNS: Dizziness, drowsiness, headache,light-headedness, malaise, paradoxical stimulationGI: Abdominal cramps or pain, constipation,diarrhea, GI bleeding, heartburn,hepatotoxicity, nausea, vomitingGU: Urine discolorationC

234cholestyramineHEME: Agranulocytosis, anemiaSKIN: Allergic dermatitis, ecchymosis,petechiaeOther: Anaphylaxis, angioedemaNursing Considerations• If needed, crush chlorzoxazone tablets andmix with food or liquid for easier swallowing.• Assess patients, especially those who havea history of allergies, for evidence ofhypersensitivity, such as rash, hives, anditching.WARNING Monitor patient for signs ofhepatotoxicity, including fever, rash, jaundice,and darkened urine. Notify prescriberimmediately and expect to discontinuedrug if any of these signs or symptomsoccur. Monitor patient for abnormalliver function test results, such as elevatedAST, ALT, alkaline phosphatase, and bilirubinlevels, and expect to discontinue drug,as ordered, if any of these occurs.• Ensure adequate rest, and provide otherpain-relief measures as needed.• Institute safety measures to prevent falls orinjury (such as raising bed rails and assistingwith ambulation) until drug’s full CNSeffects are known.PATIENT TEACHING• Advise patient to take a missed dose ofchlorzoxazone as soon as possible unlessit’s almost time for the next dose.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to avoid alcohol and otherCNS depressants during therapy.• Inform patient that, in rare instances,urine may turn orange or reddish purpleduring therapy.• Advise patient to store drug in a tightlycapped container at room temperature.cholestyramineQuestran, Questran LightClass and CategoryChemical class: Quaternary ammoniumanion exchange resinTherapeutic class: Antihyperlipidemic,antipruritic (cholestasis)Pregnancy category: Not ratedIndications and Dosages As adjunct to reduce serum cholesterollevel in patients with primary hypercholesterolemia,to relieve pruritus associatedwith partial biliary obstructionORAL SUSPENSIONAdults. Initial: 4 g once or twice dailybefore meals. Maintenance: 8 to 24 g equallydivided and given 2 to 6 times a day.Maximum: 24 g daily when used as antihyperlipidemicand 16 g daily when used asantipruritic.Route Onset Peak DurationP.O. In 1–2 wk* Unknown 2–4 wk †Mechanism of ActionIncreases bile acid excretion in feces. Theresulting decreased bile acid level increasesthe activity of the enzyme that regulatescholesterol synthesis in the liver. As a result,the liver increases its cholesterol synthesisto produce more bile acids. However, theliver’s synthesis of cholesterol typically can’tmatch the amount needed to synthesize bileacids, which reduces the cholesterol level.Also, a decreased cholesterol level causesliver cells to increase their uptake of LDLs,which further reduces the cholesterol level.Cholestyramine may relieve pruritus bydecreasing the body’s bile acid level. Thisreduces the amount of excess bile acids thatare deposited in the dermis and that typicallycause pruritus in patients withcholestasis.ContraindicationsComplete biliary obstruction (when bileisn’t excreted into intestine), hypersensitivityto cholestyramine or its componentsInteractionsDRUGSchenodiol, digitalis glycosides, fat-solublevitamins, folic acid, gemfibrozil, penicillin G(oral), phenylbutazone, propranolol (oral),tetracyclines (oral), thiazide diuretics (oral),thyroid hormones, ursodiol, vancomycin(oral): Decreased absorption and effects of* For hypercholesterolemia; in 1 to 3 wk forpruritus.† For hypercholesterolemia; 1 to 2 wk forpruritus.

these drugsoral anticoagulants: Decreased or increasedanticoagulant effectAdverse ReactionsCNS: Headache, dizzinessGI: Bloating, constipation, diarrhea, epigastricpain, eructation, fecal impaction, flatulence,indigestion, nausea, vomitingNursing Considerations• Store cholestyramine at room temperature.• Don’t give dry powder because it maycause esophageal distress; mix it in a beverage.WARNING Be aware that long-term use mayincrease bleeding tendency from hyperprothrombinemiacaused by vitamin Kdeficiency. If this occurs, patient willrequire treatment with vitamin K 1 .• Monitor for deficiencies of fat-solublevitamins, such as A and D. If long-termtherapy prevents absorption of these vitamins,expect to provide supplementation.PATIENT TEACHING• Urge patient to follow a low-cholesterol,low-fat diet and regular exercise program.• Tell patient to take drug before meals.• Instruct patient to mix dry powder as follows:Place amount of powder needed fordose in any beverage and stir vigorously.Then, vigorously stir in another 2 to 4 ozof beverage. After drinking mixture, rinseglass with more liquid, and swallow it tomake sure full dose is taken. Patient alsomay mix drug in thin soups or moist,pulpy fruits, such as applesauce or crushedpineapple.• Tell patient to drink plenty of fluids andincrease bulk in his diet to minimize constipation;remind him to notify prescriberif constipation, nausea, or other adverseGI reactions develop.• Explain that serum cholesterol level willneed to be measured often for first fewmonths of therapy and periodically thereafter.• Advise patient to take other drugs at least1 hour before or 4 to 6 hours aftercholestyramine to avoid interference withtheir absorption.• Tell patient to take a missed dose as soonas he remembers but not to take double orextra doses.choline salicylate 235choline salicylateArthropanClass and CategoryChemical class: SalicylateTherapeutic class: Analgesic, antiinflammatory,antipyreticPregnancy category: C (first trimester), Notrated (later trimesters)Indications and Dosages To treat mild to moderate pain, reducefeverLIQUIDAdults and adolescents. 435 to 870 mgevery 4 hr, p.r.n. Maximum: 5,325 mg daily.Children ages 11 to 12. 435 to 652.5 mgevery 4 hr, p.r.n. Maximum: Five dosesdaily.Children ages 9 to 11. 435 to 543.8 mgevery 4 hr, p.r.n. Maximum: Five dosesdaily.Children ages 6 to 9. 435 mg every 4 hr,p.r.n. Maximum: Five doses daily.Children ages 4 to 6. 326.5 mg every 4 hr,p.r.n. Maximum: Five doses daily.Children ages 2 to 4. 217.5 mg every 4 hr,p.r.n. Maximum: Five doses daily.Children up to age 2. Individualizeddosage. Maximum: Five doses daily. To treat rheumatoid arthritisLIQUIDAdults and adolescents. 870 to 1,740 mgup to four times daily.Children age 12 and younger. 107 to133 mg/kg daily in divided doses.Route Onset Peak DurationP.O. Unknown Several wk* UnknownMechanism of ActionBlocks cyclooxygenase, an enzyme neededfor prostaglandin synthesis. As mediators inthe inflammatory process, prostaglandinscause local vasodilation, swelling, and pain.They also influence pain transmission fromthe periphery to the spinal cord. By blockingcyclooxygenase and inhibiting prostaglandins,this NSAID decreases inflammatorysymptoms and relieves pain. It also* For rheumatoid arthritis.C

236ciclesonideacts on the heat-regulating center in thehypothalamus and causes peripheralvasodilation, sweating, and heat loss.ContraindicationsHypersensitivity to nonacetylated salicylatesInteractionsDRUGSantacids: Increased clearance and decreasedblood level of salicylatecarbonic anhydrase inhibitors, phenytoin,valproic acid: Decreased blood levels andtherapeutic effects of these drugscorticosteroids: Decreased blood salicylatelevel, increased salicylate dosage requirementsinsulin, sulfonylureas: Increased hypoglycemicresponsemethotrexate: Increased therapeutic andtoxic effects of methotrexate, especiallywhen given in chemotherapeutic dosesoral anticoagulants: Increased blood level ofunbound anticoagulant and risk of bleedingsalicylate-containing products: Increasedplasma salicylate level, possibly to toxicleveluricosuric drugs: Decreased uricosuric drugefficacyAdverse ReactionsCNS: Confusion, dizziness, drowsiness, hallucinations,headache, light-headednessCV: TachycardiaEENT: Hearing loss, tinnitusGI: Constipation, diarrhea, epigastric pain,heartburn, indigestion, nausea, vomitingHEME: Easy bruising, unusual bleedingNursing Considerations• Use choline salicylate cautiously inpatients with renal impairment.• Don’t give salicylates to children and adolescentswith chickenpox or influenzasymptoms because of the risk of Reye’ssyndrome.WARNING During high-dose or long-termtherapy, watch for salicylate intoxication,(headache, dizziness, tinnitus, hearing loss,confusion, drowsiness, diaphoresis, vomiting,diarrhea, hyperventilation, and possiblyCNS disturbance, electrolyte imbalance,respiratory acidosis, hyperthermia,and dehydration). Prepare for inducedvomiting, gastric lavage, activated charcoal,and peritoneal dialysis or hemodialysis,as ordered.PATIENT TEACHING• Tell patient to store drug at room temperature,away from heat, light, and moisture.• Instruct patient to take drug with full glassof water or with food.• Tell patient to take a missed dose as soonas he remembers but to avoid doublingthe dose.• If patient has arthritis, explain that optimaldrug effects may not occur for 2 to3 weeks.• Teach patient to recognize and immediatelyreport signs of salicylate toxicity.• Because drug is closely related to aspirin,advise against taking aspirin-containingOTC products during therapy.ciclesonideAlvescoClass and CategoryChemical class: Non-halogenated glucocorticoidTherapeutic class: Antiasthmatic, antiinflammatoryPregnancy category: CIndications and Dosages To prevent asthma attacks as part ofmaintenance therapyINHALATION AEROSOLAdults and children age 12 and over usingbronchodilator therapy. Initial: 80 mcgb.i.d. Maximum: 160 mcg b.i.d.Adults and children age 12 and overswitching from another inhaled corticosteroid.Initial: 80 mcg b.i.d., adjusted tolowest effective dose when stabilized.Maximum: 320 mg b.i.d.Adults and children age 12 and older usingoral corticosteroid therapy. Initial andmaximum: 320 mcg b.i.d., adjusted to lowesteffective dose when stabilized. To treat nasal congestion in seasonal orallergic rhinitisINHALATION AEROSOLAdults and children age 6 and over.200 mcg daily as 2 sprays in each nostril.Mechanism of ActionInhibits cells involved in the asthma inflammatoryresponse, such as mast cells,

eosinophils, basophils, lymphocytes,macrophages, and neutrophils. Ciclesonidealso inhibits production or secretion ofchemical mediators, such as histamine,eicosanoids, leukotrienes, and cytokines.Route Onset Peak DurationInhala- Unknown 4 wk or Severaltion longer daysContraindicationsHypersensitivity to ciclesonide or its components,primary treatment of status asthmaticusor other acute asthma episodes thatrequire intensive measuresInteractionsDRUGSketoconazole: Increased exposure time ofciclesonideAdverse ReactionsCNS: Dizziness, fatigue, headacheEENT: Cataracts, conjunctivitis, dry mouthor throat, dysphonia, glaucoma, hoarseness,nasal congestion, nasopharyngitis, oral candidiasis,pharyngolaryngeal pain, sinusitisENDO: Adrenal insufficiency, cushingoidsymptoms, decreased bone mineral density,hyperglycemia, slower growth in childrenGI: NauseaMS: Arthralgia, back or limb pain, musculoskeletalchest painRESP: Bronchospasm, cough, pneumonia,upper respiratory tract infectionSKIN: Facial edema, urticariaOther: Angioedema, influenzaNursing Considerations• Use cautiously in patients with tuberculosis;fungal, bacterial, viral, or parasiticinfection; ocular herpes simplex; ormeasles or chickenpox because these conditionsmay worsen with ciclesonide therapy.• Also use cautiously in patients with a historyof increased intraocular pressure,glaucoma, or cataracts because ciclesonidemay increase intraocular pressure or causecataract formation and in patients withmajor risk factors for decreased bone mineralcontent, such as prolonged immobilization,family history of osteoporosis, orlong-term use of drugs that can reducebone mass, such as anticonvulsants andciclesonide 237oral corticoseroids.• Inspect patient’s oral cavity regularly forabnormalities. Have patient rinse mouthfollowing inhalation of ciclesonide toreduce risk of oral candidiasis. If oral candidiasisoccurs, expect to continueciclesonide therapy, unless severe.• If patient takes a systemic corticosteroid,expect to taper dosage by no more than2.5 mg/day at weekly intervals, starting1 week after ciclesonide therapy begins.WARNING If patient is switched from systemiccorticosteroid to ciclesonide, assessfor adrenal insufficiency (fatigue, hypotension,lassitude, nausea, vomiting, weakness)early in therapy and wheneverpatient has infection, stress, trauma, surgery,or other steroid-depleting conditionsor procedures. Notify prescriber immediatelyif signs or symptoms develop.• As prescribed, administer a fast-actinginhaled bronchodilator if an acute asthmaattack occurs. Ciclesonide is not a bronchodilatorand its action takes longer thanneeded to abort acute asthma symptoms.If bronchospasm occurs immediately afterciclesonide use, expect to stop drug andstart another drug regimen.•Monitor growth in children becauseciclesonide may suppress growthPATIENT TEACHING• Urge patient to use ciclesonide regularly,as prescribed, but not for acute bronchospasm.Also tell her never to increaseor decrease the dosage without consultingprescriber.• Tell patient to use ciclesonide only withthe actuator supplied with the product.Explain that when the dose indicatorshows a red zone in the window, about 20inhalations are left, indicating a need for arefill. When the indicator shows zero, sheshould discard the inhaler. Advise againstrelying solely on the dose indicator, especiallyif inhaler has been dropped, but tokeep track of number of inhalations used.• Instruct patient to use inhaler according topackage instructions. Stress need to makesure canister is firmly seated in the plasticmouthpiece adapter before each use andto press inhaler slowly but firmly until itcan go no further in the adapter for eachspray. Inform patient that she doesn’t needto shake inhaler before use.C

238Nursing Considerations• Monitor patient’s vital signs and cardiovascularstatus closely because cilostazolmay cause cardiovascular lesions, whichcould lead to problems, such as endocarcilostazol• On first use, advise her to spray threetimes into the air (away from her eyes)looking for a fine mist. If inhaler hasn’tbeen used for more than 10 days, it shouldbe primed again.• Instruct patient to gargle and rinse hermouth after each dose to help prevent drymouth and throat, relieve throat irritation,and prevent oral yeast infection.• Tell patient to always replace cap after use,to keep mouthpiece clean, and to cleanmouthpiece once a week with a clean, drytissue or cloth.• Explain that the full effect of drug may notoccur for 4 weeks or more.• Stress importance of notifying prescriberif symptoms continue or worsen.• Instruct patient to notify prescriber immediatelyif asthma attacks don’t respond tobronchodilators during ciclesonide use.• If patient is switching from an oral corticosteroidto ciclesonide, urge her to carrymedical identification indicating the needfor supplemental systemic corticosteroidsduring stress or severe asthma attack.• Caution patient to avoid contact with peoplewho have infections because drug suppressesthe immune system, increasing therisk of infection. Instruct patient to notifyprescriber about exposure to chickenpox,measles, or other infections because additionaltreatment may be needed.cilostazolPletalClass and CategoryChemical class: Quinolinone derivativeTherapeutic class: Phosphodiesterase IIIinhibitor, platelet aggregation inhibitorPregnancy category: CIndications and Dosages To reduce symptoms of intermittentclaudicationTABLETSAdults. 100 mg b.i.d. taken at least 30 minbefore or 2 hr after breakfast and dinner.Mechanism of ActionMay inhibit phosphodiesterase, decreasingphosphodiesterase activity and suppressingcyclic adenosine monophosphate (cAMP)degradation. This action increases cAMP inplatelets and blood vessels, which inhibitsplatelet aggregation and causes vasodilation.This in turn relieves symptoms ofclaudication.ContraindicationsHeart failure, hypersensitivity to cilostazolor its componentsInteractionsDRUGSdiltiazem, erythromycin, itraconazole, ketoconazole,omeprazole: Increased plasmacilostazol levelFOODSgrapefruit: Increased risk of adverse reactionshigh-fat foods: Faster cilostazol absorptionand increased risk of adverse reactionsACTIVITIESsmoking: Decreased cilostazol effects byabout 20%Adverse ReactionsCNS: Cerebral hemorrhage, dizziness,headache, paresthesiaCV: Angina, chest pain, hypertension,hypotension, palpitations, peripheraledema, prolonged QT interval, subacutethrombosis, tachycardia, torsades de pointesEENT: Pharyngitis, rhinitisENDO: Diabetes mellitus, hot flashes,hyperglycemiaGI: Abdominal pain, abnormal stool, diarrhea,elevated liver function test results,flatulence, GI hemorrhage, hepatic dysfunction,indigestion, jaundice, vomitingGU: Elevated BUN level, hematuriaHEME: Agranulocytosis, aplastic anemia,bleeding tendency, decreased platelet count,granulocytopenia, leukopenia, thrombocytopeniaMS: Back pain, myalgiaRESP: Cough, interstitial pneumonia, pulmonaryhemorrhageSKIN: Eruptions, pruritus, rash, Stevens-Johnson syndromeOther: Infection, increased blood uric acidlevel

dial hemorrhage.• Monitor blood glucose level to detecthyperglycemia. Also assess for signs oftype 2 diabetes mellitus, such as polyuria,polydipsia, polyphagia, and fatigue.PATIENT TEACHING• Instruct patient to take cilostazol on anempty stomach because high-fat foods canincrease the risk of adverse reactions.• Warn patent to avoid grapefruit juice duringtherapy because it can increase the riskof adverse reactions.• Urge patient not to smoke because itdecreases drug’s effects.• Explain that assessment of drug effectivenessis based on ability to walk increaseddistances. Stress that drug effects won’tappear until 2 to 4 weeks after therapystarts and that full effects may take up to12 weeks.cimetidineApo-Cimetidine (CAN), Gen-Cimetidine(CAN), Novo-Cimetine (CAN), Nu-Cimet(CAN), PMS-Cimetidine (CAN), Tagamet,Tagamet HBcimetidinehydrochlorideNovo-Cimetine (CAN), TagametClass and CategoryChemical class: Imidazole derivativeTherapeutic class: Antiulcer agent, gastricacid secretion inhibitor, H 2 -receptor antagonistPregnancy category: BIndications and Dosages To treat and prevent recurrence of duodenalulcerORAL SOLUTION, TABLETSAdults and adolescents. Initial: 800 mg atbedtime, 300 mg q.i.d. with meals and atbedtime, or 400 to 600 mg in morning andat bedtime for 4 to 6 wk. Maintenance:400 mg at bedtime.Children. 20 to 40 mg/kg daily in divideddoses q.i.d. with meals and at bedtime.I.V. OR I.M. INJECTIONAdults. Initial: 300 mg every 6 to 8 hr.Dosage increased, if needed, by increasingcimetidine 239frequency. Maximum: 2,400 mg daily. To treat active, benign gastric ulcerORAL SOLUTION, TABLETSAdults and adolescents. 800 mg at bedtime,300 mg q.i.d. with meals and at bedtime,or 600 mg b.i.d. in morning and atbedtime, or 800 mg at bedtime for up to8wk.Children. 20 to 40 mg/kg daily in divideddoses q.i.d. with meals and at bedtime.I.V. ORI.M. INJECTIONAdults and adolescents. Initial: 300 mgevery 6 to 8 hr. Dosage increased, if needed,by increasing frequency. Maximum:2,400 mg daily. To manage gastroesophageal reflux diseaseORAL SOLUTION, TABLETSAdults and adolescents. 1,600 mg daily individed doses (800 mg b.i.d or 400 mgq.i.d.) for up to 12 wk.Children. 40 to 80 mg/kg daily in divideddoses q.i.d. To treat pathological hypersecretory conditions,such as Zollinger-Ellison syndromeORAL SOLUTION, TABLETSAdults and adolescents. 300 mg q.i.d. withmeals and at bedtime. Given more often, ifneeded. Maximum: 2,400 mg daily.I.V. OR I.M. INJECTIONAdults and adolescents. Initial: 300 mgevery 6 to 8 hr. Dosage increased, if needed,by increasing frequency. Maximum:2,400 mg daily. To treat heartburn and acid indigestionORAL SOLUTION, TABLETSAdults and adolescents. Initial: 200 mgwith water at onset of symptoms.Maximum: 400 mg every 24 hr for no morethan 2 wk unless prescribed.DOSAGE ADJUSTMENT Oral dosage for allindications reduced to 300 mg every 12 hr(and increased to every 8 hr with caution, ifneeded) for patients with renal impairment. To prevent stress-related upper GI bleedingduring hospitalizationI.V. INFUSIONAdults. 50 mg/hr by continuous infusionfor 7 days.Mechanism of ActionBlocks histamine’s action at H 2 -receptorsites on stomach’s parietal cells. This actionreduces gastric fluid volume and acidity.C

240cinacalcet hydrochlorideCimetidine also decreases the amount ofgastric acid secreted in response to food,caffeine, insulin, betazole, or pentagastrin.Route Onset Peak DurationP.O. Unknown 1–2 hr 4–5 hrI.V., I.M. Unknown Unknown 4–5 hrIncompatibilitiesDon’t mix cimetidine with aminophyllineor barbiturates in I.V. solution. Don’t mixdrug with pentobarbital sodium in thesame syringe.ContraindicationsHypersensitivity to cimetidine or its componentsInteractionsDRUGSantacids, anticholinergics, metoclopramide:Decreased cimetidine absorptionbenzodiazepines, calcium channel blockers,carbamazepine, chloroquine, labetalol, lidocaine,metoprolol, metronidazole, moricizine,pentoxifylline, phenytoin, propafenone, propranolol,quinidine, quinine, sulfonylureas,tacrine, theophyllines, triamterene, tricyclicantidepressants, valproic acid, warfarin:Reduced metabolism and increased bloodlevels and effects of these drugs, possiblytoxicity from these drugscarmustine: Increased carmustine myelotoxicitydigoxin, fluconazole: Possibly decreasedblood levels of these drugsferrous salts, indomethacin, ketoconazole,tetracyclines: Decreased effects of thesedrugsflecainide: Increased flecainide effectsfluorouracil: Increased blood fluorouracillevel after long-term cimetidine useketoconazole: Decreased blood ketoconazolelevelopioid analgesics: Increased toxic effects ofopioid analgesicsoral anticoagulants: Increased anticoagulanteffectprocainamide: Increased blood procainamidelevelsuccinylcholine: Increased neuromuscularblockadetocainide: Decreased tocainide effectsFOODScaffeine: Reduced metabolism and increasedblood level and effects of caffeineACTIVITIESalcohol use: Possibly increased blood alcohollevelAdverse ReactionsCNS: Confusion, dizziness, hallucinations,headache, peripheral neuropathy, somnolenceENDO: Mild gynecomastia if used longerthan 1 monthGI: Mild and transient diarrheaGU: Impotence, transiently elevated serumcreatinine levelSKIN: RashOther: Pain at I.M. injection siteNursing ConsiderationsWARNING Be aware that rapid administrationof cimetidine can increase risk ofarrhythmias and hypotension.• For I.V. injection, dilute cimetidine in normalsaline solution to a total volume of20 ml. Inject over 5 minutes or more.• For intermittent I.V. infusion, dilute cimetidinein at least 50 ml of D 5 W or othercompatible I.V. solution. Infuse over 15 to20 minutes.• For I.M. injection, don’t dilute cimetidinebefore administering it.• Be alert for confusion in elderly or debilitatedpatients who receive cimetidine.PATIENT TEACHING• Tell patient to use a liquid-measuringdevice to ensure accurate dose of solution.• Advise patient to avoid alcohol while takingcimetidine to prevent interactions.• Instruct patient to avoid taking antacidswithin 1 hour of taking cimetidine.• Warn patient that cigarette smokingincreases gastric acid secretion and canworsen gastric disease.• Caution patient not to take drug for morethan 14 days, unless prescribed.cinacalcethydrochlorideSensiparClass and CategoryChemical class: CalcimimeticTherapeutic class: Calcium reducer

Pregnancy category: CIndications and Dosages To treat secondary hyperparathyroidismin patients with chronic renal diseasewho are on dialysisTABLETSAdults. Initial: 30 mg daily P.O., increasedevery 2 to 4 wk in sequential doses of 60,90, 120, and 180 mg daily, as needed. To treat hypercalcemia in patients withparathyroid carcinomaTABLETSAdults. Initial: 30 mg daily P.O., increasedevery 2 to 4 wk in sequential doses of30 mg b.i.d., 60 mg b.i.d., 90 mg b.i.d., andthen 90 mg t.i.d. or q.i.d., as needed to normalizeserum calcium level.Route Onset Peak DurationP.O. Unknown 2–6 hr UnknownMechanism of ActionIncreases sensitivity of calcium-sensingreceptors on the surface of parathyroid cellsto extracellular calcium. This sensitivitydirectly reduces parathyroid hormone(PTH) level, which in turn decreases serumcalcium level.ContraindicationsHypersensitivity to cinacalcet or its componentsInteractionsDRUGSamitriptyline, carvedilol, desipramine, flecainide,metoprolol, thioridazine, tricyclicantidepressants (most), vinblastine: Possiblyincreased blood level of these drugserythromycin, itraconazole, ketoconazole:Possibly increased blood cinacalcet levelAdverse ReactionsCNS: Asthenia, dizzinessCV: Arrhythmia, hypertension, hypotension,worsening heart failureENDO: HypocalcemiaGI: Anorexia, diarrhea, nausea, vomitingMS: MyalgiaSKIN: Rash, urticariaOther: Allergic reaction, angioedema, noncardiacchest painNursing Considerations• Use cinacalcet cautiously in patients with ahistory of seizures because reduced bloodcalcium level may lower seizure threshold.Also use cautiously in patients with hepaticinsufficiency because cinacalcet metabolismmay be reduced.• Monitor patient for hypocalcemia exhibitedby cramping, myalgia, paresthesia,seizures, and tetany. Also monitor patient’sblood calcium and phosphorus levelswithin 1 week after starting therapy oradjusting dosage, and every month or twoonce maintenance dose is established, asordered. If hypocalcemia develops, notifyprescriber immediately because treatmentto raise calcium level will be needed.Treatment may include giving supplementalcalcium, starting or increasing dosageof calcium-based phosphate binder orvitamin D sterols, or temporarily withholdingcinacalcet.• Be aware that if patient starts or stopstherapy with a strong CYP3A4 inhibitor,such as erythromycin, itraconazole, orketoconazole, cinacalcet dosage may needto be adjusted.• Monitor dialysis patient’s intact PTH levels1 to 4 weeks after therapy starts or doseis adjusted and then every 1 to 3 monthsthereafter, as ordered. Expect to reducedosage or discontinue cinacalcet , asordered, in a patient whose intact PTHlevel falls below the target range of 150 to300 pg/ml.PATIENT TEACHING• Instruct patient to take cinacalcet withfood or shortly after a meal.• Caution patient to take tablet whole andnot divide it or crush it.• Review signs and symptoms of hypocalcemiawith patient and urge him to notifyprescriber of changes.cinoxacinCinobaccinoxacin 241Class and CategoryChemical class: Quinolone derivativeTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat UTI caused by Enterobacterspecies, Escherichia coli, KlebsiellaC

242ciprofloxacinspecies, Proteus mirabilis, or ProteusvulgarisCAPSULESAdults. 1 g daily in divided doses b.i.d. toq.i.d. for 7 to 14 days.DOSAGE ADJUSTMENT After initial 500-mgdose, dosage reduced to 250 mg t.i.d. if creatinineclearance is 50 to 80 ml/min/1.73m 2 , 250 mg b.i.d. if clearance is 20 to 50 ml/min/1.73 m 2 , and 250 mg daily if clearanceis less than 20 ml/min/1.73 m 2 . To prevent UTI in women with a historyof chronic UTICAPSULESAdults. 250 mg at bedtime for up to 5 mo.Mechanism of ActionInhibits the enzyme DNA gyrase, which isresponsible for the unwinding and supercoilingof bacterial DNA before it replicates.By inhibiting this enzyme, cinoxacin causesbacterial cells to die.ContraindicationsHypersensitivity to cinoxacin, other quinolones,or their componentsInteractionsDRUGSantacids that contain aluminum or magnesium,didanosine (chewable tablets, bufferedtablets, pediatric powder for oral solution),metal cations (such as iron), multivitaminsthat contain zinc, sucralfate: Possibly interferencewith cinoxacin absorptionprobenecid: Increased blood cinoxacin leveltheophylline: Possibly increased blood theophyllinelevelFOODScaffeine: Decreased metabolism of caffeine,resulting in increased blood caffeine levelAdverse ReactionsCNS: Dizziness, headacheCV: EdemaEENT: Altered tasteGI: Abdominal cramps, anorexia, diarrhea,elevated liver function test results, nausea,vomitingGU: Perineal burningHEME: EosinophiliaSKIN: Angioedema, photosensitivity, pruritus,rash, urticariaNursing Considerations• Obtain results of urine culture and sensitivitytest before administering first doseof cinoxacin.• Review results of liver function tests, asindicated, during treatment.• Administer drug with food, if needed;food decreases peak blood level but doesn’tchange total absorption.PATIENT TEACHING• Tell patient to take cinoxacin with food, ifneeded, to avoid GI distress.• Instruct patient to drink 2 to 3 L of fluiddaily unless contraindicated.• Tell patient not to take antacids that containaluminum or magnesium; didanosinechewable tablets, buffered tablets, or pediatricpowder for oral solution; sucralfate;metal cations such as iron; or multivitaminsthat contain zinc for at least 2 hoursbefore or after taking cinoxacin becausethey can interfere drug’s absorption.• Advise patient to limit caffeine intakewhile taking cinoxacin because drug maycause caffeine to accumulate in the body.• Advise patient to immediately reportedema, rash, or severe adverse GI reactions.• Tell patient to immediately report tendoninflammation, pain, or rupture to prescriberbecause other drugs in the sameclass as cinoxacin have caused tendon rupture,requiring drug to be discontinued.• Warn patient about the potential forseizures, which have occurred with otherdrugs in the same class as cinoxacin.ciprofloxacinCipro, Cipro I.V., Cipro XR, ProquinXRClass and CategoryChemical class: Fluoroquinolone derivativeTherapeutic class: AntibioticPregnancy category: CIndications and Dosages To prevent inhalation anthrax afterexposure or to treat inhalation anthraxORAL SUSPENSION, TABLETSAdults and adolescents. 500 mg every 12 hrfor 60 days.Children. 15 mg/kg every 12 hr for 60 days.Maximum: 500 mg/dose.

I.V. INFUSIONAdults and adolescents. 400 mg every 12 hrfor 60 days.Children. 10 mg/kg every 12 hr for 60 days.Maximum: 400 mg/dose or 800 mg daily. To treat acute sinusitis caused by gramnegativeorganisms (includingCampylobacter jejuni, Citrobacterdiversus, Citrobacter freundii, Enterobactercloacae, Escherichia coli,Haemophilus influenzae, Haemophilusparainfluenzae, Klebsiella pneumoniae,Morganella morganii, Neisseria gonorrhoeae,Proteus mirabilis, Proteus vulgaris,Providencia rettgeri, Providenciastuartii, Pseudomonas aeruginosa,Serratia marcescens, Shigella flexneri,and Shigella sonnei) and gram-positiveorganisms (including Enterococcus faecalis,Staphylococcus aureus,Staphylococcus epidermidis, andStreptococcus pneumoniae)ORAL SUSPENSION, TABLETSAdults. 500 mg every 12 hr for 10 days.I.V. INFUSIONAdults. For mild to moderate infections,400 mg every 12 hr. To treat bone and joint infections causedby susceptible organisms listed aboveORAL SUSPENSION, TABLETSAdults. For mild to moderate infections,500 mg every 12 hr for 4 to 6 wk. For severeor complicated infections, 750 mg every12 hr for 4 to 6 wk.I.V. INFUSIONAdults. For mild to moderate infections,400 mg every 12 hr for 4 to 6 wk. For severeor complicated infections, 400 mg every8hr. To treat skin and soft-tissue infectionscaused by susceptible organisms listedaboveORAL SUSPENSION, TABLETSAdults. For mild to moderate infections,500 mg every 12 hr for 7 to 14 days. Forsevere or complicated infections, 750 mgevery 12 hr for 7 to 14 days.I.V. INFUSIONAdults. For mild to moderate infections,400 mg every 12 hr. For severe or complicatedinfections, 400 mg every 8 hr. To treat chronic bacterial prostatitiscaused by susceptible organisms listedaboveciprofloxacin 243ORAL SUSPENSION, TABLETSAdults. 500 mg every 12 hr for 28 days.I.V. INFUSIONAdults. 400 mg every 12 hr. To treat infectious diarrhea caused bysusceptible organisms listed aboveORAL SUSPENSION, TABLETSAdults. 500 mg every 12 hr for 5 to 7 days. To treat UTI caused by susceptibleorganisms listed aboveORAL SUSPENSION, TABLETSAdults. For acute uncomplicated infections,100 mg every 12 hr for 3 days. For mild tomoderate infections, 250 mg every 12 hr for7 to 14 days. For severe or complicatedinfections, 500 mg every 12 hr for 7 to14 days.I.V. INFUSIONAdults. For mild to moderate infections,200 mg every 12 hr. For severe or complicatedinfections, 400 mg every 12 hr. To treat complicated UTI caused by E.coli, K. pneumoniae, Enterococcus faecalis,P. mirabilis, or P. aeruginosa oracute uncomplicated pyelonephritiscaused by E. coliE.R. TABLETSAdults. 1,000 mg daily for 7 to 14 days. To treat acute cystitis caused by E. coli,P. mirabilis, E. faecalis, orStaphylococcus saprophyticusE.R. TABLETSAdults. 500 mg daily for 3 days. To treat lower respiratory tract infectionscaused by susceptible organismslisted aboveORAL SUSPENSION, TABLETSAdults. For mild to moderate infections,500 mg every 12 hr for 7 to 14 days. Forsevere or complicated infections, 750 mgevery 12 hr for 7 to 14 days.I.V. INFUSIONAdults. For mild to moderate infections,400 mg every 12 hr. For severe or complicatedinfections, 400 mg every 8 hr. To treat intra-abdominal infectionscaused by susceptible organisms listedaboveI.V. INFUSIONAdults. 400 mg every 8 hr along with parenteralmetronidazole. To treat mild to severe nosocomial pneumoniacaused by susceptible organismslisted aboveC

244Nursing Considerations• Obtain culture and sensitivity test results,as ordered, before giving ciprofloxacin.• Use drug cautiously in patients with CNSdisorders and patients who may be moresusceptible to drug’s effect on QT interval,such as those taking Class IA or III antiarciprofloxacinI.V. INFUSIONAdults. 400 mg every 8 hr. To treat typhoid fever caused by Salmonellatyphi or infectious diarrheacaused by C. jejuni, E. coli, S. flexneri,or S. sonneiORAL SUSPENSION, TABLETSAdults. 500 mg every 12 hr for 10 days. To treat uncomplicated urethral or cervicalgonococcal infections caused by N.gonorrhoeaeORAL SUSPENSION, TABLETSAdults. 250 mg as a single dose.DOSAGE ADJUSTMENT Dosage reduced to250 to 500 mg every 12 hr if creatinineclearance is 30 to 50 ml/min/1.73 m 2 ; andto 250 to 500 mg P.O. or 200 to 400 mg I.V.every 18 hr if creatinine clearance is 5 to29 ml/min/1.73 m 2 . To treat acute cystitis caused by E. colior K. pneumoniaeE.R. TABLETS (PROQUIN XR)Adults. 500 mg daily for 3 days withevening meal.Mechanism of ActionInhibits the enzyme DNA gyrase, which isresponsible for the unwinding and supercoilingof bacterial DNA before it replicates.By inhibiting this enzyme, ciprofloxacincauses bacterial cells to die.IncompatibilitiesDon’t administer parenteral ciprofloxacinwith aminophylline, amoxicillin, cefepime,clindamycin, dexamethasone, floxacillin,furosemide, heparin, or phenytoin.ContraindicationsHypersensitivity to ciprofloxacin, quinolones,or their componentsInteractionsDRUGSantacids, didanosine, iron supplements,sucralfate, multivitamins that contain iron orzinc: Decreased ciprofloxacin absorptioncyclosporine: Elevated serum creatinine andblood cyclosporine levelsglyburide: Severe hypoglycemiamethotrexate: Increased blood methotrexatelevel and increased risk of toxicityNSAIDs (except acetylsalicylic acid):Increased risk of seizures with high doses ofciprofloxacinoral anticoagulants: Enhanced anticoagulanteffectsphenytoin: Increased or decreased bloodphenytoin levelprobenecid: Increased blood ciprofloxacinlevel and, possibly, toxicitytheophylline: Increased blood level, half-life,and risk of adverse effects of theophyllinetizanidine: Increased tizanidine effectsFOODScaffeine: Increased caffeine effectsdairy products: Delayed drug absorptionAdverse ReactionsCNS: Agitation, anxiety, cerebral thrombosis,confusion, dizziness, headache, insomnia,light-headedness, migraine, nightmares,paranoia, peripheral neuropathy,restlessness, seizures, syncope, toxic psychosisCV: Angina, atrial flutter, cardiopulmonaryarrest, cardiovascular collapse, hypertension,MI, orthostatic hypotension, palpitations,phlebitis, tachycardia, torsades depointes, vasculitis, ventricular ectopyEENT: Oral candidiasisGI: Abdominal pain, constipation, diarrhea,elevated liver function test results, flatulence,GI bleeding, hepatic failure or necrosis,hepatitis, indigestion, intestinal perforation,jaundice, nausea, pancreatitis, pseudomembranouscolitis, vomitingGU: Crystalluria, hematuria, increasedserum creatinine level, interstitial nephritis,nephrotoxicity, renal calculi, renal failure,urine retention, vaginal candidiasisHEME: Agranulocytosis, bone marrowdepression, hemolytic anemia, lymphadenopathy,pancytopeniaMS: Tendinitis, tendon ruptureSKIN: Erythema multiforme, exfoliativedermatitis, photosensitivity, rash, Stevens-Johnson syndrome, toxic epidermal necrolysis,urticariaRESP: Bronchospasm, pulmonaryembolism, respiratory arrestOther: Acidosis, anaphylaxis, angioedema,serum sicknesslike reaction

hythmics or those with uncorrectedhypokalemia or a history of QT-intervalprolongation.• Dilute I.V. ciprofloxacin concentrate to1 to 2 mg/ml using D 5 W or sodium chloridefor injection. Don’t dilute solutionsthat come from manufacturer in D 5 Wbefore I.V. infusion. Infuse slowly over1 hour.• Store reconstituted solution up to 14 daysat room temperature or refrigerated.• Don’t give oral suspension by feedingtube.• Be aware that E.R. and immediate-releasetablets aren’t interchangeable and thatProquin XR and Cipro XR aren’t interchangeable.• Patient should be well hydrated duringtherapy to help prevent alkaline urine,which may lead to crystalluria andnephrotoxicity.• Assess patient’s hepatic, renal, and hematologicfunctions periodically, as ordered,if he’s receiving prolonged therapy.• Monitor patient closely for diarrhea,which may reflect pseudomembranouscolitis. If it occurs, notify prescriber andexpect to withhold drug and treat diarrhea.• Assess patient for evidence of peripheralneuropathy. Notify prescriber and expectto stop drug if patient complains of burning,numbness, pain, tingling, or weaknessin extremities or if physical examinationreveals deficits in light touch, pain, temperature,position sense, vibratory sensation,or motor strength.• Monitor patients (especially children, elderlypatients, patients receiving corticosteroids,and patients who have renal failureor who have had a kidney, heart, orlung transplant) for evidence of tendonrupture, such as inflammation, pain, andswelling at the site. Be aware that tendonrupture may occur during or after ciprofloxacintherapy. Notify prescriber aboutsuspected tendon rupture, and havepatient rest and refrain from exercise untiltendon rupture has been ruled out. Ifpresent, expect to provide supportive careas ordered.• Assess patient routinely for signs of rashor other hypersensitivity reactions, evenafter patient has received multiple doses.Stop drug at first sign of rash, jaundice, orcitalopram hydrobromide 245other sign of hypersensivitity, and notifyprescriber immediately. Be prepared toprovide supportive emergency care.PATIENT TEACHING• Urge patient to complete the prescribedcourse of therapy, even if he feels betterbefore it’s finished.• Tell patient not to take drug with dairyproducts or calcium-fortified juices alone.• Advise patient to take ciprofloxacin2 hours before or 6 hours after antacids,iron supplements, or multivitamins thatcontain iron or zinc. Tell him to shake oralsuspension for 15 seconds, not to chewmicrocapsules, and not to split, crush, orchew E.R. tablets.• Encourage patient to drink plenty of fluidsduring therapy to help prevent crystalluria.• Urge patient to avoid caffeinated productsbecause caffeine may accumulate in thebody during ciprofloxacin therapy andcause excessive stimulation.• Caution patient to avoid excessive exposureto sunlight or artificial ultravioletlight because severe sunburn may result.Tell patient to notify prescriber if sunburndevelops; drug will need to be stopped.• Urge patient to avoid hazardous activitiesuntil CNS effects of drug are known.• Advise patient to notify prescriber aboutchanges in limb sensation or movementand about inflammation, pain, or swellingover a joint. Urge patient to rest the affectedlimb at the first sign of discomfort.• Tell patient to stop taking drug and tonotify prescriber at first sign of rash orother hypersensitivity reaction.• Urge patient to report watery, bloodystools to prescriber immediately, even upto 2 months after drug therapy has ended.citalopramhydrobromideCelexaClass and CategoryChemical class: Racemic, bicyclic phthalatederivativeTherapeutic class: AntidepressantPregnancy category: CC

246citalopram hydrobromideIndications and Dosages To treat depressionORAL SOLUTION, TABLETSAdults. Initial: 20 mg daily. Increased by20 mg at weekly intervals, as prescribed.Usual: 40 mg daily. Maximum: 60 mg daily.DOSAGE ADJUSTMENT For elderly patients,maximum dosage is 40 mg daily.Route Onset Peak DurationP.O. 1–wk Unknown UnknownMechanism of ActionBlocks serotonin reuptake by adrenergicnerves, which normally release this neurotransmitterfrom their storage sites whenactivated by a nerve impulse. This blockedreuptake increases serotonin levels at nervesynapses, which may elevate mood andreduce depression.ContraindicationsHypersensitivity to citalopram or itscomponents, use within 14 days of MAOinhibitor therapyInteractionsDRUGSamitriptyline, bromocriptine, buspirone,clomipramine, dextromethorphan, fluoxetine,fluvoxamine, furazolidone, imipramine, levodopa,lithium, meperidine, naratriptan,nefazodone, paroxetine, pentazocine,phenelzine, procarbazine, selegiline, sertraline,sibutramine, sumatriptan, tramadol,tranylcypromine, trazodone, venlafaxine,zolmitriptan: Possibly enhanced serotonergiceffects of citalopram, resulting in agitation,chills, confusion, diaphoresis, diarrhea,fever, hyperreflexia, hypomania, incoordination,myoclonus, or tremoraspirin, NSAIDs, warfarin: Increased risk ofbleeding ranging from ecchymoses to lifethreateninghemorrhagecarbamazepine: Possibly increased clearanceof citalopramcimetidine: Possibly increased blood citalopramleveldesipramine, metoprolol: Increased bloodlevels of these drugsfurazolidone, procarbazine, selegiline:Possibly hyperthermia, rigidity, myoclonus,and extreme agitation progressing to deliriumand comaitraconazole, ketoconazole, macrolide antibiotics,omeprazole: Possibly decreased clearanceof citalopramMAO inhibitors: Increased risk of lifethreateningserotonin syndrome or neurolepticmalignant syndromewarfarin: Possibly increased PTAdverse ReactionsCNS: Agitation, akathisia, anxiety, asthenia,delirium, dizziness, drowsiness, dyskinesia,fatigue, fever, insomnia, myoclonus, neurolepticmalignant syndrome, seizures, serotoninsyndrome, suicidal ideation, tremorCV: Chest pain, prolonged QT interval,thrombosis, ventricular arrhythmiasEENT: Blurred vision, dry mouth, rhinitis,sinusitisGI: Abdominal pain, anorexia, diarrhea, GIbleeding, hepatic necrosis, indigestion, nausea,pancreatitis, vomitingGU: Acute renal failure, anorgasmia,decreased libido, dysmenorrhea, ejaculationdisorders, impotence, priapismHEME: Abnormal bleeding, decreased PT,hemolytic anemia, thrombocytopeniaMS: Arthralgia, myalgia, rhabdomyolysisRESP: Upper respiratory tract infectionSKIN: Diaphoresis, ecchymosis, erythemamultiformeOther: Anaphylaxis, angioedema, hyponatremia,weight gain or lossNursing ConsiderationsWARNING When citalopram dosage increases,monitor patient for possible serotoninsyndrome, which may include agitation,chills, confusion, diaphoresis, diarrhea,fever, hyperactive reflexes, poor coordination,restlessness, shaking, talking or actingwith uncontrolled excitement, tremor, andtwitching. In its most severe form, serotoninsyndrome can resemble neurolepticmalignant syndrome, which includes ahigh fever, muscle rigidity, autonomicinstability with possible changes in vitalsigns, and mental status changes.• Be aware that effective antidepressanttherapy may convert depression intomania in predisposed people. If patientdevelops symptoms of mania, notify prescriberimmediately and expect to discontinuecitalopram.• Monitor patient with hepatic disease forincreased adverse reactions because drug isextensively metabolized in the liver.

• Assess elderly patients and those takingdiuretics for signs suggesting syndrome ofinappropriate secretion of antidiuretichormone, including hyponatremia andincreased serum and urine osmolarity.• If patient (especially a child or adolescent)takes citalopram for depression, monitorhim closely for suicidal tendencies, especiallywhen therapy starts or dosagechanges, because depression may worsenat these times.• To stop therapy, expect to reduce dosagegradually to avoid serious adverse reactions.PATIENT TEACHING• Inform patient that citalopram’s fulleffects may take up to 4 weeks.• Advise patient not to self-medicate forcoughs, colds, or allergies without consultingprescriber because these preparationscan increase the risk of adverse reactions.• Caution patient not to stop citalopramabruptly because doing so may lead toserious adverse reactions.• If patient (especially a child or adolescent)takes citalopram for depression, urge caregiversto monitor him closely for suicidaltendencies, especially when therapy startsor dosage changes.• Caution against taking OTC NSAIDs,aspirin, or other remedies (includingherbal products, such as St. John’s wort)while taking citalopram because they mayincrease the risk of bleeding.• Urge patient to report sudden, severe, orunusual adverse reactions promptly toprescriber. Although uncommon, lifethreateningadverse effects may occur.clarithromycinBiaxin, Biaxin XL, Biaxin XL-PAKClass and CategoryChemical class: Macrolide derivativeTherapeutic class: AntibioticPregnancy category: CIndications and Dosages To treat pharyngitis and tonsillitiscaused by Streptococcus pyogenesORAL SUSPENSION, TABLETSAdults and adolescents. 250 mg every12 hr for 10 days.clarithromycin 247Children. 15 mg/kg daily in divided dosesevery 12 hr for 10 days. To treat acute maxillary sinusitis causedby Haemophilus influenzae, Moraxellacatarrhalis, or Streptococcus pneumoniaeORAL SUSPENSION, TABLETSAdults and adolescents. 500 mg every 12 hrfor 14 days.Children. 15 mg/kg daily in divided dosesevery 12 hr for 10 days.E.R. TABLETSAdults and adolescents. 1,000 mg every24 hr for 14 days. To treat acute exacerbations of chronicbronchitis caused by H. influenzae, M.catarrhalis, or S. pneumoniaeORAL SUSPENSION, TABLETSAdults and adolescents. 250 to 500 mgevery 12 hr for 7 to 14 days.Children. 15 mg/kg daily in divided dosesevery 12 hr for 10 days.E.R. TABLETSAdults and adolescents. 1,000 mg every24 hr for 7 days. To treat uncomplicated skin and softtissueinfections caused byStaphylococcus aureus or S. pyogenesORAL SUSPENSION, TABLETSAdults and adolescents. 250 mg every 12 hrfor 7 to 14 days.Children. 15 mg/kg daily in divided dosesevery 12 hr for 10 days. To treat pneumonia caused byChlamydia pneumoniae, Mycoplasmapneumoniae, or S. pneumoniaeORAL SUSPENSION, TABLETSAdults and adolescents. 250 mg every12 hr for 7 to 14 days.Children. 15 mg/kg daily in divided dosesevery 12 hr for 10 days. To treat pneumonia caused by H.influenzaeORAL SUSPENSION, TABLETSAdults and adolescents. 250 mg every12 hr for 7 days.Children. 15 mg/kg daily in divided dosesevery 12 hr for 10 days. To treat acute otitis media caused by H.influenzae, M. catarrhalis, or S. pneumoniaeORAL SUSPENSION, TABLETSChildren. 15 mg/kg daily in divided dosesevery 12 hr for 10 days.C

248Nursing Considerations• Expect to obtain a specimen for cultureand sensitivity tests before giving firstdose.• Use clarithromycin cautiously in patientswith renal impairment. Be aware thatpatients with severe renal impairment mayneed decreased dosage or prolongeddosage interval and that clarithromycin isnot recommended in combination withranitidine bismuth citrate therapy ifpatient has a creatinine clearance less than2.5 ml/min/1.73 m 2 or a history of acuteporphyria.• Assess patient’s bowel pattern daily; severediarrhea may indicate pseudomembranouscolitis caused by Clostridium difficile. Ifdiarrhea occurs, notify prescriber andexpect to withhold clarithromycin andtreat with fluids, electrolytes, protein, andan antibiotic effective against C. difficile.PATIENT TEACHING• Stress the importance of taking the fullcourse of clarithromycin exactly as preclarithromycin To treat active duodenal ulcer caused byHelicobacter pyloriORAL SUSPENSION, TABLETSAdults and adolescents. 500 mg every 8 hrfor 14 days with omeprazole 40 mg daily inthe morning. Then, omeprazole continuedat 20 mg daily in the morning days15 through 28. Or, 500 mg every 12 hr for14 days with lansoprazole 30 mg and amoxicillin1 g every 12 hr for 14 days. To prevent or treat Mycobacteriumavium complex in patients with HIVinfectionORAL SUSPENSION, TABLETSAdults and adolescents. 500 mg every12 hr for 7 to 14 days.Children. 7.5 mg/kg every 12 hr. Maximum:500 mg b.i.d.Mechanism of ActionInhibits RNA-dependent protein synthesisin many types of aerobic, anaerobic, grampositive,and gram-negative bacteria. Bybinding with the 50S ribosomal subunit ofthe bacterial 70S ribosome, clarithromycincauses bacterial cells to die.ContraindicationsConcurrent therapy with astemizole, cisapride,pimozide, or terfenadine; hypersensitivityto clarithromycin, erythromycin, orany macrolide antibioticInteractionsDRUGSastemizole, disopyramide, quinidine: Possiblyprolonged QT interval or torsades depointescarbamazepine, other drugs metabolized bycytochrome P450 enzyme system: Increasedblood levels of these drugscisapride, disopyramide, pimozide, quinidine,terfenadine: Increased risk of arrhythmiascolchicine: Increased risk of colchicine toxicitydigoxin: Increased serum digoxin leveldihydroergotamine, ergotamine: Risk ofacute ergot toxicitylovastatin, simvastatin: Risk of rhabdomyolysisoral anticoagulants: Potentiated anticoagulanteffectsrifabutin, rifampin: Decreased bloodclarithromycin level by more than 50%sildenafil: Possibly prolonged blood sildenafilleveltheophylline: Increased blood theophyllineleveltriazolam: Possibly increased CNS effectszidovudine: Decreased blood zidovudinelevelAdverse ReactionsCNS: Anxiety, confusion, dizziness, fatigue,hallucinations, headache, insomnia, mania,nightmares, seizures, somnolence, tremor,vertigoCV: Prolonged QT interval, ventriculararrhythmiasEENT: Altered smell, altered taste, glossitis,hearing loss, oral moniliasis, stomatitis, tinnitus,tongue or tooth discolorationENDO: HypoglycemiaGI: Abdominal pain, diarrhea, indigestion,nausea, pancreatitis, pseudomembranouscolitisGU: Anorexia, elevated BUN level, hepaticdysfunction, vomitingHEME: Leukopenia, neutropenia, increasedprothrombin time, thrombocytopeniaSKIN: Pruritus, rash, Stevens-Johnson syndrome,toxic epidermal necrolysis, urticariaOther: Anaphylaxis, new or worseningmyasthenia gravis symptoms, superinfection

scribed, even after feeling better.• Caution patient not to crush or chew E.R.tablets.• Advise patient to take drug with food if hetakes E.R. tablets or has GI distress.• If patient takes suspension form, instructhim not to refrigerate it.• Tell patient to report severe nausea, rash,or itching.• Instruct patient not to take OTC or prescriptiondrugs without consulting prescriberof clarithromycin.•Urge patient to immediately report watery,bloody stools to prescriber, even if theyoccur up to 2 months after therapy hasended.clidinium bromideQuarzanClass and CategoryChemical class: Synthetic quaternaryammonium derivativeTherapeutic class: AnticholinergicPregnancy category: Not ratedIndications and Dosages As adjunct to treat peptic ulcerCAPSULESAdults. 2.5 to 5 mg t.i.d. or q.i.d. 30 to60 min before meals and at bedtime.DOSAGE ADJUSTMENT Dosage limited to2.5 mg t.i.d. before meals for elderly ordebilitated patients.Route Onset Peak DurationP.O. 1 hr Unknown Up to 3 hrMechanism of ActionInhibits acetylcholine’s muscarinic actionsat postganglionic parasympathetic receptorsites, including smooth muscles, secretoryglands, and the CNS. These actions relaxsmooth muscles and diminish GI, GU, andbiliary tract secretions.clidinium bromide 249ContraindicationsAngle-closure glaucoma, benign bladderneck obstruction, hypersensitivity to clidiniumbromide or its components, ileus,intestinal atony (elderly or debilitatedpatients), intestinal obstruction, myastheniagravis, myocardial ischemia, ocular adhesionsbetween lens and iris, prostatic hypertrophy,renal disease, severe ulcerative colitis,tachycardia, toxic megacolon, unstablecardiovascular status in acute hemorrhageInteractionsDRUGSamantadine: Increased risk of clidiniumadverse effectsatenolol: Increased atenolol effectsCNS depressants: Increased clidinium effectsphenothiazines: Decreased antipsychoticeffectivenesstricyclic antidepressants: Increased clidiniumadverse effectsACTIVITIESalcohol use: Increased clidinium effectsAdverse ReactionsCNS: Confusion, dizziness, drowsiness,excitement, fever, headache, insomnia,memory loss, nervousness, weaknessCV: Palpitations, tachycardiaEENT: Blurred vision, cycloplegia, drymouth, increased intraocular pressure, lossof taste, mydriasis, nasal congestion,pharyngitis, photophobiaGI: Bloating, constipation, dysphagia,heartburn, ileus, nausea, vomitingGU: Impotence, urinary hesitancy, urineretentionSKIN: Decreased sweating, flushing, rash,urticariaNursing Considerations• Avoid high doses in patients with ulcerativecolitis because clindinium may inhibitintestinal motility and cause or worsentoxic megacolon. Also avoid high doses inpatients with hiatal hernia or refluxesophagitis because drug may aggravateesophagitis.• Use drug cautiously in patients with heartfailure, arrhythmias, hypertension, autonomicneuropathy, hyperthyroidism, allergies,asthma, or debilitating chronic lungdisease.WARNING Monitor elderly patients forexcitement, agitation, drowsiness, andconfusion, even with small doses, becausethese patients are more sensitive to clidinium’seffects. If these reactions occur, notifyprescriber and expect to decrease dosage.• Take safety precautions to protect patientfrom injury from falling.C

250clindamycinPATIENT TEACHING• Instruct patient to take clidinium exactlyas prescribed and not to stop taking itsuddenly because it can cause withdrawalsymptoms, such as vomiting, diaphoresis,and dizziness.• Advise patient to take drug 30 to 60 minutesbefore meals.• Tell patient not to store capsules in dampplaces, such as the bathroom.• Teach patient how to prevent or relieveconstipation and dry mouth.• Instruct patient to avoid alcohol and otherCNS depressants because they increase thedrug’s effects.• Instruct patient to report constipation,vision changes, sore throat, difficulty urinating,and palpitations.clindamycinhydrochlorideCleocin, Dalacin CclindamycinpalmitatehydrochlorideCleocin Pediatric, Dalacin C FlavoredGranules (CAN)clindamycinphosphateCleocin, Clindesse, Dalacin CPhosphate (CAN), EvoclinClass and CategoryChemical class: LincosamideTherapeutic class: Antibacterial and antiprotozoalantibioticPregnancy category: BIndications and Dosages To treat serious respiratory tract infectionscaused by anaerobes such as occurwith anaerobic pneumonitis, empyema,and lung abscess and those caused bypneumococci, staphylococci, and streptococci;serious skin and soft-tissue infectionscaused by anaerobes, staphylococci,and streptococci; septicemia caused byanaerobes; intra-abdominal infectionscaused by anaerobes such as occur withintra-abdominal abscess and peritonitis;infections of the female pelvis and genitaltract caused by anaerobes such asoccur with endometritis, nongonococcaltubo-ovarian abscess, pelvic cellulitis,and postsurgical vaginal cuff infection;bone and joint infections caused byStaphylococcus aureus; as adjunct therapyin chronic bone and joint infectionsCAPSULES, ORAL SOLUTIONAdults and adolescents. For serious infections,150 to 300 mg every 6 hr; for severeinfections, 300 to 450 mg every 6 hr.Children. For serious infections, 8 to16 mg/kg daily in equally divided dosest.i.d. or q.i.d.; for severe infections, 16 to20 mg/kg/day in equally divided doses t.i.d.or q.i.d.I.V. INFUSION, I.M. INJECTIONAdults and adolescents age 16 and over.For serious infections, 600 to 1,200 mgdaily in equally divided doses b.i.d. to q.i.d.;for severe infections, 1,200 to 2,700 mgdaily in equally divided doses b.i.d. to q.i.d.;for life-threatening infections, 4,800 mgdaily in equally divided doses b.i.d. to q.i.d.Children ages 1 month to 16 years. 20 to40 mg/kg daily in equally divided dosest.i.d. or q.i.d., depending on severity ofinfection.Neonates less than age 1 month. 15 to20 mg/kg daily in equally divided dosest.i.d. or q.i.d., depending on severity ofinfection. To treat vaginal infections caused byGardnerella or HaemophilusVAGINAL CREAMNonpregnant adults. 100 mg (1 applicatorful)into vagina daily, preferably at bedtime,for 3 to 7 consecutive days.Pregnant adults in second or thirdtrimester. 100 mg (1 applicatorful) intovagina daily, preferably at bedtime, for7 consecutive days. To treat acne vulgarisFOAMAdults and adolescents. Apply to affectedarea daily.Mechanism of ActionInhibits protein synthesis in susceptiblebacteria by binding to the 50S subunits of

acterial ribosomes and preventing peptidebond formation, which causes bacterialcells to die.IncompatibilitiesTo prevent physical incompatibility, don’tadminister with aminophylline, ampicillin,barbiturates, calcium gluconate, magnesiumsulfate, or phenytoin.ContraindicationsHypersensitivity to clindamycin or lincomycinInteractionsDRUGSerythromycin: Possibly blocked access ofclindamycin to its site of actionkaolin-pectin antidiarrheals: Decreasedabsorption of oral clindamycinneuromuscular blockers: Increased neuromuscularblockadeAdverse ReactionsCNS: Fatigue, headacheCV: Hypotension, thrombophlebitis (afterI.V. injection)EENT: Glossitis, metallic or unpleasanttaste (with high I.V. doses), stomatitisGI: Abdominal pain, diarrhea, esophagitis,nausea, pseudomembranous colitis, vomitingGU: Cervicitis, vaginitis, and vulvar irritation(with vaginal form)HEME: Agranulocytosis, eosinophilia,leukopenia, neutropenia, thrombocytopenicpurpuraSKIN: Pruritus, rash, urticariaOther: Anaphylaxis; induration, pain, orsterile abscess after injection; superinfectionNursing Considerations• Expect to obtain a specimen for cultureand sensitivity testing before giving firstdose.• Use clindamycin cautiously in patientswho have a history of asthma, significantallergies, or GI disease; in those with renalor hepatic dysfunction; and in elderly oratopic patients.WARNING Don’t give 75- and 150-mg capsulesto tartrazine-sensitive patients.• Store oral solution for up to 2 weeks atroom temperature or reconstituted parenteralsolution for up to 24 hours atroom temperature.clindamycin 251• Give I.V. dose by infusion only; don’t givebolus dose. Dilute 300 mg of clindamycinin 50 ml of diluent and give over 10 minutes.Dilute 600 mg of clindamycin in 100ml of diluent and give over 20 minutes.Dilute 900 mg of clindamycin in 100 ml ofdiluent and give over 30 minutes.WARNING Don’t use diluents that containbenzyl alcohol when clindamycin is to beadministered to neonates because a fataltoxic syndrome may occur.• Give I.M. injection deep into large musclemass, such as the gluteus maximus. Rotateinjection sites, and avoid giving more than600 mg by I.M. injection.• Check I.V. site often for phlebitis and irritation.• For topical foam, wash the affected areawith mild soap, let it dry fully, and thenapply foam to entire affected area.• Monitor results of liver function tests,CBC, and platelet counts during prolongedtherapy.• Observe patient for signs and symptomsof superinfection, such as vaginal itchingand sore mouth, which may occur 2 to9 days after therapy begins.• Assess patient’s bowel pattern daily; severediarrhea may indicate pseudomembranouscolitis caused by Clostridium difficile. Ifdiarrhea occurs, notify prescriber andexpect to withhold clindamycin and treatwith fluids, electrolytes, protein, and anantibiotic effective against C. difficile.PATIENT TEACHING• Tell patient to complete the prescribedcourse of therapy, even if he feels betterbefore it’s finished.• Instruct patient to take oral clindamycinwith at least 8 oz of water to preventesophageal irritation.• Advise patient to take oral drug with food,if needed, to reduce GI distress.• Tell patient not to refrigerate reconstitutedoral solution because it may become thickand difficult to pour and to discardunused drug after 14 days.• If patient will use topical foam, tell him towash affected area with mild soap, let itdry fully, and then apply foam to entirearea. Caution against dispensing foamdirectly onto hands or face because foamwill melt when it contacts warm skin.Instead, patient should dispense amountC

252clofibrateto be used into the cap or onto a cool surface.Tell patient to pick up a smallamount with fingertips and gently massageinto affected area until foam disappears.If foam feels warm or looks runny,tell patient to run the can under coldwater before dispensing.• Warn patient not to rely on latex or rubbercondoms and diaphragms for 72 hoursafter vaginal treatment because mineral oilin vaginal cream may weaken these items.• Explain that having sexual intercourseafter using vaginal cream can increase irritation.• Inform patient that I.M. injection may bepainful.• Tell patient to immediately report aninflamed mouth or vagina, and rash orlesions.• Urge patient to immediately report watery,bloody stools to prescriber, even up to 2months after drug therapy has ended.clofibrateAbitrate, Atromid-S, Claripex (CAN),Novofibrate (CAN)Class and CategoryChemical class: Aryloxyisobutyric acidderivativeTherapeutic class: AntihyperlipidemicPregnancy category: CIndications and Dosages To treat primary hyperlipidemia (typeIII) that doesn’t respond to diet, andtype IV and type V hyperlipidemia thatdon’t respond to diet in patients at riskfor abdominal pain and pancreatitisCAPSULESAdults. 1.5 to 2 g daily in divided dosesb.i.d. to q.i.d.Route Onset Peak DurationP.O. 2–5 days 3 wk 3 wkMechanism of ActionIncreases the amount of cholesterol that’ssecreted into bile and of bile that’s excretedin the feces. Clofibrate also may increasethe activity of lipoprotein lipase, whichdegrades VLDLs.ContraindicationsHepatic dysfunction, hypersensitivity toclofibrate, lactation, peptic ulcer, pregnancy,primary biliary cirrhosis, renal dysfunctionInteractionsDRUGSchenodiol, ursodiol: Counteracted effectivenessof these drugsdantrolene: Decreased plasma protein bindingof dantrolenefurosemide: Increased furosemide and clofibrateeffectsinsulin, sulfonylureas: Increased antidiabeticeffectoral anticoagulants: Increased bleeding tendencyoral contraceptives: Decreased effectivenessof clofibratephenytoin: Displacement of phenytoin frombinding siteprobenecid: Increased clofibrate effectsrifampin: Decreased clofibrate effectsAdverse ReactionsCNS: Dizziness, drowsiness, fatigue, headache,weaknessCV: Angina, edema, phlebitisEENT: StomatitisGI: Abdominal pain, bloating, diarrhea,flatulence, nausea, vomitingGU: Decreased libido, decreased urine output,impotence, proteinuriaHEME: EosinophiliaMS: Arthralgia, myalgiaSKIN: Alopecia, dry skin and hair, pruritus,rash, urticariaOther: Weight gainNursing Considerations• Obtain baseline CBC, liver and renal functionstudies, and cholesterol profile, asordered.• Use clofibrate cautiously in patients with ahistory of hepatic disease or jaundice andin those with peptic ulcer disease.PATIENT TEACHING• Tell patient to take clofibrate with milk orfood to reduce GI distress.• Tell patient that repeated laboratory testswill be needed to evaluate serum cholesteroland triglyceride levels.• Stress the importance of diet, exercise, andweight loss to control cholesterol.• Tell patient to report ankle or leg swelling,chest pain, decreased urine output, severe

GI reactions, and unusual weight gain.• If patient takes an anticoagulant, tell himto watch carefully for signs and symptomsof abnormal bleeding.• If patient takes antidiabetic drugs, instructhim to stay alert for signs of hypoglycemiafrom interactions with these drugs.• Advise women of childbearing age to usecontraception during and for severalmonths after clofibrate therapy because ofteratogenic effects.clomipraminehydrochlorideAnafranilClass and CategoryChemical class: Dibenzazepine derivativeTherapeutic class: Antiobsessional tricyclicantidepressantPregnancy category: CIndications and Dosages To treat obsessive-compulsive disorderCAPSULES, TABLETSAdults. Initial: 25 mg daily. Graduallyincreased to 100 mg daily in divided dosesover 2 wk, then to maximum of 250 mgdaily in divided doses over next few weeks.At maximum dose, total daily amount maybe given at bedtime.Children age 10 and over. Initial: 25 mgdaily. Gradually increased to the lesser of3 mg/kg daily or 100 mg daily in divideddoses over 2 wk, then to maximum of3 mg/kg daily or 200 mg daily, whichever isless. At maximum dose, total daily amountmay be given at bedtime.Route Onset Peak DurationP.O. Unknown 2–4 wk UnknownMechanism of ActionMay inhibit neuronal reuptake of norepinephrineand serotonin, which may be afactor in normalizing neurotransmission inobsessive-compulsive behavior.ContraindicationsAcute recovery period after MI, hypersensitivityto clomipramine or its components,use of an MAO inhibitor within 14 daysclomipramine hydrochloride 253InteractionsDRUGSanticholinergics: Increased anticholinergiceffectsbarbiturates: Decreased level and effects ofclomipramine; additive CNS depressionbupropion, cimetidine, haloperidol, H 2 -receptor antagonists, selective serotonin reuptakeinhibitors, valproic acid: Increasedblood level and therapeutic and adverseeffects of clomipraminecarbamazepine: Decreased blood clomipraminelevel; increased carbamazepine levelclonidine: Severely increased blood pressureand risk of hypertensive crisisCNS depressants: Increased CNS depressiondicumarol: Increased anticoagulant effectgrepafloxacin, quinolones, sparfloxacin:Increased risk of life-threatening arrhythmiasguanethidine: Antagonized antihypertensiveeffect of guanethidinelevodopa: Delayed absorption and decreasedbioavailability of levodopaMAO inhibitors: Increased risk of seizures,coma, or deathrifamycins: Decreased clomipramine levelsympathomimetics: Possibly potentiated cardiovasculareffectsthyroid drugs: Increased effects of thyroiddrugs and clomipramineACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Anxiety, confusion, depersonalization,depression, dizziness, drowsiness, emotionallability, fatigue, headache, insomnia, panicreaction, paresthesia, somnolence, suicidalideation (children and teens), syncope,tremor, unusual dreams, yawningCV: Orthostatic hypotension, palpitations,tachycardiaEENT: Blurred vision, dry mouth, epistaxis,pharyngitis, rhinitis, sinusitis, unpleasanttasteGI: Abdominal pain, anorexia, constipation,diarrhea, flatulence, increased appetite,indigestion, nausea, vomitingGU: Dysmenorrhea, ejaculation failure,impotence, urinary hesitancy, urine retentionRESP: BronchospasmSKIN: Abnormal skin odor, acne, dermatitis,dry skin, photosensitivity, rash, urticariaOther: Weight gainC

254clonazepamNursing Considerations• Be aware that stopping clomipramineabruptly may cause withdrawal symptomsand worsen disorder.WARNING Don’t give drug within 14 days ofan MAO inhibitor to avoid possibleseizures, coma, or death.WARNING Monitor children and teensclosely for evidence of suicidal ideation;clomipra-mine increases the risk in thesegroups.PATIENT TEACHING• Tell patient not to use alcohol, barbiturates,or other CNS depressants;clomipramine increases their effects.WARNING Urge parents to watch their childor teen closely for abnormal thinking orbehavior or increased aggression or hostility.Stress the need to notify prescriber ifthey occur.• Inform male patients about risk of sexualdysfunction while taking drug.• Caution patient that drug may causedrowsiness, especially during initial dosageadjustment.• Warn patient not to stop taking drugabruptly.• Instruct patient to take a missed dose assoon as he remembers unless it’s almosttime for the next scheduled dose, in whichcase he should skip the missed dose. Warnagainst doubling the next dose.• Teach patient how to prevent photosensitivityreactions.• Tell patient to report difficulty urinating,dizziness, dry mouth, sedation, and mentalchanges.• Caution patient to avoid hazardous activitiesuntil CNS effects of drug are known.clonazepamApo-Clonazepam (CAN), Clonapam(CAN), Gen-Clonazepam (CAN), Klonopin,Rivotril (CAN)Class, Category, and ScheduleChemical class: BenzodiazepineTherapeutic class: AnticonvulsantPregnancy category: DControlled substance schedule: IVIndications and Dosages To treat Lennox-Gastaut syndrome(type of absence seizure disorder) andakinetic and myoclonic seizuresTABLETSAdults and children over age 10. 1.5 mgdaily in divided doses t.i.d. Increased by0.5 to 1 mg every 3 days, if needed, untilseizures are controlled. Maximum: 20 mgdaily.Children age 10 and under or weighingless than 30 kg (66 lb). 0.01 to 0.03 mg/kgdaily in divided doses b.i.d. or t.i.d.Increased by 0.25 to 0.5 mg every third dayup to maintenance dosage. Maintenance:0.1 to 0.2 mg/kg daily, preferably in threeequal doses, or if unequal, with largest dosegiven at bedtime. Maximum: 0.05 mg/kgdaily. To treat panic disorderTABLETSAdults. Initial: 0.25 mg b.i.d. Increased, ifneeded, to 1 mg daily after 3 days. If morethan 1 mg daily is required, dosageincreased in increments of 0.125 to 0.25 mgb.i.d. every 3 days until panic disorder iscontrolled or adverse reactions make furtherincreases undesirable. This maintenancedosage may be given as a single doseat bedtime. Maximum: 4 mg daily.Mechanism of ActionPrevents seizures by potentiating the effectsof gamma-aminobutyric acid (GABA),which is an inhibitory neurotransmitter.Suppresses the spread of seizure activitycaused by seizure-producing foci in the cortex,thalamus, and limbic structures.ContraindicationsAcute angle-closure glaucoma, hepatic disease,hypersensitivity to benzodiazepines ortheir componentsInteractionsDRUGSantianxiety drugs, barbiturates, MAOinhibitors, opioids, phenothiazines, tricyclicantidepressants: Increased CNS depressionACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Ataxia, confusion, depression, dizziness,drowsiness, emotional lability, fatigue,headache, memory loss, nervousness,reduced intellectual ability, suicidal ideationCV: Palpitations

EENT: Blurred vision, eyelid spasm,increased salivation, loss of taste, pharyngitis,rhinitis, sinusitisGI: Abdominal pain, anorexia, constipationGU: Difficult ejaculation, dysmenorrhea,dysuria, enuresis, impotence, nocturia,urine retention, UTIHEME: Anemia, eosinophilia, leukopenia,thrombocytopeniaMS: Dysarthria, myalgiaRESP: Bronchitis, coughOther: Allergic reactionNursing Considerations• Use clonazepam cautiously in patientswith renal failure, mixed seizure disorder(because drug can increase the risk of generalizedtonic-clonic seizures), or respiratorydisease and troublesome secretions(because clonazepam increases salivation)and in elderly patients (because they’remore sensitive to drug’s CNS effects).• Monitor blood drug level, CBC, and liverfunction test results during long-term orhigh-dose therapy, as ordered.WARNING Don’t stop drug abruptly; expectto taper dosage gradually to avoid withdrawalsymptoms and seizures.• Monitor patient closely for evidence ofsuicidal thinking or behavior, especiallywhen therapy starts or dosage changes.PATIENT TEACHING• Tell patient to take drug exactly as prescribed.Explain that stopping abruptlycan cause seizures and withdrawal symptoms.• Advise patient to avoid alcohol and sleepinducingdrugs during therapy. Instructhim to consult prescriber before takingany OTC drugs.• Urge patient to carry medical identificationof his seizure disorder and drug therapy.• Warn patient about possible drowsiness.• Instruct patient to report severe dizziness,persistent drowsiness, palpitations, difficultyurinating, seizure activity, and otherdisruptive adverse reactions.• Suggest that parents monitor child’s performancein school because clonazepamcan cause drowsiness or inattentiveness.• Urge caregivers to watch patient closely forevidence of suicidal tendencies, especiallywhen therapy starts or dosage changes,and to report concerns to prescriberclonidine 255immediately.• Urge female patient who becomes pregnantwhile taking clonazepam to enroll inthe Antiepileptic Drug Pregnancy Registryby calling 1-888-233-2334. Explain thatthe registry is studying the safety ofantiepileptic drugs during pregnancy.clonidineCatapres-TTSclonidinehydrochlorideCatapres, Dixarit (CAN), DuraclonClass and CategoryChemical class: Imidazoline derivativeTherapeutic class: Analgesic, antihypertensivePregnancy category: CIndications and Dosages To manage hypertensionTABLETSAdults. Initial: 0.1 mg b.i.d., increased by0.1 mg/wk to produce desired response.Maintenance: 0.2 to 0.6 mg daily in divideddoses b.i.d. or t.i.d. Maximum: 2.4 mg daily.TRANSDERMAL PATCHAdults. Initial: 0.1-mg patch applied tohairless area of intact skin on upper arm ortorso every 7 days. After 1 to 2 wk, if bloodpressure isn’t controlled, two 0.1-mg patchesor one 0.2-mg patch applied to skin.Dosage adjusted, as needed, every 7 days.Maximum: Two 0.3-mg patches worn atsame time. To treat severe hypertensionTABLETSAdults. 0.2 mg, then 0.1 mg every 1 hr untildiastolic blood pressure reaches acceptablerange or 0.8 mg has been administered.DOSAGE ADJUSTMENT Dosage individualizedfor patients with renal failure. As adjunct to relieve severe pain (incancer patients) that isn’t adequatelyrelieved by opioid analgesics aloneCONTINUOUS EPIDURAL INFUSIONAdults. Initial: 30 mcg/hr. Titrated up ordown, if needed, depending on comfort.Maximum: 40 mcg/hr.Children old enough to tolerate placementC

256clonidineand management of epidural catheter.Initial: 0.5 mcg/kg/hr. Then, titrated toachieve comfort.Route Onset Peak DurationP.O. 30–60 min 2–4 hr 8 hrTrans- 2–3 days Unknown 7 daysdermalMechanism of ActionStimulates peripheral alpha-adrenergicreceptors in the CNS to produce transientvasoconstriction and then stimulates centralalpha-adrenergic receptors in the brainstem to reduce peripheral vascular resistance,heart rate, and systolic and diastolicblood pressure. May produce analgesia bypreventing transmission of pain signals tothe brain at presynaptic and postjunctionalalpha 2 -adrenoreceptors in the spinal cord.With epidural administration, clonidineproduces analgesia in body areas innervatedby the spinal cord segments in which thedrug concentrates.ContraindicationsAnticoagulant therapy (epidural infusion);bleeding diathesis; hypersensitivity to clonidineor its components, including adhesiveused in transdermal patch; injection siteinfection (epidural infusion)InteractionsDRUGSbarbiturates, other CNS depressants:Increased depressant effects of these drugsbeta blockers, calcium channel blockers, digoxin:Additive effects, such as bradycardiaand AV block; increased risk of worsenedhypertensive response when clonidine iswithdrawn (beta blockers only)diuretics, other antihypertensive drugs:Increased hypotensive effectepidural local anesthetics: Prolonged effectsof epidural local anesthetics when usedwith epidural clonidinelevodopa: Decreased levodopa effectivenessprazosin, tricyclic antidepressants: Decreasedantihypertensive effect of clonidineACTIVITIESalcohol use: Enhanced CNS depressanteffects of alcoholAdverse ReactionsCNS: Agitation, delusional perception,depression, dizziness, drowsiness, fatigue,headache, malaise, nervousness, paresthesia,sedation, syncope, weaknessCV: Arrhythmias, chest pain, congestiveheart failure, high-degree AV block, orthostatichypotension, Raynaud’s phenomenonEENT: Accommodation disorder, blurredvision, burning eyes, decreased lacrimation,dry eyes and mouth, salivary gland painGI: Constipation, hepatitis, mildly elevatedliver function test results, nausea, vomitingGU: Decreased libido, erectile dysfunction,nocturiaHEME: ThrombocytopeniaSKIN: Angioneurotic edema, pruritus, rash,urticariaOther: Weight gain, withdrawal symptomsNursing Considerations• Use clonidine cautiously in elderlypatients, who may be more sensitive to itshypotensive effect.• Monitor blood pressure and heart rateoften during clonidine therapy.• Expect transdermal clonidine to take 2 to3 days to lower blood pressure.• Remove patch before patient has an MRIto avoid possible burns at the patch site.• Be aware that stopping drug abruptly canelevate serum catecholamine levels andcause such withdrawal symptoms as nervousness,agitation, headache, confusion,tremor, and rebound hypertension.• Expect hypertension to return within48 hours after drug is discontinued.PATIENT TEACHING• Advise patient to take drug exactly as prescribedand not to stop abruptly becausewithdrawal symptoms and severe hypertensionmay occur.• Instruct patient to consult prescriber ifdry mouth or drowsiness becomes a problemduring oral clonidine therapy. Tominimize these effects, prescriber maysuggest taking most of dosage at bedtime.• If a transdermal patch loosens during 7-day application period, tell patient to placeadhesive overlay directly over patch toensure adhesion.• Tell patient to rotate transdermal sites.• Instruct patient to remove patch and placea fresh one on another site if skin irritation,redness, or rash develops at patchsite.

• Advise patient to fold used transdermalpatch in half with adhesive sides togetherand discard it out of the reach of children.• Because of possible sedation, advisepatient to avoid hazardous activities untildrug’s CNS effects are known.• Advise men that libido may decrease.• Instruct patient to report chest pain, dizzinesswith position changes, excessivedrowsiness, rash, urine retention, andvision changes. As needed, tell patient torise slowly to avoid hypotensive effects.• Inform patient who wears contact lensesthat clonidine may cause dry eyes.clopidogrelbisulfatePlavixClass and CategoryChemical class: Thienopyridine derivativeTherapeutic class: Platelet aggregationinhibitorPregnancy category: BIndications and Dosages To reduce atherosclerotic events, such asstroke and MI, in patients with atherosclerosisdocumented by recent stroke,MI, or peripheral artery diseaseTABLETSAdults. 75 mg daily. To reduce atherosclerotic events, such asstroke and MI, in patients with acutecoronary syndrome (unstable angina ornon–Q-wave MI)TABLETSAdults. Loading dose: 300 mg. Maintenance:75 mg daily. To reduce rate of death, reinfarction, orstroke in patients with ST-segment elevationacute MITABLETSAdults. 75 mg once daily. Or, loading doseof 300 mg followed by 75 mg once daily.Mechanism of ActionBinds to adenosine diphosphate (ADP)receptors on the surface of activatedplatelets. This action blocks ADP, whichdeactivates nearby glycoprotein IIb/IIIareceptors and prevents fibrinogen fromclopidogrel bisulfate 257attaching to receptors. Without fibrinogen,platelets can’t aggregate and form thrombi.Route Onset Peak DurationP.O. 2 hr 3–7 days* 5 daysContraindicationsActive pathological bleeding, including pepticulcer and intracranial hemorrhage;hypersensitivity to clopidogrel or its componentsInteractionsDRUGSaspirin: Increased risk of bleedingCYP2C19 inhibitors, such as cimetidine,esomeprazole, etravirine, felbamate, fluconazole,fluoxetine, fluvoxamine, ketoconazole,omeprazole, ticlopidine, voriconazole:Decreased plasma clopidogrel level,decreased platelet inhibitionfluvastatin, phenytoin, tamoxifen, tolbutamide,torsemide: Interference with metabolismof these drugsNSAIDs: Increased risk of GI bleeding,interference with NSAID metabolismwarfarin: Prolonged bleeding time, interferencewith warfarin metabolismAdverse ReactionsCNS: Confusion, depression, dizziness,fatigue, hallucinations, headacheCV: Chest pain, edema, hypercholesterolemia,hypertension, hypotension, vasculitisEENT: Altered taste; conjunctival, ocular, orretinal bleeding; epistaxis; rhinitis; taste disordersGI: Abdominal pain; acute liver failure;colitis; diarrhea; duodenal, gastric, or pepticulcer; elevated liver function test results;gastritis; indigestion; nausea; noninfectioushepatitis; pancreatitisGU: Elevated serum creatinine level, glomerulopathy,UTIHEME: Agranulocytosis, aplastic anemia,neutropenia, pancytopenia, prolongedbleeding time, thrombocytopenic purpura,thrombotic thrombocytopenic purpura,unusual bleeding or bruisingMS: Arthralgia, back pain, myalgiaRESP: Bronchitis, bronchospasm, cough,dyspnea, interstitial pneumonitis, upperrespiratory tract infection* With repeated doses.C

258clorazepate dipotassiumSKIN: Erythema multiforme, lichen planus,pruritus, purpura, rash, Stevens-Johnsonsyndrome, toxic epidermal necrolysisOther: Anaphylaxis, angioedema, flulikesymptoms, serum sicknessNursing Considerations• Avoid clopidogrel in patients who have agenetic variation in CYP2C19 or arereceiving CYP2C19 inhibitors. Plateletinhibition may decline, increasing the riskof adverse cardiovascular effects after MI.• Use clopidogrel cautiously in patients withsevere hepatic or renal disease, risk ofbleeding from trauma or surgery, or conditionsthat predispose to bleeding (suchas peptic ulcer disease or thromboticthrombocytopenic purpura).• In patient with acute coronary syndrome,expect to give aspirin with clopidogrel.WARNING Clopidogrel prolongs bleedingtime; expect to stop it 5 days before electivesurgery.• Obtain blood cell count, as ordered, wheneversigns and symptoms suggest a hematologicproblem.• Monitor patient who takes aspirin closelybecause risk of bleeding is increased.PATIENT TEACHING• Discourage use of NSAIDs, including OTCpreparations, during clopidogrel therapybecause of potential for bleeding.• Caution patient that bleeding may continuelonger than usual. Instruct him toreport unusual bleeding or bruising.• Because he has an increased risk of bleeding,urge patient to inform all other healthcare providers, including dentists, that hetakes clopidogrel before having surgery orother procedures or taking a new drug.• Instruct patient to inform his health careproviders about his clopidogrel therapy.clorazepatedipotassiumApo-Clorazepate (CAN), Novo-Clopate(CAN), Tranxene (CAN), Tranxene-SD,Tranxene-SD Half StrengthClass, Category, and ScheduleChemical class: BenzodiazepineTherapeutic class: Alcohol withdrawaladjunct, antianxiety drug, anticonvulsantPregnancy category: Not ratedControlled substance schedule: IVIndications and Dosages To relieve anxietyCAPSULES, TABLETSAdults and adolescents. Initial: 15 mg atbedtime or 7.5 to 15 mg b.i.d. Dosageadjusted, as needed, to 15 to 60 mg daily individed doses b.i.d. to q.i.d. Maximum:90 mg daily.E.R. TABLETSAdults and adolescents. 11.25 mg daily assubstitute for capsules or tablets in patientswho were stabilized on 3.75 mg t.i.d. ofthose forms; 22.5 mg daily as substitute forcapsules or tablets in patients who were stabilizedon 7.5 mg t.i.d. of those forms. To relieve symptoms of acute alcoholwithdrawalCAPSULES, TABLETSAdults. Initial: 30 mg followed by 15 mgb.i.d. to q.i.d. on day 1 of therapy; 15 mgthree to six times on day 2; 7.5 to 15 mgt.i.d. on day 3; 7.5 mg b.i.d. to q.i.d. on day4; and thereafter, 3.75 mg b.i.d. to q.i.d.Maximum: 90 mg daily. As adjunct to treat partial seizure disorderCAPSULES, TABLETSAdults and adolescents. Initial: Up to7.5 mg t.i.d. Increased, if needed, by up to7.5 mg/wk. Maximum: 90 mg daily.Children ages 9 to 12. Initial: 7.5 mg b.i.d.Increased, if needed, by up to 7.5 mg/wk.Maximum: 60 mg daily.E.R. TABLETSAdults and adolescents. 11.25 mg daily assubstitute for capsules or tablets in patientswho were stabilized on 3.75 mg t.i.d. ofthose forms; 22.5 mg daily as substitute forcapsules or tablets in patients who were stabilizedon 7.5 mg t.i.d. of those forms.DOSAGE ADJUSTMENT Initial dosage reducedto 3.75 to 15 mg daily to treat anxiety in elderlypatients.Mechanism of ActionPotentiates action of gamma-aminobutyricacid (GABA) and other inhibitory neurotransmittersby binding to specific benzodiazepinereceptor sites in limbic and corticalareas of CNS, which helps control emotionalbehavior and suppresses spread of seizure

activity. Drug also helps relieve symptomsof alcohol withdrawal by depressing CNS.ContraindicationsAngle-closure glaucoma, hypersensitivity tochlorazepate or its componentsInteractionsDRUGSbarbiturates, MAO inhibitors, opioids, otherantidepressants, phenothiazines: Potentiatedeffects of clorazepatecimetidine, disulfiram, fluoxetine, isoniazid,ketoconazole, metoprolol, oral contraceptives,propoxyphene, propranolol, valproic acid:Increased blood clorazepate levelclozapine: Possibly increased risk of shockACTIVITIESalcohol use: Potentiated clorazepate effectsAdverse ReactionsCNS: Anxiety, ataxia, confusion, depression,dizziness, drowsiness, fatigue, headache, insomnia,irritability, nervousness, psychosis,slurred speech, suicidal ideation, tremorCV: HypotensionEENT: Blurred vision, diplopia, dry mouthGI: Anorexia, constipation, diarrhea, elevatedliver function test results, nausea, vomitingGU: Elevated BUN and serum creatininelevels, incontinence, libido changes, menstrualirregularities, urine retentionHEME: Decreased hematocritSKIN: RashOther: Drug dependenceNursing ConsiderationsWARNING Be aware that prolonged use oftherapeutic doses can lead to dependence.• Monitor liver function test results duringtherapy.• Watch closely for evidence of suicidalthinking or behavior, especially when therapystarts or dosage changes.PATIENT TEACHING• Tell patient to take clorazepate with food ifGI distress occurs.• Advise patient to avoid alcohol and otherCNS depressants while taking drug.• Urge patient to avoid hazardous activitiesuntil CNS effects of drug are known.• Urge caregivers to watch patient closely forevidence of suicidal tendencies, especiallywhen therapy starts or dosage changes,and to report concerns to prescribercloxacillin sodium 259immediately.• Urge female patient who becomes pregnantwhile taking clorazepate to enroll inthe antiepileptic drug pregnancy registryby calling 1-888-233-2334. Explain thatthe registry is studying the safety ofantiepileptic drugs during pregnancy.cloxacillin sodiumApo-Cloxi (CAN), Cloxapen, Novo-Cloxin (CAN), Nu-Cloxi (CAN), Orbenin(CAN), TegopenClass and CategoryChemical class: Penicillinase-resistant isoxazolylpenicillin derivativeTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat mild to moderate upper respiratorytract infections or localized skin andsoft-tissue infections caused by penicillinase-producingstaphylococciCAPSULES, ORAL SOLUTION, I.V. INFUSION, I.V. ORI.M. INJECTIONAdults and children weighing 20 kg (44 lb)or more. 250 mg every 6 hr. Maximum: 6 gdaily.Children and infants weighing less than20 kg. 50 mg/kg daily in equally divideddoses every 6 hr. To treat severe lower respiratory tractinfections or disseminated infectionscaused by penicillinase-producingstaphylococciCAPSULES, ORAL SOLUTION, I.V. INFUSION, I.V. ORI.M. INJECTIONAdults and children weighing 20 kg ormore. 500 mg every 6 hr. Maximum: 6 gdaily.Infants and children weighing less than20 kg. 100 mg/kg daily in divided dosesevery 6 hr.Mechanism of ActionInhibits cell wall synthesis and causes celllysis and death in bacteria that make rigid,cross-linked cell walls in several steps.Cloxacillin affects the final stage of crosslinkingby binding with and inactivatingpenicillin-binding protein, the enzyme thatcauses linkage in cell wall strands.C

260clozapineIncompatibilitiesDon’t mix cloxacillin with aminoglycosidesbecause of risk of mutual inactivation.ContraindicationsHypersensitivity to cloxacillin, penicillin, ortheir componentsInteractionsDRUGSchloramphenicol, erythromycins, sulfonamides,tetracyclines: Decreased cloxacillineffectshepatotoxic drugs, such as fluconazole:Increased risk of hepatotoxicitymethotrexate: Increased blood methotrexatelevel and risk of toxicityprobenecid: Increased and prolonged bloodcloxacillin levelAdverse ReactionsCNS: HeadacheEENT: Glossitis, oral candidiasisGI: Abdominal pain, diarrhea, elevated liverfunction test results, nausea, pseudomembranouscolitis, vomitingGU: Hematuria, vaginal candidiasisMS: Muscle twitchingSKIN: Pruritus, rash, urticariaOther: AnaphylaxisNursing Considerations• Use cloxacillin cautiously in patientshypersensitive to cephalosporins (allergicreaction may be delayed) and those withhypertension (drug is relatively high insodium).• For I.V. injection, reconstitute 250-mg vialwith 4.9 ml of sterile water for injection,500-mg vial with 4.8 ml, and 2,000-mgvial with 6.8 ml. Shake to dissolve.• For direct I.V. injection, give over 2 to4 minutes through tubing of a compatibleinfusing I.V. solution. If giving by intermittentI.V. infusion, further dilute with asuitable diluent (see package insert) andadminister over 30 to 40 minutes.• For I.M. injection, reconstitute 250-mgvial with 1.9 ml of sterile water for injectionand 500-mg vial with 1.7 ml of sterilewater. Shake to dissolve.• Be aware that parenteral solutions are stable24 hours at room temperature and72 hours if refrigerated.PATIENT TEACHING• Tell patient to finish full course of therapy,even if he feels better before drug is gone.• Instruct patient to take oral cloxacillin 1 to2 hours before meals.• Tell patient to take oral form of cloxacillinwith a full glass of water (not fruit juice orsoda).• Instruct patient taking oral solution torefrigerate container and to discardunused portion after 14 days. Also instructhim to use a calibrated measuring deviceto ensure accurate doses.• Advise patient to report signs or symptomsof allergic reaction.clozapineClozaril, FazacloClass and CategoryChemical class: Dibenzodiazepine derivativeTherapeutic class: AntipsychoticPregnancy category: BIndications and Dosages To treat severe schizophrenia unresponsiveto standard drugs; to reduce risk ofrecurrent suicidal behavior in schizophreniaor schizoaffective disordersORALLY DISINTEGRATING TABLETS, TABLETSAdults. Initial: 12.5 mg once or twice daily.Increased by 25 to 50 mg daily to 300 to450 mg daily by the end of 2 wk. Dosageadjustments shouldn’t exceed 100 mg onceor twice per wk. Maximum: 900 mg daily.Route Onset Peak DurationP.O. 1–6 hr Unknown 4–12 hrMechanism of ActionMay produce antipsychotic effects by interferingwith dopamine binding todopamine—especially D 4 —receptors in thelimbic region of the brain and by antagonizingadrenergic, cholinergic, histaminic,and serotoninergic receptors.ContraindicationsAngle-closure glaucoma, coma, history ofclozapine-induced agranulocytosis or severegranulocytopenia, hypersensitivity to clozapineor its components, myeloproliferativedisorders, severe CNS depression, uncontrolledepilepsy, WBC count below3,500/mm 3

InteractionsDRUGSanticholinergics: Potentiated anticholinergiceffectsbenzodiazepines, psychotropics: Additivehypotensive effects; increased risk ofcardiopulmonary collapsebone marrow depressants: Potentiatedmyelosuppressive effectscarbamazepine, phenytoin: Decreased bloodclozapine levelcimetidine, citalopram, erythromycin:Increased blood clozapine levelCNS depressants: Increased CNS depressiondigoxin, warfarin: Increased blood level ofdigoxin and warfarin; displacement ofclozapine from its binding sitelithium: Increased risk of confusion, dyskinesia,neuroleptic malignant syndrome, andseizuresselective serotonin reuptake inhibitors: Markedlyincreased blood clozapine level;increased risk of adverse effects and leukocytosisACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Agitation, akinesia, anxiety, ataxia,confusion, depression, dizziness, drowsiness,dystonia, fatigue, fever, headache,hyperkinesia, hypokinesia, insomnia,lethargy, myoclonic jerks, neurolepticmalignant syndrome, nightmares, restlessness,rigidity, sedation, seizures, sleep disturbance,slurred speech, syncope, tardivedyskinesia, tremor, vertigo, weaknessCV: Cardiac arrest, cardiomyopathy, chestpain, deep vein thrombosis, ECG changes,hypercholesterolemia, hypertension, hypertriglyceridemia,hypotension, myocarditis,orthostatic hypotension, tachycardiaEENT: Blurred vision, dry mouth, increasednasal congestion, increased salivation,pharyngitis, tongue numbness or sorenessENDO: Ketoacidosis, severe hyperglycemiaGI: Abdominal discomfort, anorexia, constipation,diarrhea, elevated liver functiontest results, heartburn, nausea, vomitingGU: Abnormal ejaculation; urinary frequency,urgency, and incontinence; urineretentionHEME: Agranulocytosis, eosinophilia,leukopenia, neutropeniaMS: Back or leg pain, muscle spasm orweakness, myalgiaRESP: Dyspnea, respiratory arrestSKIN: RashOther: Weight gainclozapine 261Nursing Considerations• Use clozapine cautiously in patients withhepatic, renal, or cardiovascular diseaseand in elderly patients with dementiarelatedpsychosis because they haveincreased risk of serious or fatal adversereactions.WARNING Rarely, clozapine causes severe orlife-threatening adverse reactions, such asagranulocytosis, cardiac or respiratoryarrest, deep vein thrombosis, myocarditis(especially in first month), neurolepticmalignant syndrome, and severe hyperglycemiawith ketoacidosis in nondiabeticpatients. It also may cause seizures andtardive dyskinesia. Monitor patient closely.WARNING Check patient’s baseline WBCcount and absolute neutrophil count(ANC) before therapy and weekly for first6 months. If WBC count is at least3,500/mm 3 and ANC at least 2,000/mm 3 ,check every 2 weeks for next 6 months. Ifcounts remain stable, expect to continuechecking every 4 weeks thereafter.• If patient develops mild leukopenia(WBCs 3,000 to 3,500/mm 3 ) or granulocytopenia(ANC 1,500 to 2,000/mm 3 ),expect to check counts twice weekly untilnormal. In moderate leukopenia (WBCs2,000 to 3,000/mm 3 ) or granulocytopenia(ANC 1,000 to 1,500/mm 3 ), expect to stopdrug temporarily and check counts dailyuntil improved. Follow manufacturer’sdirection for resuming drug and monitoring.In severe leukopenia (WBCs less than2,000/mm 3 ) or granulocytopenia (ANCless than 1,000/mm 3 ), expect to stop drugpermanently and monitor counts daily,then as specified by manufacturer.• Monitor temperature. A transient increaseabove 100.4° F (38° C) may occur, mostoften within the first 3 weeks of therapy.• When therapy ends, expect to check WBCcount and ANC weekly for at least 4 weeksor until WBC count is 3,500/mm 3 or moreand ANC is 2,000/mm 3 or more.• Monitor patients, especially male patientsand younger patients, for dystonia, particularlyduring the first few days of treatment.Be alert for complaints of neckC

262coagulation factor VIIa (recombinant)spasms, which sometimes may progress tothroat tightness, trouble swallowing orbreathing, and tongue protrusion.PATIENT TEACHING• Tell patient that he’ll receive only a 1-weeksupply at a time.• Instruct patient taking orally disintegratingtablets (Fazaclo) to leave tablet in blisterpack until ready to take it. Tell him topeel foil back to remove tablet (ratherthan pushing tablet through foil) and thento immediately place tablet in mouth andlet it dissolve before swallowing. Explainthat no water is needed.• Inform patient that he’ll need weeklyblood tests. Review evidence of dyscrasias(fatigue, fever, sore throat, weakness); urgepatient to report them to prescriber if theyoccur.• Instruct patient to avoid hazardous activitiesuntil drug’s CNS effects are known.•Advise patient to rise slowly from lying orsitting position to minimize orthostatichypotension.•If patient stops drug for more than 2 days,stress need to contact prescriber forinstructions; dosage will need to bechanged.•Tell patient to consult prescriber beforeusing alcohol or taking OTC drugs.•Advise female patients to notify prescriberif pregnancy occurs or is suspected.coagulation factorVlla (recombinant)NovoSeven, NovoSeven RTClass and CategoryChemical class: Vitamin K–dependentglycoproteinTherapeutic class: Antihemophilic, hemostaticPregnancy category: CIndications and Dosages To treat bleeding episodes in patientswith hemophilia A or B or withinhibitors to Factor VIII or Factor IXI.V. INJECTIONAdults. 90 mcg/kg as bolus injected over2 to 5 min every 2 hr until hemostasisachieved; then every 3 to 6 hr, as needed. To prevent bleeding in surgical interventionor invasive procedure in hemophiliaA or B patients with inhibitors to factorVIII or factor IXI.V. INJECTIONAdults. 90 mcg/kg as bolus injected over2 to 5 min immediately before surgery orprocedure; then every 2 hr throughout surgeryor procedure. After minor surgery:90 mcg/kg injected over 2 to 5 min every2 hr for 48 hr; then 90 mcg/kg injected over2 to 5 min every 2 to 6 hr until healing hasoccurred. After major surgery: 90 mcg/kgover 2 to 5 min every 2 hr for 5 days; then90 mcg/kg over 2 to 5 min every 4 hr untilhealing has occurred. To treat or prevent bleeding episodes inpatients with congenital factor VII deficiencyI.V. INFUSIONAdults. 15 to 30 mcg/kg over 2 to 5 minevery 4 to 6 hr until hemostasis occurs. To treat patients with acquired hemophiliaI.V. INFUSIONAdults. 70 to 90 mcg/kg over 2 to 5 minevery 2 to 3 hr until hemostasis occurs.Mechanism of ActionActivates the extrinsic pathway of coagulationby forming complexes with tissue factorto activate factors IX and X. Activatedfactor X complexes with other factors toconvert prothrombin to thrombin.Thrombin then converts fibrinogen to fibrin,which leads to formation of a hemostaticplug to produce local hemostais. Thisprocess may also occur on the surface ofactivated platelets.ContraindicationsHypersensitivity to recombinant coagulationfactor VIIa, to its components, or tomouse, hamster, or bovine proteinsInteractionsDRUGSactivated and nonactivated prothrombincomplex concentrates: Increased risk ofthrombosiswarfarin: Possibly reversed warfarin effectsAdverse ReactionsCNS: Fever, headacheCV: Acute MI, bradyarrhythmia, chesttightness or pain, edema, hypertension,

hypotension, supraventricular tachycardia,thrombosisEENT: EpistaxisGI: Nausea, vomitingHEME: Disseminated intravascular coagulation,hemorrhageMS: ArthralgiaRESP: WheezingSKIN: Pruritus, purpura, rash, urticariaOther: Anaphylaxis, injection site reactionNursing Considerations• Patients with disseminated intravascularcoagulation, advanced atherosclerotic disease,crush injury, septicemia, or concomitanttreatment with activated or nonactivatedprothrombin complex concentrateare at increased risk for a thromboticevent such as myocardial ischemia orinfarction and cerebral ischemia or infarction.• Monitor factor VII–deficient patient’s PTand factor VII coagulant activity beforeand after giving drug. If factor VIIa activityfails to reach the expected level, the PTisn’t corrected, or bleeding isn’t controlled,notify prescriber. Patient may have developedantibodies to the drug. Be preparedto obtain specimen for antibody analysis.• Reconstitute drug with correct amount ofsterile water (2.2 ml for 1.2-mg vial, 4.3 mlfor 2.4-mg vial, and 8.5 ml for 4.8-mgvial). Clean the rubber stopper with alcohol,and insert syringe needle into centerof the stopper, aiming needle against theside of the vial so a stream of sterile waterruns down vial wall. Do not inject diluentdirectly onto powder. Gently swirl vialuntil powder is dissolved. Don’t shakereconstituted solution. If solution isfoamy, let it settle before giving drug.Once reconstituted, use within 3 hours.• Monitor patient’s clotting status closely. Ifintravascular coagulation is confirmed bytest results or if signs and symptomsoccur, notify prescriber and expect toreduce dosage or stop drug.PATIENT TEACHING• Tell patient to immediately report evidenceof allergic reaction, such as hives,rash, chest tightness, or difficulty breathing.• Tell patient that he’ll need regular laboratorytests to check effectiveness of drug.codeine phosphatecodeine sulfateMechanism of ActionMay produce analgesia through partialmetabolism to morphine. Drug binds withmu, delta, and kappa receptors in the spinalcord and with mu 1 and kappa 3 receptorshigher in the CNS, decreasing intracellularcAMP, which inhibits adenylate cyclaseactivity and prevents release of pain neurotransmitters,such as substance P anddopamine, and altering perception of andemotional response to pain. Drug also supcodeine263Class, Category, and ScheduleChemical class: Phenanthrene derivativeTherapeutic class: Antitussive, opioidanalgesicPregnancy category: CControlled substance schedule: IIIndications and Dosages To treat mild to moderate painORAL SOLUTION, TABLETS, I.M. OR SUBCUTANEOUSINJECTIONAdults. 15 to 60 mg (usual, 30 mg) every4 hr, p.r.n.Children age 1 year or over. 0.5 mg/kgevery 4 to 6 hr, p.r.n.I.V. INJECTIONAdults. 15 to 60 mg (usual, 30 mg) every4hr. To treat cough from chemical ormechanical irritation of respiratory systemORAL SOLUTION, TABLETSAdults and adolescents. 10 to 20 mg every4 to 6 hr. Maximum: 120 mg daily.Children ages 6 to 12. 5 to 10 mg every 4 to6 hr. Maximum: 60 mg daily.Children ages 2 to 6. 2.5 to 5 mg every 4 to6hr.Maximum: 30 mg daily.Route Onset Peak DurationP.O. 30–45 min 1–2 hr 4 hr*I.M. 10–30 min 30–60 min 4 hr*SubQ 10–30 min Unknown 4 hr** For pain; 4 to 6 hr for cough.C

264colchicinepresses cough by acting on opiate receptorsin the cough center.ContraindicationsHypersensitivity to codeine, other opioids,or their components; significant respiratorydepressionInteractionsDRUGSanticholinergics, paregoric: Increased risk ofsevere constipationantihypertensives, diuretics: Potentiatedhypotensive effectsbuprenorphine: Decreased codeine effectivenessCNS depressants: Additive CNS effectshydroxyzine: Increased analgesia; increasedCNS depressant and hypotensive effectsMAO inhibitors: Increased risk of unpredictable,severe, and sometimes fatal reactionsmetoclopramide: Antagonized effect ofmetoclopramide on GI motilitynaloxone: Antagonized codeine effectnaltrexone: Precipitated withdrawal symptomsin codeine-dependent patientsneuromuscular blockers: Additive respiratorydepressant effectsother opioids: Additive CNS, respiratorydepressant, and hypotensive effectsACTIVITIESalcohol use: Additive CNS effectsAdverse ReactionsCNS: Coma, delirium, depression, disorientation,dizziness, drowsiness, euphoria,hallucinations, headache, lack of coordination,lethargy, light-headedness, mental andphysical impairment, mood changes, restlessness,sedation, seizures, tremorCV: Bradycardia, heart block, hypertension,orthostatic hypotension, palpitations,tachycardiaEENT: Altered taste, blurred vision, diplopia,dry mouth, laryngeal edema, laryngospasm,miosisGI: Abdominal cramps and pain, anorexia,constipation, flatulence, gastroesophagealreflux, ileus, indigestion, nausea, vomitingGU: Decreased libido, difficult ejaculation,dysuria, impotence, oliguria, ureteralspasm, urinary incontinence, urine retentionMS: Muscle rigidityRESP: Apnea, bronchoconstriction,bronchospasm, depressed cough reflex, respiratorydepressionSKIN: Diaphoresis, flushing, pallor, pruritus,rash, urticariaOther: Anaphylaxis, facial edema, physicaland psychological dependenceNursing Considerations• Evaluate patient for therapeutic response,including decreased pain, cough, andfacial grimacing.• Take safety precautions, if needed.• Monitor respiratory depth, effort, andrate. Notify prescriber immediately if respiratoryrate drops below 10 breaths/min.• Assess urine output to detect retention.WARNING Assess patient for evidence ofphysical and psychological dependence.• Rotate sites for subcutaneous delivery.Repeated injection in same site may causetissue irritation, pain, and induration.PATIENT TEACHING• Advise patient to avoid alcohol or otherCNS depressants while taking codeine.• To minimize nausea, suggest that patienttake drug with food.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Caution patient to get up slowly from asitting or lying position.• To prevent constipation, urge patient toconsume plenty of fluids and high-fiberfoods, if not contraindicated.• Instruct patient to take codeine exactly asprescribed and not to adjust dose or frequencywithout consulting prescriber.• Advise patient to report shortness ofbreath or difficulty breathing.• Urge breast-feeding women to notify prescriberbefore taking codeine because drugappears in breast milk and could lead tooverdose in infant.colchicineColcrysClass and CategoryChemical class: Colchicum alkaloid derivativeTherapeutic class: Antigout, anti-inflammatoryPregnancy category: C (oral form), D (parenteralforms)

Indications and Dosages To prevent gouty arthritis attacksTABLETS (COLCRYS)Adults and adolescents age 16 and over.0.5 to 0.6 mg once or twice daily.Maximum: 1.2 mg daily.I.V. INFUSION OR INJECTIONAdults. 0.5 to 1 mg once or twice daily.Maximum: 4 mg daily. To treat acute gouty arthritisTABLETS (COLCRYS)Adults. Initial: 1.2 mg at first sign of flare;then 0.6 mg 1 hr later. Maximum: 1.8 mgover a 1-hr period.I.V. INFUSION OR INJECTIONAdults. 2 mg over 2 to 5 min; then 0.5 mgevery 6 hr or 1 mg every 6 to 12 hr untilpain decreases. Maximum: 4 mg daily.DOSAGE ADJUSTMENT For elderly patients,maximum I.V. dosage reduced to 2 mg/24 hr; maximum oral dosage to 2 mg/24 hr.After initial I.V. course, elderly patientshould receive no form of colchicine for21 days. If treatment of a gout flare occursduring prophylactic treatment, dosageshouldn’t exceed 1.2 mg at the first sign offlare, followed by 0.6 mg 1 hour later, andthen prophylactic dose resumed 12 hr later.For patient taking strong CYP3A4inhibitor (atazanavir, clarithromycin, indinavir,itraconazole, ketoconazole, nefazodone,nelfinavir, ritonavir, saquinavir,telithromycin), moderate CYP3A4 inhibitor(amprenavir, aprepitant, diltiazem, ertthromycin,fluconazole, fosamprenavir,grapefruit juice, verapamil), or P-gpinhibitor (cyclosporine, ranolazine), dosageusually halved and not repeated for 3 days.For patient with moderate to severerenal impairment, dosage adjusted on individualbasis. For patient with severe hepaticimpairment receiving colchicine prophylacticly,dosage decreased on individual basis.For patient with severe hepatic impairmentreceiving colchicine treatment for acutegout flare but not prophylaxis, dosage notadjusted but treatment course shouldn’t berepeated more than once very 2 weeks. To treat familial Mediterranean fever(FMF)TABLETS (COLCRYS)Adults and adolescents ages 12 and over.1.2 mg to 2.4 mg daily, with daily totaldivided into two doses, if desired.colchicine 265Mechanism of ActionIn gouty arthritis, leukocytes phagocytoseurate crystals in affected joints, aprocess that releases chemotactic factors,degradation enzymes, and otherinflammatory substances. Colchicinehelps stop this process, probably by disruptingmicrotubules in leukocytes.Normally, microtubules contribute tocell structure and movement. Whencolchicine binds to tubulin (proteinfrom which microtubules are made), themicrotubule falls apart, as shown. Thisprocess disrupts cell function and preventsleukocytes from invading jointsand causing inflammation.Leukocyte exteriorMicrotubuleTubulinCellmembraneColchicineLeukocyte interiorChildren ages 6 to 12. 0.9 mg to 1.8 mgdaily, with daily total divided into twodoses, if desired.Children ages 4 to 6. 0.3 mg to 1.8 mgdaily, with daily total divided into twodoses, if desired.DOSAGE ADJUSTMENT For adults needingcontrol of FMF, dosage increased in incrementsof 0.3 mg daily to a maximum of2.4 mg daily.For adults with intolerable adverseeffects, dosage decreased in increments of0.3 mg daily to tolerable level.For patients taking strong CYP3A4inhibitor (atazanavir, clarithromycin, indinavir,itraconazole, ketoconazole, nefazodone,nelfinavir, ritonavir, saquinavir,telithromycin), moderate CYP3A4 inhibitor(amprenavir, aprepitant, diltiazem, erythromycin,fluconazole, fosamprenavir, grapefruitjuice, verapamil), or P-gp inhibitor(cyclosporine, ranolazine), dosage usuallyC

266colchicinehalved and not repeated for 3 days.For patient with moderate to severerenal impairment or severe hepatic impairment,dosage adjusted on individual basis.Route Onset Peak DurationP.O. In 12 hr In 24–48 hr UnknownI.V. In 6–12 hr Unknown UnknownContraindicationsBlood dyscrasias; hypersensitivity tocolchicine or its components; serious cardiac,GI, hepatic, or renal disordersIncompatibilitiesDon’t combine colchicine with bacteriostaticagents, any solution or injection thatcontains D 5 W, and any other solution thatmay change colchicine’s pH because precipitationmay occur.InteractionsDRUGSanticoagulants, such as heparin; plateletaggregation inhibitors, such as aspirin;thrombolytics, such as alteplase: Increasedrisk of GI ulcers or hemorrhageantineoplastics: Possibly increased serumuric acid level and decreased therapeuticeffectiveness of colchicinecyclosporine: Increased cyclosporine levelmoderate CYP3A4 inhibitors, such as amprenavir,aprepitant, diltiazem, erythromycin,fluconazole, fosamprenavir, grapefruitjuice, verapamil: Increased risk of colchicinetoxicityNSAIDs, such as phenylbutazone: Possiblyincreased risk of bone marrow depression,GI bleeding, leukopenia, thrombocytopeniastrong CYP3A4 inhibitors, such asatazanavir, clarithromycin, indinavir, itraconazole,ketoconazole, nefazodone, nelfinavir,ritonavir, saquinavir, telithromycin:Increased risk of colchicine toxicityP-gp inhibitors, such as cyclosporine, ranolazine:Increased risk of colchicine toxicityvitamin B 12 : Possibly impaired absorptionof and increased dosage requirements forvitamin B 12ACTIVITIESalcohol use: Increased risk of adverse GIeffectsAdverse ReactionsCNS: Peripheral neuropathyCV: Arrhythmias (I.V. form)GI: Abdominal pain, anorexia, diarrhea,nausea, vomitingHEME: Agranulocytosis, aplastic anemia,thrombocytopeniaMS: MyopathySKIN: Alopecia, rashOther: Injection site pain and tenderness,median nerve neuritis in affected arm, andskin and soft-tissue necrosis if extravasationoccurs (I.V. form)Nursing Considerations• Patients receiving prophylactic treatmentfor gout and who have hepatic impairmentor are being treated with CYP3A4inhibitors shouldn’t receive colchicine foracute gout flares.WARNING Avoid subcutaneous or I.M.administration of colchicine because theseroutes may cause tissue necrosis andsloughing. To prevent extravasation, makesure I.V. catheter is patent and correctlypositioned before giving drug.Throughout therapy, check I.V. injectionsite often for pain, tenderness, and skinpeeling. Consult prescriber about switchingto oral form.WARNING To reduce risk of toxicity, avoidgiving colchicine by any route within7 days after full I.V. course (4 mg). Ifpatient takes any drug that increases riskof colchicine toxicity, expect to wait 3 daysafter oral therapy before starting secondoral course. Elderly or debilitated patientsand those with a history of cardiac diseaseor impaired renal or hepatic function areat increased risk for cumulative toxicity.• Dilute I.V. form with 10 to 20 ml of normalsaline solution. Or, give colchicineinto a large vein through an I.V. line withnormal saline solution infusion.• Administer I.V. form over 2 to 5 minutes.• Expect to monitor CBC and platelet andreticulocyte counts at baseline and every3 months after therapy starts.• Notify prescriber immediately and expectto stop colchicine if patient develops evidenceof toxicity, such as abdominal pain,diarrhea, nausea, or vomiting.PATIENT TEACHING• Instruct patient to have blood tests every3 months, as ordered, during therapy.• Explain that gouty arthritis pain and

swelling typically subside in 24 to 48 hoursafter therapy begins.• Advise patient to notify prescriber immediatelyif abdominal pain, diarrhea, nausea,or vomiting occurs.colesevelamhydrochlorideWelcholClass and CategoryChemical class: Nonabsorbed hydrogelpolymerTherapeutic class: Bile acid sequestrantPregnancy category: BIndications and Dosages As adjunct to diet and exercise to reduceelevated LDL cholesterol levels inpatients with primary hypercholesterolemia;as adjunct to diet and exerciseto improve glycemic control in type 2diabetes mellitusTABLETSAdults. 3.75 g once daily or 1.875 g b.i.d.with a meal and a beverage.Mechanism of ActionBinds with bile acids in intestine, preventingtheir absorption and forming an insolublecomplex that’s excreted in feces. Thisaction decreases amount of bile acidsreturning through enterohepatic circulationto the liver. As a result, the liver must convertmore cholesterol to bile acids, whichincreases liver’s demand for cholesterol.This, in turn, causes increase in productionand activity of the hepatic enzyme hydroxymethyl-glutaryl-coenzymeA (HMG-CoA)reductase, which is needed for cholesterolproduction. However, synthesis of cholesterolin the liver typically can’t match theamount needed to synthesize bile acids.Because cholesterol levels can’t be sustained,LDLs, lipoproteins composed mostlyof cholesterol, are increasingly removedfrom the blood, thereby decreasing the LDLlevel in the blood.ContraindicationsHistory of bowel obstruction or pancreatitisinduced by hypertriglyceridemia, hypersensitivityto colesevelam or its components,colesevelam hydrochloride 267serum triglyceride level greater than500 mg/dlInteractionsDRUGSdrugs with narrow therapeutic index, glyburide,levothyroxine, oral contraceptives,phenytoin: Possibly altered effectiveness ofthese drugswarfarin: Reduced INRAdverse ReactionsCNS: AstheniaCV: Hypertension, hypertriglyceridemiaEENT: Oral blistering, pharyngitis, rhinitisENDO: Hypoglycemia, hypertriglyceridemiaGI: Abdominal distention or pain, bowel oresophageal obstruction, constipation, dyspepsia,elevated liver enzymes, fecalimpaction, indigestion, nausea, pancreatitis,worsening of hemorrhoidsMS: MyalgiaSKIN: RashOther: Flu syndromeNursing Considerations• Colesevelam shouldn’t be given to patientswith gastroparesis or other GI motilitydisorders or to patients who had major GItract surgery and are at risk for bowelobstruction from constipating effects.• Use cautiously in patients with dysphagiaor esophageal obstruction because size oftablet can cause dysphagia or esophagealobstruction.• Use colesevelam cautiously in patientswhose total triglycerides exceed 300 mg/dl;bile acid sequestrants can increase it.• Evaluate patient’s lipid levels before startingtherapy for primary hyperlipidemia,again in 4 to 6 weeks, and then periodically,as ordered, during therapy. Expect drugto be discontinued if patient developshypertriglyceridemia-induced pancreatitisor triglyceride level exceeds 500 mg/dl.• Monitor diabetic patient’s blood glucoselevel regularly, as ordered, to assess effectivenessof colesevelam therapy.• When giving colesevelam with a drug thathas a narrow therapeutic index, expect togive that drug at least 4 hours before colesevelamto prevent reduced effectiveness.• Because colesevelam may decrease or delayabsorption of other drugs, administer itseparately if possible.C

268colestipol hydrochloride• Make sure that patient drinks enoughfluid when taking drug.WARNING Monitor patients with preexistingconstipation, who are at increased risk fordeveloping fecal impaction.• Monitor frequency of bowel movementsand consistency of stools in patients withcoronary artery disease or hemorrhoidsbecause constipation may aggravate theseconditions.PATIENT TEACHING• Instruct patient to take drug with mealsand drink plenty of liquids when taking it.• Tell patient to protect tablets from moisture.• Caution patient against changing prescribeddosage or stopping colesevelamabruptly because serum lipid level mayincrease significantly.• Remind patient that drug therapy doesn’treduce the need for dietary changes.• Urge patient to keep regularly scheduledappointments for follow-up blood tests.• Instruct patient to take vitamin supplementsat least 4 hours before colesevelam.colestipolhydrochlorideColestidClass and CategoryChemical class: Diethylenetriamine and 1-chloro-2,3-epoxypropane copolymer, highmolecular-weightanion exchange resinTherapeutic class: AntihyperlipidemicPregnancy category: Not ratedIndications and Dosages To treat primary hypercholesterolemiaGRANULESAdults. 15 to 30 g daily in divided dosesb.i.d. to q.i.d., before meals and at bedtime.TABLETSAdults. Initial: 2 g once daily or in divideddoses b.i.d., increased every 1 to 2 mo in2-g increments once or twice daily.Maximum: 16 g daily.Mechanism of ActionCombines with bile acids in the intestine,preventing their absorption and forming aninsoluble complex that’s excreted in feces.Loss of bile acids increases hepatic productionof cholesterol to form new bile acidsand increases oxidation of cholesterol tobile acids. Depletion of cholesterol increaseshepatic LDL receptor activity, whichremoves LDLs from the blood.ContraindicationsComplete biliary obstruction, hypersensitivityto colestipol or its componentsInteractionsDRUGSchenodiol, ursodiol: Possibly reduced therapeuticeffects of colestipoldigitalis glycosides: Possibly increased risk ofdigitalis toxicity when colestipol is stoppedfurosemide, sulfonylureas, thyroid hormones:Decreased absorption and therapeuticeffects of these drugsoral anticoagulants: Possibly increased ordecreased anticoagulant effectpenicillin G, propranolol, tetracyclines (oral),thiazide diuretics: Decreased absorption ofthese drugsvancomycin (oral): Possibly markeddecrease in vancomycin antibacterial actionvitamins (fat-soluble): Possibly interferencewith vitamin absorptionAdverse ReactionsCNS: HeadacheGI: Abdominal distention and pain, constipation,diarrhea, eructation, esophagealreaction, fecal impaction, heartburn, nausea,vomitingNursing Considerations• Mix colestipol granules with at least 90 mlof fluid before giving it to prevent accidentalinhalation or esophageal distress.• Because colestipol may interact with variousdrugs, give it on a separate schedulefrom other drugs when possible.• Make sure patient has adequate fluidintake, and obtain an order for a stool softeneror laxative to prevent constipation.To prevent impaction, expect to decreasedosage or discontinue drug if constipationoccurs or worsens.• Expect to discontinue drug if no responseoccurs after 3 months.• Monitor patient’s serum cholesterol levelas appropriate, usually at baseline, 4 to6 weeks after starting therapy, and thenevery 3 months. Expect to reduce monitoringfrequency to every 4 months if

esponse is adequate.• Be aware that HDL and serum triglyceridelevels may increase or remain unchangedduring colestipol therapy.• Keep in mind that adverse GI reactions aremore common in patients over age 60.PATIENT TEACHING• To help minimize adverse GI reactions,advise patient to mix granules thoroughlyin fluid so they’re completely wet beforedrinking.• Remind patient that colestipol doesn’treduce the importance of dietary changes.• Caution patient not to increase ordecrease prescribed dosage or to suddenlystop taking drug. Explain that stoppingdrug abruptly may significantly increaseserum lipid levels.• Instruct patient to keep appointments forfollow-up blood tests.• Teach patient how to prevent constipation,and advise him to contact prescriber ifconstipation occurs or worsens.colistimethatesodiumColy-Mycin MClass and CategoryChemical class: PolypeptideTherapeutic class: AntibioticPregnancy category: CIndications and Dosages To treat acute or chronic gram-negativeinfections caused by Enterobacter aerogenes,Escherichia coli, Klebsiellapneumoniae, and Pseudomonas aeruginosaI.M. INJECTION,I.V. INJECTION, I.V. INFUSIONAdults. 2.5 to 5 mg/kg daily in 2 to 4 divideddoses. Maximum: 5 mg/kg/day.DOSAGE ADJUSTMENT For obese patients,dosage should be based on ideal bodyweight. For patients with severe renalimpairment, dosage reduced to 1.5 mg/kgdaily and interval reduced to every 36 hr.For patients with moderate renal impairment,interval shouldn’t exceed twice dailyand may need to be once daily or every 36hr. For patients with mild renal impairment,interval shouldn’t exceed twice daily.colistimethate sodium 269Mechanism of ActionPenetrates into and disrupts bacterial cellmembrane, resulting in cell death.Colistimethate is an inactive pro-drug ofthe bioactive form colistin. Colistin binds togram-negative bacterial cell membranephospholipids, increasing cell membranepermeability and causing loss of metabolitesessential to bacterial existence.ContraindicationsHypersensitivity to colistimethate or itscomponents, renal diseaseInteractionsDRUGSaminoglycosides, vancomycin: Increased riskof developing nephrotoxicitycuraniform muscle relaxants, such as tubocurarine,decamethonium, ether, gallamine,succinylcholine: Potentiated neuromuscularblocking effect of these drugssodium cephalothin: Possibly enhancednephrotoxicityAdverse ReactionsCNS: Dizziness, fever, paresthesia, slurredspeech, tingling of extremities, vertigoGI: Nausea, pseudomembranous colitis,vomitingGU: Decreased creatinine clearance andurine output, increased BUN and serumcreatinine, nephrotoxicityMS: Muscle weaknessRESP: Apnea, respiratory distressSKIN: Pruritus, rash, urticariaNursing Considerations• Use colistimethate cautiously in patientswith impaired renal function.• Reconstitute each 150-mg vial with 2 mlsterile water for injection to yield 75 mg/ml. During reconstitution, swirl vial gentlyto avoid frothing.• When giving by I.V. injection, slowly injecthalf of total daily dose over 3 to 5 minutesand repeat dose 12 hours later, as ordered.• When giving by I.V. infusion, slowly injecthalf of total daily dose over 3 to 5 minutes.Then add remaining half of total dailydose to an appropriate solution, such asnormal saline solution or D 5 W, with typeand amount of solution dictated bypatient’s fluid and electrolyte needs.Starting 1 to 2 hours after first dose, slowlyinfuse remaining drug over 22 to 23 hours.C

270conivaptan hydrochlorideIf patient has renal impairment, use areduced infusion rate. Once the infusion isprepared, use within 24 hours.• Notify prescriber if patient develops neurologicchanges (paresthesia, tingling oflimbs, pruritus, vertigo, dizziness, slurredspeech). Dosage may need to be reduced.WARNING Monitor patient’s BUN andserum creatinine levels, as ordered. If elevated,notify prescriber because drug maycause nephrotoxicity (usually reversible ifdrug is stopped) with possible renal shutdown.Toxic levels interfere with nervetransmission at neuromuscular junctions,resulting in apnea and muscle weakness.• Monitor patient receiving drug I.M.because apnea and neuromuscular blockademay occur with this route, especiallyin patients with impaired renal function.Before giving drug I.M., make sure dose isappropriate for degree of renal function.• Monitor patient’s bowel elimination. Ifdiarrhea develops, obtain stool culture tocheck for pseudomembranous colitis. Ifconfirmed, expect to stop drug and givefluid, electrolytes, and antibiotics effectiveagainst Clostridium difficile.PATIENT TEACHING• Caution patient to avoid performing hazardousactivities, including driving, duringcolistimethate therapy.• Tell patient to immediately report tinglingin her extremities, vertigo, dizziness, generalizedpruritus, or slurred speechbecause dosage may need to be decreased.• Explain need for frequent blood tests duringtherapy to check kidney function.• Urge patient to tell prescriber about diarrheathat’s severe or lasts longer than3 days. Remind patient that watery orbloody stools can occur 2 or more monthsafter antibiotic therapy and can be serious,requiring prompt treatment.conivaptanhydrochlorideVaprisolClass and CategoryChemical class: Arginine vasopressinantagonist (antidiuretic hormone)Therapeutic class: Aquaretic (sodium/waterstabilizer)Pregnancy category: CIndications and Dosages To treat euvolemic and hypervolemichyponatremia in hospitalized patientssuch as may occur in the syndrome ofinappropriate antidiuretic hormone,hypothyroidism, adrenal insufficiency, orpulmonary disordersI.V. INFUSIONAdults. Loading dose: 20 mg over 30 minutesfollowed by 20 mg as a continuousinfusion over 24 hours. Additional 20 mgdaily may be given by continuous infusionfor 1 to 3 days, as needed. Maximum: 40 mgdaily with total duration of therapy, includingloading dose, not to exceed 4 days.Route Onset Peak DurationI.V. Unknown 24 hr UnknownMechanism of ActionBinds with arginine vasopressin V2 receptorsites in collecting ducts of kidneys. Bydoing so, drug blocks action of argininevasopressin on V2 receptor, decreases waterresorption in collecting ducts, increasesexcretion of free water (urine output), andincreases serum sodium concentration, thuscorrecting water and sodium imbalance.IncompatibilitiesDon’t mix with lactated Ringer’s solution,normal saline solution, or other drugs.ContraindicationsHypersensitivity to conivaptan or its components;patients with hypovolemichyponatremia; use with potent CYP3A4inhibitors such as clarithromycin, indinavir,itraconazole, ketoconazole, and ritonavirInteractionsDRUGSamphotericin B, cisplatin, corticosteroids:Possibly additive hypokalemic effectsclarithromycin, indinavir, itraconazole, ketoconazole,ritonavir, and other strong CYP3A4inhibitors: Increased blood conivaptan leveldigoxin: Possibly increased digoxin level andrisk of digioxin toxicitydrugs metabolized by CYP3A4, such asHMG-CoA reductase inhibitors: Possiblyincreased risk of rhabdomyolysis

Adverse ReactionsCNS: Confusion, fever, headache, insomniaCV: Atrial fibrillation, hypertension, hypotension,orthostatic hypotension, peripheraledemaEENT: Dry mouth, oral candidiasis, pharyngealpainENDO: Hyperglycemia, hypoglycemiaGI: Constipation, diarrhea, nausea, thirst,vomitingGU: Hematuria, pollakiuria, polyuria, UTIHEME: AnemiaRESP: PneumoniaSKIN: Erythema, pruritusOther: Dehydration, hypokalemia, hypomagnesemia,hyponatremia, infusion sitereactions (erythema, pain, phlebitis,swelling)Nursing Considerations• Conivaptan shouldn’t be used to treatpatients with heart failure.• Use cautiously in patients with hepatic orrenal dysfunction because levels remainelevated longer in these patients.• Give drug only through large veins, andchange infusion site every 24 hours. Drugmay cause serious infusion site reactionseven when diluted and infused correctly.Inspect site regularly; change immediatelyif reactions occur.• Dilute 20-mg (4-ml) loading dose with100 ml of 5% dextrose injection beforeadministration. Gently invert bag severaltimes to mix thoroughly. Use mixturewithin 24 hours, infusing over 30 minutes.• Dilute 20-mg (4-ml) or 40-mg (8-ml)continuous infusion dose with 250 ml ofD 5 W before use. Gently invert the bag severaltimes to mix thoroughly. Infuseimmediately over 24 hours. If infusion isinterrupted for any reason, discard anyremaining solution 24 hours after mixing.• Monitor neurologic status and serumsodium level closely during therapybecause rapid increase in serum sodiumlevel (more than 12 mEq/L/24 hr) mayresult in serious neurologic impairment. Ifserum sodium level rises faster thanexpected, stop infusion temporarily andnotify prescriber. If it keeps rising, expectconivaptan to be discontinued. If hyponatremiapersists or recurs and patient hasno neurologic abnormalities, drug may beresumed at a reduced rate.cortisone acetate 271• Monitor vital signs, and assess patient regularlyfor hypovolemia. If patient developshypovolemia or hypotension while receivingconivaptan, stop infusion, notify prescriber,and provide supportive care, asprescribed. After hypovolemia andhypotension have been corrected, drugmay be resumed at a reduced rate.• Store ampules in cardboard container,protected from light, until ready for use.PATIENT TEACHING•Instruct patient to report any infusion sitediscomfort immediately.•Tell patient that frequent laboratory testswill be performed to monitor his serumsodium level and volume status.cortisone acetateCortisone Acetate-ICN (CAN), Cortone(CAN), Cortone AcetateClass and CategoryChemical class: GlucocorticoidTherapeutic class: Anti-inflammatory,corticosteroid replacement, immunosuppressantPregnancy category: Not ratedIndications and Dosages To treat allergic and inflammatory disorders,collagen disorders, congenitaladrenal hyperplasia, dermatologic disorders,edema (from systemic lupus erythematosusor nephrotic syndrome), GIdisorders, hematologic disorders, multiplesclerosis (acute exacerbations), neoplasticdiseases, primary or secondaryadrenocortical insufficiency, respiratorydisorders, rheumatic disorders, trichinosiswith myocardial or neurologicinvolvement, and tuberculous meningitisTABLETSAdults and adolescents. Initial: 25 to300 mg before 9 a.m. daily. Maintenance:Dosage adjusted based on patient response.Children. 2.5 to 10 mg/kg daily before9 a.m. For adrenocortical insufficiency,0.7 mg/kg/day before 9 a.m.I.M. INJECTIONAdults and adolescents. Initial: 25 to300 mg daily. Maintenance: Dosage adjustedbased on patient response.Children. 0.83 to 5 mg/kg every 12 to 24 hr.C

272cortisone acetateFor adrenocortical insufficiency, 0.7 mg/kgdaily or every third day, or 0.23 to 0.35 mg/kg daily.Route Onset Peak DurationP.O. Rapid 2 hr 1.25–1.5 daysI.M. Slow 20–48 hr 1.25–1.5 daysMechanism of ActionBinds to intracellular glucocorticoid receptorsand suppresses inflammatory andimmune responses by:• inhibiting neutrophil and monocyte accumulationat the inflammation site andsuppressing their phagocytic and bactericidalactivity• stabilizing lysosomal membranes• suppressing the antigen response of macrophagesand helper T cells• inhibiting synthesis of cellular mediatorsof inflammatory response, such as cytokines,interleukins, and prostaglandins.ContraindicationsHypersensitivity to cortisone or its components,idiopathic thrombocytopenic purpura(parenteral form), live-virus vaccineadministration, systemic fungal infectionInteractionsDRUGSanticholinesterases: Possibly antagonizedanticholinesterase effects in myastheniagravisbarbiturates: Decreased cortisone effectiveness,increased cortisol clearancedigitalis glycosides: Possibly digitalis toxicityestrogens, oral contraceptives: Increased cortisoneeffects and risk of toxicityhydantoins, rifampin: Increased metabolismand decreased effects of cortisoneisoniazid: Decreased blood isoniazid levelneuromuscular blockers: Possibly enhancedblockade of neuromuscular blockers, leadingto increased or prolonged respiratorydepression or apneaoral anticoagulants: Possibly obstructedanticoagulant effectspotassium-wasting diuretics: Possiblyhypokalemiasalicylates: Decreased effectiveness andblood level of salicylatessomatrem: Decreased growth-promotingeffectAdverse ReactionsCNS: Ataxia, behavior changes, depression,dizziness, euphoria, fatigue, headache,increased ICP with papilledema, insomnia,lassitude, malaise, mood swings, paresthesia,seizures, steroid psychosis, syncope, vertigoCV: Arrhythmias (from hypokalemia), fatembolism, heart failure, hypertension,hypotension, thromboembolism, thrombophlebitisEENT: Exophthalmos, glaucoma, increasedintraocular pressure, nystagmus, posteriorsubcapsular cataractsENDO: Adrenal insufficiency during stress,Cushing’s syndrome, diabetes mellitus,growth suppression in children, hyperglycemia,negative nitrogen balance from proteincatabolismGI: Abdominal distention, hiccups,increased appetite, nausea, pancreatitis,peptic ulcer, ulcerative esophagitis, vomitingGU: Glycosuria, menstrual irregularities,perineal burning or tinglingHEME: LeukocytosisMS: Arthralgia; aseptic necrosis of femoraland humeral heads; compression fractures;muscle atrophy, weakness, and twitching;myalgia; osteoporosis; spontaneous fractures;steroid myopathy; tendon ruptureSKIN: Acne; diaphoresis; ecchymosis; erythema;hirsutism; hyperpigmentation;hypopigmentation; necrotizing vasculitis;petechiae; purpura; rash; scarring; sterileabscesses; striae; subcutaneous fat atrophy;thin, fragile skin; urticariaOther: Anaphylaxis, hypocalcemia, hypokalemia,hypokalemic alkalosis, impairedwound healing, masking of infection, metabolicalkalosis, suppressed skin test reaction,weight gainNursing Considerations• Use cortisone cautiously in patients withocular herpes simplex because cornealperforation may occur.• Expect prescriber to order baseline ophthalmologicexamination before therapystarts because prolonged use of cortisonemay result in glaucoma, increased intraocularpressure, and damage to optic nerve.• Assess patient for signs and symptoms ofinfection before giving cortisone becausedrug may mask them. Be aware that new

infections may develop during therapybecause of risk of immunosuppression. Ifa new infection develops, expect to administerappropriate antibiotics.• Obtain serum electrolyte levels beforetherapy, as ordered, and monitor resultsoften during therapy to detect electrolyteimbalances. Increased calcium excretion,potassium depletion, and sodium andwater retention may occur with largedoses of cortisone. Anticipate the need forpotassium and calcium supplementationand sodium restriction, if indicated.• Keep in mind that prescriber will orderlowest effective dose.• To avoid peptic ulcer formation from cortisone,expect patient to receive concurrentantacid or antihistamine therapy.WARNING Be aware that live-virus vaccinesshouldn’t be given during cortisone therapybecause patient may become immunosuppressedand develop the viral infection.WARNING Assess for adrenal suppression orinsufficiency (fatigue, hypotension, lassitude,nausea, vomiting, and weakness) inpatient exposed to stress or receiving prolongedcortisone therapy. Notify prescriberimmediately if patient has evidence of thislife-threatening adverse reaction.• Watch for signs and symptoms of steroidpsychosis (confusion, delirium, euphoria,insomnia, mood swings, personalitychanges, severe depression), which maydevelop 15 to 30 days after starting drug.Be prepared to stop drug if such signsoccur. If stopping isn’t possible, expect toadminister a psychotropic drug.• Watch for cushingoid signs, such as acne,buffalo hump, central obesity, ecchymosis,moon face, striae, and weight gain. Notifyprescriber at once if they occur.• Expect to taper oral cortisone dosageslowly to prevent withdrawal syndrome(abdominal or back pain, anorexia, dizziness,fever, headache, and syncope).PATIENT TEACHING• Instruct patient to take oral cortisoneexactly as prescribed, every morningbefore 9 a.m. Advise him to take it withfood if GI distress occurs.• Caution patient not to stop drug abruptlybecause doing so may lead to adrenalinsufficiency, withdrawal symptoms, orboth.cromolyn sodium 273• Inform patient about adrenal insufficiencyand need for possible dosage increasesduring stress. Advise him to notify prescriberimmediately if signs or symptomsdevelop or if he’s exposed to stress.• Caution patient to avoid exposure to peoplewith infections because cortisone cancause immunosuppression. Also, teachhim to recognize and immediately reportsigns and symptoms of infection.• Teach patient to recognize and reportadverse reactions, including Cushing’s syndrome.• Urge patient receiving long-term cortisonetherapy to carry medical identification.• Recommend regular eye examinations.• Urge patient to keep follow-up appointmentswith prescriber, which may includelaboratory tests, to evaluate effects of therapy.cromolyn sodium(disodiumcromoglycate, sodiumcromoglycate)Apo-Cromolyn (CAN), Gastrocrom,Intal Syncroner (CAN), Nalcrom (CAN),Nasalcrom, Novo-cromolyn (CAN)Class and CategoryChemical class: Disodium chromoglycateTherapeutic class: Antiasthmatic, antiinflammatoryPregnancy category: BIndications and Dosages To prevent bronchial asthma attacksAEROSOL (METERED-DOSE INHALER)Adults and children over age 5. 2 meteredsprays (1.6 to 2 mg) every 4 to 6 hr.Maximum: 16 sprays (12.8 to 16 mg) daily.CAPSULES FOR INHALATIONAdults and children over age 2. 1 capsule(20 mg) every 4 to 6 hr. Maximum: 8 capsules(160 mg) daily.SOLUTION FOR NEBULIZATIONAdults and children over age 2. 20 mgevery 4 to 6 hr. Maximum: 160 mg daily. To prevent bronchospasm caused byenvironmental exposure or exerciseAEROSOL (METERED-DOSE INHALER)Adults and children over age 5. 2 meteredC

274cromolyn sodiumMechanism of ActionIn asthma, inflammation results whenantigen reexposure causes mast cells todegranulate and release histamine andchemical mediators. Cromolyn helpsreduce inflammation by preventingdegranulation. After exposure to an antigen,mast cells become sensitized to it andimmunoglobulin E (IgE) antibodiesappear on their surfaces. When the antigenreturns, it attaches to IgE (1 in theillustration) and triggers events that leadto degranulation (2). By preventing granulesfrom opening on the cells’ surfaces(3), cromolyn blocks release of histamineand chemical mediators.Antigen IgE antibody Nucleus12DegranulationMast cellGranule3Degranulationblockedby cromolynsprays (1.6 to 2 mg) as a single dose at least10 to 15 min (no longer than 1 hr) beforeexposure or exercise. Maximum: 16 sprays(12.8 to 16 mg) daily.CAPSULES FOR INHALATIONAdults and children over age 2. 1 capsule(20 mg) as single dose inhaled at least 10 to15 min (no longer than 1 hr) before exposureor exercise. Maximum: 8 capsules(160 mg) daily.SOLUTION FOR NEBULIZATIONAdults and children over age 2. Initial:20 mg inhaled 10 to 15 min (no longer than1 hr) before exposure or exercise. Repeatedp.r.n. during prolonged exercise. Maximum:160 mg daily. To treat allergic rhinitisNASAL SOLUTIONAdults and children over age 2. 1 spray(5.2 mg) in each nostril at regular intervalst.i.d. or q.i.d. Maximum: 1 spray (5.2 mg)in each nostril 6 times daily. To prevent systemic mastocytosisCAPSULES, ORAL CONCENTRATEAdults and adolescents. 200 mg q.i.d.,30 min before meals and at bedtime.Children ages 2 to 12. 100 mg q.i.d., 30 minbefore meals and at bedtime. Maximum:40 mg/kg/day.Children under age 2. 5 mg/kg q.i.d. Maximum:40 mg/kg daily.ContraindicationsArrhythmias, coronary artery disease (aerosol);hypersensitivity to cromolyn or itscomponents, status asthmaticus (all forms);nasal polyps (nasal solution)Route Onset Peak DurationAerosol Minutes Unknown Up to 2 hrNasal 1 wk 1–4 wk UnknownsolutionNebulizer Minutes Unknown 3–6 hrsolutionAdverse ReactionsCNS: Dizziness, headache, neuritisEENT: Burning eyes, hoarseness, laryngealedema, nasal congestion, and swollenparotid glands (all forms); increased sneezing,nasal stinging, and throat irritation(nasal solution); taste perversion (aerosol)GI: Anorexia, diarrhea (capsules and oralconcentrate), nausea, vomitingGU: Dysuria, urinary frequencyMS: Arthralgia, joint swellingRESP: Cough, wheezingSKIN: Rash, urticariaNursing ConsiderationsWARNING Be aware that cromolyn sodiumshouldn’t be used to relieve acute asthmaattack or severe bronchospasm; it shouldbe used only for prevention.• Don’t give cromolyn sodium throughhandheld nebulizer. Instead, administervia power-operated nebulizer with a facemask or mouthpiece.• Evaluate patient for effective inhalation;patient must be able to inhale adequatelyfor nebulizer solution to be effective.

• Thoroughly mix oral concentrate or capsulecontents into half a glass of hot water(not fruit juice, milk, or food), and let coolbefore administering.• Give drug at regular intervals to maximizeeffectiveness.PATIENT TEACHING• Teach patient how to use power-operatednebulizer; warn against using handheldnebulizer.• Advise patient to use cromolyn sodium10 to 15 minutes before exercising orexposure to other precipitating factors.• Instruct patient to thoroughly mix oralconcentrate with hot water (not fruit juice,milk, or food) and let it cool before drinking.• Inform patient that nasal spray may causeminor nasal irritation.• Explain that cromolyn sodium may takeup to 1 month to reach full therapeuticeffects.crotamiton; cyclizine 275Adverse ReactionsSKIN: Contact dermatitis, irritation, pruritus,rashNursing Considerations• Expect pruritus to continue for 4 to6 weeks after treatment.PATIENT TEACHING• Advise patient to shake lotion bottle wellbefore applying.• Warn him to keep drug away from eyes,nose, mouth, and inflamed skin.• Advise patient to use a topical corticosteroidfor dermatitis and an antihistaminefor pruritus, as prescribed.• Instruct patient to change clothing andbed linens the morning after final applicationand to take a cleansing bath 48 hoursafter final application.• Inform patient that pruritus may continuefor 4 to 6 weeks after treatment.• Advise patient to notify prescriber if skinirritation or rash occurs.CcrotamitonEuraxClass and CategoryChemical class: Synthetic chloroformate saltTherapeutic class: Antipruritic, scabicidePregnancy category: CIndications and Dosages To treat scabiesCREAM, LOTIONAdults. 30 to 60 g (thin layer) massagedinto skin from chin down and repeated in24 hr. Applied p.r.n. to skin folds, creases,and areas of intense pruritus for up to48 hr. To relieve pruritus caused by scabiesCREAM, LOTIONAdults. 30 to 60 g (thin layer) massagedgently into affected areas until drug is completelyabsorbed. Repeated p.r.n.Mechanism of ActionExerts a toxic effect on Sarcoptes scabiei byan unknown mechanism.ContraindicationsAbrasions, application to mucous membranes,breaks in skin, hypersensitivity tocrotamiton or its components, inflammationcyclizinehydrochlorideMarezinecyclizine lactateMarzine (CAN)Class and CategoryChemical class: Piperazine derivativeTherapeutic class: Anticholinergic, antiemeticPregnancy category: BIndications and Dosages To prevent postoperative vomitingI.M. INJECTIONAdults and adolescents. 50 mg 15 to30 min before surgery ends; then every 4 to6 hr, p.r.n., for first few postoperative days.Children ages 6 to 12. 25 mg 15 to 30 minbefore surgery ends; then t.i.d., p.r.n., forfirst few postoperative days.Children up to age 6. 12.5 mg 15 to 30 minbefore surgery ends; then t.i.d., p.r.n., forfirst few postoperative days. To prevent and treat motion sicknessTABLETSAdults and adolescents. 50 mg 30 min

276cyclobenzaprine hydrochloridebefore travel; then every 4 to 6 hr, p.r.n.Maximum: 200 mg daily.Children ages 6 to 12. 25 mg 30 min beforetravel; then every 6 to 8 hr, p.r.n. Maximum:75 mg daily.I.M. INJECTIONAdults and adolescents. 50 mg every 4 to6 hr, p.r.n.Children. 1 mg/kg t.i.d., p.r.n.Route Onset Peak DurationP.O., I.M. 30–60 min Unknown 4–6 hrMechanism of ActionMay act centrally on the vomiting center byblocking chemoreceptor trigger zones.Cyclizine also may reduce the sensitivity ofthe labyrinthine apparatus in the inner ear.ContraindicationsHypersensitivity to cyclizine or its components,shockInteractionsDRUGSanticholinergics: Possibly potentiated anticholinergiceffectsapomorphine: Possibly decreased emeticresponse of apomorphineCNS depressants: Possibly potentiated CNSdepressionACTIVITIESalcohol use: Possibly potentiated CNSdepressionAdverse ReactionsCNS: Dizziness, drowsiness, euphoria, excitation,hallucinations, insomnia, nervousness,restlessness, seizures (in children), vertigoCV: Hypotension, palpitations, tachycardiaEENT: Blurred vision; diplopia; dry mouth,nose, and throat; tinnitusGI: Anorexia, constipation, diarrhea, nausea,vomitingGU: Urinary frequency and hesitancy, urineretentionSKIN: Jaundice, rash, urticariaNursing Considerations• Help patient with ambulation, and takesafety precautions to prevent injury fromfalls if drowsiness or dizziness occurs.• Don’t schedule allergen skin tests until atleast 5 days after stopping cyclizine; drugmay interfere with test results.PATIENT TEACHING• Urge patient to avoid alcohol and otherCNS depressants during cyclizine therapy.• Advise patient to ask for help with ambulationif he feels drowsy or dizzy.cyclobenzaprinehydrochlorideFlexerilClass and CategoryChemical class: Tricyclic amine saltTherapeutic class: Skeletal muscle relaxantPregnancy category: BIndications and Dosages As adjunct to rest and physical therapyfor relief of muscle spasm associatedwith acute, painful musculoskeletal conditionsTABLETSAdults and adolescents. 5 mg t.i.d.,increased as needed to 10 mg t.i.d.Maximum: 30 mg daily for 3 wk.DOSAGE ADJUSTMENT Dosage frequencyreduced in elderly patients and those withhepatic impairment.Route Onset Peak DurationP.O. 1 hr 1–2 wk 12–24 hrMechanism of ActionActs in the brain stem to reduce or abolishtonic muscle hyperactivity. Becausecyclobenzaprine doesn’t act at the neuromuscularjunction or directly on skeletalmuscle, it relieves muscle spasm withoutdisrupting muscle function.ContraindicationsAcute recovery phase of MI; age less than12; arrhythmias, including heart block andother conduction disturbances; heart failure;hypersensitivity to cyclobenzaprine orits components; hyperthyroidism; MAOinhibitor use within 14 daysInteractionsDRUGSanticholinergics, antidyskinetics: Possiblypotentiated anticholinergic effects of thesedrugsCNS depressants, tricyclic antidepressants:

Possibly additive CNS depressant effects ofthese drugs, increased risk of adverse effectsof antidepressants and cyclobenzaprineguanadrel, guanethidine: Possibly decreasedor blocked antihypertensive effects of thesedrugsMAO inhibitors: Possibly hyperpyretic crisis,severe seizures, and deathACTIVITIESalcohol use: Possibly additive CNS depressionAdverse ReactionsCNS: Asthenia, confusion, depression,dizziness, drowsiness, fatigue, fever,headache, insomnia, irritability, nervousness,paresthesia, seizures, tremor, weaknessCV: Arrhythmias, including tachycardia;orthostatic hypotension; palpitations;vasodilationEENT: Blurred vision, diplopia, dry mouth,transient vision loss, unpleasant tasteGI: Constipation, hiccups, indigestion, nausea,vomitingGU: Libido changes, urinary frequency,urine retentionSKIN: Diaphoresis, facial flushing, pruritus,rashNursing Considerations• Use cyclobenzaprine cautiously in patientswith history of low seizure threshold.• If possible, avoid giving drug to elderlypatients because of its anticholinergiceffects.• To prevent falls, take safety precautions ifpatient is confused, dizzy, or weak.PATIENT TEACHING• Urge patient to avoid alcohol and otherCNS depressants during therapy.• Inform patient about possible lack ofalertness and dexterity.• Advise patient to ask for assistance withwalking, driving, or hazardous activities ifhe experiences dizziness or weakness.cycloserineSeromycinClass and CategoryChemical class: D-alanine analogue,Streptomyces garyphalus or Streptomycesorchidaceus derivativeTherapeutic class: AntitubercularPregnancy category: Ccycloserine 277Indications and Dosages To treat tuberculosis with other antituberculoticsafter failure of primarydrugs, including ethambutol, isoniazid,pyrazinamide, rifampin, streptomycinCAPSULESAdults and adolescents. 250 mg every12 hr for 2 wk; then every 6 to 8 hr for2 wk. Dosage increased gradually to maintainblood cycloserine level below 30 mcg/ml. Maximum: 1 g daily.Children. 10 to 20 mg/kg daily in divideddoses every 12 hr. Maximum: 1 g daily.Mechanism of ActionInhibits bacterial cell wall synthesis ingram-positive organisms, includingMycobacterium tuberculosis. In early stagesof bacterial cell wall synthesis, cycloserineinhibits two enzymes that help form peptidoglycan,which is needed to make the cellmembrane rigid and protective.ContraindicationsChronic alcoholism, depression, hypersensitivityto cycloserine or its components, psychosis,renal disease, seizure disorder, severeanxietyInteractionsDRUGSethionamide: Possibly increased risk ofseizuresisoniazid: Possibly increased risk of adverseCNS effectsphenytoin: Possibly increased blood phenytoinlevelpyridoxine: Possibly anemia or peripheralneuritisACTIVITIESalcohol use: Possibly increased risk ofseizuresAdverse ReactionsCNS: Aggression, anxiety, coma, confusion,depression, dizziness, drowsiness, headache,irritability, lethargy, memory loss, nervousness,nightmares, psychosis, restlessness,seizures, suicidal tendencies, tremor, vertigoCV: Heart failureHEME: Leukocytosis, megaloblastic anemiaMS: Dysarthria, hyperreflexiaSKIN: Dermatitis, photosensitivityC

278cyclosporineOther: Folic acid deficiency, vitamin B 12deficiencyNursing Considerations• Monitor blood cycloserine level, as appropriate.Blood level should be maintainedat 25 to 30 mcg/ml.• Monitor mental status, mood, and affectfor aggression or depression.• Monitor CBC to detect blood dyscrasias.• To prevent injury from falls, take safetyprecautions if adverse CNS reactions, suchas dizziness or drowsiness, develop.PATIENT TEACHING• Urge patient to avoid alcohol while takingcycloserine.• Instruct patient to seek help immediatelyif he has suicidal thoughts.• Advise patient to avoid driving and to askfor assistance with walking or hazardousactivities if he develops adverse CNS reactions,such as dizziness and drowsiness.• Tell patient to contact prescriber if symptomshaven’t improved after 2 to 3 weeks.• Emphasize the importance of complyingwith drug therapy because effective treatmentmay take years to complete.cyclosporine(cyclosporin A)Neoral, Sandimmune, SangCyaClass and CategoryChemical class: Tolypocladium inflatumGams– or Cylindrocarpon lucidumBooth–derived polypeptideTherapeutic class: Antipsoriatic, antirheumatic,immunosuppressantPregnancy category: CIndications and Dosages To prevent or treat organ rejection inkidney, liver, and heart allogenic transplantationCAPSULES, MODIFIED CAPSULES, MODIFIED ORALSOLUTION, ORAL SOLUTIONAdults and children. Initial: 12 to 15 mg/kgdaily in divided doses every 12 hr starting4 to 12 hr before surgery and continuing1 to 2 wk afterward. Then, dosage reducedby 5% every wk to maintenance dose.Maintenance: 5 to 10 mg/kg daily in divideddoses every 12 hr.I.V. INFUSIONAdults. 2 to 6 mg/kg daily starting 4 to12 hr before surgery and continuing afterwarduntil patient can tolerate oral form ofdrug. To treat severe rheumatoid arthritisMODIFIED CAPSULES, MODIFIED ORAL SOLUTIONAdults. 2.5 mg/kg daily in divided dosesevery 12 hr, increased by 0.5 to 0.75 mg/kgdaily after 8 wk and again after 12 wk.Maximum: 4 mg/kg daily. To treat psoriasisMODIFIED CAPSULES, MODIFIED ORAL SOLUTIONAdults. Initial: 2.5 mg/kg daily in divideddoses b.i.d., increased by 0.5 mg/kg dailyafter 4 wk. Then dosage increased every2 wk, if needed. Maximum: 4 mg/kg daily.Mechanism of ActionCauses immunosuppression by inhibitingthe proliferation of T lymphocytes, the productionand release of lymphokines, andthe release of interleukin-2.ContraindicationsAbnormal renal function, neoplastic diseases,and uncontrolled hypertension inpatients with psoriasis or rheumatoidarthritis (modified capsules and oral solution);hypersensitivity to cyclosporine, itscomponents, or polyoxyethylated castor oil(I.V. infusion)InteractionsDRUGSACE inhibitors, angiotensin II receptorantagonists, potassium-sparing diuretics,potassium supplements: Increased risk ofhyperkalemiaallopurinol, amiodarone, azithromycin,bromocriptine, clarithromycin, colchicine,danazol, diltiazem, erythromycin, fluconazole,hormonal contraceptives, imatinib, itraconazole,ketoconazole, methylprednisolone,metoclopromide, nefazodone, nicardipine,oral contraceptives, quinupristin and dalfopristin,verapamil, voriconazole: Increasedcyclosporine levelamphotericin B, azapropazon, cimetidine,ciprofloxacin, colchicine, co-trimoxazole, fibricacid derivatives (bezafibrate, fenofibrate),gentamicin, ketoconazole, melphalan,NSAIDs, ranitidine, tacrolimus, tobramycin,vancomycin: Increased risk of nephrotoxicityatorvastatin, fluvastatin, lovastatin, pravastatin,simvastatin: Risk of myotoxicity

osentan, carbamazepine, nafcillin,octreotide, orlistat, oxcarbazepine, phenobarbital,phenytoin, rifampin, St. John’s wort,sulfinpyrazone, terbinafine, ticlopidine:Decreased blood cyclosporine level andtherapeutic responsecolchicine: Possibly colchicine toxicity, suchas myopathy and neuropathydigoxin: Increased blood digoxin level andrisk of digitalis toxicityindinavir, nelfinavir, ritonavir, saquinavir:Possibly increased blood cyclosporine levelmethotrexate: Increased blood methotrexatelevel and risk of renal dysfunctionmethylprednisolone (high dose): Increasedrisk of seizuresother immunosuppressants: Possibly excessiveimmunosuppressionprednisolone: Increased prednisolone levelrepaglinide: Possibly increased repaglinidelevel and risk of hypoglycemiasirolimus: Increased blood sirolimus levelvaccines (killed or live virus): Possibly suppressedimmune response and increasedadverse effects of vaccineFOODSGrapefruit, grapefruit juice: Increased risk ofnephrotoxicityPotassium-rich foods: Increased risk ofhyperkalemiaAdverse ReactionsCNS: Altered level of consciousness, confusion,headache, intracranial hypertension,loss of motor function, paresthesia, psychiatricdisturbances, seizures, tremorCV: Chest pain, hypertensionEENT: Gingival hyperplasia, optic discedema, oral candidiasis, visual impairmentENDO: GynecomastiaGI: Diarrhea, nausea, pancreatitis, vomitingGU: Albuminuria, hematuria, nephropathyassociated with BK virus, proteinuria, renalfailureHEME: Anemia, leukopenia, thrombocytopeniaSKIN: Acne, cancer, flushing, hirsutism,rashOther: Anaphylaxis, hyperkalemia, hypomagnesemia,life-threatening infections,lymphoma and other malignanciescyclosporine 279Nursing Considerations• Be aware that capsules and oral solutionaren’t interchangeable with modified capsulesand modified oral solution. Modifiedforms have greater bioavailability.• Prepare I.V. infusion by diluting each milliliterof concentrate in 20 to 100 ml ofnormal saline solution or D 5 W. Use glasscontainers because of possible leaching ofdiethylhexyphthalate from polyvinyl chloridebags into cyclosporine solution.• Administer I.V. infusion over 2 to 6 hr. Ifneeded, drug may be infused over 24 hr.WARNING Closely monitor patient for anaphylaxis,at least during first 30 minutes ofI.V. administration. Make sure emergencyequipment and drugs are immediatelyavailable.WARNING Be aware that rapid I.V. infusionmay cause acute nephrotoxicity.• Don’t draw blood to measure cyclosporinelevel through same I.V. tubing used toadminister drug, even if line was flushedafter administration. Blood level may befalsely elevated.• Discard diluted solution after 24 hours.• Be aware that oral solution contains alcoholand shouldn’t be administered topatient who drinks heavily or has a historyof alcohol dependence.• Don’t add water to oral solution because itwill alter drug’s effectiveness.• Avoid giving oral cyclosporine with grapefruitjuice, which may raise trough level,increasing risk of nephrotoxicity.• Monitor blood pressure, especially inpatients with a history of hypertension,because drug can worsen this condition.Expect to decrease dosage if hypertensiondevelops.• Monitor liver and renal function tests, asordered, to detect decreased function.• Although uncommon, cyclosporine maycause neurotoxicity, especially after livertransplantation. Watch for evidence ofencephalopathy (impaired consciousness,loss of motor function, psychiatric disurbance,seizures, visual disturbance).• Be aware that cyclosporine use may resultin increased serum cholesterol levels.• Be aware that St. John’s wort may decreaseblood cyclosporine level.• Store capsules at 77° F (25° C) in prepackagedfoil wrap to protect them from light.• Expect about 50% of patients treated forpsoriasis to relapse about 4 months aftertherapy stops.C

280cyclosporineWARNING Watch for evidence of infection(such as fever, pain, cough, malaise)because patients receiving immunosuppressantssuch as cyclosporine are atincreased risk for viral, bacterial, fungal,and parasitic infection. Watch for bothgeneralized and localized infections,including worsening of pre-existing infections,and be aware that these infectionsmay become life-threatening. Activation oflatent viral infections may also occur andinclude BK virus–associated nephropathythat can lead to decreased renal functionand renal graft loss.PATIENT TEACHING• Instruct patient to take drug at same timeeach day and in same relation to type andtiming of food intake to help increasecompliance and maintain steady bloodlevel.• Advise patient to mix oral solution in aglass—not plastic—container with roomtemperatureorange or apple juice toimprove flavor. Caution him to avoidgrapefruit juice because it alters drugmetabolism.• Instruct patient to use syringe supplied bymanufacturer to ensure accurate measurementof oral solution dose and to wipe—not rinse—syringe after use to preventcloudiness.• Advise patient not to stop taking drugwithout consulting prescriber.• Instruct patient to avoid virus vaccinesduring therapy and people who havereceived such vaccines. Or, suggest wearinga protective mask when he’s around them.• Caution patient to avoid people who haveinfections during therapy becausecyclosporine causes immunosuppression.• Advise good dental hygiene because of riskof gingival hyperplasia.• Advise patient to discard oral solutionafter it has been opened for 2 months.• Inform patient with rheumatoid arthritisthat drug effects may not appear for 4 to6 weeks.• Caution patient to avoid excessive exposureto ultraviolet light.

daclizumab(dacliximab)ZenapaxDClass and CategoryChemical class: Monoclonal antibodyTherapeutic class: ImmunosuppressantPregnancy category: CIndications and Dosages To prevent acute organ rejection afterkidney transplantationI.V. INFUSIONAdults and children. 1 mg/kg given in fivedoses. Dose 1 given no more than 24 hrbefore transplantation; doses 2 through 5given at 14-day intervals.Mechanism of ActionInhibits interleukin-2–mediated activationof lymphocytes, which prevents WBCs fromattacking the transplanted kidney. Drugalso reduces the body’s infection-fightingability.ContraindicationsHypersensitivity to daclizumab or its componentsAdverse ReactionsCNS: Anxiety, chills, depression, dizziness,fatigue, fever, headache, insomnia, pricklysensation, tremor, weaknessCV: Chest pain, edema, hypertension,hypotension, tachycardia, thrombosisEENT: Blurred vision, pharyngitis, rhinitisENDO: HyperglycemiaGI: Abdominal distention and pain, constipation,diarrhea, flatulence, gastritis, heartburn,hemorrhoids, indigestion, nausea,vomitingGU: Dysuria, hematuria, hydronephrosis,oliguria, renal insufficiency, renal tubularnecrosis, urine retentionHEME: BleedingMS: Arthralgia, back pain, leg cramps,myalgiaRESP: Atelectasis, cough, crackles, dyspnea,hypoxia, lung congestion, pleural effusion,daclizumab; dalfampridine 281pulmonary edemaSKIN: Acne, diaphoresis, hirsutism,impaired wound healing, night sweats, pruritus,rashOther: Dehydration, fluid overload, injectionsite pain and redness, lymphoceleNursing Considerations• Dilute calculated dose of daclizumab in50 ml of normal saline solution. Gentlyinvert bag to mix. To prevent foaming,don’t shake it.• Use room temperature solution within4 hours or refrigerate it for up to 24 hours.Discard unused solution.• Because daclizumab’s compatibility withother drugs isn’t known, don’t add orsimultaneously infuse other drugs throughsame I.V. line.• Monitor blood glucose level for increasesduring therapy.WARNING Although daclizumab seldomcauses severe hypersensitivity reactions,keep drugs to treat such a reaction nearbyfor immediate use.PATIENT TEACHING• Urge patient to complete the course oftherapy and return for follow-up visits.dalfampridineAmpyraClass and CategoryChemical: AminopyridineTherapeutic: Potassium channel blockerPregnancy category: CIndications and Dosages To improve walking in patients withmultiple sclerosisTABLETSAdults. 10 mg twice dailyRoute Onset Peak DurationP.O. 1–2 hr 3–4 hr 10–11 hrMechanism of ActionMay improve walking in multiple sclerosispatients by blocking potassium channels.When potassium channels are blocked,there is increased conduction of actionpotentials in demyelinated axons resultingin improved muscle action.D

282dalteparin sodiumContraindicationsHistory of seizures, hypersensitivity to dalfampridineor its components, moderate orsevere renal impairment (creatinine clearanceof 50 ml/min/1.73 m 2 or less)InteractionsDRUGSother aminopyridine agents: Increased riskof adverse reactionsAdverse ReactionsCNS: Asthenia, balance disorder, confusion,dizziness, headache, insomnia, paresthesia,seizuresEENT: Nasopharyngitis, pharyngolaryngealpainGI: Constipation, dyspepsia, nauseaGU: UTIMS: Back pain, multiple sclerosis relapseNursing Considerations• Check patient’s creatinine clearance, asordered, before starting dalfampridine.• Use dalfampridine cautiously in patientswith mild renal failure (creatinine clearance51 to 80 ml/min/1.73 m 2 ) becauseseizures may occur. If they do, expect drugto be discontinued.• Drug shouldn’t be taken with compounded4-AP, 4-aminopyridine, or fampridinebecause the risk of seizures may increase.• Monitor patient’s ability to walk to determinedrug’s effectiveness.PATIENT TEACHING• Tell patient to space dalfampridine dosesabout 12 hours apart.• Instruct patient, especially one with mildrenal impairment, to notify prescriber andstop dalfampridine if seizures occur.• Review signs and symptoms of UTI (painon urination, frequency or urgency withurination, cloudy appearance to urine)and tell patient to report any such effectsto the prescriber.dalteparin sodium(tedelparin)FragminClass and CategoryChemical class: Low-molecular-weightheparinTherapeutic class: Anticoagulant, antithromboticPregnancy category: BIndications and Dosages To prevent ischemic complications inpatients who receive aspirin as part oftreatment for unstable angina andnon–Q-wave MISUBCUTANEOUS INJECTIONAdults. 120 international units/kg every12 hr with aspirin (75 to 165 mg daily)until patient is stable, usually 5 to 8 days.Maximum: 10,000 international units/dose. To prevent blood clots in patients undergoinghip replacement surgerySUBCUTANEOUS INJECTIONAdults. Initial: 2,500 international units1 to 2 hr before surgery, repeated in 8 to12 hr and again 8 to 12 hr later.Maintenance: 5,000 international unitsevery morning for 5 to 10 days postoperativelyor until patient is fully ambulatory.Alternate: 5,000 international units theevening before surgery; then 5,000 internationalunits daily (starting the next evening)for 5 to 10 days or until patient is fullyambulatory. To prevent blood clots in patients undergoingabdominal surgery who are at riskfor thromboembolic complicationsSUBCUTANEOUS INJECTIONAdults. 2,500 international units daily,starting 1 to 2 hr before surgery and repeatedfor 5 to 10 days. For patients at high risk(those with cancer), 5,000 internationalunits the evening before surgery, repeateddaily for 5 to 10 days; or 2,500 internationalunits 1 to 2 hr before surgery followed by2,500 international units 12 hr later andthen 5,000 international units daily for 5 to10 days. To prevent blood clots in patients withsevere mobility restrictions during acuteillnessSUBCUTANEOUS INJECTIONAdults. 5,000 international units daily. To treat symptomatic venous thromboembolismand prevent recurrence inpatients with cancerSUBCUTANEOUS INJECTIONAdults. 200 international units/kg (not toexceed 18,000 international units) oncedaily for 30 days. Then 150 internationalunits/kg once daily for 5 more mo.

Mechanism of ActionBinds to and accelerates the activity ofantithrombin III, thus inhibiting thrombinand blocking the formation of fibrin clots.IncompatibilitiesDon’t mix dalteparin with other drugs.ContraindicationsActive major bleeding; hypersensitivity tolow-molecular-weight heparins, heparin, orpork products; thrombocytopenia associatedwith positive tests for antiplatelet antibodiesin the presence of dalteparinInteractionsDRUGSNSAIDs, oral anticoagulants, platelet aggregationinhibitors, thrombolytics: Possiblyincreased risk of hemorrhage and spinal orepidural hematomaAdverse ReactionsGI: Elevated liver emzymesHEME: Hemorrhage, thrombocytopeniaSKIN: Alopecia, bullous eruption, necrosis,pruritus, rashOther: Anaphylaxis, injection sitehematoma and painNursing Considerations• Use dalteparin with extreme caution inpatients with a history of heparin-inducedthrombocytopenia; those at increased riskfor hemorrhage (such as those who use aplatelet inhibitor or have bacterial endocarditis,bleeding disorders, active ulcerativeGI disease, uncontrolled hypertension,or hemorrhagic stroke); and those withrecent brain, eye, or spinal surgery.• Use drug cautiously in patients withbleeding diathesis, diabetic retinopathy,platelet defects, recent GI bleeding, severehepatic or renal insufficiency, or thrombocytopenia.• Before giving first dose, tell Jewish orIslamic patients that drug comes fromporcine intestine.• Risk factors for thromboembolic eventsinclude age over 40, cancer, history of deepvein thrombosis or pulmonary embolism,obesity, and planned use of anesthesia formore than 30 minutes.• Don’t give drug by I.M. or I.V. injection.• With patient seated or supine, administerdrug deep into subcutaneous tissue in U-shaped area around navel, upper outerdanaparoid sodium 283thigh, or upper outer quadrant of buttocks.If using area around navel or onthigh, lift skin fold with thumb and forefingerwhile giving injection. Insert entirelength of needle at a 45- to 90-degreeangle. Rotate sites daily.• Routine coagulation tests and dosageadjustments usually aren’t required.WARNING Monitor patient receiving dalteparinand epidural or spinal anesthesiaor spinal puncture because spinalhematomas can occur, causing long-termor permanent paralysis. Watch for evidenceof neurologic impairment, such aschanges in sensory or motor function. Ifpresent, notify prescriber immediately;patient needs urgent care to minimizeeffect of hematoma. Use of indwellingepidural catheters, concurrent use of otherdrugs that affect hemostasis, a history oftraumatic or repeated epidural or spinalpunctures, or a history of spinal deformityor spinal surgery increases the risk ofspinal or epidural hematoma in patientsreceiving dalteparin.PATIENT TEACHING• If therapy will continue at home, teachpatient or caregiver to select injecitonsites, give subcutaneous injections, androtate sites daily. Tell patient to discarddrug if it’s discolored or contains particles.Review safe handling and disposal ofsyringes and needles.• Teach patient to store drug at room temperature,away from moisture and heat.• Urge patient to report adverse reactions,especially bleeding, and to seek help immediatelyif signs of thromboembolism develop,such as severe dyspnea (pulmonaryembolism) or neurologic deficits (cerebralembolism).• Stress the importance of follow-up visits.danaparoid sodiumOrgaranClass and CategoryChemical class: Glycosaminoglycan heparinoid,low-molecular-weight heparinTherapeutic class: Anticoagulant, antithromboticPregnancy category: BD

284dantrolene sodiumIndications and Dosages To prevent deep vein thrombosis afterhip replacement surgerySUBCUTANEOUS INJECTIONAdults. 750 anti-factor Xa units b.i.d. (firstdose 1 to 4 hr preoperatively; second doseno sooner than 2 hr after surgery) for 7 to14 days, as indicated.Mechanism of ActionInhibits thrombin generation in coagulationpathway, thus preventing fibrin formationand clotting.ContraindicationsActive major bleeding (including hemorrhagicstroke); hypersensitivity to low-molecularweightheparins, heparin, or pork products;severe hemorrhagic disorders, such as hemophiliaand thrombocytopenic purpura; sulfitesensitivity; type II thrombocytopenia associatedwith positive laboratory tests for antiplateletantibodies in the presence of danaparoidInteractionsDRUGSNSAIDs, oral anticoagulants, platelet aggregationinhibitors: Possibly increased risk ofbleedingAdverse ReactionsCNS: Asthenia, dizziness, fever, headache,insomniaCV: Chest pain, edemaGI: Abdominal pain, constipation, nausea,vomitingGU: Urine retention, UTIHEME: Anemia, excessive bleedingMS: Arthralgia, myalgiaSKIN: Pruritus, rashOther: Anaphylaxis, injection site painNursing Considerations• Use danaparoid with extreme caution inpatients at increased risk for hemorrhage(such as those with severe uncontrolledhypertension, acute bacterial endocarditis,bleeding disorders, active ulcerative GIdisease, severe renal dysfunction, or nonhemorrhagicstroke); those with a postoperativeindwelling epidural catheter; andthose with recent had brain, eye, or spinalsurgery.• Before administering first dose, informJewish and Islamic patients that drugcomes from porcine intestinal mucosa.• Don’t give drug by I.M. or I.V. injection.• Administer drug with patient lying down.Use a 25G or 26G needle to minimize tissuetrauma. Select site on left or rightanterolateral or posterolateral abdominalwall. Hold skin fold gently between thumband forefinger, and insert entire length ofneedle deep into subcutaneous tissue at a45- to 90-degree angle. Don’t pinch or rubsite afterward. Rotate sites.• Expect to monitor results of CBC andfecal occult blood tests during therapy.Typical coagulation tests, such as PT,APTT, clotting time, whole blood clottingtime, and thrombin time, aren’t useful formonitoring drug’s anticoagulant effect.PATIENT TEACHING• If therapy must continue at home, teachpatient or caregiver how to give subcutaneousinjections. Review injection sites,and instruct her to rotate them daily. Tellher to discard drug if it’s discolored orcontains particles. Review safe handlingand disposal of syringes and needles.• Teach patient to store drug at room temperature,away from moisture and heat.• Instruct patient to consult prescriberbefore using aspirin, ibuprofen, indomethacin,ketoprofen, naproxen, and otherNSAIDs because they may increase therisk of bleeding.• Advise patient to stop taking drug andseek help immediately if she experiencessevere dizziness, fever, rash, wheezing, orprolonged or unexplained bleeding andpain at the injection site.dantrolene sodiumDantrium, Dantrium IntravenousClass and CategoryChemical class: Hydantoin derivative, imidazolidinedionesodium saltTherapeutic class: Antispastic, malignanthyperthermia therapy adjunctPregnancy category: C (parenteral), Notrated (oral)Indications and Dosages To treat chronic spastic conditionscaused by severe chronic disorders, suchas cerebral palsy, stroke, multiple sclerosis,and spinal cord injury

CAPSULESAdults and adolescents. Initial: 25 mg dailyfor 7 days. Then dosage increased to 25 mg/day every 4 to 7 days until desired responseoccurs or dosage reaches 100 mg q.i.d.Maximum: 400 mg daily.Children. Initial: 0.5 mg/kg b.i.d. for 7 days.Then increased by 0.5 mg/kg daily every4 to 7 days until desired response occurs ordosage reaches 3 mg/kg q.i.d. Maximum:400 mg daily. To prevent malignant hyperthermiabefore surgeryCAPSULESAdults and children. 4 to 8 mg/kg daily individed doses t.i.d. or q.i.d. 1 or 2 daysbefore surgery, with last dose given 3 to 4 hrbefore surgery.I.V. INFUSIONAdults and children. Initial: 2.5 mg/kg60 to 75 min before anesthesia and infusedover 1 hr. Additional individualized dosesgiven as needed during surgery. To treat malignant hyperthermic crisisI.V. INJECTIONAdults and adolescents. Initial: 1 mg/kg byrapid bolus; repeated, p.r.n., until symptomssubside or cumulative dose of 10 mg/kg has been reached and if symptoms reappear. To treat postmalignant hyperthermiccrisisCAPSULESAdults and children. 4 to 8 mg/kg daily individed doses q.i.d. for 1 to 3 days.I.V. INJECTIONAdults and children. Initial: Individualizeddosage beginning with 1 mg/kg or more asneeded if oral therapy can’t be used.Maximum: 10 mg/kg total dose.Route Onset Peak DurationP.O. 1 wk* Unknown UnknownMechanism of ActionActs directly on skeletal muscle to reducethe force of reflex muscle contraction. Thisin turn reduces hyperreflexia, spasticity,involuntary movements, and clonus, probablyby preventing calcium release from thesarcoplasmic reticulum of skeletal muscle* For spasticity; unknown for malignanthyperthermia.dantrolene sodium 285cells. Blocked calcium release also inhibitsthe activation of acute catabolism associatedwith malignant hyperthermic crisis syndrome.IncompatibilitiesDon’t administer parenteral dantrolenewith acidic solutions, including D 5 W andnormal saline solution.ContraindicationsFor oral drug only: Active hepatic disease(such as cirrhosis and hepatitis), conditionsin which spasticity helps maintain uprightposture and improve balance or function,skeletal muscle spasms caused by rheumaticdisordersInteractionsDRUGScalcium channel blockers (especially verapamil):Possibly hyperkalemia, shock, lifethreateningarrhythmiashepatotoxic drugs: Increased risk of hepatotoxicitywith long-term oral dantrolene usesedatives: Possibly profound sedationACTIVITIESalcohol use: Possibly increased CNS depressionAdverse ReactionsCNS: Chills, confusion, depression, dizziness,drowsiness, fatigue, fever, headache,insomnia, light-headedness, malaise, nervousness,seizures, slurred speech or otherspeech problems, weaknessCV: Heart failure (I.V.), labile blood pressure,pericarditis, phlebitis, tachycardiaEENT: Abnormal vision, altered taste,diplopia, lacrimationGI: Abdominal cramps, anorexia, constipation,diarrhea, dysphagia, gastric irritation,GI bleeding, hepatitis, hepatotoxicityGU: Crystalluria, dysuria, erectile dysfunction,hematuria, nocturia, urinary frequency,urinary incontinence, urine retentionMS: Backache, myalgiaRESP: Feeling of suffocation, pleural effusionSKIN: Acne, diaphoresis, eczematoid eruption,erythema (I.V.), extravasation with tissuedamage, hirsutism, pruritus, rash,urticariaNursing Considerations• Use dantrolene cautiously in patients withimpaired pulmonary function, especiallyD

286Adverse ReactionsCNS: Anxiety, asthenia, confusion, dizziness,fever, headache, insomnia, peripheralneuropathyCV: Cardiac failure, chest pain, hypertension,hypotension, peripheral edema,supraventricular tachycardiaEENT: Pharyngolaryngeal pain, oral candaptomycinthose with COPD, and in those withsevere cardiac or hepatic dysfunction.• Reconstitute drug with 60 ml sterile water forinjection. Shake vial until clear. Store reconstitutedsolution at room temperature, protectedfrom direct sunlight. Discard after 6 hours.• To prevent precipitation, transfer reconstituteddrug to a plastic I.V. bag, rather thana glass bottle, for infusion.• Because drug has a high pH, infuse into acentral vein, if possible, to avoid tissuedamage from extravasation.• Monitor blood pressure and heart rateoften during administration to detecttachycardia and blood pressure changes.• Notify prescriber about persistent diarrheawith oral therapy; drug may need to bestopped.• Monitor results of liver function tests—especially ALT, AST, alkaline phosphatase,and total bilirubin levels—to detecthepatotoxicity. Expect to stop drug after45 days if benefits aren’t sufficient becauserisk of hepatotoxicity increases with doseand time, especially for women andpatients over age 35.PATIENT TEACHING• Advise patient to take dantrolene withfood if gastric irritation develops.• Tell patient that drug may weaken musclesused for walking and climbing stairs.• Explain drug’s sedating effects. Cautionpatient to avoid sedatives (unless prescribed),including alcohol.• Advise patient to report yellow skin orsclerae, itching, anorexia, and fatigue.• If patient misses a dose, tell her to waituntil the next scheduled dose if more than2 hours have passed since the missed dose.Instruct her not to double the dose.• Caution patient not to stop taking drugwithout consulting prescriber. Gradualdosage reduction may be required, especiallyafter long-term use.daptomycinCubicinClass and CategoryChemical class: Cyclic lipopeptideTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat complicated skin and skin structureinfections caused by Staphylococcusaureus (including methicillinresistantisolates), Streptococcus pyogenes,Streptococcus agalactiae,Streptococcus dysgalactiae subspeciesEquisimilis, and Enterococcus faecalis(vancomycin-susceptible isolates only)I.V. INFUSIONAdults. 4 mg/kg administered over 30 mindaily for 7 to 14 days. Maximum: 6 mg/kgI.V. every 24 hr.DOSAGE ADJUSTMENT For patients withcreatinine clearance less than 30 ml/min/1.73 m 2 , 4 or 6 mg/kg (depending on infectiontype) once every 48 hr. To treat Staphylococcus aureus bloodstreaminfections, including right-sidedinfective endocarditis, caused bymethicillin-susceptible and methicillinresistantisolatesI.V. INFUSIONAdults. 6 mg/kg administered over 30 mindaily for 2 to 6 wk. Maximum: 6 mg/kg I.V.every 24 hr.DOSAGE ADJUSTMENT For patients withcreatinine clearance less than 30 ml/min/1.73 m 2 , dosage is 4 or 6 mg/kg (dependingon infection) once every 48 hr.Mechanism of ActionBinds to bacterial membranes to causerapid depolarization of membrane potential.This loss of membrane potentialinhibits protein, DNA, and RNA synthesis,which results in bacterial cell death.ContraindicationsHypersensitivity to daptomycin or its componentsInteractionsDRUGSHMG-CoA reductase inhibitors: Possiblyincreased CK level and increased risk ofmyopathy

didiasis, sore throatENDO: Hyperglycemia, hypoglycemiaGI: Abdominal pain, anorexia, constipation,diarrhea, dyspepsia, dysphagia, elevatedliver enzymes, GI hemorrhage, nausea,pseudomembranous colitis, vomitingGU: Renal failure, UTI, vaginal candidiasisHEME: Anemia, eosinophilia, increasedINR, leukocytosis, thrombocytopenia,thrombocytosisMS: Arthralgia, back or limb pain, elevatedmyoglobin level, myopathy, rhabdomyolysis,osteomyelitisRESP: Cough, dyspnea, pleural effusion,pneumonia, pulmonary eosinophilia, shortnessof breathSKIN: Cellulitis, diaphoresis, erythema,pruritus, rash, urticaria, vesiculobullousrashOther: Anaphylaxis, bacteremia, elevatedalkaline phosphatase level, elevated serumsodium bicarbonate level, fungal infection,hyperkalemia, hypokalemia, hypomagnesemia,injection site reactions, sepsisNursing Considerations• Obtain blood samples for culture and sensitivitytesting before starting daptomycin.• Reconstitute daptomycin powder by slowlytransferring 10 ml normal saline for injectioninto vial and pointing needle towardwall of vial to minimize foaming. Thengently rotate vial until all powder is wet.Don’t agitate or shake vial. Let vial standundisturbed for 10 minutes, and then gentlyrotate or swirl contents for a few minutes,as needed, to obtain a completelyreconstituted solution.• Further dilute reconstituted daptomycinsolution with normal saline for injection,and give by I.V. infusion over 30 minutes.Reconstituted drug is stable in infusionbag for 12 hours at room temperature or48 hours refrigerated.• Daptomycin may cause a significant falseincrease in PT and INR. If this occurs duringdaptomycin therapy, draw blood samplejust before next daptomycin dose andevaluate other causes of the increase.• Monitor patient closely for diarrhea,which may herald pseudomebranous colitiscaused by Clostridium difficile. If diarrheaoccurs, notify prescriber. Ifpseudomembranous colitis develops,expect to discontinue drug and give fluids,darbepoetin alfa 287electrolytes, protein, and antibiotic effectiveagainst C. difficile.• Monitor patient for evidence of superinfection,and inform prescriber if present.Expect to stop drug and provide care.• Assess patient for muscle pain or weakness,especially of distal limbs. Expect tomonitor CK level weekly or more often inpatients recently or currently taking anHMG-CoA reductase inhibitor. Expect tostop daptomycin, as ordered, if patient hasmyopathy or marked rise in CK level.• Monitor patient’s BUN and serum creatininelevels closely, especially if renal insufficiencyis already present.PATIENT TEACHING• Inform patient that diarrhea may occur2 months or more after daptomycin therapystops. If severe or prolonged, advisepatient to notify prescriber as soon as possible;additional treatment may be needed.• Urge patient to immediately report musclepain, tenderness, or weakness and othersymptoms of myopathy.darbepoetin alfaAranespClass and CategoryChemical class: 165-amino acid glycoproteinidentical to human erythropoietinTherapeutic class: AntianemicPregnancy category: CIndications and Dosages To treat anemia from chronic renal failureI.V. OR SUBCUTANEOUS INJECTIONAdults. Initial: 0.45 mcg/kg as a single doseevery wk. Maintenance: Dosage individualizedand increased monthly to maintain ahemoglobin level not to exceed 12 g/dl.DOSAGE ADJUSTMENT Dosage reduced byabout 25% if hemoglobin level increasesand approaches 12 g/dl. If it continues toincrease, doses temporarily withheld untilhemoglobin level begins to decrease; thentherapy is restarted at a dose about 25%below previous dose. Dosage reduced byabout 25% if hemoglobin level increases bymore than 1 g/dl in a 2-wk period. Dosageincreased by about 25% of previous dose ifhemoglobin level increases less than 1 g/dlD

288darbepoetin alfaover 4 wk but only if serum ferritin level is100 mcg/L or greater and serum transferrinsaturation is 20% or greater. Furtherincreases made at 4-wk intervals until specifiedhemoglobin level is obtained.DOSAGE ADJUSTMENT For conversion fromepoetin alfa to darbepoetin alfa, dosageadministered every wk for patient who previouslyreceived epoetin alfa 2 to 3 times/wk and once every 2 wk for patient whopreviously received epoetin alfa once/wk.For conversion from epoetin alfa, 6.25 mcg/wk darbepoetin alfa given every wk forpatients who received less than 2,500 units/wk of epoetin alfa; 12.5 mcg/wk darbepoetinalfa every wk for patients who received2,500 to 4,999 units/wk of epoetin alfa;25 mcg/wk darbepoetin alfa every wk forpatients who received 5,000 to 10,999 units/wk of epoetin alfa; 40 mcg/wk darbepoetinalfa every wk for patients who received11,000 to 17,999 units/wk of epoetin alfa;60 mcg/wk darbepoetin alfa every wk forpatients who received 18,000 to 33,999 units/wk of epoetin alfa; 100 mcg/wk darbepoetinalfa every wk for patients who received34,000 to 89,999 units/wk of epoetin alfa;200 mcg/wk darbepoetin alfa every wk forpatients who received 90,000 or moreunits/wk of epoetin alfa. To treat chemotherapy-induced anemiain patients with nonmyeloid malignanciesand hemoglobin level less than 10 g/dlSUBCUTANEOUS INJECTIONAdults. Initial: 2.25 mcg/kg as a single doseevery wk. Maintenance: Dosage individualizedto maintain a target hemoglobin level.DOSAGE ADJUSTMENT Dosage increased to4.5 mcg/kg if hemoglobin level increasesless than 1.0 g/dl after 6 wk of therapy. If itincreases more than 1.0 g/dl over 2 wk or itexceeds 12 g/dl, dosage reduced by about25%. If hemoglobin level exceeds 13 g/dl,doses temporarily withheld until it falls to12 g/dl. Then therapy is restarted at a doseabout 25% less than last dose given.Route Onset Peak DurationI.V., SubQ 2–6 wk Unknown UnknownMechanism of ActionStimulates release of reticulocytes from thebone marrow into the bloodstream, wherethey develop into mature RBCs.IncompatibilitiesDon’t mix darbepoetin alfa with any otherdrug.ContraindicationsHypersensitivity to human albumin orproducts made from mammal cells; uncontrolledhypertensionAdverse ReactionsCNS: Asthenia, dizziness, fatigue, fever,headache, seizures, stroke, transientischemic attackCV: Acute MI, angina, arrhythmias, cardiacarrest, chest pain, congestive heart failure,hypertension, hypotension, peripheraledema, vascular access hemorrhage, vascularaccess thrombosisGI: Abdominal pain, constipation, diarrhea,nausea, vomitingMS: Arthralgia, back pain, limb pain, musclespasm, myalgiaRESP: Bronchitis, cough, dyspnea, pneumonia,pulmonary embolism, upper respiratorytract infectionSKIN: Pruritus, rash, urticariaOther: Dehydration, fluid overload, infection,flulike symptoms, injection site pain,sepsisNursing Considerations• Before starting darbepoetin alfa therapy,expect to correct folic acid or vitamin B 12deficiencies because these conditions mayinterfere with drug’s effectiveness.• Darbepoetin alfa shouldn’t be given tocancer patients when a cure is anticipatedbecause drug may decrease survival rateand increase tumor progression in patientswith certain types of cancers, such asbreast, non-small cell lung, head and neck,lymphoid, and cervical cancers.• To ensure effective drug response, expectto obtain serum ferritin level and transferrinsaturation before and during therapy,as ordered. If serum ferritin level is lessthan 100 mcg/L or serum transferrin saturationis less than 20%, expect to beginsupplemental iron therapy.• Don’t shake vial during preparation toavoid denaturing drug and rendering itbiologically inactive.• Discard drug if you see particulate matteror discoloration.• Don’t dilute drug before giving it.

• Needle cover on prefilled syringe containsdry natural rubber and may cause allergicreaction in those with latex sensitivity.• Discard unused portion of drug because itcontains no preservatives.• Monitor patient closely for hypertensionduring therapy. Expect to reduce dosage orwithhold drug if blood pressure is poorlycontrolled with antihypertensive anddietary measures.• Monitor hemoglobin level weekly, asordered, until hemoglobin stabilizes andmaintenance dosage has been achieved.Then monitor hemoglobin level regularly,as ordered. After each dosage adjustment,expect to check hemoglobin level weeklyfor 4 weeks until it stabilizes in responseto dosage change.WARNING If hemoglobin level increasesmore than about 1 g/dl during any 2-weekperiod or it exceeds 12 g/dl, the risk ofcardiac arrest, seizures, stroke, worsenedhypertension, congestive heart failure, vascularthrombosis, vascular ischemia, vascularinfarction, acute MI, fluid overloadwith peripheral edema, tumor prgression,and shortened survival increases. Expectto decrease dosage if this occurs.• Expect to discontinue darbepoetin in cancerpatients if hemoglobin level hasn’tincreased after 8 weeks or if patient continuesto need transfusions despite therapy.• Institute seizure precautions according tofacility policy.• For patients with chronic renal failure whoaren’t receiving dialysis, expect to givelower doses than those given to patientsreceiving dialysis. Also, monitor renalfunction test results and fluid and electrolytebalance in these patients for signsof declining renal function. If patientstarts dialysis, monitor hemoglobin andblood pressure closely and expect maintenancedosage to be adjusted, as needed.• Store drug at 2° to 8° C (36° to 46° F).Don't freeze, and do protect from light.PATIENT TEACHING• Advise patient that the risk of seizures ishighest during the first 90 days of therapy.Discourage her from engaging in hazardousactivities during this time.• Stress the importance of complying withthe dosage regimen and keeping follow-upmedical and laboratory appointments.• Advise patient to follow up with her prescriberfor blood pressure monitoring.• Encourage patient to eat adequate quantitiesof iron-rich foods.• If patient will self-administer darbepoetin,teach her and her caregiver the properadministration technique.• Caution patient and her caregiver not toreuse needles, syringes, or drug product.Thoroughly instruct them in proper needleand syringe disposal using a punctureresistantcontainer.• Explain that needle cover on prefilledsyringe contains dry natural rubber andmay cause allergic reaction in those withlatex sensivitity.• Review possible adverse reactions, andurge patient to notify prescriber if sheexperiences chest pain, headache, rash,seizures, shortness of breath, or swelling.darifenacinEnablexdarifenacin 289Class and CategoryChemical class: Muscarinic receptor antagonistTherapeutic class: Bladder antispasmodicPregnancy category: CIndications and Dosages To treat overactive urinary bladder withsymptoms of urge incontinence, includingurgency and frequencyE.R. TABLETSAdults. Initial: 7.5 mg daily, increased to15 mg daily after 2 wk as needed.DOSAGE ADJUSTMENT For patients withmoderate hepatic impairment and thosetaking potent CYP3A4 inhibitors (such asclarithromycin, itraconazole, ketoconazole,nefazodone, nelfinavir, and ritonavir) dailydosage should not exceed 7.5 mg.Route Onset Peak DurationP.O. Unknown 7 hr UnknownMechanism of ActionAntagonizes effect of acetylcholine on muscarinicreceptors in detrusor muscle,decreasing muscle spasms that cause inappropriatebladder emptying. This actionincreases bladder capacity and volume,D

290decitabinewhich relieves sensations of urgency andfrequency and enhances bladder control.ContraindicationsGastric retention, hypersensitivity to darifenacinor its components, uncontrollednarrow-angle glaucoma, urine retention,and patients at risk for these conditionsInteractionsDRUGSanticholinergics: Increased frequency andseverity of anticholinergic adverse reactionsflecainide, thioridazine, tricyclic antidepressants:Risk of toxicity with these drugspotent CYP3A4 inhibitors (such as clarithromycin,itraconazole, ketoconazole, nefazodone,nelfinavir, and ritonavir): Decreasedmetabolism and increased effects of darifenacin,possibly increasing the risk ofadverse reactionsAdverse ReactionsCNS: Asthenia, confusion, dizziness, hallucinationsCV: Hypertension, palpitations, peripheraledemaEENT: Abnormal vision, dry eyes ormouth, pharyngitis, rhinitis, sinusitisGI: Abdominal pain, constipation, diarrhea,indigestion, nausea, vomitingGU: Urine retention, UTI, vaginitisMS: Arthralgia, back painRESP: BronchitisSKIN: Dry skin, pruritus, rashOther: Angioedema, flulike symptoms,hypersensitivity reactions, weight gainNursing Considerations• Use darifenacin cautiously in patients withsignificant bladder outflow obstruction;they have increased risk of urine retention.• Use darifenacin cautiously in patients withsevere constipation, ulcerative colitis, ormyasthenia gravis because it may decreaseGI motility. Also use drug cautiously inobstructive GI disorders because itincreases the risk of gastric retention.PATIENT TEACHING• Tell patient to swallow tablets with liquidand not to crush, split, or break them.• Advise patient to avoid exercising in hotweather because darifenacin decreasessweating, increasing the risk of heatstroke.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.decitabineDacogenClass and CategoryChemical class: Analogue of naturalnucleoside 2'-deoxycytidineTherapeutic class: AntineoplasticPregnancy category: DIndications and Dosages To treat myelodysplastic syndromes(MDS) including secondary MDS of allFrench-American-British subtypes andintermediate 1 and 2 and high-riskInternational Prognostic Scoring SystemgroupsI.V. INFUSIONAdults. 15 mg/m 2 over 3 hr, repeated every8 hr for 3 days with cycle repeated every6 wk for at least four cycles.DOSAGE ADJUSTMENT For hematologicrecovery that requires more than 6 wk butless than 8 wk, doses delayed for up to 2 wkand temporarily reduced to 11 mg/m 2 every8 hr. For recovery that requires more than8 wk but less than 10 wk, doses delayed upto 2 more wk and reduced to 11 mg/m 2every 8 hr, maintained or increased in subsequentcycles as clinically indicated.Mechanism of ActionInhibits DNA methyltransferase after phosphorylationand direct incorporation intoDNA, resulting in hypomethylation of theDNA and cellular differentiation. In neoplasticcells, hypomethylation may restorenormal function to genes essential for controllingcellular differentiation and proliferation.In rapidly dividing cells, decitabinealso may cause cell death by forming covalentadducts between DNA methyltransferaseand decitabine-saturated DNA.ContraindicationsHypersensitivity to decitabine or its componentsAdverse ReactionsCNS: Anxiety, confusion, dizziness, fatigue,fever, headache, hypoesthesia, insomnia,lethargy, malaise, rigorsCV: Chest discomfort or pain, hypotension,peripheral edemaEENT: Bleeding gums, blurred vision, lip or

tongue ulceration, oral mucous petechiae,oral candidasis, pharyngitis, postnasal drip,sinusitis, stomatitisENDO: HyperglycemiaGI: Abdominal distention, abdominal pain,anorexia, ascities, constipation, decreasedappetite, diarrhea, dysphagia, dyspepsia,gastroesophageal reflux disease, hyperbilirubinemia,nausea, vomitingGU: Dysuria, urinary frequency, UTIHEME: Anemia, leukopenia, neutropenia,thrombocytopenia, thrombocythemiaMS: Arthralgia, back or limb pain, myalgiaRESP: Decreased breath sounds, cough,crackles, hypoxia, pneumonia, pulmonaryedemaSKIN: Alopecia, cellulites, ecchymosis, erythema,hematoma, pallor, petechiae, pruritus,rash, urticariaOther: Bacteremia; candidal infection; dehydration;facial edema; hyperkalemia; hypoalbuminemia;hypokalemia; hypomagnesemia;hyponatremia; injection site swelling, pain,and redness; lymphadenopathyNursing Considerations• Use cautiously in patients with liver orrenal impairment.• Follow facility protocols for preparing andhandling antineoplastic drugs and for disposingof used equipment.• Reconstitute with 10 ml sterile water usingaseptic technique; each milliliter containsabout 5 mg of decitabine. Immediatelyafter reconstitution, further dilute withnormal saline solution, dextrose 5%, orlactated Ringer’s solution to a final concentrationof 0.1 to 1 mg/ml. Use within15 minutes. If delay is expected, reconstitutedrug using cold dilution solution andstore in refrigerator for up to 7 hours.• Monitor CBC—including hematocrit,platelet count, and WBC with differential—aswell as electrolyte, liver enzyme,and serum creatinine levels before andintermittently during decitabine therapy,as ordered.• If patient develops leukopenia, look forevidence of infection, such as fever. Expectto obtain appropriate specimens for cultureand sensitivity testing.WARNING Monitor patient closely for nonhematologictoxicities, such as active oruncontrolled infection, serum creatininelevel greater than 2 mg/dl, or serum glutamicpyruvic transaminase or total bilirubin2 or more times the upper limit ofnormal. If present, notify prescriber andexpect decitabine therapy to be withhelduntil resolved.PATIENT TEACHING• Advise male patients not to father a childduring decitabine therapy and for2 months after. Also urge female patientsto use contraception to avoid pregnancyduring therapy and to notify prescriberimmediately if pregnancy occurs.• Urge patient to have needed dental workcompleted before starting decitabine therapy,if possible, or to defer such work untilblood counts return to normal becausedecitabine can delay healing and causegingival bleeding. Teach patient properoral hygiene, and advise him to use a softbristledtoothbrush.• If patient develops bone marrow depression,instruct him to avoid people withinfections and to report fever, cough, orlower back or side pain; they may indicateinfection.• Stress the need to avoid accidental cutsfrom sharp objects, such as razor blades orfingernail clippers, because excessivebleeding or infection may occur.• Advise patient with stomatitis to eat bland,soft foods served cold or at room temperatureto decrease irritation.• Stress the need to comply with the dosageregimen and to keep follow-up medicaland laboratory appointments.deferasiroxExjadeClass and CategoryChemical class: Benzoic acidTherapeutic class: Iron chelatorPregnancy category: Bdeferasirox 291Indications and Dosages To treat chronic iron overload caused byblood transfusionsTABLETSAdults and children age 2 and over. Initial:20 mg/kg/day, increased by 5 to 10 mg/kgevery 3 to 6 mo. Maximum: 30 mg/kg/day.D

292obtain baseline assessment of patient’srenal function by collecting blood samplesto measure serum creatinine level twicebefore starting deferasirox. When therapystarts, monitor serum creatinine level, asordered, especially in elderly patients,patients taking other drugs that depressrenal function, and patients with increasedrisk of complications, pre-existing renalconditions, or comorbid conditions. Forpatients at increased risk for renal failure,expect to monitor serum creatinine levelweekly for first month of therapy andmonthly thereafter. Report increasedserum creatinine level, and expectdeferasirox dosage to be decreased.• Because deferasirox may cause hepaticabnormalities and failure, obtain baselineassessment of hepatic function beforetherapy starts by collecting blood samplesto measure liver enzymes and bilirubinlevel. When therapy starts, monitor theselevels every 2 weeks for first month andthen monthly thereafter. Notify prescriberabout elevations, and expect to decreasedose for severe or persistent elevations.• Obtain auditory and ophthalmic testing(including slit lamp examination anddilated fundoscopy) before deferasiroxtherapy begins and yearly thereafter, asordered, because drug infrequently causesauditory or visual disturbances.• Monitor patient’s blood counts regularly,as ordered, because deferasirox can causecytopenias. If cytopenia occurs, expectdrug to be discontinued until bloodcounts return to normal.• Especially in the first month of therapy,assess patient closely for hypersensitivityreactions, such as anaphylaxis orangioedema. Notify prescriber immediatelyif present, and expect drug to be discontinued.Provide care, as needed.• Inspect patient’s skin regularly for rash. Ifit occurs and becomes severe, drug may bewithheld temporarily.• Watch for evidence of GI ulceration andhemorrhage, especially if patient takesdrugs that increase the risk of ulcerationand bleeding, such as NSAIDs, corticosteroids,oral bisphosphonates, or anticoagulants.Notify prescriber of suspected GIulceration or hemorrhage, and preparepatient for further evaluation and treatdeferasiroxMechanism of ActionBinds iron with high affinity and removes itin feces. Deferasirox is a tridentate ligan.Route Onset Peak DurationP.O. Unknown 1.5–4 hr UnknownContraindicationsHypersensitivity to deferasirox or its components,hearing impairmentInteractionsDRUGSaluminum-containing antacids, phenobarbital,phenytoin, rifampicin, ritonavir: Possiblydecreased effectiveness of deferasiroxanticoagulants, corticosteroids, NSAIDs, oralbisphosphonates: Increased risk of GI ulcerationor hemorrhagecyclosporine, hormonal contraceptives, midazolam,simvastatin: Possibly decreased effectivenessof these drugsiron chelators: Possibly combined effectpaclitaxel, repaglinide: Increased plasma levelsand effects of these drugsFOODSfood: Increased bioavailability of deferasiroxAdverse ReactionsCNS: Dizziness, fatigue, fever, headache,hyperactivity, insomniaEENT: Acute tonsillitis, cataracts, decreasedhearing, ear infection, elevated intraocularpressure, high-frequency hearing loss, lensopacities, nasopharyngitis, pharyngolaryngealpain, pharyngitis, retinal disturbances,rhinitisGI: Abdominal pain, diarrhea, elevated liverenzymes, gallstones, hepatic failure, hepatitis,nausea, pancreatitis, upper GI ulcerationand hemorrhage, vomitingGU: Acute renal failure, glycosuria, increasedcreatinine, proteinuria, renal tubulopathyHEME: Agranulocytosis, neutropenia,thrombocytopeniaMS: Arthralgia, back painRESP: Bronchitis, cough, respiratory tractinfectionSKIN: Leukocytoclastic vascultitis, purpura,rash, urticariaOther: Anaphylaxis, angioedema, drugfever, influenzaNursing Considerations• Because deferasirox can cause renal failure,

ment, as prescribed.PATIENT TEACHING• Instruct patient to take deferasirox30 minutes before eating. Tell her to completelydisperse the tablet in water, orangejuice, or apple juice; drink the suspensionimmediately; and then add liquid to anyremaining residue and drink again.• Tell patient to avoid taking aluminumbasedantacids at the same time asdeferasirox and to seek prescriber advicebefore taking other drugs, including OTCpreparations such as NSAIDs, because ofpotential interactions.• Advise her to report any hearing or visualdisturbances.• If patient has diarrhea or vomiting, tell herto notify prescriber and to stay hydrated.• Caution her to avoid hazardous activities,such as driving, if she becomes dizzy.demeclocyclinehydrochlorideDeclomycinClass and CategoryChemical class: Tetracycline derivativeTherapeutic class: AntibioticPregnancy category: DIndications and Dosages To treat Rocky Mountain spotted fever,typhus infections, Q fever, and rickettsialpoxand tick fevers caused byRickettsieae; psittacosis (ornithosis),lymphogranuloma venereum, granulomainguinale, and Mycoplasma pneumoniaeor Borrelia recurrentis infections;infections caused by gramnegativeorganisms, such as Bacteroidesspecies, Bartonella bacilliformis,Brucella species, Campylobacter fetus,Francisella tularensis, Haemophilusducreyi, Vibrio cholerae, and Yersiniapestis; infections caused by susceptiblestrains of Acinetobacter calcoaceticus,Enterobacter aerogenes, Escherichiacoli, Haemophilus influenzae (respiratorytract infections), Herellea species,Klebsiella species (respiratory tractinfections and UTIs), and Shigellaspecies; infections caused by susceptibledemeclocycline hydrochloride 293strains of Staphylococcus aureus (skinand soft-tissue infections) andStreptococcus species; infections causedby Actinomyces species, Bacillusanthracis, Clostridium species,Fusobacterium fusiforme, Listeriamonocytogenes, Treponema pallidum,and Treponema pertenue; and acuteintestinal amebiasisCAPSULES, TABLETSAdults and adolescents. 150 mg every 6 hror 300 mg every 12 hr.Children ages 8 to 12. 6 to 12 mg/kg dailyin divided doses every 6 to 12 hr. To treat gonorrheaCAPSULES, TABLETSAdults and adolescents. 600 mg followedby 300 mg every 12 hr for 4 days for totaldose of 3,000 mg.Mechanism of ActionBinds with ribosomal subunits of susceptiblebacteria and alters the cytoplasmicmembrane, inhibiting bacterial protein synthesisand rendering organism ineffective.ContraindicationsHypersensitivity to demeclocycline or othertetracyclinesInteractionsDRUGSantacids, calcium supplements, cholestyramine,choline, colestipol, iron supplements,magnesium-containing laxatives, magnesiumsalicylate, sodium bicarbonate: Decreaseddemeclocycline absorptiondigoxin: Possibly increased blood digoxinlevel and risk of digitalis toxicitymethoxyflurane: Increased nephrotoxicityoral anticoagulants: Increased anticoagulationoral contraceptives: Decreased contraceptiveeffectivenesspenicillins: Decreased bactericidal action ofpenicillinsvitamin A: Possibly benign intracranialhypertensionFOODSmilk, other dairy products: Decreased drugabsorptionAdverse ReactionsCNS: Dizziness, headache, light-headedness,vertigoEENT: Tinnitus, vision changesGI: Abdominal cramps, diarrhea, nausea,D

294desipramine hydrochloridepseudomembranous colitis, vomitingGU: Elevated BUN level, nephrogenic diabetesinsipidusHEME: Eosinophilia, hemolytic anemia,neutropenia, thrombocytopeniaSKIN: Photosensitivity, pruritus, rash,urticariaOther: Anaphylaxis, angioedemaNursing Considerations• Expect to monitor renal and liver functiontests during demeclocycline therapy.WARNING Watch for nephrogenic diabetesinsipidus during long-term therapy.• Assess patient’s bowel pattern daily; severediarrhea may indicate pseudomembranouscolitis caused by Clostridium difficile. Ifdiarrhea occurs, notify prescriber andexpect to withhold demeclocycline andtreat with fluids, electrolytes, protein, andan antibiotic effective against C. difficile.PATIENT TEACHING• Stress importance of completing therapyas prescribed, even if symptoms improve.• Advise patient not to take demeclocyclinewithin 3 hours of other drugs or dairyproducts; its absorption may decrease.• Instruct patient to avoid taking antacidsbecause of impaired drug absorption.• Advise patient to avoid direct sunlight, usesunscreen, and wear protective clothingoutdoors; among tetracyclines, demeclocyclinecauses the most photosensitivity.• Urge patient to immediately report edema,rash, or other hypersensitivity reactions.• Urge patient to report watery, bloodystools to prescriber immediately, even upto 2 months after drug therapy has ended.• Tell patient to avoid hazardous activities iflight-headed, dizzy, or vertigo occurs.• Instruct woman of childbearing age tonotify prescriber if she may be pregnant;drug may need to be discontinued.desipraminehydrochlorideNorpramin, Pertofrane (CAN)Class and CategoryChemical class: Dibenzazepine derivativeTherapeutic class: AntidepressantPregnancy category: CIndications and Dosages To treat depressionTABLETSAdults. Initial: 100 to 200 mg daily as singledose or divided doses. Increased graduallyto 300 mg daily, if needed. Maximum:300 mg daily.Adolescents. Initial: 25 to 50 mg daily individed doses. Increased gradually, if needed.Maximum: 100 mg daily.Children ages 6 to 12. Initial: 10 to 30 mgdaily, or 1 to 5 mg/kg, in divided doses.DOSAGE ADJUSTMENT For elderly patients,initial dosage decreased to 25 to 50 mgdaily in divided doses; increased gradually,if needed,, to maximum of 150 mg daily.Route Onset Peak DurationP.O. 2–3 wk Unknown UnknownMechanism of ActionBlocks serotonin and norepinephrine reuptakeby adrenergic nerves, which normallyrelease these neurotransmitters from theirstorage sites when activated by a nerveimpulse. By blocking reuptake, this tricyclicantidepressant increases serotonin and norepinephrinelevels at nerve synapses, whichmay elevate mood and reduce depression.ContraindicationsAcute recovery phase of MI; hypersensitivityto desipramine, other tricyclic antidepressants,or their components; MAOinhibitor therapy within 14 daysInteractionsDRUGSactivated charcoal: Prevention of desipramineabsorption, reduced effectsbarbiturates: Decreased blood desipraminelevel, increased CNS depressionbupropion, haloperidol, H 2 -receptor antagonists,valproic acid: Increased blood leveland adverse effects of desipraminecarbamazepine: Increased blood carbamazepinelevel, decreased blood desipraminelevelcimetidine: Increased blood desipraminelevel and anticholinergic effects (drymouth, urine retention, blurred vision)clonidine: Increased risk of hypertensive crisisdicumarol: Increased anticoagulant effectgrepafloxacin, quinolones, sparfloxacin:Increased risk of arrhythmias, including

torsades de pointesguanethidine: Antagonized antihypertensiveeffect of guanethidinelevodopa: Delayed levodopa absorption,increased risk of hypotensionMAO inhibitors: Increased risk of lifethreateningadverse effects, such as hyperpyreticor hypertensive crisis and severeseizuresphenothiazines: Increased desipramine level,risk of inhibited phenothiazine metabolismand neuroleptic malignant syndromequinidine: Increased blood quinidine levelrifamycins: Decreased desipramine effectsselective serotonin reuptake inhibitors:Increased desipramine effectssympathomimetics: Possibly arrhythmias,possibly increased or decreased vasopressoreffects of sympathomimeticsACTIVITIESalcohol use: Possibly increased CNS or respiratorydepression, hypotension, alcoholeffectsdesmopressin acetate 295Adverse ReactionsCNS: Agitation, akathisia, anxiety, ataxia,confusion, delusions, disorientation, dizziness,drowsiness, extrapyramidal reactions,fatigue, headache, hypomania, insomnia,lack of coordination, nervousness, nightmares,paresthesia, peripheral neuropathy,psychosis exacerbation, restlessness, seizures,sleep disturbance, stroke, suicidal ideation(children and teens), tremor, weaknessCV: Arrhythmias, including heart block;hypertension; hypotension; palpitationsEENT: Black tongue, blurred vision, drymouth, mydriasis, stomatitis, taste perversion,tinnitusENDO: Breast enlargement and galactorrhea(women), gynecomastia (men), hyperglycemia,hypoglycemia, syndrome of inappropriateADH secretionGI: Abdominal cramps, anorexia, constipation,diarrhea, elevated liver function testresults, elevated pancreatic enzyme levels,epigastric distress, hepatitis, ileus, increasedappetite, nausea, vomitingGU: Acute renal failure, impotence, libidochanges, nocturia, painful ejaculation, testicularswelling, urinary frequency and hesitancy,urine retentionHEME: Agranulocytosis, eosinophilia,thrombocytopeniaSKIN: Acne, alopecia, dermatitis, diaphoresis,dry skin, flushing, petechiae, photosensitivity,pruritus, purpura, rash, urticariaOther: Angioedema, drug fever, weight gainNursing Considerations• Use desipramine with extreme caution inpatients with cardiovascular disease, glaucoma,seizure disorder, thyroid disease, orurine retention or with a family history ofsudden death, cardiac arrhythmias, orconduction disturbances.WARNING Desipramine increases risk ofsuicidal ideation in children and teens;monitor them closely for evidence.WARNING Expect drug to produce sedationand possibly to lower seizure threshold.Take safety and seizure precautions.Seizures may precede arrhythmias anddeath in some patients. Alert prescriberimmediately if seizure activity occurs.• Monitor blood glucose level often.• Be prepared to obtain blood sample forleukocyte and differential counts if patientdevelops fever during therapy.• Expect to discontinue drug as soon as possiblebefore elective surgery because of itspossible adverse cardiovascular effects.PATIENT TEACHINGWARNING Urge parents to watch child orteen closely and to report abnormal thinkingor behavior, aggression, or hostility.• Urge patient to use sunscreen outdoorsand to avoid sunlamps and tanning beds.• Instruct patient to notify prescriber immediatelyabout a fast and pounding heartbeat,fainting, severe agitation or restlessness,and strange behavior or thoughts.• Caution patient not to stop drug abruptly;doing so may cause dizziness, headache,hyperthermia, irritability, malaise, nausea,sleep disturbances, and vomiting.• Advise against drinking alcohol because ofincreased risk of adverse CNS reactions.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Urge diabetic patient to monitor bloodglucose level often.desmopressinacetateDDAVP Injection, DDAVP Nasal Spray,DDAVP Rhinal Tube, DDAVP RhinyleD

296desmopressin acetateNasal Solution (CAN), DDAVP Tablets,Octostim (CAN), Stimate, Stimate NasalSprayClass and CategoryChemical class: Synthetic ADH analogueTherapeutic class: Antidiuretic, antihemorrhagicPregnancy category: BIndications and Dosages To manage primary nocturnal enuresisTABLETSAdults and children age 6 and over. Initial:0.2 mg at bedtime, increased as needed.Maximum: 0.6 mg daily. To control symptoms of central diabetesinsipidusTABLETSAdults and children age 6 and over. Initial:0.05 mg b.i.d., increased as needed. Usual:0.1 to 0.8 mg in divided doses b.i.d. or t.i.d.Maximum: 1.2 mg daily.I.V. INFUSION, I.M. OR SUBCUTANEOUS INJECTIONAdults. 2 to 4 mcg daily in divided dosesb.i.d. Dosage adjusted as needed.NASAL SOLUTIONAdults and adolescents. 0.1 to 0.4 ml daily(10 to 40 mcg daily) as a single dose or individed doses b.i.d. or t.i.d. Dosage adjustedas needed. If daily dose is divided, eachdose adjusted separately.Children ages 3 months to 12 years.0.25 mcg/kg daily as a single dose or individed doses b.i.d. Dosage adjusted asneeded. If daily dose is divided, each doseadjusted separately. To prevent or manage bleeding episodesin hemophilia A or mild to moderatetype I von Willebrand’s diseaseI.V. INFUSIONAdults and children weighing more than10 kg (22 lb). 0.3 mcg/kg diluted in 50 mlof normal saline solution and infused over15 to 30 min. If used preoperatively, given30 min before procedure.Children weighing 10 kg or less. 0.3 mcg/kg diluted in 10 ml normal saline solutionand infused over 15 to 30 min. If used preoperatively,given 30 min before procedure.NASAL SOLUTION (STIMATE NASAL SPRAY)Adults and children weighing more than50 kg (110 lb). 150 mcg in each nostril.If used preoperatively, given 2 hr beforeprocedure.Adults and children weighing 50 kg orless. 150 mcg in one nostril. If used preoperatively,given 2 hr before procedure.Route Onset Peak DurationP.O. 1 hr* 4–7 hr* 8–12 hr*I.V. 15–30 min†30–60 min† 3 hr‡Nasal In 1 hr* 1–5 hr* 8–20 hr*Mechanism of ActionExerts an antidiuretic effect similar to thatof vasopressin by increasing cellular permeabilityof renal collecting ducts and distaltubules, thus enhancing water reabsorption,reducing urine flow, and increasing osmolality.As an antihemorrhagic, drug increasesblood level of clotting factor VIII (antihemophilicfactor) and activity of vonWillebrand factor (factor VII VWF ). It alsomay increase platelet aggregation and adhesionat injury sites by directly affectingblood vessel walls.ContraindicationsHypersensitivity to desmopressin or itscomponents, moderate to severe renalimpairment (creatinine clearance below50 ml/min/1.73 m 2 ), previous or currenthyponatremiaInteractionsDRUGScarbamazepine, chlorpromazine, lamotrigine,NSAIDs, opioid analgesics, selective serotoninreuptake inhibitors, tricyclic antidepressants:Possibly increased risk of water intoxicationwith hyponatremiademeclocycline, lithium: Possibly decreasedantidiuretic effect of desmopressinimipramine, oxybutinin: Increased risk ofhyponatremic seizuresvasopressor drugs: Possibly potentiated vasopressoreffect of desmopressinAdverse ReactionsCNS: Asthenia, chills, dizziness, headache,strokeCV: Hypertension (with high doses), MI,* For antidiuretic effect.† For antihemorrhagic effect.‡ For von Willebrand disease; 4 to 20 hr formild hemophilia A.

thrombosis, transient hypotensionEENT: Conjunctivitis, epistaxis, lacrimation,nasal congestion (nasal form), ocularedema, pharyngitis, rhinitisGI: NauseaGU: Vulvar pain (parenteral form)SKIN: FlushingOther: Anaphylaxis, hyponatremia, injectionsite pain and redness; water intoxicationNursing Considerations• Use desmopressin cautiously in patientswith conditions associated with fluid andelectrolyte imbalance, such as cysticfibrosis, heart failure, and renal disorders;these patients are prone to hyponatremia.• Also use cautiously in patients withhabitual or psychogenic polydipsia; theymay be more likely to drink excessivewater, raising the risk of hyponatremia.• Nasal cavity scarring, edema, and otherabnormalities may cause erratic absorptionand require a different administrationroute.• Check blood pressure often during therapy.WARNING Monitor patient closely for evidenceof hyponatremia, such as headache,nausea, vomiting, restlessness, fatigue,lethargy, depressed reflexes, and changes inmental status. If left undetected, seizures,coma, and respiratory arrest may occur.Monitor patient’s serum sodium level, andnotify prescriber of abnormalities.PATIENT TEACHING• To prevent hyponatremia and water intoxicationin a child or an elderly patient,urge family to restrict patient’s fluids asprescribed.• Tell patient to refrigerate nasal solution.• Teach patient to prime nasal spray pump(only once) and spray dose into one orboth nostrils, as prescribed, while inhalingbriskly. Instruct her to clean tip of sprayerwith hot water and dry it with clean tissue.Advise her to keep track of doses givenand to discard bottle after 50 doses.• Instruct patient who uses Stimate NasalSpray to prime pump before first use bypressing down four times. Advise her todiscard pump after 25 or 50 doses,depending on bottle, because delivery ofan accurate dose can’t be assured.• For nasal tube, teach patient to draw prescribedamount of solution into calibratedplastic tube, insert one end of tube into aIndications and Dosages To treat endocrine disorders, such ascongenital adrenal hyperplasia, hypercalcemiaassociated with cancer, andnonsuppurative thyroiditis; acute episodesor exacerbations of rheumatic disorders;collagen diseases, such as systemiclupus erythematosus and acuterheumatic carditis; severe dermatologicdiseases; severe allergic conditions, suchas seasonal or perennial allergic rhinitis,bronchial asthma, serum sickness, anddrug hypersensitivity reactions; respiratorydiseases, such as symptomatic sardexamethasone297nostril and the other end into her mouth,and gently blow into tube to deposit solutiondeep into nasal cavity. Caution hernot to let drug drain into her mouth.• Teach patient or caregiver how to administersubcutaneous injection, if appropriate.• Urge patient to report adverse reactions.dexamethasoneDecadron, Decadron Elixir,Deronil (CAN), DexamethasoneIntensol, Dexasone (CAN), Dexone,Hexadrol, Oradexon (CAN)dexamethasoneacetateCortastat LA, Dalalone D.P., DalaloneL.A., Decadron-LA, Decaject L.A.,Dexacen LA-8, Dexacorten-LA,Dexasone L.A., Dexone LA, Solurex LAdexamethasonesodium phosphateCortastat, Dalalone, Decadrol,Decadron Respihaler, Decaject,Dexacen-4, Dexacorten, DexacortTurbinaire, Dexasone, Dexone,Hexadrol Phosphate, Primethasone,SolurexClass and CategoryChemical class: Synthetic adrenocorticalsteroidTherapeutic class: Anti-inflammatory, diagnosticaid, immunosuppressantPregnancy category: CD

298Mechanism of ActionBinds to intracellular glucocorticoid receptorsand suppresses inflammatory andimmune responses by:• inhibiting neutrophil and monocyte accudexamethasonecoidosis, Löffler’s syndrome, berylliosis,fulminating or disseminated pulmonarytuberculosis, and aspiration pneumonitis;hematologic disorders, such as idiopathicthrombocytopenic purpura andsecondary thrombocytopenia in adults,autoimmune hemolytic anemia, aplasticcrisis, and congenital hypoplastic anemia;tuberculous meningitis and trichinosiswith neurologic or myocardialinvolvement To manage leukemias and lymphomasin adults and acute leukemia in children;to induce diuresis or remission ofproteinuria in idiopathic nephrotic syndromewithout uremia or nephrotic syndromecaused by systemic lupus erythematosus To provide palliative therapy duringacute exacerbations of GI diseases, suchas ulcerative colitis and regional enteritisELIXIR, ORAL SOLUTION, TABLETS, I.V. OR I.M.INJECTIONAdults. Highly individualized dosage basedon severity of disorder. Usual: 0.75 to 9 mg/day as a single dose or in divided doses.ELIXIR, ORAL SOLUTION, TABLETSChildren. Highly individualized based onseverity of disorder. Usual: 83.3 to 333.3 mcg/kg daily in divided doses t.i.d. or q.i.d.I.M. INJECTIONChildren. Highly individualized based onseverity of disorder. Usual: 27.76 to166.65 mcg/kg every 12 to 24 hr. To manage adrenocortical insufficiencyELIXIR, ORAL SOLUTION, TABLETS, I.V. OR I.M.INJECTIONAdults. 0.5 to 9 mg daily as a single dose orin divided doses.ELIXIR, ORAL SOLUTION, TABLETSChildren. 23.3 mcg/kg daily in divideddoses t.i.d.I.M. INJECTIONChildren. 23.3 mcg/kg daily in divideddoses t.i.d. given every third day; alternatively,7.76 to 11.65 mcg/kg daily. To test for Cushing’s syndromeELIXIR, ORAL SOLUTION, TABLETSAdults. 0.5 mg every 6 hr for 48 hr followedby collection of 24-hr urine specimen todetermine 17-hydroxycorticosteroid level.Or, 1 mg at 11 p.m. followed by plasma cortisoltest performed at 8 a.m. the next day. To distinguish Cushing’s syndrome relatedto pituitary corticotropin excess fromCushing’s syndrome from other causesELIXIR, ORAL SOLUTION, TABLETSAdults. 2 mg every 6 hr for 48 hr followedby collection of 24-hr urine specimen todetermine 17-hydroxycorticosteroid level. To decrease cerebral edemaELIXIR, ORAL SOLUTION, TABLETSAdults. 2 mg every 8 to 12 hr as maintenanceafter parenteral form has controlledinitial symptoms.I.V. OR I.M. INJECTIONAdults. 10 mg I.V. followed by 4 mg I.M.every 6 hr. Decreased after 2 to 4 days, ifneeded, gradually tapering off over 5 to7 days unless inoperable or recurring braintumor is present. If such a tumor is present,dosage gradually decreased after 2 to 4 daysto maintenance dosage of 2 mg I.M. every8 to 12 hr and switched to P.O. regimen assoon as possible. To treat unresponsive shockI.V. INFUSION AND INJECTIONAdults. 20 mg as a single dose followed by3 mg/kg over 24 hr as a continuous infusion;40 mg as a single dose followed by40 mg every 2 to 6 hr, as needed; or1 mg/kg as a single dose. All regimens usedno more than 3 days. To decrease localized inflammationINTRA-ARTICULAR INJECTIONAdults. 2 to 4 mg for large joint; 0.8 to1 mg for small joint; 2 to 3 mg for bursae;0.4 to 1 mg for tendon sheaths.SOFT-TISSUE INJECTIONAdults. 2 to 6 mg; 1 to 2 mg for ganglia.INTRALESIONAL INJECTIONAdults. 0.8 to 1.6 mg/injection site. To decrease inflammation in allergicconditions or nasal polyps (except insinuses)NASAL AEROSOLAdults and children age 12 and over.2 sprays (0.2 mg) in each nostril b.i.d. ort.i.d. Maximum: 12 sprays (1.2 mg) daily.Children ages 6 to 12. 1 or 2 sprays (0.1 to0.2 mg) in each nostril b.i.d. Maximum:8 sprays (0.8 mg) daily.

mulation at inflammation site and suppressingphagocytic and bactericidal action• stabilizing lysosomal membranes• suppressing antigen response of macrophagesand helper T cells• inhibiting synthesis of inflammatoryresponse mediators, such as cytokines,interleukins, and prostaglandins.ContraindicationsAdministration of live-virus vaccine topatient or family member, hypersensitivityto dexamethasone or its components(including sulfites), idiopathic thrombocytopenicpurpura (I.M. administration), systemicfungal infectionsInteractionsDRUGSaminoglutethimide, antacids, barbiturates,carbamazepine, hydantoins, mitotane,rifampin: Decreased dexamethasone effectsamphotericin B (parenteral), carbonic anhydraseinhibitors: Risk of hypokalemiaanticholinesterases: Decreased anticholinesteraseeffectiveness in myasthenia gravisaspirin, NSAIDs: Increased risk of adverseGI effectscholestyramine: Increased dexamethasoneclearancecyclosporine: Increased activity of bothdrugs, possibly resulting in seizuresdigoxin: Increased risk of digitalis toxicityrelated to hypokalemiaephedrine: Decreased half-life and increasedclearance of dexamethasoneerythromycin, indinavir: Increased clearanceand decreased levels of these drugsestrogens, ketoconazole, macrolide antibiotics:Decreased dexamethasone clearanceisoniazid: Decreased blood isoniazid levelneuromuscular blockers: Possibly potentiatedor counteracted neuromuscular blockadeoral anticoagulants: Altered coagulationtimes, requiring reduced anticoagulantdosageoral contraceptives: Increased half-life andconcentration of dexamethasonephenytoin: Increased risk of seizurespotassium-wasting diuretics: Increasedpotassium loss and risk of hypokalemiasalicylates: Decreased blood level and effectivenessof salicylatessomatrem: Possibly inhibition of somatrem’sgrowth-promoting effectdexamethasone 299thalidomide: Increased risk of toxic epidermalnecrolysistheophyllines: Altered effects of either drugtoxoids, vaccines: Decreased antibody responseACTIVITIESalcohol use: Increased risk of GI bleedingAdverse ReactionsCNS: Depression, emotional lability,euphoria, fever, headache, increased ICPwith papilledema, insomnia, light-headedness,malaise, neuritis, neuropathy, paresthesia,psychosis, seizures, syncope, tiredness,vertigo, weaknessCV: Arrhythmias, bradycardia, edema, fatembolism, heart failure, hypercholesterolemia,hyperlipidemia, hypertension,myocardial rupture, tachycardia, thromboembolism,thrombophlebitis, vasculitisEENT: Cataracts, glaucoma, vision changes(all forms); epistaxis, loss of smell and taste,nasal burning and dryness, oral candidiasis,perforated nasal septum, pharyngitis,rebound nasal congestion, rhinorrhea,sneezing (nasal aerosol)ENDO: Cushingoid symptoms, decreasediodine uptake, growth suppression in children,hyperglycemia, menstrual irregularities,secondary adrenocortical and pituitaryunresponsivenessGI: Abdominal distention, bloody stools,elevated liver function test results, heartburn,hepatomegaly, increased appetite,indigestion, intestinal perforation, melena,nausea, pancreatitis, peptic ulcer with possibleperforation, ulcerative esophagitis,vomitingGU: Glycosuria, increased or decreasednumber and motility of spermatozoa, perinealirritation, urinary frequencyHEME: Leukocytosis, leukopeniaMS: Aseptic necrosis of femoral andhumeral heads; muscle atrophy, spasms, orweakness; myalgia; osteoporosis; pathologicfracture of long bones; tendon rupture(intra-articular injection); vertebral compressionfractureRESP: BronchospasmSKIN: Acne, allergic dermatitis, diaphoresis,ecchymosis, erythema, hirsutism, necrotizingvasculitis, petechiae, subcutaneous fatatrophy, striae, thin and fragile skin, urticariaOther: Aggravated or masked signs ofinfection, anaphylaxis, angioedema, hypernatremia,hypocalcemia, hypokalemia,D

300dexamethasonehypokalemic alkalosis, impaired woundhealing, metabolic acidosis, sodium andfluid retention, suppressed skin test reaction,weight gainNursing Considerations• Use dexamethasone cautiously in patientswith congestive heart failure, hypertension,or renal insufficiency because drugcan cause sodium retention, which maylead to edema and hypokalemia.• Also use cautiously in patients who havehad intestinal sugery and in those withpeptic ulcer, diverticulitis, or ulcerativecolitis because of the risk of perforation.• Give once-daily dose of dexamethasone inthe morning to coincide with the body’snatural cortisol secretion.• Give oral drug with food to decrease GIdistress.• Be aware that dosage forms with a concentrationof 24 mg/ml are for I.V. use only.• Shake I.M. solution before injecting deepinto large muscle mass.WARNING Avoid subcutaneous injection; itmay cause atrophy and sterile abscess.• Inject undiluted I.V. dose directly into I.V.tubing of infusing compatible solutionover 30 seconds or less, as prescribed.WARNING Don’t give acetate form by I.V.injection.• Shake nasal aerosol container well, andhold it upright about 6 (15 cm) from areabeing treated. Keep spray out of patient’seyes, and advise her not to inhale it.• Expect to taper drug rather than stoppingit abruptly; prolonged use can cause adrenalsuppression.• Monitor fluid intake and output and dailyweight, and watch for crackles, dyspnea,peripheral edema, and steady weight gain.• Evaluate growth if patient is a child.• Test stool for occult blood.• Monitor results of hematology studies andblood glucose, serum electrolyte, cholesterol,and lipid levels. Dexamethasone maycause hyperglycemia, hypernatremia,hypocalcemia, hypokalemia, or leukopenia.It also may increase serum cholesteroland lipid levels, and it may decrease iodineuptake by the thyroid.• Assess patient for evidence of osteoporosis,Cushing’s syndrome, and other systemiceffects during long-term use.• Monitor neonate for signs of hypoadrenocorticismif mother received dexamethasoneduring pregnancy. Be aware thatsome preparations contain benzyl alcohol,which may cause a fatal toxic syndrome inneonates and immature infants.• Watch for hypersensitivity reactions aftergiving acetate or sodium phosphate form;both may contain bisulfites or parabens, towhich some people are allergic.PATIENT TEACHING• Instruct patient not to store drug in dampor hot places and to protect liquid formfrom freezing.• Instruct patient to take once-daily oraldose in the morning with food to helpprevent GI distress.• Caution against consuming alcohol duringdexamethasone therapy because it increasesthe risk of GI bleeding.• Advise patient to follow a low-sodium,high-potassium, high-protein diet, if prescribed,to help minimize weight gain,which is common with dexamethasonetherapy. Instruct her to inform prescriberif she’s on a special diet.• Instruct patient not to stop drug abruptly.• Advise patient to notify prescriber if conditionrecurs or worsens after dosage isreduced or therapy stops.• Urge patient to have regular eye examinationsduring long-term use.• Advise patient on long-term therapy tocarry medical identification and to notifyall health care providers that she takesdexamethasone.• Instruct patient (especially a child) toavoid close contact with anyone who haschickenpox or measles and to notify prescriberimmediately if exposure occurs.• Advise patient and family members toavoid live-virus vaccinations during therapyunless prescriber approves.• Inform diabetic patient that drug mayaffect her blood glucose level.• If drug is injected into a joint, instructpatient to avoid putting excessive pressureon it and to notify prescriber if it becomesred or swollen.• Tell patient to notify prescriber aboutanorexia, depression, light-headedness,malaise, muscle pain, nausea, vomiting,and early hyperadrenocorticism (abdominaldistention, amenorrhea, easy bruising,extreme weakness, facial hair, increased

appetite, moon face, weight gain). Tellpatient and family about possible changesin appearance.• Urge patient to notify prescriber about illness,surgery, or changes in stress level.dexchlorpheniraminemaleateDexchlor, Polaramine, PolaramineRepetabsClass and CategoryChemical class: Propylamine derivativeTherapeutic class: AntihistaminePregnancy category: BIndications and Dosages To treat allergic conjunctivitis; transfusionreaction; dermographism; mild,uncomplicated allergic skin reactions,such as urticaria and angioedema;perennial and seasonal allergic rhinitis;and vasomotor rhinitis and as adjunctto treat anaphylaxisE.R. TABLETSAdults and adolescents. 4 to 6 mg daily atbedtime or every 8 to 10 hr, p.r.n.SYRUP, TABLETSAdults and adolescents. 2 mg every 4 to6 hr, p.r.n.Children ages 6 to 12. 1 mg every 4 to 6 hror 150 mcg/kg in divided doses q.i.d., p.r.n.Children ages 2 to 6. 0.5 mg every 4 to 6 hr,p.r.n.Route Onset Peak DurationP.O. 15–60 Unknown* 4–8 hr*min*Mechanism of ActionBinds to central and peripheral H 1 receptors,competing with histamine for thesesites and preventing histamine from reachingits site of action. By blocking histamine,dexchlorpheniramine:• inhibits respiratory, vascular, and GIsmooth-muscle contraction, which preventswheezing• decreases capillary permeability, which* For syrup and tablets; unknown for E.R.tablets.Nursing Considerations• Use dexchlorpheniramine cautiously inelderly patients and those with CV disease,hyperthyroidism, increased intraocularpressure, prostatic hypertrophy, or renaldisease.• Monitor patient for adverse reactions,especially in elderly patients and children.• Watch for evidence of overdose, includingclumsiness; drowsiness; dry mouth, nose,or throat; dyspnea; flushed or red face;hallucinations; insomnia; light-headedness;seizures; and unsteadiness.PATIENT TEACHING• Inform patient that drug provides tempodexchlorpheniraminemaleate 301reduces itching, flares, and wheals• decreases lacrimal and salivary glandsecretions, reducing nasal secretions, itching,sneezing, and watery eyes.ContraindicationsAngle-closure glaucoma; benign prostatichyperplasia; bladder neck obstruction;hypersensitivity to dexchlorpheniramine orother antihistamines; lower respiratorytract disorders, such as asthma; MAOinhibitor use within 14 days; pyloroduodenalobstruction; stenosing peptic ulcerInteractionsDRUGSanticholinergics: Potentiated anticholinergiceffectsCNS depressants: Increased CNS depressionMAO inhibitors: Possibly severe hypotensionand prolonged and intensified anticholinergicand sedative effects ofdexchlorpheniramineACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Ataxia, confusion, dizziness, drowsiness,euphoria, excitement, headache,insomnia, irritability, nervousness, neuritis,nightmares, paresthesia, restlessness, vertigo,weaknessCV: Hypotension, palpitations, tachycardiaEENT: Acute labyrinthitis, blurred vision,dry mouth, tinnitus, vision changesGI: Anorexia, constipation, diarrhea, indigestion,nausea, vomitingGU: Urinary hesitancy, urine retentionRESP: Tenacious bronchial secretionsSKIN: Diaphoresis, photosensitivity, rashD

302dexmethylphenidate hydrochloriderary relief of symptoms.• Advise patient to take drug with food, water,or milk to reduce GI irritation. Informher that she can crush regular (not E.R.)tablets and mix with food or fluid.• For E.R. tablets, tell patient not to break,crush, or chew them before swallowing.• Urge patient to take missed dose as soonas possible unless it’s almost time for nextdose.• Because drug may cause drowsiness, cautionpatient to avoid hazardous activitiesuntil its CNS effects are known.• Instruct her to avoid prolonged sun exposureand to use a sunscreen.• Suggest that patient use sugarless candy orgum, ice chips, or saliva substitute torelieve dry mouth. If dryness lasts longerthan 2 weeks, urge her to notify prescriber.• Caution patient to avoid alcohol and CNSdepressants, such as sedatives, sleepngpills, and tranquilizers, during therapy.• If patient takes high doses of aspirin, urgeher to inform prescriber because antihistaminesmay mask adverse reactions toaspirin overdose, such as tinnitus.• Inform patient that drug needs to be discontinued3 to 4 days before skin tests forallergies are performed.dexmethylphenidatehydrochlorideFocalin, Focalin XRClass, Category, and ScheduleChemical class: d-threo-enantiomer ofmethylphenidateTherapeutic class: CNS stimulantPregnancy category: CControlled substance schedule: IIIndications and Dosages To treat attention deficit hyperactivitydisorder (ADHD)TABLETSAdults and children age 6 and over whoare new to methylphenidate. 2.5 mg b.i.d.at least 4 hr apart, increased weekly by2.5 to 5 mg. Maximum: 10 mg b.i.d.Adults and children age 6 and over whotake methylphenidate. Half of racemicmethylphenidate dosage. Maximum: 10 mgb.i.d. at least 4 hr apart.DOSAGE ADJUSTMENT Drug stopped if noimprovement within 1 mo after appropriatedosage adjustments. Dosage decreased ordrug stopped for paradoxical aggravation ofsymptoms or adverse reactions.E.R. CAPSULES, E.R. TABLETSAdults who are new to methylphenidate.10 mg daily, increased after 1 wk as neededto 20 mg daily.Children age 6 and over who are new tomethylphenidate. 5 mg daily, increasedweekly as needed by 5-mg increments.Maximum: 20 mg daily.Adults and children age 6 and over whotake methylphenidate. Half of racemicmethylphenidate dosage. Maximum: 20 mgdaily.Mechanism of ActionMay block reuptake of norepinephrine anddopamine into presynaptic neurons in cerebralcortex, which increases availability ofnorepinephrine and dopamine in extraneuronalspace.ContraindicationsDiagnosis or family history of Tourette’ssyndrome; glaucoma; hypersensitivity todexmethylphenidate, methylphenidate, ortheir components; marked anxiety, tension,and agitation; motor tics; use within14 days of MAO inhibitorInteractionsDRUGSanticoagulants (oral), anticonvulsants, antidepressants(tricyclic and selective serotoninreuptake inhibitors): Possibly decreasedmetabolism of these drugsantihypertensives: Decreased therapeuticeffect of these drugsdopamine and other vasopressors: Increasedtherapeutic effect of these drugsMAO inhibitors: Increased adverse effects,risk of hypertensive crisisAdverse ReactionsCNS: Cerebral arteritis or occlusion, dizziness,drowsiness, dyskinesia, fever,headache, insomnia, motor or vocal tics,nervousness, seizures, Tourette’s syndrome,toxic psychosisCV: Angina, arrhythmias, hypertension,hypotension, increased or decreased pulserate, palpitations, tachycardia

EENT: Accommodation abnormality,blurred visionGI: Abdominal pain, anorexia, nauseaHEME: Thrombocytopenic purpuraMS: ArthralgiaSKIN: Erythema multiforme, exfoliativedermatitis, necrotizing vasculitis, rash,urticariaOther: Weight loss (prolonged therapy)Nursing ConsiderationsWARNING Be aware that dexmethylphenidatemay induce CNS stimulation, mania,and psychosis and may worsen behaviordisturbances and thought disorders. Usedrug cautiously in children with psychosisor mania. Be aware that withdrawal symptomsmay occur with long-term use.• Also know that dexmethylphenidateshould be used cautionly in patients withserious structural cardiac abnormalities,cardiomyopathy, serious heart rhythmabnormalities, or other serious cardiacproblems because drug may increase riskof sudden death from these conditions.• Monitor blood pressure and pulse rate todetect hypertension and excessive stimulation.Notify prescriber if signs appear.• Dexmethylphenidate shouldn’t be used totreat severe depression or to prevent ortreat normal fatigue.WARNING Monitor patient for signs ofphysical or psychological dependence. Usedrug cautiously in patients with a historyof drug abuse, including alcoholism.• Monitor CBC and differential and plateletcounts, as ordered, during prolonged therapy.• Expect to stop drug if seizures occur. Drugmay lower seizure threshold, especially inpatients with a history of seizures or EEGabnormalities.• Monitor children on long-term dexmethylphenidatetherapy for signs of growthsuppression, which has been noted duringlong-term use of stimulants.• Dosages of drugs affected by dexmethylphenidate,such as anticoagulants andantihypertensives, may need adjustment.PATIENT TEACHING• Tell patient that extended-release capsulesshould either be taken whole, withoutbeing chewed, crushed, or divided, or capsulecontents should be sprinkled on asmall amount of applesauce.• Urge patient to notify prescriber if she hasexcessive nervousness, fever, insomnia,nausea, palpitations, or rash while takingdexmethylphenidate.• Caution patient with seizure disorder thatdrug may cause seizures.• Advise patient to protect drug from lightand moisture.• Teach patient (or parent) to watch forimprovement in signs and symptoms ofADHD, such as decreased impulsivenessand increased attention. Stress the needfor continued follow-up care, and suggestparticipation in an ADHD program.dexrazoxaneZinecarddexrazoxane 303Class and CategoryChemical class: PiperazinedioneTherapeutic class: Cardioprotective agent,chelating agentPregnancy category: CIndications and Dosages To prevent or reduce severity of cardiomyopathyrelated to doxorubicin therapyin women with metastatic breast cancerI.V. INJECTIONAdults. Initial: 500 mg/m2 for every 50 mg/m 2 of doxorubicin every 3 wk.DOSAGE ADJUSTMENT In patients withhyperbilirubinemia, dosage proportionatelyreduced (depending on severity) to maintaina dexrazoxane-to-doxorubicin ratio of10:1. If creatinine clearance is less than40 ml/min/1.73 m 2 , dosage decreased 50%.Mechanism of ActionRapidly enters cardiac cells and acts as anintracellular heavy metal chelator. In cardiactissues, anthracyclines, such as doxorubicin,form complexes with iron or copper,damaging cardiac cell membranes andmitochondria. Dexrazoxane combines withintracellular iron and protects againstanthracycline-induced free radical damageto the myocardium. It also prevents conversionof ferrous ions back to ferric ions foruse by free radicals.IncompatibilitiesDon’t mix dexrazoxane in same I.V. linewith other drugs.D

304Indications and Dosages To treat insulin-induced hypoglycemiaCHEWABLE TABLETS, ORAL GELAdults and children. Initial: 10 to 20 g.Repeated in 10 to 20 min, if needed, basedon serum glucose level.I.V. INFUSION OR INJECTIONAdults and children. Initial: 20 to 50 ml of50% solution given at 3 ml/min.Maintenance: 10% to 15% solution by continuousinfusion until blood glucose levelreaches therapeutic range.Infants and neonates. 2 ml/kg of 10% to25% solution until blood glucose levelreaches therapeutic range. To replace caloriesI.V. INFUSIONAdults and children. Individualized dosageof 2.5%, 5%, or 10% solution, based onneed for fluids or calories and given byperipheral I.V. line. Or 10% to 70% soludextroseContraindicationsHypersensitivity to dexrazoxane or its components;use with chemotherapy regimensthat do not contain an anthracycline, suchas daunorubicin, doxorubicin, epirubicin,idarubicin, or mitoxantroneInteractionsbone marrow depressants: Possibly enhancedbone marrow depressionAdverse ReactionsHEME: Myelosuppression (granulocytopenia,leukopenia, thrombocytopenia)Other: Injection site painNursing ConsiderationsWARNING Use gloves when preparingreconstituted solution. If dexrazoxanepowder or solution contacts your skin ormucosa, immediately and thoroughlywash with soap and water.• To reconstitute, mix with 25 or 50 ml of0.167 molar sodium lactate, supplied bymanufacturer, to produce 10 mg/ml. Givereconstituted solution by slow I.V. push, orfurther dilute with normal saline solutionor D 5 W to 1.3 to 5 mg/ml, as prescribed,for rapid I.V. infusion.• Dexrazoxane may interfere with tumorresponse to doxorubicin, especially if givenat start of fluorouracil-doxorubicincyclophosphamidetherapy.• Monitor patient with immunosuppressionor decreased bone marrow reserves fromprior chemotherapy or radiation therapyto prevent worsening of her condition.Notify prescriber if condition deteriorates.PATIENT TEACHING• Inform patient that dexrazoxane protectsthe heart from damage by myelosuppressionand that she’ll be given the drug by ahealth care professional in the hospital orclinic before receiving chemotherapy.• Inform patient that dexrazoxane andchemotherapy may make her feel generallyunwell, but urge her to continue treatmentunless prescriber tells her to stop.• Instruct patient to report chills, fever,mouth sores, pain at injection site, sorethroat, unusual bleeding or bruising,unusual tiredness or weakness, and vomiting.Dosage may need to be changed ortherapy stopped.•Inform patient that drug may worsensymptoms of bone marrow suppressioncaused by anthracycline chemotherapy,including increased risk of infection.• Teach patient importance of avoidinginjury and infection during dexrazoxanetherapy. For example, advise her to use asoft-bristled toothbrush to prevent damageto teeth and gums; to avoid peoplewith colds, flu, or bronchitis; and to avoidanyone who has recently had oral poliovaccine because of the increased risk ofinfection from live virus.dextrose(d-glucose)B-D Glucose, Glutose, Insta-Glucose,Insulin Reactionglucose2.5% Dextrose Injection, 5% DextroseInjection, 10% Dextrose Injection,20% Dextrose Injection, 25% DextroseInjection, 50% Dextrose Injection,60% Dextrose Injection, 70% DextroseInjectionClass and CategoryChemical class: MonosaccharideTherapeutic class: Antidiabetic, nutritionalsupplementPregnancy category: C

tion given by central vein, if needed, typicallywith amino acids or other solutions.Route Onset Peak DurationP.O. 10–20 min 40 min UnknownI.V. 2–3 min Unknown UnknownMechanism of ActionPrevents protein and nitrogen loss, promotesglycogen deposition, prevents ordecreases ketosis, and, in large amounts,acts as an osmotic diuretic. Dextrose isreadily metabolized and undergoes oxidationto carbon dioxide and water. The oralform—glucose—is absorbed directly intothe bloodstream from the intestines and isdistributed, used, or stored in the liver.IncompatibilitiesDon’t give dextrose through same infusionset as blood or blood products becausepseudoagglutination of RBCs may occur.ContraindicationsFor all solutions: Diabetic coma with excessivelyelevated blood glucose levelFor concentrated solutions: Anuria, alcoholwithdrawal syndrome in dehydratedpatient, glucose-galactose malabsorptionsyndrome, hepatic coma, hypersensitivity tocorn or corn products, intracranial orintraspinal hemorrhage, overhydrationInteractionsDRUGScorticosteroids, corticotropin: Increased riskof fluid and electrolyte imbalance if dextrosesolution contains sodium ionsAdverse ReactionsCNS: Confusion, feverGU: GlycosuriaOther: Dehydration; hyperosmolar coma;hypervolemia; hypovolemia; injection siteextravasation with tissue necrosis, infection,phlebitis, and venous thrombosisNursing Considerations• Use dextrose cautiously in patients withrenal impairment because solutions containaluminum that could be toxic in prolongedparenteral therapy.• Give highly concentrated dextrose solutionby central venous catheter—not by subcutaneousor I.M. route.WARNING Rapid or excessive delivery ofdextrose solution in a very low–birthweightinfant may increase serum osmolalityand cause intracerebral hemorrhage.• Assess infusion site regularly for signs ofinfiltration, such as pain or swelling.• Assess patient for glucosuria by using aurine reagent strip or collecting a urinesample and reviewing urinalysis results.• When discontinuing a concentrated solution,expect to give a 5% to 10% dextroseinfusion to avoid rebound hypoglycemia.• Monitor patient for signs of hypervolemia,such as jugular vein distention and crackles.PATIENT TEACHING• Advise patient to swallow oral dextrose; itisn’t absorbed from the buccal cavity.• Instruct patient to monitor her blood glucoselevel as directed.• Stress importance of reporting discomfort,pain, or signs of infection at I.V. site.dezocineDalgandezocine 305Class and CategoryChemical class: Aminotetralin, syntheticopioidTherapeutic class: AnalgesicPregnancy category: CIndications and Dosages To relieve painI.V. INJECTIONAdult. Initial: 5 mg followed by 2.5 to10 mg every 2 to 4 hr, p.r.n. Maximum:120 mg daily.I.M. INJECTIONAdult. Initial: 10 mg followed by 5 to 20 mgevery 3 to 6 hr, p.r.n. Maximum: 20 mg/dose, 120 mg daily.Route Onset Peak DurationI.V. In 15 min 30 min 2–4 hrI.M. In 30 min 1–2 hr 2–4 hrMechanism of ActionBinds with opiate receptors at many CNSsites, affecting perception of and emotionalresponse to pain.ContraindicationsHypersensitivity to dezocine or its componentsD

306diazepamInteractionsDRUGSCNS depressants, general anesthetics, hypnotics,sedatives, tranquilizers: IncreasedCNS depressant effectsopioids: Possibly decreased therapeutic opioideffects and withdrawal symptoms inpatient receiving long-term opioid therapyACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Dizziness, sedation, vertigoGI: Nausea, vomitingOther: Injection site redness and swellingNursing Considerations• Use dezocine cautiously and in low dosesin elderly patients and those who havecommon bile duct, hepatic, renal, or respiratorydisease.• Discard solution if it contains precipitate.• Monitor blood pressure, pulse, and respiratoryrate often after giving first dose,especially if given by I.V. route.WARNING Avoid giving dezocine to opioiddependentpatient. Doing so may precipitatewithdrawal symptoms becausedezocine can antagonize opioid effects.• Assess patient for pain relief often, anddocument findings.PATIENT TEACHING• Instruct patient to notify prescriber if painisn’t relieved within 1 hour.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.diazepamApo-Diazepam (CAN), Diastat,Diazepam Intensol, Dizac,Novo-Dipam (CAN), Valium, Vivol (CAN)Class, Category, and ScheduleChemical class: BenzodiazepineTherapeutic class: Anticonvulsant, anxiolytic,sedative-hypnotic, skeletal muscle relaxantPregnancy category: DControlled substance schedule: IVIndications and Dosages To relieve anxietyORAL SOLUTION, TABLETSAdults. 2 to 10 mg b.i.d. to q.i.d.DOSAGE ADJUSTMENT Dosage reduced to2 to 2.5 mg daily or b.i.d. and increasedgradually as needed and tolerated for elderlyor debilitated patients.Children age 6 months and over. Initial:1 to 2.5 mg t.i.d. or q.i.d. Increased graduallyas needed and tolerated.I.V. OR I.M. INJECTIONAdults. 2 to 5 mg every 3 to 4 hr, p.r.n., formoderate anxiety; 5 to 10 mg every 3 to4 hr, p.r.n., for severe anxiety.Children. Individualized dosage. Maximum:0.25 mg/kg given over 3 min, repeated after15 to 30 min if needed, and after another15 to 30 min if needed. To treat symptoms of acute alcoholwithdrawalORAL SOLUTION, TABLETSAdults. 10 mg t.i.d. or q.i.d. during first24 hr. Then 5 mg t.i.d. or q.i.d., if needed.I.V. OR I.M. INJECTIONAdults. 10 mg and then 5 to 10 mg in 3 to4 hr, if needed. To provide muscle relaxation, to providesedationORAL SOLUTION, TABLETSAdults. 2 to 10 mg t.i.d. or q.i.d.DOSAGE ADJUSTMENT Dosage reduced to2 to 2.5 mg once or twice daily andincreased gradually as needed and toleratedfor elderly or debilitated patients.Children age 6 months and over. Initial:1 to 2.5 mg t.i.d. or q.i.d. Increased graduallyas needed and tolerated.I.V. OR I.M. INJECTIONAdults. 2 to 5 mg every 3 to 4 hr, p.r.n., formoderate anxiety; 5 to 10 mg every 3 to4 hr, p.r.n., for severe anxiety.Children. Individualized dosage. Maximum:0.25 mg/kg given over 3 min, repeated after15 to 30 min if needed, and after another15 to 30 min if needed. To treat seizuresORAL SOLUTION, TABLETSAdults. 2 to 10 mg b.i.d. to q.i.d.DOSAGE ADJUSTMENT Dosage reduced to2 to 2.5 mg once or twice daily andincreased gradually as needed and toleratedfor elderly or debilitated patients.Children age 6 months and over. Initial:1 to 2.5 mg t.i.d. or q.i.d. Increased graduallyas needed and tolerated. To treat status epilepticus and severerecurrent seizuresI.V. INJECTION

Adults. 5 to 10 mg repeated every 10 to15 min, as needed, up to a cumulative doseof 30 mg. Regimen repeated, if needed, in2 to 4 hr. (Use I.M. route if I.V. access isimpossible.)Children age 5 and over. 1 mg repeatedevery 2 to 5 min, as needed, up to a cumulativedose of 10 mg. Regimen repeated, ifneeded, in 2 to 4 hr.Children ages 1 month to 5 years. 0.2 to0.5 mg repeated every 2 to 5 min, as needed,up to a cumulative dose of 5 mg.Regimen repeated, if needed, in 2 to 4 hr.RECTAL GELAdults and adolescents. 0.2 mg/kg roundedup to next available unit dose (or roundeddown for elderly or debilitated patient).Repeated in 4 to 12 hr, if needed.Children ages 6 to 12. 0.3 mg/kg roundedup to next available unit dose. Repeated in4 to 12 hr, if needed.Children ages 2 to 6. 0.5 mg/kg rounded upto next available unit dose. Repeated in 4 to12 hr, if needed. To provide preoperative sedationI.V. OR I.M. INJECTIONAdults. 5 to 10 mg 30 min before surgery. To reduce anxiety before cardioversionI.V. INJECTIONAdults. 5 to 15 mg 5 to 10 min before procedure. To reduce anxiety before endoscopic proceduresI.V. INJECTIONAdults. Up to 20 mg titrated to desiredsedation and given immediately before procedure.I.M. INJECTIONAdults. 5 to 10 mg 30 min before procedure. To treat tetanusI.V. OR I.M. INJECTIONAdults and children age 5 and over. Initial:5 to 10 mg repeated every 3 to 4 hr, if needed.Sometimes larger doses for adults.DOSAGE ADJUSTMENT Initial dose reduced to2 to 5 mg and increased gradually as neededand tolerated for debilitated patients.Children ages 1 month to 5 years. 1 to2 mg repeated every 3 to 4 hr, as needed.Adverse ReactionsCNS: Anterograde amnesia, anxiety, ataxia,confusion, depression, dizziness, drowsiness,fatigue, headache, insomnia, lethargy, lightheadedness,paradoxical reactions, psychidiazepam307Mechanism of ActionMay potentiate effects of gamma-aminobutyricacid (GABA) and other inhibitoryneurotransmitters by binding to specificbenzodiazepine receptors in limbic and corticalareas of CNS. GABA inhibits excitatorystimulation, which helps control emotionalbehavior. Limbic system contains a densearea of benzodiazepine receptors, whichmay explain drug’s antianxiety effects.Diazepam suppresses spread of seizureactivity caused by seizure-producing foci incortex, thalamus, and limbic structures.IncompatibilitiesDon’t mix diazepam injection with aqueoussolutions. Don’t mix diazepam emulsion forI.M. injection with morphine or glycopyrrolateor administer it through an infusionset that contains polyvinyl chloride.ContraindicationsAcute angle-closure glaucoma, hypersensitivityto diazepam or its components,untreated open-angle glaucomaInteractionsDRUGSantacids: Altered rate of diazepam absorptionanticonvulsants: Decreased effectiveness ofthese drugscimetidine, disulfiram, fluoxetine, fluvoxamine,isoniazid, itraconazole, ketoconazole,metoprolol, omeprazole, oral contraceptives,propoxyphene, propranolol, valproic acid:Decreased diazepam metabolism, increasedblood level and risk of adverse effectsCNS depressants: Increased CNS depressiondigoxin: Increased serum digoxin level andrisk of digitalis toxicitylevodopa: Decreased antidyskinetic effect oflevodopaphenytoin: Decreased metabolic eliminationof phenytoin, increased risk of adverse reactionsprobenecid: Faster onset or more prolongedeffects of diazepamranitidine: Delayed elimination andincreased blood level of diazepamrifampin: Decreased blood diazepam leveltheophyllines: Antagonized sedative effect ofdiazepamACTIVITIESalcohol use: Increased CNS depressionD

308diazepamatric effects, sedation, sleepiness, slurredspeech, suicidal ideation, tremor, vertigoCV: Hypotension, palpitations, tachycardiaEENT: Blurred vision, diplopia, dry mouth,increased salivationGI: Anorexia, constipation, diarrhea, elevatedliver enzymes, jaundice, nausea, vomitingGU: Libido changes, urinary incontinence,urine retentionHEME: NeutropeniaMS: Dysartrhia, muscle weaknessRESP: Respiratory depressionSKIN: DermatitisOther: Physical and psychological dependenceNursing Considerations• Use diazepam with extreme caution inpatients with a history of alcohol or drugabuse because it can cause physical andpsychological dependence, and in patientswith hepatic disorders such as hepaticfibrosis and hepatitis because of potentiallysignificant increase in drug’s half-life.• Use diazepam cautiously in patients withhepatic or renal impairment. Severe hepaticimpairment is a contraindication to use.• Expect to give a lower diazepam dose topatient with chronic respiratory insufficiencybecause of the risk of respiratorydepression.• Mix concentrated oral solution (Intensol)with liquid or semisolid food. Use suppliedcalibrated dropper to measure doses.• Protect diazepam injection from light.Don’t use solution that’s more than slightlyyellow or that contains precipitate.• Give I.M. injection into deltoid muscle forrapid, complete absorption. Using othersites may cause slow, erratic absorption.• Before administering emulsion form, ask ifpatient is allergic to soybeans because thisform contains soybean oil.• For an infant or a child, administer I.V.injection slowly over 3 minutes in a dosenot to exceed 0.25 mg/kg.• Give emulsion form within 6 hours ofopening ampule because it contains nopreservatives and allows rapid microbialgrowth. Use polyethylene-lined or glassinfusion sets and polyethylene orpolypropylene plastic syringes for administration.Don’t use a filter with a pore sizeless than 5 microns because a smaller sizemay break down the emulsion.• Don’t mix emulsion form with anythingother than its emulsion base. Otherwise, itmay become unstable and increase the riskof serious adverse reactions.• Monitor patient for adverse reactions,especially if she has hypoalbuminemia,which increases the risk of sedation.WARNING Watch for signs of physical andpsychological dependence (strong desireor need to continue taking diazepam, needto increase dose to maintain drug effects,and posttherapy withdrawal symptoms,such as abdominal cramps, insomnia, irritability,nervousness, and tremor).• Monitor patient closely for increase in frequencyor severity of grand mal seizureswhen diazepam is used with standard anticonvulsanttherapy. Dosage of other anticonvulsantsmay need to be increased.• Avoid abrupt withdrawal of diazepam, asordered, when used as part of the patient’sseizure control regimen because a transientincrease in frequency or severity ofseizures may occur.• Monitor severely depressed patient or onewith depression-related anxiety for suicidaltendencies, particularly when therapystarts and dosage changes; depression mayworsen temporarily during these times.• Watch for psychiatric and paradoxicalreactions to diazepam, especially in childrenand the elderly. If reations occur,notify prescriber and expect drug to bediscontinued.• Monitor patient for decreased drug effectiveness,especially with prolonged use.• Check patient’s blood counts and liverfunction periodically, as ordered, becauseprolonged diazepam therapy rarely causesneutropenia and jaundice.PATIENT TEACHING• Instruct patient not to take more drug,more often, or for a longer time than prescribed.Warn her that physical and psychologicaldependence can occur, andteach her to recognize the signs.• Advise patient not to take drug to relieveeveryday stress.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to avoid CNS depressantsand alcohol during therapy.• Instruct patient not to stop taking drugabruptly without prescriber’s supervision.

If patient has a history of seizures, warnthat abrupt withdrawal may trigger them.• Instruct patient to mix Diazepam Intensolwith water, soda, or a similar beverage;applesauce; or pudding just before takingit. Caution her not to save the mixture forlater. Tell her to use calibrated dropperthat’s provided to measure each dose.• Teach patient how to self-administer a rectalform, if prescribed.• Instruct female patient of childbearing ageto notify prescriber immediately if she isor could be pregnant because diazepamtherapy will need to be discontinued.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes.diazoxideHyperstat, ProglycemClass and CategoryChemical class: Benzothiadiazine derivativeTherapeutic class: Antihypertensive, antihypoglycemicPregnancy category: CIndications and Dosages To manage hypoglycemia caused byhyperinsulinismCAPSULES, ORAL SUSPENSIONAdults and children. Initial: 1 mg/kg every8hr.Maintenance: 3 to 8 mg/kg daily in2 or 3 equal doses given every 8 or 12 hr.Maximum: 15 mg/kg daily.Infants and neonates. Initial: 3.3 mg/kgevery 8 hr. Maintenance: 8 to 15 mg/kgdaily in 2 or 3 equal doses given every 8 or12 hr. To treat severe hypertension in hospitalizedpatientsI.V. INJECTIONAdults and children. Initial: 1 to 3 mg/kgby rapid bolus, repeated every 5 to 15 minuntil diastolic pressure falls below 100 mmHg. Repeated in 4 hr and again in 24 hr, ifneeded, until oral antihypertensive therapybegins. Maximum: 150 mg/dose, 1.2 g daily.Mechanism of ActionDirectly affects smooth muscle cells ofperipheral arteries and arterioles, causingthem to dilate. This action decreasesdiazoxide 309peripheral resistance, which helps reduceblood pressure. Diazoxide also inhibitsinsulin release from the pancreas, stimulatescatecholamine release, and increases hepaticglucose release.Route Onset Peak DurationP.O. In 1 hr Unknown 8 hrI.V. 1 min 2–5 min 2–12 hrContraindicationsAcute aortic dissection; hypersensitivity todiazoxide, thiazides, other sulfonamidederivatives, or their components; treatmentof compensatory hypertension, as occurswith aortic coarctationInteractionsDRUGSallopurinol, colchicine, probenecid, sulfinpyrazone:Increased serum uric acid levelantihypertensives: Additive hypotensiveeffectsbeta blockers: Increased hypotensive effectsof diazoxidediuretics, especially thiazides: Potentiatedhyperglycemic, hyperuricemic, and antihypertensiveeffects of diazoxideestrogens, NSAIDs, sympathomimetics:Antagonized diazoxide hypotensive effectsinsulin, oral antidiabetics: Possiblydecreased effectiveness of these drugsoral anticoagulants: Increased anticoagulationperipheral vasodilators, ritodrine (I.V.):Additive, possibly severe, hypotensive effectsAdverse ReactionsCNS: Anxiety, apprehension, cerebral ischemia,dizziness, euphoria, headache, insomnia,light-headedness, malaise, somnolence,weaknessCV: Bradycardia, chest pain, hypotension,palpitations, tachycardia, transient hypertensionEENT: Blurred vision, dry mouth, increasedsalivation, taste perversion, tinnitus, transienthearing lossENDO: Transient hyperglycemiaGI: Abdominal pain, anorexia, constipation,diarrhea, ileus, nausea, vomitingMS: GoutSKIN: Diaphoresis, flushing, pruritus, rash,sensation of warmthOther: Extravasation with injection site cellulitisand pain; fluid and sodium retentionD

310Nursing Considerations• Because dichloralphenazone has vasoconstrictiveand sympathomimetic actions,assess patients with peripheral vasculardisease or recent angina pectoris or MI forsigns and symptoms indicating aggravadichloralphenazoneNursing Considerations• Use diazoxide cautiously in patients withuncompensated heart failure (can causefluid retention and heart failure) andpatients with impaired cardiac or cerebralcirculation in whom abrupt blood pressuredrop, mild tachycardia, and decreasedblood perfusion may be harmful.• Give I.V. drug undiluted over 10 to 30 seconds.Don’t give it I.M. or subcutaneously.• Keep patient supine during I.V. injectionand for 1 hour afterward.• Monitor blood pressure throughout treatmentto check for hypertension. Beforemonitoring ends, measure patient’s standingblood pressure if she’s ambulatory.• Assess I.V. site often for extravasation;drug is alkaline and can irritate tissue.• Expect to adjust dosage if patient switchesfrom oral suspension to capsules; suspensioncauses a higher blood diazoxide level.• If diabetic patient receives I.V. diazoxide totreat hypertension, watch for evidence ofhyperglycemia because parenteral formcommonly causes transient hyperglycemia.• Monitor blood glucose level of all patientswho receive oral diazoxide to see if drughas raised blood glucose level to normal.PATIENT TEACHING• Tell patient who receives I.V. diazoxide thatshe’ll be on bed rest until taking oral drug.• Advise patient to protect oral suspensionfrom light.• Tell patient to take oral drug on a regularschedule and not to skip or double doses.• Urge patient to monitor blood glucose levelif she takes oral drug for hypoglycemia.• Caution patient not to take antidiabeticdrugs unless prescribed.• Advise patient to notify prescriber if shehas signs of hyperglycemia, such asincreased urinary frequency, increasedthirst, and fruity breath.dichloralphenazone(all contain 325 mg of acetaminophen,100 mg of dichloralphenazone, and 65 mgof isometheptene mucate)Amidrine, I.D.A., Iso-Acetozone,Isocom, Midchlor, Midrin, Migquin,Migragap, Migratine, Migrazone,Migrend, Migrex, MitrideClass and CategoryChemical class: Sympathomimetic amineTherapeutic class: AnalgesicPregnancy category: Not ratedIndications and Dosages To relieve tension headacheCAPSULESAdults. 1 to 2 caps every 4 hr. Maximum:8 capsules daily. To relieve migraine headacheCAPSULESAdults. 2 caps followed by 1 cap every hruntil relief occurs. Maximum: 5 capsulesevery 12 hr.Route Onset Peak DurationP.O. 30–60 min 1–3 hr 3–4 hrMechanism of ActionDichloralphenazone reduces emotionalreaction to pain through mild sedativeeffect. Acetaminophen raises pain thresholdby acting on hypothalamus. Isomethepteneconstricts dilated cranial and cerebral arteriolesthrough sympathomimetic action,reducing stimuli for vascular headaches.ContraindicationsHeart disease, hepatic disease, hypersensitivityto acetaminophen or isometheptene,MAO inhibitor therapy within 14 days,severe renal disease, uncontrolled glaucoma,uncontrolled hypertensionInteractionsDRUGSCNS depressants: Additive sedative effectshepatic enzyme inducers, other hepatotoxicdrugs: Increased risk of hepatotoxicityMAO inhibitors: Increased risk of severehypertension and hyperpyrexiaACTIVITIESalcohol use: Additive sedative effects,increased risk of hepatotoxicityAdverse ReactionsCNS: Dizziness, drowsinessSKIN: Rash

tion or deterioration of these conditions.• Institute safety precautions to preventinjury from falls.PATIENT TEACHINGWARNING Caution patient not to take dichloralphenazonewithin 14 days of anMAO inhibitor; doing so can cause severehypertension or hyperpyrexia.• Advise patient to take drug only after aheadache or migraine warning signoccurs. Too-frequent use may make drugless effective and may worsen headaches.• Instruct patient to lie down in a quiet,dark room after taking drug.• Because of possible dizziness or drowsiness,caution patient to avoid hazardousactivities until drug’s CNS effects areknown.• Caution patient to avoid alcohol and CNSdepressants during therapy because theyincrease dizziness, drowsiness, and the riskof hepatotoxicity.• Advise patient to notify prescriber if drugbecomes less effective or if headachesoccur more often.• Teach patient how to read drug labels andavoid taking too much acetaminophen,which can cause hepatic or renal damage.• Explain that decreasing dichlralphenazonedose may prevent dizziness or rash.• Instruct patient to store drug away fromheat, moisture, and direct light.dichlorphenamideDaranideClass and CategoryChemical class: Sulfonamide derivativeTherapeutic class: Antiglaucoma drugPregnancy category: CIndications and Dosages To manage chronic open-angle glaucoma,secondary glaucoma, and acuteangle-closure glaucoma (preoperatively)TABLETSAdults. Initial: 100 to 200 mg followed by100 mg every 12 hr. Maintenance: 25 to50 mg once daily to t.i.d.Mechanism of ActionInhibits the enzyme carbonic anhydrase,which normally is in renal proximal tubuledichlorphenamide 311cells, choroid plexes of the brain, and ciliaryprocesses of the eyes. In eyes, enzyme inhibitiondecreases aqueous humor secretion,which reduces intraocular pressure.Route Onset Peak DurationP.O. 30–60 min 2–4 hr 6–12 hrContraindicationsAdrenocortical insufficiency, hepatic insufficiency,hyperchloremic acidosis, hypersensitivityto dichlorphenamide or sulfa drugs,hypokalemia, hyponatremia, renal failure,severe obstructive pulmonary diseaseInteractionsDRUGSdiflunisal: Increased adverse effects of dichlorphenamide,significantly decreasedintraocular pressuresalicylates: Increased risk of dichlorphenamidetoxicity, including CNS depressionand metabolic acidosisAdverse ReactionsCNS: Depression, disorientation, dizziness,drowsiness, lassitude, paresthesiaCV: ArrhythmiasEENT: Metallic taste, pharyngitisENDO: HyperglycemiaGI: Anorexia, diarrhea, hepatic dysfunction,nausea, vomitingGU: Phosphaturia, renal calculi, renal colic,urinary frequencyHEME: Hemolytic anemia, leukopenia,pancytopenia, thrombocytopeniaSKIN: PhotosensitivityOther: Hyperchloremia, hyperuricemia,weight lossNursing Considerations• Use dichlorphenamide cautiously inpatients with emphysema, pulmonaryobstruction, or severe respiratory acidosis.• Monitor serum potassium level often(especially in elderly patients and thosetaking digoxin) because diuresis may causehypokalemia.PATIENT TEACHING• Instruct patient to take dichlorphenamidewith food or full glass of water to decreaseGI distress.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.WARNING Urge patient to immediatelyD

312diclofenacreport evidence of blood dyscrasias, suchas fever, numbness or tingling, rash, sorethroat, and unusual bleeding or bruising.• Advise patient to avoid prolonged exposureto sunlight, to apply sunscreen, and towear protective clothing outdoors.• Instruct patient to take a missed dose assoon as she remembers it, unless it’salmost time for the next dose.• Tell patient to store drug at room temperatureand protect from moisture and heat.diclofenacpotassiumCataflam, Voltaren Rapide (CAN), Zipsordiclofenac sodiumApo-Diclo (CAN), Novo-Difenac (CAN),Nu-Diclo (CAN), Voltaren,Voltaren SR (CAN)Class and CategoryChemical class: Phenylacetic acid derivativeTherapeutic class: Analgesic, antiinflammatoryPregnancy category: BIndications and Dosages To relieve pain and inflammation inrheumatoid arthritisDELAYED-RELEASE TABLETS, TABLETSAdults. Initial: 150 to 200 mg daily individed doses t.i.d. or q.i.d. Maintenance:75 to 100 mg/ day, divided, t.i.d.Maximum: 225 mg daily.E.R. TABLETSAdults. Initial: 75 or 100 mg daily, morningor evening, or 75 mg b.i.d., morning andevening.RECTAL SUPPOSITORIESAdults. 50 or 100 mg as substitute for lastP.O. dose of day. To relieve pain and inflammation inosteoarthritisDELAYED-RELEASE TABLETS, TABLETSAdults. 100 to 150 mg daily in divided dosesb.i.d. or t.i.d. Maximum: 150 mg daily. To relieve pain in patients with ankylosingspondylitisDELAYED-RELEASE TABLETS, TABLETSAdults. 100 to 125 mg daily in 4 or 5 divideddoses. To relieve pain and dysmenorrheaTABLETSAdults. 50 mg t.i.d., p.r.n.; if needed,100 mg for first dose only.DOSAGE ADJUSTMENT Dosage reduced, ifneeded, for elderly patients and those withserious renal dysfunction. To relieve mild to moderate acute painCAPSULESAdults. 25 mg four times daily.Route Onset Peak DurationP.O.* 30 min Unknown 8 hrMechanism of ActionBlocks the activity of cyclooxygenase, theenzyme needed to synthesize prostaglandins,which mediate inflammatory responseand cause local pain, swelling, and vasodilation.By blocking cyclooxygenase andinhibiting prostaglandins, diclofenacreduces inflammatory symptoms. Thismechanism also relieves pain becauseprostaglandins promote pain transmissionfrom periphery to spinal cord.ContraindicationsActive GI bleeding or ulcers; asthma attacks,rhinitis, or urticaria from aspirin or otherNSAIDs; hypersensitivity to diclofenac orNSAIDs; treatment of perioperative painafter coronary artery bypass graftingInteractionsDRUGSacetaminophen: Increased risk of adverserenal effects with long-term concurrent useanticoagulants, thrombolytics: Prolonged PT,increased risk of bleedingantihypertensives: Decreased antihypertensiveeffectivenessaspirin, other NSAIDs, salicylates: IncreasedGI irritability and bleeding, decreaseddiclofenac effectivenessbeta blockers: Impaired antihypertensiveeffectcefamandole, cefoperazone, cefotetan, plicamycin,valproic acid: Increased risk of hypoprothrombinemiacimetidine: Altered blood diclofenac levelcolchicine, corticotropin (long-term use), glucocorticoids,potassium supplements:* For tablets; unknown for delayed-releaseand E.R. tablets.

Increased GI irritability and bleedingcyclosporine, gold compounds, nephrotoxicdrugs: Increased risk of nephrotoxicitydigoxin: Increased blood digoxin levelinsulin, oral antidiabetics: Decreased effectsof these drugslithium: Increased risk of lithium toxicityloop diuretics: Decreased diuretic effectsmethotrexate: Increased risk of methotrexatetoxicityphenytoin: Increased blood phenytoin levelpotassium-sparing diuretics: Increased riskof hyperkalemiaprobenecid: Increased diclofenac toxicityFOODSfood: Delayed absorption of delayed-releasetabletsACTIVITIESalcohol use: Increased risk of GI irritabilityand bleedingAdverse ReactionsCNS: Aseptic meningitis, cerebral hemorrhage,dizziness, drowsiness, headacheCV: Bradycardia and other arrhythmias,hypotension, vasculitisEENT: Glaucoma, hearing loss, tinnitusENDO: HypoglycemiaGI: Abdominal pain, constipation, diarrhea,dysphagia, elevated liver function testresults, esophageal ulceration, flatulence, GIbleeding or ulceration, hepatic failure, hepatitis,indigestion, jaundice, nausea, perforationof stomach or intestineGU: Acute renal failure, interstitial nephritisHEME: Agranulocytosis, aplastic anemia,eosinophilia, leukocytosis, leukopenia, pancytopenia,porphyria, thrombocytopeniaSKIN: Erythema multiforme, exfoliativedermatitis, pruritus, rash, Stevens-Johnsonsyndrome, toxic epidermal necrolysisOther: Anaphylaxis, angioedema, fluidretention, hyperkalemia, hyperuricemia,hyponatremia, lymphadenopathyNursing Considerations• Use diclofenac with extreme caution andfor shortest possible time in patients witha history of GI bleeding or ulcer diseasebecause NSAIDs increase risk of GI bleedingand ulceration.• Don’t substitute one form of oraldiclofenac for another. Different formulationsaren’t bioequivalent.• Be aware that serious GI tract ulcerationdiclofenac 313and bleeding, as well as perforation ofstomach or intestine, can occur withoutwarning or symptoms. Elderly patients areat greater risk. Monitor patient for signs ofGI irritation and ulceration, especially ifpatient has a predisposing condition (suchas a history of GI bleeding); takes an oralcorticosteroid, anticoagulant, or NSAID(long-term); smokes; is an alcoholic; isover age 60; has poor general health; ortests positive for Helicobacter pylori. Tominimize risk, give diclofenac with food. Ifpatient develops GI distress, withholddrug and notify prescriber immediately.• Use diclofenac cautiously in patients withhypertension, and monitor blood pressureclosely; drug can cause or worsen hypertension.• Assess patient for hypotension. If patienttakes a potassium-sparing diuretic, checkfor elevated serum potassium level.WARNING Monitor patient closely forthrombotic events, including MI andstroke, because NSAIDs such as diclofenacincrease the risk for such events.• Report signs of bleeding, such as bleedinggums, bloody or cloudy urine, ecchymoses,melena, and petechiae.• Monitor BUN and serum creatinine levelsin elderly patients, patients taking ACEinhibitors or diuretics, and patients withheart failure or impaired renal or hepaticfunction. These patients may have anincreased risk of renal failure.• Assess patient’s skin routinely for rash orother signs of hypersensitivity reaction;drug may cause serious skin reactionswithout warning. At first sign of reaction,stop drug and notify prescriber.• Because severe hepatic reactions mayoccur during diclofenac therapy, monitorliver function test results and serum uricacid level. Liver enzyme elevations usuallyoccur within 2 months of starting drugand should be reported promptly becausedosage may need adjustment. Also monitorpatient for evidence of hepatic dysfunction(diarrhea, fatigue, flulike symptoms,jaundice, lethargy, nausea, pruritus,right upper quadrant tenderness).• Report weight gain of more than 1 kg(2 lb) in 24 hours because it suggests fluidretention.PATIENT TEACHINGD

314dicloxacillin sodium• Advise patient not to chew, crush, or dissolvetablet, but to swallow it whole.• Instruct patient to take diclofenac withfood to minimize GI distress.• To decrease risk of esophageal ulceration,instruct patient not to lie down for 15 to30 minutes after taking drug.• Warn patient to avoid hazardous activitiesuntil diclofenac’s CNS effects are known.• Urge patient to notify prescriber aboutringing or buzzing in ears, impaired hearing,dizziness, or GI distress or bleeding.• Advise patient to consult prescriber beforetaking aspirin or other OTC analgesics ordrinking alcohol.• Explain that diclofenac may increase riskof serious adverse cardiovascular reactions;urge patient to seek immediatemedical attention for signs and symptomssuch as chest pain, shortness of breath,weakness, and slurred speech.• Tell patient that diclofenac also mayincrease risk of serious adverse GI reactions;stress need to seek immediate medicalattention for such evidence as epigastricor abdominal pain, indigestion, blackor tarry stools, and vomiting blood ormaterial that looks like coffee grounds.• Alert patient about possibly serious skinreactions and need to seek immediatemedial attention for such as problems asblisters, fever, itching, rash, and other signsof hypersensitivity.• Urge patient to promptly report adverseeffects (nausea, fatigue, lethargy, diarrhea,pruritus, jaundice, right upper quadrantdiscomfort, flulike symptoms).dicloxacillin sodiumDycill, Dynapen, PathocilClass and CategoryChemical class: Isoxazolyl penicillinderivativeTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat mild to moderate upper respiratorytract and localized skin and softtissueinfections caused by penicillinaseproducingstaphylococciCAPSULES, ORAL SOLUTIONAdults and children weighing 40 kg (88 lb)or more. 125 mg every 6 hr.Children weighing less than 40 kg.12.5 mg/kg daily divided into four equaldoses and given every 6 hr. To treat severe infections, such as lowerrespiratory tract or disseminated infections,caused by penicillinase-producingstaphylococciCAPSULES, ORAL SOLUTIONAdults and children weighing 40 kg ormore. 250 mg every 6 hr, or higher doses, ifneeded. Maximum: 6 g daily.Children over age 1 month weighing lessthan 40 kg. 25 mg/kg daily divided into4 equal doses and given every 6 hr, or higherdoses if needed.Mechanism of ActionInhibits cell wall synthesis in susceptiblebacteria, which assemble rigid, cross-linkedcell walls in several steps. Dicloxacillinaffects final cross-linking by inactivatingpenicillin-binding protein (the enzymeneeded to link cell wall strands). Thisaction inhibits cell wall synthesis and causescell lysis and death.ContraindicationsHypersensitivity to dicloxacillin, other penicillins,beta-lactamase inhibitors (such aspiperacillin/tazobactam), cephalosporins,imipenem, or their componentsInteractionsDRUGShepatotoxic drugs: Increased risk of hepatotoxicitymethotrexate: Decreased methotrexateclearance and increased risk of toxicityoral contraceptives: Decreased contraceptiveactionprobenecid: Increased and prolonged blooddicloxacillin leveltetracyclines: Decreased dicloxacillin effectivenessFOODSall foods: Possibly delayed absorptionAdverse ReactionsCNS: Dizziness, fatigue, fever, insomniaEENT: Black “hairy” tongue, dry mouth,glossitis, laryngeal edema, laryngospasm,stomatitis, taste perversionGI: Abdominal pain, anorexia, diarrhea,flatulence, nausea, pseudomembranous

colitis, transient hepatitis, vomitingGU: Nephropathy, vaginitisMS: Prolonged muscle relaxationSKIN: Dermatitis, erythema multiforme,pruritus, rash, urticaria, vesicular eruptionsOther: Anaphylaxis, serum sicknesslikereaction, superinfectionNursing Considerations• Before dicloxacillin therapy begins, expectto obtain body fluid and tissue samples forculture and sensitivity tests, as ordered,and review the results, if possible. Alsocheck for history of sensitivity to cephalosporins,penicillins, and other substances.• If diarrhea develops, notify prescriber; itcould be the development of pseudomembranouscolitis.PATIENT TEACHING• Instruct patient to take drug 1 hour beforeor 2 hours after meals.• Instruct patient to take drug around theclock, not to miss a dose, and to completethe entire prescription unless directed otherwiseby prescriber.• Advise patient to take oral solution with acold beverage but not acidic juice, such asorange juice. Explain that solution is effectivefor 7 days at room temperature andfor 14 days if refrigerated.• Caution patient not to open capsules andmix contents with food or liquids becausean unpleasant taste and decreased drugabsorption will result.• Instruct parent to shake oral solutionthoroughly and measure doses with a calibrateddevice for accuracy.• Advise patient to notify prescriber if sheexperiences adverse GI reactions or signsof hypersensitivity or superinfection.• If patient takes an oral contraceptive,advise her to use an additional form ofcontraception during therapy.• Instruct patient to store drug away fromheat, moisture, and direct light and torefrigerate—but not freeze—oral solution.dicumarolClass and CategoryChemical class: Coumarin derivativeTherapeutic class: AnticoagulantPregnancy category: Xdicumarol 315Indications and Dosages To prevent and treat pulmonaryembolus, thromboembolus, and venousthrombus; to prevent thromboembolismrelated to atrial fibrillation andmechanical heart valvesTABLETSAdults. Initial: 200 to 300 mg on the firstday. Maintenance: 25 to 200 mg daily.DOSAGE ADJUSTMENT Dosage reduced forelderly patients and those with hepatic orrenal impairment.Route Onset Peak DurationP.O. 1–5 days Unknown 5–6 daysMechanism of ActionPrevents coagulation by interfering with theliver’s ability to synthesize vitaminK–dependent clotting factors. This in turndepletes clotting factors II (prothrombin),VII, IX, and X. Normally, clots result from acascade of proteolytic reactions that involveseveral clotting factors, including vitaminK–dependent factors. These clotting factorsmust be converted to an activated formbefore the clotting cascade can continue. Bydepleting vitamin K–dependent clottingfactors, dicumarol interferes with the clottingcascade and prevents coagulation.ContraindicationsActive bleeding; aneurysm; ascorbic aciddeficiency; bacterial endocarditis; blooddyscrasia; continuous tube drainage ofsmall intestine; diverticulitis; eclampsia orpreclampsia; emaciation; hemophilia; hemorrhagictendency; history of bleedingdiathesis or warfarin-induced necrosis;leukemia; major regional lumbar blockanesthesia; malnutrition; pericardial effusion;pericarditis; polyarthritis; pregnancy;prostatectomy; recent surgery on brain, eye,GI tract, or prostate; recovery from spinalpuncture; severe hepatic or renal impairment;stroke; surgery resulting in large,open surfaces; threatened abortion; thrombocytopenicpurpura; uncontrolled ormalignant hypertension; visceral cancer;vitamin K deficiencyInteractionsDRUGSacetaminophen, androgens, beta blockers,chlorpropamide, clofibrate, corticosteroids,D

316dicyclomine hydrochloridecyclophosphamide, dextrothyroxine, disulfiram,erythromycin, fluconazole, gemfibrozil,glucagon, hydantoins, influenza virus vaccine,isoniazid, ketoconazole, miconazole,moricizine, propoxyphene, quinolones, streptokinase,sulfonamides, tamoxifen, thioamines,thyroid drugs, urokinase: Increasedeffects of dicumarol and risk of bleedingAdverse ReactionsCNS: Fever, malaiseENDO: Adrenal hemorrhageGI: Abdominal cramps and distention, anorexia,diarrhea, flatulence, nausea, vomitingGU: Menorrhagia, priapismHEME: Hemorrhage, leukopeniaSKIN: Alopecia, pruritus, rash, urticariaOther: Allergic reaction, purple toes syndromeNursing Considerations• Use dicumarol cautiously in elderlypatients and those with hepatic or renalimpairment.• Monitor results of serial PT and INR tests,and expect to adjust dosage accordingly.• If patient also receives heparin, expectheparin therapy to continue until INRreaches desired level: 2 to 3 times the controlvalue for pulmonary embolus, thromboembolus,or venous thrombus; or 3 to4.5 times the control value for thromboembolismrelated to atrial fibrillation ormechanical valves.• If PT or INR are prolonged, withhold onedicumarol dose, as prescribed, and, toreverse anticoagulation, give vitamin K. Ifpatient has severe bleeding, expect to giveblood to offset vitamin K’s delayed onset.• Assess patient for signs of hemorrhage,such as ecchymosis, epistaxis, gingivalbleeding, hematuria, and melena.• To reduce bleeding, apply pressure to I.M.or venipuncture sites for up to 5 minutes.PATIENT TEACHING• Instruct patient to take dicumarol at thesame time every day.• Inform patient that drug’s full effects maynot occur for 2 to 7 days.• Instruct patient to have frequent coagulationtests, as prescribed.• Advise patient to stabilize her intake offoods high in vitamin K. Urge her to consultprescriber before starting a weightlossdiet, altering eating habits, or takingnew vitamins or other nutritional supplements;these activities may alter her vitaminK intake.• Caution patient to avoid activities thatmay cause bleeding. Advise the use of asoft toothbrush and an electric razor.• Urge patient to consult prescriber beforetaking OTC drugs, including herbs; theymay affect anticoagulant effect.• Instruct patient to take a missed dose assoon as she remembers unless it’s nearlytime for the next dose. Urge her to reportmissed doses to prescriber.• Caution patient to immediately notify prescriberif signs of bleeding occur, such asabdominal pain or swelling; back pain;bloody or black stools; bloody urine;coughing up blood; joint pain, swelling, orstiffness; severe or continuing headache;and vomiting blood or material that lookslike coffee grounds.• Urge patient to carry medical identificationand tell all health care providers thatshe takes dicumarol.• Explain that coagulation will graduallyreturn to normal after therapy stops.Remind patient to keep watching forbleeding.dicyclominehydrochlorideBentyl, Bentylol (CAN), Formulex (CAN),Spasmoban (CAN)Class and CategoryChemical class: Tertiary amineTherapeutic class: Anticholinergic, antispasmodicPregnancy category: Not ratedIndications and Dosages To control diarrhea and GI tract spasmsCAPSULES, TABLETSAdults and adolescents. 10 to 20 mg t.i.d.or q.i.d., increased as needed and tolerated.Maximum: 160 mg daily.Children ages 6 to 12. 10 mg t.i.d. or q.i.d.E.R. TABLETSAdults and adolescents. 30 mg b.i.d.SYRUPAdults and adolescents. 10 to 20 mg t.i.d.or q.i.d., increased as needed and tolerated.

Maximum: 60 mg daily.Children ages 2 to 13. 10 mg t.i.d. or q.i.d.Children ages 6 months to 2 years. 5 to10 mg t.i.d. or q.i.d.I.M. INJECTIONAdults. 20 mg every 4 to 6 hr. Dosageadjusted as needed and tolerated.Mechanism of ActionInhibits acetylcholine’s muscarinic actionsat postganglionic parasympathetic receptorsin smooth muscles, secretory glands, andthe CNS. These actions relax smooth musclesand diminish GI, GU, and biliary tractsecretions.ContraindicationsAdhesions between iris and lens, angleclosureglaucoma, GI obstruction, hemorrhagicshock, hepatic disease, hiatal hernia,hypersensitivity to any anticholinergic,ileus, intestinal atony in elderly or debilitatedpatients, myasthenia gravis, myocardialischemia, obstructive uropathy, renal disease,severe ulcerative colitis, tachycardia,toxic megacolonInteractionsDRUGSadsorbent antidiarrheals, antacids:Decreased dicyclomine absorptionamantadine, anticholinergics, phenothiazines,tricyclic antidepressants: Increaseddicyclomine effectsantimyasthenics: Reduced intestinal motilityatenolol: Increased atenolol effectscyclopropane: Risk of ventricular arrhythmiashaloperidol: Decreased antipsychotic effectof haloperidolketoconazole: Decreased ketoconazoleabsorptionmetoclopramide: Decreased effect of metoclopramideon GI motilityopioid analgesics: Increased risk of ileus,severe constipation, and urine retentionpotassium chloride, especially wax-matrixpreparations: Possibly GI ulcerationurinary alkalinizers (antacids that containcalcium or magnesium, carbonic anhydraseinhibitors, citrates, sodium bicarbonate):Delayed excretion and increased risk ofadverse effects of dicyclominedicyclomine hydrochloride 317Adverse ReactionsCNS: Agitation, dizziness, drowsiness, dyskinesia,excitement, fever, insomnia, lethargy,light-headedness (I.M. use), nervousness,paresthesia, syncopeCV: Palpitations, tachycardiaEENT: Blurred vision, cycloplegia, drymouth, loss of taste, mydriasis, nasal congestion,photophobiaGI: Constipation, dysphagia, heartburn,ileus, vomitingGU: Impotence, urine retentionSKIN: Decreased sweating, flushing, pruritusOther: Heatstroke; injection site pain, redness,and swellingNursing Considerations• Assess patient for tachycardia before givingdicyclomine; heart rate may increase.• Don’t give drug by I.V. route.• Watch for symptoms of hypersensitivity,such as agitation and pruritus. They usuallyresolve within 48 hours of stoppingdrug.• During long-term use, assess patient forchronic constipation and fecal impaction,and take corrective measures, as prescribed.PATIENT TEACHING• Instruct patient to store dicyclomine in atightly sealed container at room temperature,protected from moisture and directlight. Advise her not to refrigerate syrup.• Inform patient that dicyclomine relievessymptoms but doesn’t cure the disorder.• For best results, instruct patient to takedrug 30 to 60 minutes before eating.• Advise patient not to take an antacid or ananti-diarrheal within 2 hours of dicyclomine.• Inform patient that blurred vision, dizziness,or drowsiness may occur.• To prevent constipation, advise patient toeat high-fiber foods and drink at leasteight glasses of water daily.WARNING Urge patient to avoid gettingoverheated during exercise or in hotweather because heatstroke may result.Inform patient that hot baths or saunasmay cause dizziness or fainting.• Instruct patient to change position slowlyto avoid light-headedness.• Inform patient that stopping drug abruptlymay cause dizziness and vomiting.• Tell patient to take a missed dose as soonas she remembers unless it’s nearly timefor the next dose. Caution against doublingthe dose.D

318diflunisaldiflunisalApo-Diflunisal (CAN), Dolobid, Novo-Diflunisal (CAN)Class and CategoryChemical class: Difluorophenyl, salicylicacid derivativeTherapeutic class: Analgesic, antiinflammatoryPregnancy category: C (first trimester), Notrated (later trimesters)Indications and Dosages To relieve mild to moderate painTABLETSAdults. 1 g followed by 0.5 g every 8 to12 hr. Maximum: 1.5 g daily. To reduce inflammation in osteoarthritisor rheumatoid arthritisTABLETSAdults. 0.5 to 1 g daily in divided dosesb.i.d. Maximum: 1.5 g daily.DOSAGE ADJUSTMENT Dosage reduced forelderly patients and those who use diuretics;who could be harmed by prolongedbleeding time; or who have compromisedcardiac function, conditions that cause fluidretention, hepatic or renal impairment,hypertension, or upper GI disease.Route Onset Peak DurationP.O.* 1 hr 2–3 hr 8–12 hrMechanism of ActionBlocks the activity of cyclooxygenase, theenzyme needed to synthesize prostaglandins,which mediate the inflammatoryresponse and cause local vasodilation,swelling, and pain. By blocking cyclooxygenaseand inhibiting prostaglandins, thisNSAID reduces inflammatory symptoms.This mechanism also relieves pain becauseprostaglandins promote pain transmissionfrom the periphery to the spinal cord.ContraindicationsAsthma attacks, rhinitis, or urticaria precipitatedby aspirin or other NSAIDs; hypersensitivityto diflunisal; treatment of perioperativepain after coronary artery bypassgraft surgery* For analgesia; unknown for anti-inflammatoryeffects.InteractionsDRUGSacetaminophen: Increased risk of adverserenal effects with long-term use of bothdrugsantacids: Decreased blood diflunisal levelantihypertensives: Decreased antihypertensiveeffectsaspirin, other NSAIDs, salicylates: IncreasedGI irritability and bleeding, decreased diflunisaleffectivenessbeta blockers: Impaired antihypertensiveeffects of beta blockercefamandole, cefoperazone, cefotetan, plicamycin,valproic acid: Increased risk of hypoprothrombinemiacolchicine, corticotropin (long-term use),glucocorticoids, potassium supplements:Increased GI irritability and bleedingcyclosporine, gold compounds, nephrotoxicdrugs: Increased risk of nephrotoxicitydigoxin: Increased blood digoxin levelheparin, oral anticoagulants, thrombolytics:Prolonged PT, increased risk of bleedinghydrochlorothiazide: Increased blood hydrochlorothiazidelevelinsulin, oral antidiabetics: Increased hypoglycemiceffectsloop diuretics: Decreased loop diuretic effectivenessmethotrexate: Increased risk of methotrexatetoxicityphenytoin: Increased blood phenytoin levelprobenecid: Increased diflunisal toxicityACTIVITIESalcohol use: Increased GI irritability andbleedingAdverse ReactionsCNS: Aseptic meningitis, cerebral hemorrhage,dizziness, drowsiness, headache,insomniaCV: VasculitisEENT: TinnitusENDO: HypoglycemiaGI: Abdominal pain, constipation, diarrhea,esophageal irritation, GI bleeding or ulceration,hepatic failure, hepatitis, indigestion,jaundice, nausea, perforation of stomach orintestine, vomitingGU: Acute renal failure, interstitial nephritisHEME: Agranulocytosis, aplastic anemia,leukopenia, pancytopenia, thrombocytopeniaSKIN: Erythema multiforme, exfoliative

dermatitis, rash, Stevens-Johnson syndrome,toxic epidermal necrolysisOther: Anaphylaxis, angioedema, hyponatremiaNursing Considerations• Use diflunisal with extreme caution andfor shortest time possible in patients witha history of GI bleeding or ulcer diseasebecause NSAIDs such as diflunisalincrease the risk.• Serious GI tract ulceration and bleeding,as well as perforation of stomach or intestine,can occur without warning or symptoms.Elderly patients are at greater risk.To minimize risk, give diflunisal withfood. If patient has GI distress, withholddrug and notify prescriber immediately.• Use diflunisal cautiously in patients withhypertension, and monitor blood pressureclosely during therapy; drug can cause orworsen hypertension.• Use drug cautiously in elderly patients,those with renal dysfunction, and thosewho should avoid prolonged bleedingtime.WARNING Monitor patient closely forthrombotic events, including stroke andMI, because NSAIDs such as diflunisalincrease the risk of these events.• Monitor BUN and serum creatinine levelsin elderly patients, patients taking ACEinhibitors or diuretics, and patients withheart falure or impaired hepatic or renalfunction. These patients may have anincreased risk of renal failure.• Assess patient’s skin routinely for rash orother signs of hypersensitivity reaction;drug may cause serious skin reactionswithout warning. At first sign of reaction,stop drug and notify prescriber.• Assess type, location, and intensity of painbefore and 1 to 2 hours after giving drug.• Assess patient carefully because long-termor high-dose therapy may mask fever.PATIENT TEACHING• Teach patient not to crush or chewdiflunisal tablets.• Instruct patient to take tablet with a fullglass of water and not to lie down for30 minutes afterward to avoid esophagealirritation.• Inform patient that drug will start workingin about 1 week but that full effectsmay not occur for several weeks.• Explain that diflunisal may increase therisk of serious adverse cardiovascular reactions;urge patient to seek immediatemedical attention for such signs andsymptoms as chest pain, shortness ofbreath, slurred speech, and weakness.• Tell patient that diflunisal also mayincrease risk of serious adverse GI reactions;stress need to seek immediate medicalattention for signs and symptoms suchas abdominal or epigastric pain, black ortarry stools, indigestion, and vomitingblood or material that resembles coffeegrounds.• Alert patient about possibly serious skinreactions and the need to seek immediatemedial attention for such as problems asblisters, fever, itching, rash, and other signsof hypersensitivity.• Caution patient to avoid acetaminophen,alcohol, aspirin, and other salicylates duringdiflunisal therapy, unless directed otherwiseby prescriber.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to tell health care providersabout diflunisal therapy before surgery,including dental surgery. Therapy shouldstop for 1 week before procedure.digoxinLanoxicaps, Lanoxin, Lanoxin ElixirPediatric, Lanoxin Injection, LanoxinInjection Pediatric, Novo-Digoxin (CAN)Class and CategoryChemical class: Digitalis glycosideTherapeutic class: Antiarrhythmic,cardiotonicPregnancy category: Cdigoxin 319Indications and Dosages To treat heart failure, atrial flutter, atrialfibrillation, and paroxysmal atrialtachycardia with rapid digitalizationCAPSULES, I.V. INJECTIONAdults. Loading: 10 to 15 mcg/kg in 3 divideddoses every 6 to 8 hr, with first doseequal to 50% of total dose. Maintenance:125 to 350 mcg daily once or twice daily.Children over age 10. Loading: 8 to 12 mcg/kg in 3 or more divided doses, with firstdose equal to 50% of total dose. SubsequentD

320digoxindoses given every 6 to 8 hr. Maintenance:2 to 3 mcg/kg once daily.Children ages 6 to 10. Loading: 15 to30 mcg/kg in 3 or more divided doses, withfirst dose equal to 50% of total dose.Subsequent doses given every 6 to 8 hr.Maintenance: 4 to 8 mcg/kg daily in2 divided doses.Children ages 2 to 5. Loading: 25 to 35 mcg/kg in 3 or more divided doses, with firstdose equal to 50% of total dose. Subsequentdoses given every 6 to 8 hr. Maintenance:6 to 9 mcg/kg daily in 2 divided doses.Infants ages 1 to 24 months. Loading: 30 to50 mcg/kg in 3 or more divided doses, withfirst dose equal to 50% of total dose.Subsequent doses every 6 to 8 hr.Maintenance: 7.5 to 12 mcg/kg daily in2 divided doses.Full-term neonates. Loading: 20 to 30 mcg/kg in 3 or more divided doses, with firstdose equal to 50% of total dose. Subsequentdoses given every 6 to 8 hr. Maintenance:5 to 8 mcg/kg daily in 2 divided doses.Premature neonates. Loading: 15 to25 mcg/kg in 3 or more divided doses, withfirst dose equal to 50% of total dose.Subsequent doses given every 6 to 8 hr.Maintenance: 4 to 6 mcg/kg daily in2 divided doses.ELIXIR, TABLETSAdults. Loading: 10 to 15 mcg/kg total dosegiven in 3 divided doses every 6 to 8 hr,with first dose equal to 50% of total dose.Maintenance: 125 to 500 mcg daily.Children over age 10. Loading: 10 to15 mcg/kg total given in 3 divided dosesevery 6 to 8 hr, with first dose equal to 50%of total dose. Maintenance: 2.5 to 5 mcg/kgdaily.Children ages 5 to 10. Loading: 20 to35 mcg/kg in 3 divided doses every 6 to8hr.Maintenance: 5 to 10 mcg/kg daily in2 divided doses.Children ages 2 to 5. Loading: 30 to 40 mcg/kg in 3 divided doses every 6 to 8 hr.Maintenance: 7.5 to 10 mcg/kg daily in2 divided doses.Infants ages 1 to 24 months. Loading: 35 to60 mcg/kg in 3 divided doses every 6 to8hr.Maintenance: 10 to 15 mcg/kg daily in2 divided doses.Full-term neonates. Loading: 25 to 35 mcg/kg in 3 divided doses every 6 to 8 hr.Maintenance: 6 to 10 mcg/kg daily in2 divided doses.Premature neonates. Loading: 20 to 30 mcg/kg in 3 divided doses every 6 to 8 hr.Maintenance: 5 to 7.5 mcg/kg daily in2 divided doses.DOSAGE ADJUSTMENT Dosage carefullyadjusted for patients who are elderly ordebilitated or have implanted pacemakersbecause toxicity may develop at doses toleratedby most patients.Route Onset Peak DurationP.O. 30–120 min 6–8 hr 3–4 daysI.V. 5–30 min 1–5 hr 3–4 daysMechanism of ActionIncreases the force and velocity of myocardialcontraction, resulting in positiveinotropic effects. Digoxin produces antiarrhythmiceffects by decreasing the conductionrate and increasing the effectiverefractory period of the AV node.ContraindicationsHypersensitive carotid sinus syndrome,hypersensitivity to digoxin, presence or historyof digitalis toxicity or idiosyncraticreaction to digoxin, ventricular fibrillation,ventricular tachycardia unless heart failureoccurs unrelated to digoxin therapyInteractionsDRUGSadsorbent antidiarrheals, such as kaolin andpectin; bulk laxatives; cholestyramine; colestipol;oral neomycin; sulfasalazine: Inhibiteddigoxin absorptionamiodarone, propafenone: Elevated blooddigoxin level, possibly to toxic levelantacids: Inhibited digoxin absorptionantiarrhythmics, pancuronium, parenteralcalcium salts, rauwolfia alkaloids, sympathomimetics:Increased risk of arrhythmiasdiltiazem, verapamil: Increased blood digoxinlevel, possibly excessive bradycardiaedrophonium: Excessive slowing of heartrateerythromycin, neomycin, tetracycline:Possibly increased blood digoxin levelhypokalemia-causing drugs, potassium-wastingdiuretics: Increased risk of digitalis toxicityfrom hypokalemiaindomethacin: Decreased renal clearance

and increased blood level of digoxinmagnesium sulfate (parenteral): Possiblycardiac conduction changes and heart blockquinidine, quinine: Increased blood digoxinlevelspironolactone: Increased half-life and riskof adverse effects of digoxinsuccinylcholine: Increased risk of digoxininducedarrhythmiassucralfate: Decreased digoxin absorptionFOODShigh-fiber food: Inhibited digoxin absorptionAdverse ReactionsCNS: Confusion, depression, drowsiness,extreme weakness, headache, syncopeCV: Arrhythmias, heart blockEENT: Blurred vision, colored halos aroundobjectsGI: Abdominal discomfort or pain, anorexia,diarrhea, nausea, vomitingOther: Electrolyte imbalancesdigoxin immune Fab (ovine) 321Nursing Considerations• Give parenteral digoxin undiluted, ordilute with a fourfold or greater volume ofsterile water for injection, normal salinesolution, or D 5 W for I.V. administration.Once diluted, give immediately. Discard ifsolution is markedly discolored or containsprecipitate.• Before giving each dose, take patient’s apicalpulse and notify prescriber if it’s below60 beats/minute (or other specified level).• Monitor patient closely for signs of digitalistoxicity, such as altered mental status,arrhythmias, heart block, nausea, visiondisturbances, and vomiting. If they appear,notify prescriber, check serum digoxinlevel as ordered, and expect to withholddrug until level is known. Monitor ECGtracing continuously.• If patient has acute or unstable chronicatrial fibrillation, assess for drug effectiveness.Ventricular rate may not normalizeeven when serum drug level falls withintherapeutic range; raising the dosage probablywon’t produce a therapeutic effectand may lead to toxicity.• Frequently obtain ECG tracings as orderedin elderly patients because of their smallerbody mass and reduced renal clearance.Elderly patients, especially those withcoronary insufficiency, are more susceptibleto arrhythmias—particularly ventricularfibrillation—if digitalis toxicity occurs.• Monitor paptient’s serum potassium levelregularly because hypokalemia predisposesto digitalis toxicity and serious arrhythmias.Also monitor potassium level oftenwhen giving potassium salts becausehyperkalemia in patients receiving digoxincan be fatal.PATIENT TEACHING• Stress importance of taking digoxin exactlyas prescribed. Warn about possible toxicityfrom taking too much and decreasedeffectiveness from taking too little.• Instruct patient to take digoxin at sametime each day to help increase compliance.• Teach patient how to take her pulse, andinstruct her to do so before each dose.Urge her to notify prescriber if pulse fallsbelow 60 beats/minute or suddenlyincreases.• Inform patient that small, white 0.25-mgtablets can easily be confused with otherdrugs. Caution against carrying digoxin inanything other than its original labeledcontainer.• Emphasize need to use special droppersupplied with elixir to ensure accuratedose measurement.• Instruct patient to take a missed dose assoon as she remembers if within 12 hoursof scheduled dose. If not, urge her to notifyprescriber immediately.• Urge patient to notify prescriber if sheexperiences adverse reactions, such as GIdistress or pulse changes.• Instruct patient to carry medical identificationthat indicates her need for digoxin.• Advise patient to consult prescriber beforeusing other drugs, including OTC products.digoxin immune Fab(ovine)DigibindClass and CategoryChemical class: Digoxin-specific antigenbindingfragmentsTherapeutic class: Digitalis glycoside antidotePregnancy category: CD

322Nursing Considerations• Expect each 38-mg vial of purified digoxinimmune Fab to bind about 0.5 mg ofdigoxin or digitoxin.• To reconstitute for I.V. use, dissolve 38 mgin 4 ml of sterile water for injection toyield 9.5 mg/ml. Mix gently. Further dilutewith normal saline solution to proper volumefor I.V. infusion. For very small doses,reconstituted 38-mg vial may be dilutedwith 34 ml of normal saline solution toyield 1 mg/ml.WARNING Before giving digoxin immuneFab to high-risk patient, test for allergicreaction as prescribed by diluting 0.1 ml ofreconstituted drug in 9.9 ml sodium chloridefor injection and then injecting 0.1 ml(9.5 mcg/0.1 ml) intradermally. After 20minutes, observe for an urticarial whealsurrounded by erythema. Alternatively,perform a scratch test by placing one dropof 9.5 mcg/0.1 ml dilution on patient’sskin and making a 1/4 scratch throughthe drop with a sterile needle. Inspect sitein 20 minutes. Test is considered positive ifit produces a wheal surrounded by erythema.If test causes a systemic reaction,apply tourniquet above test site, notifyprescriber, and prepare to respond to anaphylaxis.Be aware that if a skin or systemicreaction occurs, additional drugshouldn’t be given unless essential; if moreof the drug must be given, expect prescriberto pretreat patient with corticosteroidsand diphenhydramine. Prescribershould be on standby to treat anaphylaxis.• For an infant, reconstitute digoxinimmune Fab as ordered and administerwith a tuberculin syringe.• When administering to a child, watch forfluid volume overload.• When giving a large dose, expect a fasteronset but watch closely for febrile reaction.• Give I.V. infusion through a 0.22-micronmembrane filter over 30 minutes. Keep inmind that drug may be given by rapid I.V.injection if cardiac arrest is imminent.• Monitor serum potassium level often,especially during first few hours of theradigoxinimmune Fab (ovine)Indications and Dosages To treat acute toxicity from a knownamount of digoxin elixir or tabletsI.V. INJECTIONAdults and children. Individualized dosagebased on amount ingested. Dose (mg) dose ingested (mg) multiplied by 0.8 andthen divided by 0.5, multiplied by 38, androunded up to next whole vial. To treat acute toxicity from a knownamount of digoxin capsules, digitoxintablets, or I.V. injection of digoxin ordigitoxinI.V. INJECTIONAdults and children. Individualized dosagebased on amount ingested. Dose (mg) dose ingested (mg) divided by 0.5, thenmultiplied by 38 and rounded up to nextwhole vial. To treat acute toxicity from an unknownamount of digoxin or digitoxin duringlong-term therapyI.V. INJECTIONAdults and children. Individualized dosagefor digoxin toxicity: dose (mg) serumdigoxin level (ng/ml) multiplied by bodyweight (kg), then divided by 100, and thenmultiplied by 38. Individualized dosage fordigitoxin toxicity: dose (mg) serum digitoxinlevel (ng/ml) multiplied by bodyweight (kg) and then divided by 1,000,multiplied by 38, and rounded up to nextwhole vial.DOSAGE ADJUSTMENT Higher dose administered,as prescribed, if the dose based oningested amount differs substantially fromthe dose based on serum digoxin or digitoxinlevel. Dose repeated after severalhours, if needed.Route Onset Peak DurationI.V. 15–30 min Unknown 8–12 hrMechanism of ActionBinds with digoxin or digitoxin molecules.The resulting complex is excreted throughthe kidneys. As the free serum digoxin leveldeclines, tissue-bound digoxin enters theserum and also is bound and excreted.ContraindicationsHypersensitivity to digoxin immune FabAdverse ReactionsCV: Increased ventricular rate (in atrial fibrillation),worsening of heart failure or lowcardiac outputOther: Allergic reaction (difficulty breathing,urticaria), febrile reaction, hypokalemia

py. Potassium level may drop rapidly.PATIENT TEACHING• Inform patient of the purpose of digoxinimmune Fab and how it will be given.• Advise patient to notify you immediately ifshe experiences adverse reactions, especiallydifficulty breathing and urticaria.dihydroergotaminemesylateD.H.E. 45, Dihydroergotamine-Sandoz(CAN), MigranalClass and CategoryChemical class: Semisynthetic ergot alkaloidTherapeutic class: AntimigrainePregnancy category: XIndications and Dosages To treat acute migraine with or withoutauraI.V. INJECTIONAdults. 1 mg, repeated in 1 hr, if needed.Maximum: 6 mg/wk.I.M. INJECTIONAdults. 1 mg at first sign of headache,repeated every hr up to 3 mg, if needed.Maximum: 3 mg/24 hr, 6 mg/wk.NASAL SPRAYAdults. 1 spray (0.5 mg) in each nostril,repeated in 15 min for a total dose of2 sprays in each nostril or 2 mg. Maximum:3 mg/24 hr, 4 mg/wk.Route Onset Peak DurationI.V. In 5 min 15 min– About 8 hr2 hrI.M. 15–30 min 15 min– 3–4 hr2 hrNasal In 30 min 30–60 min UnknownMechanism of ActionProduces intracranial and peripheral vasoconstrictionby binding to all known 5-hydroxytryptamine 1 (5-HT 1 ) receptors,alpha 1 - and alpha 2 -adrenergic receptors,and dopaminergic receptors. Activation of5-HT 1 receptors on intracranial blood vesselsprobably constricts large intracranialarteries and closes arteriovenous anastomosesto relieve migraine headache.Adverse ReactionsCNS: Anxiety, confusion, dizziness, fatigue,headache, paresthesia, somnolence, weaknessCV: Bradycardia, chest pain, peripheralvasospasm (calf or heel pain with exertion,cool and cyanotic hands and feet, leg weakness,weak or absent pulses), tachycardiaEENT: Abnormal vision; dry mouth; episdihydroergotaminemesylate 323Activation of 5-HT 1 receptors on sensorynerves in the trigeminal system also mayinhibit the release of pro-inflammatoryneuropeptides.Peripherally, dihydroergotamine causesvasoconstriction by stimulating alphaadrenergicreceptors. At therapeutic doses,it inhibits norepinephrine reuptake,increasing vasoconstriction. Drug constrictsveins more than arteries, increasing venousreturn while decreasing venous stasis andpooling.ContraindicationsCoronary artery disease, including vasospasm;hemiplegic or basilar migraine;hypersensitivity to dihydroergotamine orother ergot alkaloids; malnutrition; peripheralvascular disease or after vascular surgery;pregnancy; sepsis; severe hepatic orrenal impairment; severe pruritus; uncontrolledhypertension; use of macrolide antibioticsor protease inhibitors; use within 24hours of 5-HT 1 agonist, ergotamine-containingor ergot-type drug, or methysergideInteractionsDRUGSbeta blockers: Possibly peripheral vasoconstrictionand peripheral ischemia, increasedrisk of gangrenemacrolides, protease inhibitors: Possiblyincreased risk of vasospasm, acute ergotismwith peripheral ischemianitrates: Decreased antianginal effects ofnitratesother ergot drugs, including ergoloid mesylates,ergonovine, methylergonovine, methysergide,and sumatriptan: Increased risk ofserious adverse effects from nasal dihydroergotaminesystemic vasoconstrictors: Risk of severehypertensionACTIVITIESsmoking: Possibly increased ischemicresponse to ergot therapyD

324dihydrotachysteroltaxis, nasal congestion or rhinitis, and sorenose (nasal spray); miosis; pharyngitis;sinusitis; taste perversionGI: Diarrhea, nausea, vomitingMS: Muscle stiffnessSKIN: Localized edema of face, feet, fingers,and lower legs; sensation of heat orwarmth; sudden diaphoresisNursing ConsiderationsWARNING Monitor patient for signs ofdihydroergotamine overdose, such asabdominal pain, confusion, delirium,dizziness, dyspnea, headache, nausea, painin legs or arms, paresthesia, seizures, andvomiting.• Assess patient’s peripheral pulses, skin sensation,warmth, and capillary refill. Aftergiving nasal dihydroergotamine, monitorpatient for signs of widespread blood vesselconstriction and adverse reactionscaused by decreased circulation to manybody areas.PATIENT TEACHING• Instruct patient to use nasal spray whenheadache pain—not aura—begins.• Teach her to prime spray pump by squeezingit four times.• Advise patient to wait 15 minutes betweeneach set of nasal sprays.• Encourage patient to lie down in a quiet,dark room after using drug.• Instruct patient to use more dihydroergotamineif headache returns or worsens butnot to exceed maximum prescribedamount or frequency.• Remind patient to take drug only as needed,not on a daily basis.• Instruct patient to discard residual nasalspray in an open ampule after 8 hours.• If patient has a headache different fromher usual migraines, caution her not to usedihydroergotamine and to notify prescriber.• Inform patient that nasal drug won’trelieve pain other than throbbingheadaches.• Advise patient to avoid alcohol, which cancause or worsen headaches, and to avoidsmoking, which may cause an ischemicresponse.• Warn patient about possible dizziness duringor after a migraine for which she tookdihydroergotamine.dihydrotachysterolDHT, DHT Intensol, HytakerolClass and CategoryChemical class: Sterol derivative, vitamin DanalogueTherapeutic class: Antihypocalcemic,antihypoparathyroidPregnancy category: CIndications and Dosages To treat hypocalcemic and idiopathictetanyCAPSULES, ORAL SOLUTION, TABLETSAdults and adolescents. Initial: 0.75 to2.5 mg daily for 3 days for acute cases;0.25 to 0.5 mg daily for 3 days for less acutecases. Maintenance: 0.25 mg/wk to 1 mgdaily, as needed to maintain normal serumcalcium level. To treat hypoparathyroidismCAPSULES, ORAL SOLUTION, TABLETSAdults and adolescents. Initial: 0.75 to2.5 mg daily for several days. Maintenance:0.2 to 1 mg daily.Children. Initial: 1 to 5 mg daily for 4 days;then continued or decreased to one-quarterthe dose. Maintenance: 0.5 to 1.5 mg daily.Route Onset Peak DurationP.O. Several hr Unknown Up to 9 wkMechanism of ActionStimulates intestinal calcium absorptionand mobilizes bone calcium when parathyroidhormone and renal tissue fail toraise the serum calcium level.ContraindicationsHypercalcemia, hypersensitivity to vitaminD, hypervitaminosis D, malabsorption syndrome,renal dysfunctionInteractionsDRUGSaluminum-containing antacids: Possiblyincreased serum aluminum level, leading totoxicitybarbiturates, phenytoin: Decreased half-lifeand therapeutic effects of vitamin Dcalcium-containing drugs, thiazide diuretics:Risk of hypercalcemia in patients withhypoparathyroidismcholestyramine, colestipol, mineral oil:

Decreased vitamin D absorptiondigitalis glycosides: Possibly hypercalcemia;possibly potentiated effects of digitalis glycosides,resulting in arrhythmiasmagnesium-containing antacids: Risk ofhypermagnesemia, especially in patientswith chronic renal failurephosphorus-containing drugs: Increased riskof hyperphosphatemiavitamin D analogues: Increased risk of vitaminD toxicityAdverse ReactionsOther: Vitamin D toxicity (long-term,high-dose therapy)Nursing Considerations• After thyroid surgery, expect to give0.25 mg once daily with 6 g of oral calciumlactate until danger of tetany haspassed.• Monitor serum calcium level regularly todetermine dosage schedule and detect orprevent hypercalcemia. The differencebetween therapeutic and toxic doses maybe small.• Watch closely for signs of vitamin D toxicity:abdominal cramps, amnesia, anorexia,ataxia, coma, constipation, depression,diarrhea, disorientation, hallucinations,headache, hypotonia, lethargy, nausea,syncope, tinnitus, vertigo, vomiting, andweakness. Renal impairment may causealbuminuria, polydipsia, and polyuria.Delayed treatment can result in deathfrom cardiac and renal failure caused bywidespread calcification of soft tissues,including the heart, blood vessels, kidneys,and lungs.• If toxicity occurs, notify prescriber andexpect to stop dihydrotachysterol immediately.Place patient on bed rest, administerfluids and a laxative, and give low-calciumdiet as ordered. For hypercalcemic crisiswith dehydration, prepare to give I.V. normalsaline solution and a loop diuretic(such as furosemide or ethacrynic acid) toincrease urinary calcium excretion.PATIENT TEACHING• Stress importance of not exceeding prescribeddihydrotachysterol dosage becauseof the risk of vitamin D toxicity.• If patient detects signs of toxicity, cautionher not to take the next dose and to notifyprescriber immediately.diltiazem hydrochloride 325• Advise patient to drop solution directlyinto her mouth or to mix it with fruitjuice, cereal, or other food.• Tell patient to take a missed dose as soonas she remembers unless it’s nearly timefor next dose. Warn her not to double it.• Advise patient to avoid OTC drugs anddietary supplements that contain aluminum,calcium, phosphorus, or vitaminD, unless directed by prescriber. Alsoadvise her to avoid antacids that containmagnesium.• Urge patient to keep follow-up appointmentsand to have her serum calcium levelmeasured periodically.diltiazemhydrochlorideApo-Diltiaz (CAN), Cardizem,Cardizem CD, Cardizem LA,Cardizem SR, Dilacor XR, Novo-Diltiazem (CAN), Nu-Diltiaz (CAN)Class and CategoryChemical class: Benzothiazepine derivativeTherapeutic class: Antianginal, antiarrhythmic,antihypertensivePregnancy category: CIndications and Dosages To treat Prinzmetal’s (variant) anginaand chronic stable anginaTABLETSAdults and adolescents. Initial: 30 mg t.i.d.or q.i.d. before meals and at bedtime,increased every 1 or 2 days as appropriate.Maximum: 360 mg daily in divided dosest.i.d. or q.i.d.E.R. TABLETSAdults and adolescents. Initial: 180 mgdaily, increased every 7 to 14 days as needed.Maximum: 360 mg daily. To control hypertensionE.R. CAPSULESAdults and adolescents. Initial: 180 to240 mg daily, adjusted after 14 days asappropriate. Maximum: 360 mg daily.S.R. CAPSULESAdults and adolescents. Initial: 60 to120 mg b.i.d., adjusted after 14 days asappropriate. Maximum: 360 mg daily.D

326diltiazem hydrochlorideMechanism of ActionDiltiazem inhibits calcium movementinto coronary and vascular smooth-musclecells by blocking slow calcium channelsin cell membranes, as shown. Thisaction decreases intracellular calcium,which:• inhibits smooth-muscle cell contractions• decreases myocardial oxygen demand byrelaxing coronary and vascular smoothmuscle, reducing peripheral vascularresistance and systolic and diastolicblood pressures• slows AV conduction time and prolongsAV nodal refractoriness• interrupts the reentry circuit in AVnodal reentrant tachycardias.Cell exteriorCellmembraneCell interiorCalciumchannelCa ++Ca ++Ca ++Ca ++Calciummovementblocked bydiltiazemTABLETSAdults and adolescents. Initial: 30 mg t.i.d.or q.i.d. before meals and at bedtime,increased every 1 or 2 days as appropriate.Maximum: 360 mg daily in divided dosest.i.d. or q.i.d.E.R. TABLETSAdults. Initial: 180 to 240 mg daily, adjustedafter 14 days, as needed. Maximum:540 mg daily. To treat atrial fibrillation, atrial flutter,and paroxysmal supraventricular tachycardiaI.V. INFUSION OR INJECTIONAdults and adolescents. 0.25 mg/kg givenby bolus over 2 min. If response is inadequateafter 15 min, 0.35 mg/kg given bybolus over 2 min. Then 10 mg/hr for continuedreduction of heart rate after bolus,increased by 5 mg/hr, as needed. Maximum:15 mg/hr for up to 24 hr.Route Onset Peak DurationP.O. 30–60 min In 2 wk UnknownP.O. (E.R.) 2–3 hr In 2 wk UnknownP.O. (S.R.) Unknown In 2 wk UnknownI.V. In 3 min 2– 7 min 30 min–10 hr*IncompatibilitiesDon’t give diltiazem through same I.V. lineas acetazolamide, acyclovir, aminophylline,*For infusion; 1 to 3 hr for injection.ampicillin sodium/sulbactam sodium,cefamandole, cefoperazone, diazepam,furosemide, heparin, hydrocortisone sodiumsuccinate, methylprednisolone sodiumsuccinate, mezlocillin, nafcillin, phenytoin,rifampin, or sodium bicarbonate.ContraindicationsAcute MI; cardiogenic shock; Lown-Ganong-Levine or Wolff-Parkinson-Whitesyndrome, second- or third-degree AVblock, and sick sinus syndrome, unless artificialpacemaker is in place; pulmonaryedema; systolic blood pressure below 90 mmHg; ventricular tachycardia (wide complex)InteractionsDRUGSanesthetic: Additive hypotension; possiblydecreased cardiac contractility, conductivity,and automaticitybenzodiazepines: Increased risk of prolongedsedationbeta blockers: Possibly increased risk ofadverse cardiovascular effectsbuspirone: Increased effects and risk of buspironetoxicitycarbamazepine, cyclosporine, lovastatin,quinidine, theophyllines: Decreased hepaticclearance and increased serum levels ofthese drugs, leading to toxicitycimetidine: Decreased diltiazem metabolism,increased blood diltiazem leveldigoxin: Increased blood digoxin levellithium: Possibly neurotoxicity

NSAIDs: Possibly antagonized antihypertensiveeffect of diltiazemprazocin: Possibly increased risk ofhypotensionprocainamide: Possibly increased risk ofprolonged QT intervalquinidine: Increased risk of adverse quinidineeffectsrifampin: Decreased blood diltiazem level toundetectable amountsAdverse ReactionsCNS: Abnormal gait, amnesia, asthenia,depression, dizziness, dream disturbances,extrapyramidal reactions, fatigue, hallucinations,headache, insomnia, nervousness,paresthesia, personality change, somnolence,syncope, tremor, weaknessCV: Angina, atrial flutter, AV block (first-,second-, and third-degree), bradycardia,bundle-branch block, heart failure,hypotension, palpitations, peripheraledema, PVCs, sinus arrest, sinus tachycardia,12-lead ECG abnormalities, ventricularfibrillation, ventricular tachycardiaEENT: Amblyopia, dry mouth, epistaxis, eyeirritation, gingival bleeding and hyperplasia,gingivitis, nasal congestion, retinopathy,taste perversion, tinnitusENDO: HyperglycemiaGI: Anorexia, constipation, diarrhea, elevatedliver function test results, indigestion,nausea, thirst, vomitingGU: Acute renal failure, impotence, nocturia,polyuria, sexual dysfunctionHEME: Hemolytic anemia, leukopenia, prolongedbleeding time, thrombocytopeniaMS: Arthralgia, muscle spasms, myalgiaRESP: Cough, dyspneaSKIN: Alopecia, diaphoresis, erythemamultiforme, exfoliative dermatitis, flushing,leukocytoclastic vasculitis, petechiae, photosensitivity,pruritus, purpura, rash, Stevens-Johnson syndrome, toxic epidermal necrolysis,urticariaOther: Angioedema, hyperuricemia, weightgainNursing Considerations• Use diltiazem cautiously in patients withimpaired hepatic or renal function, andmonitor liver and renal function, asappropriate; drug is metabolized mainly inthe liver and excreted by the kidneys.WARNING Monitor patient’s blood pressure,dimenhydrinate 327pulse rate, and heart rate and rhythm bycontinuous ECG as appropriate duringtherapy. Keep emergency equipment anddrugs available.• Assess patient for signs and symptoms ofheart failure.• If patient takes digoxin, watch for digitalistoxicity (nausea, vomiting, halo vision,elevated serum digoxin level).• Administer sublingual nitroglycerin, asprescribed, during diltiazem therapy.• Expect to discontinue drug if adverse skinreactions, usually transient, persist.PATIENT TEACHING• Explain that regular tablets can be crushedbut that capsules and E.R. tablets must beswallowed whole.WARNING Tell patient that stopping drugsuddenly may have life-threatening effects.• Advise patient to monitor blood pressureand pulse rate regularly and to report significantchanges to prescriber.• Urge patient to report chest pain, difficultybreathing, dizziness, fainting, irregularheartbeat, rash, or swollen ankles.• Instruct patient to maintain good oralhygiene, perform gum massage, and see adentist every 6 months to prevent gingivalbleeding and hyperplasia and gingivitis.dimenhydrinateDinate, Dramanate, Gravol (CAN),HydrateClass and CategoryChemical class: Ethanolamine derivativeTherapeutic class: Antiemetic, antivertigoPregnancy category: BIndications and Dosages To treat nausea, vomiting, dizziness, orvertigo associated with motion sicknessCHEWABLE TABLETS, ORAL SOLUTION, SYRUP,TABLETSAdults and adolescents. 50 to 100 mg every4 to 6 hr, p.r.n. Maximum: 400 mg/24 hr.Children ages 6 to 12. 25 to 50 mg every6 to 8 hr, p.r.n. Maximum: 150 mg/24 hr.Children ages 2 to 6. 12.5 to 25 mg every6 to 8 hr, p.r.n. Maximum: 75 mg/24 hr.I.M. INJECTIONAdults and adolescents. 50 mg every 4 hr,p.r.n.D

328dimenhydrinateChildren. 1.25 mg/kg or 37.5 mg/m 2 every6 hr, p.r.n. Maximum: 300 mg daily.I.V. INFUSION OR INJECTIONAdults and adolescents. 50 mg in 10 ml ofnormal saline solution administered slowly,over at least 2 min, every 4 hr, p.r.n.Children. 1.25 mg/kg or 37.5 mg/m 2 in10 ml of normal saline solution administeredslowly, over at least 2 min, every 6 hr,p.r.n. Maximum: 300 mg daily.Route Onset Peak DurationP.O. Unknown Unknown 3–6 hrI.M. 20–30 min Unknown 3–6 hrI.V. Immediate Unknown 3–6 hrMechanism of ActionMay inhibit vestibular stimulation andlabyrinthine stimulation and function byacting on the otolith system and, with largerdoses, on the semicircular canals.ContraindicationsAge less than 1 month, hypersensitivity todimenhydrinate or its componentsInteractionsDRUGSaminoglycosides, other ototoxic drugs:Masked symptoms of ototoxicityanticholinergics, drugs with anticholinergicactivity: Potentiated anticholinergic effectsof dimenhydrinateapomorphine: Possibly decreased emeticresponse to apomorphine in treatment ofpoisoningbarbiturates, other CNS depressants: Possiblyincreased CNS depressionMAO inhibitors: Increased anticholinergicand CNS depressant effects of dimenhydrinateACTIVITIESalcohol use: Possibly increased CNS depressionAdverse ReactionsCNS: Confusion, drowsiness, hallucinations,nervousness, paradoxical stimulationCV: Hypotension, palpitations, tachycardiaEENT: Blurred vision, diplopia, dry eyes,dry mouth, nasal congestionGI: Anorexia, constipation, diarrhea, epigastricdiscomfort, nausea, vomitingGU: DysuriaHEME: Hemolytic anemiaRESP: Thickening of bronchial secretions,wheezingSKIN: Photosensitivity, rash, urticariaOther: AnaphylaxisNursing ConsiderationsWARNING Be aware that I.V. dimenhydrinateshouldn't be administered to prematureor full-term neonates. Some I.V.preparations may contain benzyl alcohol,which can cause a fatal toxic syndromecharacterized by CNS, respiratory, circulatory,and renal impairment and metabolicacidosis.WARNING Be aware that the 50-mg/ml concentrationof dimenhydrinate is intendedfor I.M. use. For I.V. use, the solution mustbe diluted further with at least 10 ml ofdiluent, such as D 5 W or normal salinesolution, for each milliliter of dimenhydrinate.• Monitor patients with prostatic hyperplasia,stenosing peptic ulcer, pyloroduodenalobstruction, bladder neck obstruction,angle-closure glaucoma, bronchial asthma,or cardiac arrhythmias for worsening ofthese conditions caused by anticholinergiceffects.• Monitor elderly patients for increased sensitivityto dimenhydrinate, such as excessivedrowsiness, confusion, and restlessness.• Assess patients, especially children andelderly patients, for evidence of paradoxicalstimulation, such as nightmares,unusual excitement, nervousness, restlessness,or irritability.• Store parenteral drug at 15° to 30° C (59°to 86° F); don’t freeze.PATIENT TEACHING• Because dimenhydrinate may causedrowsiness, instruct patient to avoid hazardousactivities until drug’s CNS effectsare known.• Advise patient to inform health careproviders about dimenhydrinate therapy,especially if she’s being evaluated for medicalconditions that are affected by thisdrug, such as appendicitis.• Instruct patient to avoid alcohol, sedatives,and tranquilizers while taking dimenhydrinate.• Encourage patient to use sunscreen to preventphotosensitivity reactions.

diphenhydraminehydrochlorideAllerdryl (CAN), Banophen, Benadryl,Benadryl Allergy, Diphenhist CapTabs,Genahist, Hyrexin, Nytol QuickCaps,Siladryl, Sleep-Eze D Extra Strength,Unisom SleepGels Maximum StrengthClass and CategoryChemical class: Ethanolamine derivativeTherapeutic class: Antianaphylactic adjunct,antidyskinetic, antiemetic, antihistamine,antitussive (syrup), antivertigo, sedativehypnoticPregnancy category: BIndications and Dosages To treat hypersensitivity reactions, suchas perennial and seasonal allergic rhinitis,vasomotor rhinitis, allergic conjunctivitis,uncomplicated allergic skin eruptions,and transfusion reactionsCAPSULES, TABLETSAdults and adolescents. 25 to 50 mg every4 to 6 hr, p.r.n. Maximum: 300 mg daily.Children ages 6 to 12. 12.5 to 25 mg every4 to 6 hr. Maximum: 150 mg daily.Children up to age 6. 6.25 to 12.5 mg every4 to 6 hr.ELIXIRAdults and adolescents. 25 to 50 mg every4 to 6 hr, p.r.n. Maximum: 300 mg daily.Children. 1.25 mg/kg every 4 to 6 hr.Maximum: 300 mg daily.I.V. OR I.M. INJECTIONAdults and adolescents. 10 to 50 mg every4 to 6 hr up to 100 mg/dose, if needed.Maximum: 400 mg daily.Children. 1.25 mg/kg every 4 to 6 hr.Maximum: 300 mg daily. To treat sleep disordersCAPSULES, TABLETSAdults and adolescents. 50 mg 20 to30 min before bedtime. To provide antitussive effectsELIXIRAdults and adolescents. 25 mg every 4 hr.Maximum: 100 mg/24 hr.Children ages 6 to 12. 12.5 mg every 4 to6hr.Maximum: 75 mg daily.Children ages 2 to 6. 6.25 mg every 4 to 6hr. Maximum: 25 mg daily.diphenhydramine hydrochloride 329 To prevent motion sickness or treat vertigoCAPSULES, ELIXIR, TABLETSAdults and adolescents. 25 to 50 mg every4 to 6 hr, p.r.n. Maximum: 300 mg daily.Children. 1 to 1.5 mg/kg every 4 to 6 hr,p.r.n. Maximum: 300 mg daily.I.V. OR I.M. INJECTIONAdults and adolescents. Initial: 10 mg.Increased to 20 to 50 mg every 2 to 3 hr, ifneeded. Maximum: 100 mg/dose, 400 mgdaily.Children. 1 to 1.5 mg/kg I.M. every 4 to6 hr, p.r.n. Maximum: 300 mg daily. To treat symptoms of Parkinson’s diseaseand drug-induced extrapyramidal reactionsin elderly patients who can’t toleratemore potent antidyskinetic drugsCAPSULES, ELIXIR, TABLETSAdults. 25 mg t.i.d. increased gradually to50 mg q.i.d., if needed. Maximum: 300 mgdaily.I.V. OR I.M. INJECTIONAdults and adolescents. 10 to 50 mg q.i.d.,as needed. Maximum: 100 mg/dose, 400 mgdaily.Route Onset Peak DurationP.O. 15–60 min 1–3 hr 6–8 hrI.V. Immediate 1–3 hr 6–8 hrI.M. 30 min 1–3 hr 6–8 hrMechanism of ActionBinds to central and peripheral H 1 receptors,competing with histamine for thesesites and preventing it from reaching its siteof action. By blocking histamine, diphenhydramineproduces antihistamine effects,inhibiting respiratory, vascular, and GIsmooth-muscle contraction; decreasingcapillary permeability, which reduceswheals, flares, and itching; and decreasingsalivary and lacrimal gland secretions.Diphenhydramine produces antidyskineticeffects, possibly by inhibiting acetylcholinein the CNS. It also produces antitussiveeffects by directly suppressing thecough center in the medulla oblongata inthe brain. Diphenhydramine’s antiemeticand antivertigo effects may be related to itsability to bind to CNS muscarinic receptorsand depress vestibular stimulation andlabyrinthine function. Its sedative effectsare related to its CNS depressant action.D

330dipyridamoleContraindicationsBladder neck obstruction, hypersensitivityto diphenhydramine or its components,lower respiratory tract symptoms (includingasthma), MAO inhibitor therapy, narrow-angleglaucoma, pyloroduodenalobstruction, stenosing peptic ulcer, symptomaticbenign prostatic hyperplasiaInteractionsDRUGSapomorphine: Possibly decreased emeticresponse in treatment of poisoningbarbiturates, other CNS depressants: Possiblyincreased CNS depressionMAO inhibitors: Increased anticholinergicand CNS depressant effects of diphenhydramineACTIVITIESalcohol use: Possibly increased CNS depressionAdverse ReactionsCNS: Confusion, dizziness, drowsinessCV: Arrhythmias, palpitations, tachycardiaEENT: Blurred vision, diplopiaGI: Epigastric distress, nauseaHEME: Agranulocytosis, hemolytic anemia,thrombocytopeniaRESP: Thickened bronchial secretionsSKIN: PhotosensitivityNursing Considerations• Expect to give parenteral form of diphenhydramineonly when oral ingestion isn’tpossible.• Keep elixir container tightly closed.Protect elixir and parenteral forms fromlight.• Expect to discontinue drug at least 72 hoursbefore skin tests for allergies because drugmay inhibit cutaneous histamine response,thus producing false-negative results.PATIENT TEACHING• Instruct patient to take diphenhydramineat least 30 minutes before exposure to situationsthat may cause motion sickness.• Advise her to take drug with food to minimizeGI distress.• Urge patient to avoid alcohol while takingdiphenhydramine.• Instruct her to use sunscreen to preventphotosensitivity reactions.• Advise patient to avoid taking other OTCdrugs that contain diphenhydramine toprevent additive effects.dipyridamoleApo-Dipyridamole FC (CAN),Apo-Dipyridamole SC (CAN),Novo-Dipiradol (CAN), PersantineClass and CategoryChemical class: PyrimidineTherapeutic class: Coronary vasodilator,diagnostic aid, platelet aggregationinhibitorPregnancy category: BIndications and Dosages To prevent thromboemboliccomplications of cardiac valvereplacementTABLETSAdults. 75 to 100 mg q.i.d. with coumarinor indanedione derivative anticoagulant. To aid diagnosis during thallium perfusionimaging of myocardiumI.V. INFUSIONAdults. 0.57 mg/kg in 50 ml of D 5 Winfused over 4 min. Maximum: 60 mg.Route Onset Peak DurationI.V. Unknown 3.8– Unknown8.7 min*Mechanism of ActionMay increase the intraplatelet level ofadenosine, which causes coronary vasodilationand inhibits platelet aggregation.Dipyridamole also may increase theintraplatelet level of cyclic adenosinemonophosphate (cAMP) and may inhibitformation of the potent platelet activatorstimulant thromboxane A 2 , which decreasesplatelet activation. Vasodilation andincreased blood flow occur preferentially innondiseased coronary vessels, which resultsin redistribution of blood away from significantlydiseased vessels. These changes inperfusion are observed during thalliumimaging studies.ContraindicationsAsthma (I.V.), hypersensitivity to dipyridamoleor its components, hypotension,unstable angina pectoris* After start of infusion, for increasedvelocity of coronary artery blood flow.

InteractionsDRUGSadenosine: Potentiated effects of adenosinecefamandole, cefoperazone, cefotetan, plicamycin,valproic acid: Possibly hypoprothrombinemiaand increased risk of bleedingheparin, NSAIDs, thrombolytics: Possiblyincreased risk of bleedingtheophylline: Reversal of coronary vasodilationcaused by dipyridamole, possibly falsenegativethallium imaging resultAdverse ReactionsCNS: Dizziness, headacheCV: Angina, arrhythmias, ECG changes(specifically, ST-segment and T-wavechanges)GI: Abdominal pain, diarrhea, nausea,vomitingRESP: DyspneaSKIN: Flushing, pruritus, rashNursing Considerations• Protect I.V. form of dipyridamole fromdirect light and freezing.• Monitor blood pressure, pulse rate andrhythm, and breath sounds every 10 to15 minutes during I.V. infusion.• Keep parenteral aminophylline available torelieve adverse reactions to dipyridamoleinfusion.• At therapeutic doses, expect adverse reactionsto be minimal and transient. Theytypically resolve with long-term use.PATIENT TEACHING• Urge patient to take dipyrinamole at least1 hour before or 2 hours after meals forfaster absorption. If she experiences GIdistress, advise her to take drug with mealsor milk.• Advise patient to take drug at evenlyspaced intervals.• Inform patient that drug commonly istaken with other anticoagulants.• Urge her to keep appointments for coagulationtests.• Instruct patient to seek immediate emergencytreatment if chest pain occurs.• Caution patient to consult prescriberbefore taking aspirin and other OTCNSAIDs because of the possible increasedrisk of bleeding.• Advise patient to notify all health careproviders about dipyridamole use.dirithromycinDynabacdirithromycin 331Class and CategoryChemical: Semisynthetic macrolideTherapeutic: AntibioticPregnancy category: CIndications and Dosages To treat acute bacterial exacerbationsand secondary bacterial infections inpatients with bronchitis caused by Moraxellacatarrhalis or Streptococcuspneumoniae, and uncomplicated skinand soft-tissue infections caused bymethicillin-susceptible StaphylococcusaureusTABLETSAdults and adolescents. 500 mg daily for7 days. To treat streptococcal pharyngitisTABLETSAdults and adolescents. 500 mg daily for10 days. To treat community-acquired pneumoniacaused by Legionella pneumophila,Mycoplasma pneumoniae, or S. pneumoniaeTABLETSAdults and adolescents. 500 mg daily for14 days.Mechanism of ActionBinds with the 50S ribosomal subunit ofthe 70S ribosome in susceptible bacteria.This action inhibits RNA-dependent proteinsynthesis in bacterial cells, causingthem to die.ContraindicationsConcurrent use of astemizole, cisapride, orpimozide; hypersensitivity to dirithromycin,erythromycin, other macrolideantibiotics, or their components; known,potential, or suspected bacteremiaInteractionsDRUGSantacids, H 2 -receptor antagonists: Increaseddirithromycin absorptionastemizol, terfenadine: Possibly life-threateningarrhythmiastheophylline: Possibly increased serum theophyllinelevelD

332InteractionsDRUGSantiarrhythmics: Widened QRS complex,prolonged QT interval, risk of arrhythmias,serious negative inotropic effectsanticholinergics: Possibly additive antidisopyramideAdverse ReactionsCNS: Dizziness, headache, weaknessGI: Abdominal pain, diarrhea, nausea,pseudomembranous colitis, vomitingSKIN: Pruritus, rash, urticariaNursing Considerations• Use dirithromycin cautiously in patientswith impaired hepatic function. Monitorliver function test results as indicatedbecause drug is metabolized in liver.PATIENTTEACHING• Instruct patient to take dirithromycin atthe same time each day with food or within1 hour of eating.• Caution patient not to cut, chew, or crushtablets.• Advise patient to store drug at room temperaturein a dry place.• Instruct patient to complete the full courseof prescribed therapy, even if she feels betterbefore drug is gone.• Advise patient to notify prescriber immediatelyif GI problems persist.disopyramideRythmodan (CAN)disopyramidephosphateNorpace, Norpace CR,Rythmodan-LA (CAN)Class and CategoryChemical class: Substituted pyramidederivativeTherapeutic class: Class IA antiarrhythmicPregnancy category: CIndications and Dosages To rapidly control ventricular arrhythmiasCAPSULESAdults. Loading: 300 mg (200 mg if patientweighs less than 50 kg [110 lb]). If noresponse within 6 hr, 200 mg given every6 hr. If no response within 48 hr, drug discontinuedor dosage carefully increased to250 to 300 mg every 6 hr. To treat ventricular arrhythmiasCAPSULESAdults. 400 to 800 mg daily in divideddoses every 6 hr, limited to 400 mg daily ifpatient weighs less than 50 kg. Maximum:800 mg daily.Children ages 12 to 18. 6 to 15 mg/kg dailyin divided doses every 6 hr.Children ages 4 to 12. 10 to 15 mg/kg dailyin divided doses every 6 hr.Children ages 1 to 4. 10 to 20 mg/kg dailyin divided doses every 6 hr.Children under age 1. 10 to 30 mg/kg dailyin divided doses every 6 hr.DOSAGE ADJUSTMENT Initial dosage reducedto 100 mg every 6 to 8 hr for adults withcardiomyopathy or possible cardiac decompensation.In renal insufficiency, dosagereduced to 100 mg every 6 hr if creatinineclearance exceeds 40 ml/min/1.73 m 2 orhepatic function is impaired; to 100 mgevery 8 hr if clearance is 30 to 40 ml/min/1.73 m 2 ; to 100 mg every 12 hr if clearanceis 15 to 29 ml/min/1.73 m 2 ; and to 100 mgevery 24 hr if clearance is less than 15 ml/min/1.73 m 2 .E.R. CAPSULES, E.R. TABLETSAdults. 400 to 800 mg daily in divideddoses every 12 hr, limited to 200 mg every12 hr if patient weighs less than 50 kg.Maximum: 800 mg daily.Mechanism of ActionInhibits sodium influx through fast channelsof myocardial cell membranes, thusincreasing recovery period after repolarization.Disopyramide decreases automaticityin the His-Purkinje system and conductionvelocity in atria, ventricles, and accessorypathways. It prolongs QRS and QT intervalsin normal sinus rhythm and atrial arrhythmias.Drug has a potent negative inotropiceffect. It also acts as an anticholinergic andincreases peripheral vascular resistance.ContraindicationsCardiogenic shock, congenital QT-intervalprolongation, hypersensitivity to disopyramideor its components, second- or thirddegreeAV block (without pacemaker), sicksinus syndrome

cholinergic effectscisapride: Possibly increased risk of prolongedQT intervalclarithromycin, erythromycin: Increasedblood disopyramide leveldigoxin: Increased serum digoxin levelhydantoins, rifampin: Decreased blooddisopyramide levelinsulin, oral antidiabetic drugs: Possiblyintensified antidiabetic effectsquinidine: Increased blood disopyramidelevel, decreased quinidine level, or bothverapamil: Widened QRS complex, prolongedQT interval, possibly deathAdverse ReactionsCNS: Depression, dizziness, fatigue, fever,headache, insomnia, nervousness, syncopeCV: Chest pain; conduction disturbances;edema; heart failure (new or worsened);hypercholesterolemia; hypertriglyceridemia;hypotension; palpitations; proarrhythmias,including torsades de pointes; ventricularfibrillation; ventricular tachycardiaEENT: Blurred vision; dry eyes, mouth,nose, and throatENDO: Gynecomastia, hypoglycemiaGI: Abdominal distention, anorexia, constipation,diarrhea, vomitingGU: Impotence, urinary frequency andurgency, urine retentionHEME: Reversible agranulocytosis (rare),thrombocytopeniaMS: Muscle weaknessRESP: DyspneaSKIN: Decreased sweating, pruritus, rash,reversible cholestatic jaundiceOther: Hypokalemia, lupus erythematosus–like symptomsNursing ConsiderationsWARNING Because of disopyramide’s anticholinergicactivity, avoid using drug inpatients with glaucoma, myasthenia gravis,or urine retention.• Use disopyramide cautiousl,y and expectto reduce dosage in patients with impairedhepatic or renal function. Monitor hepaticand renal function, as ordered. Be awarethat E.R. form shouldn’t be given topatients with severe renal insufficiency.• When changing from immediate-release toE.R. form, expect to start maintenanceschedule 6 hours after last immediatereleasedose.• At therapeutic doses in hemodynamicallyuncompromised patients, expect drug toreduce cardiac output without decreasingresting sinus rate or affecting blood pressure.Keep in mind, however, that 2 mg/kggiven I.V. over 3 minutes can increaseheart rate and total peripheral resistance.• Monitor heart rate and rhythm by continuousECG.• Assess serum electrolyte levels, especiallypotassium level, because drug may be ineffectivein hypokalemia and its toxic effectsenhanced in hyperkalemia.• If patient takes quinidine, expect to startdisopyramide 6 to 12 hours after last doseof quinidine. If patient takes procainamide,expect to start disopyramide3 to 6 hours after the last dose of procainamide.A loading dose may not berequired in either case.PATIENT TEACHING• Warn patient not to stop taking disopyramideabruptly; doing so may cause lifethreateningcardiac problems.• Advise patient to take a missed dose assoon as possible after she remembers,unless it’s nearly time for the next dose.Caution her against doubling the dose.Urge her to notify prescriber if she missesmore than one dose.• Instruct patient to store drug at roomtemperature in a dry place.• Instruct patient to check her pulse rateregularly and report significant changes.• Urge patient to report blurred vision, constipation,difficulty urinating, dizziness,dry mouth, and trouble breathing.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to rise slowly from a lyingor sitting position to reduce dizziness.• Urge patient to avoid becoming overheatedduring hot weather or exercise becauseof risk of heatstroke.disulfiramAntabusedisulfiram 333Class and CategoryChemical class: Thiuram derivativeTherapeutic class: Alcohol abuse deterrentPregnancy category: Not ratedD

334disulfiramIndications and Dosages As adjunct to maintain sobriety in treatmentof chronic alcoholismTABLETSAdults. Initial: Up to 500 mg daily for 1 to2wk.Maintenance: 125 to 500 mg daily.Maximum: 500 mg daily.Route Onset Peak DurationP.O. 1–2 hr Unknown Up to 14 daysMechanism of ActionInterferes with the enzyme responsible forhepatic oxidation of acetaldehyde to acetate,which occurs during alcohol catabolism.Ingestion of even a small amount ofalcohol after taking disulfiram raises theblood acetaldehyde level to 5 to 10 timesnormal. Disulfiram doesn’t alter the rate ofalcohol elimination. Its major metabolite,diethyldithiocarbamate, inhibits norepinephrinesynthesis and may be responsiblefor the drug’s hypotensive effect.ContraindicationsAlcohol intoxication; coronary artery occlusion;hypersensitivity to disulfiram, its components,rubber, pesticides, or fungicides;psychosis; recent use of alcohol, alcoholcontainingpreparations, metronidazole, orparaldehyde; severe myocardial diseaseInteractionsDRUGSalfentanil: Decreased plasma clearance andprolonged duration of action of alfentanilamoxicillin-clavulanate, bacampicillin: Possiblydisulfiram-alcohol reactionascorbic acid: Possibly interference withdisulfiram-alcohol reactionCNS depressants: Possibly increased CNSdepressant effects of either drugisoniazid: Increased risk of additive neurotoxiceffect of disulfiram; possibly increasedadverse CNS effectsmetronidazole: Risk of CNS toxicity, resultingin confusion and psychosisoral anticoagulants: Possibly increased anticoagulanteffectsparaldehyde: Decreased paraldehyde metabolism,increased blood paraldehyde levelphenytoin: Possibly increased blood phenytoinlevel and risk of phenytoin toxicitytricyclic antidepressants: Possibly temporarydeliriumFOODScaffeine: Possibly increased cardiovascularand CNS effects of caffeineACTIVITIESalcohol use: Disulfiram-alcohol reaction (ifwithin 14 days of disulfiram therapy)Adverse ReactionsCNS: Drowsiness, headache, peripheralneuropathy, psychotic reaction, tirednessEENT: Blurred vision, garlic or metallictaste, optic atrophy, optic neuritisGU: ImpotenceSKIN: RashNursing Considerations• Disulfiram is given only to patients whoare highly motivated to stop drinking andwho are receiving psychotherapy or substanceabuse counseling.• Alcohol content of patient’s other drugsshould be checked before starting therapy.WARNING Never give drug to patient withouther knowledge or who is intoxicated.• If needed, crush tablet and mix with fluidsbefore administration.• Don’t give drug within 14 days of patient’singestion of alcohol-containing substance.• Expect alcohol ingestion during disulfiramtherapy to produce a severe reaction thatlasts from 30 minutes to several hours.Symptoms may include angina, anxiety,blurred vision, confusion, diaphoresis,dyspnea, heart failure, hypotension, nausea,palpitations, sinus tachycardia, syncope,thirst, throbbing headache, throbbingin neck, vertigo, vomiting, and weakness.A deep sleep usually follows.WARNING Ingestion of three or more alcoholicbeverages with a disulfiram dosegreater than 500 mg daily may cause respiratorydepression, arrhythmias, and cardiacarrest.• If patient takes phenytoin, monitor bloodphenytoin level before and during disulfiramtherapy, and adjust dosage of eitherdrug as prescribed. Interactions may notoccur if disulfiram therapy starts beforephenytoin therapy. A subtherapeuticphenytoin level may result if disulfiramtherapy stops.• If patient takes an oral anticoagulant,monitor PT before and during disulfiramtherapy, and adjust anticoagulant dosageas prescribed. Drug interactions may not

occur if disulfiram therapy starts beforewarfarin therapy. If disulfiram therapystops, be prepared to adjust warfarindosage to avoid loss of hypoprothrombinemiceffects.• Expect some adverse reactions, such asdrowsiness, headache, and impotence, tosubside over time or with a brief dosagereduction.• Because one-fifth of a disulfiram dose maystay in the body for 1 week or longer, alcoholingestion may continue to produceunpleasant symptoms for up to 2 weeksafter therapy stops.• Expect therapy to last months to years,depending on patient’s ability to abstainfrom alcohol.PATIENT TEACHING• Teach patient’s household and familymembers about precautions needed andrisks associated with disulfiram therapy.• Explain that drug doesn’t cure alcoholismbut does help deter alcohol consumption.• If patient reports daytime drowsiness,advise her to take drug in the evening.• Warn patient to avoid alcohol-containingsubstances, such as vinegar, cough syrup,and sauces, during therapy because adisulfiram-alcohol reaction may occurafter ingesting as little as 15 ml of 100-proof alcohol. Urge her to avoid alcoholcontainingliniments and lotions as well.• Teach patient what to expect if disulfiramalcoholreaction occurs. Inform her that adeep sleep usually follows the reaction.• Advise patient that a reaction can occurup to 14 days after therapy stops and thata severe reaction may cause respiratorydepression, arrhythmias, and cardiacarrest.• Instruct patient to carry medical identificationthat indicates drug, describes possiblereactions, and lists someone to notifyin case of emergency.dobutaminehydrochlorideDobutrexClass and CategoryChemical class: Synthetic catecholaminedobutamine hydrochloride 335Therapeutic class: Cardiac stimulantPregnancy category: Not ratedIndications and Dosages To treat low cardiac output and heartfailureI.V. INFUSIONAdults. 2.5 to 10 mcg/kg/min as continuousinfusion adjusted according to hemodynamicresponse.Children. 5 to 20 mcg/kg/min as continuousinfusion adjusted according to hemodynamicresponse.Route Onset Peak DurationI.V. 1–2 min Unknown Under 5 minMechanism of ActionMainly stimulates beta 1 -adrenergic receptors,and mildly stimulates beta 2 - andalpha 1 -adrenergic receptors. Beta 1 -receptorstimulation produces a positive inotropiceffect on the myocardium, increasing cardiacoutput by boosting myocardial contractilityand stroke volume. Increased myocardialcontractility raises coronary blood flow andmyocardial oxygen consumption. Systolicblood pressure typically rises as a result ofincreased stroke volume. Other hemodynamiceffects include decreased systemicvascular resistance, which reduces afterload,and decreased ventricular filling pressure,which reduces preload.IncompatibilitiesDon’t combine dobutamine with cefamandole,cefazolin, hydrocortisone sodium succinate,cephalothin, penicillin, sodium ethycrynate,and sodium heparin because ofincompatibility. Don’t mix dobutaminewith alkaline solutions, such as sodiumbicarbonate, because of possible physicalincompatibility. Don’t use diluents thatcontain sodium bisulfite or ethanol.ContraindicationsHypersensitivity to dobutamine or its components,idiopathic hypertrophic subaorticstenosisInteractionsDRUGSbeta blockers: Possibly increased alphaadrenergicactivity and peripheral resistancebretylium: Potentiated vasopressor activity,possibly arrhythmiasD

336docusatecyclopropane, halothane: Possibly seriousarrhythmiasguanethidine: Decreased hypotensive effectof guanethidine, possibly resulting in severehypertensionthyroid hormones: Increased cardiovasculareffects of thyroid hormones or dobutaminetricyclic antidepressants: Possibly potentiatedcardiovascular and vasopressor effects ofdobutamine, resulting in arrhythmias,hyperpyrexia, or severe hypertensionAdverse ReactionsCNS: Fever, headache, nervousness, restlessnessCV: Angina, bradycardia, hypertension,hypotension, palpitations, PVCs, tachycardiaGI: Nausea, vomitingRESP: DyspneaSKIN: Extravasation with tissue necrosisand sloughing, rashOther: HypokalemiaNursing Considerations• Avoid giving dobutamine to patients withuncorrected hypovolemia. Expect prescriberto order whole blood or plasmavolume expanders to correct hypovolemia.Also avoid giving dobutamine to patientswith acute MI because it can intensify orextend myocardial ischemia.• Use drug cautiously in patients allergic tosulfites because drug may cause anaphylactic-likesigns and symptoms; commerciallyavailable dobutamine injections containsodium bisulfite. Also use drug cautiouslyin patients with atrial fibrillationbecause drug increases AV conduction.Keep in mind that patient should be adequatelydigitalized before administration.• Dilute concentrate with at least 50 mlcompatible I.V. solution. A common dilutionis 500 mg (40 ml from 250-ml bag) in210 ml D 5 W or normal saline solution toyield 2,000 mcg/ml. Or dilute 1,000 mg(80 ml from 250-ml bag) in 170 ml D 5 Wor normal saline solution to yield 4,000mcg/ml. Adjust maximum concentrationaccording to patient’s fluid requirementsas prescribed. Don’t exceed 5,000 mcg/ml.Discard solution after 24 hours.• Inspect parenteral solution for particlesand discoloration before administering it.• Give I.V. drug using an infusion pump.• Monitor blood pressure often during therapy,preferably by continuous intraarterialmonitoring; systolic increase of 10 to20 mm Hg may indicate dobutamineinducedincrease in cardiac output.• If hypotension develops, expect to reducedosage or discontinue drug.• Monitor heart rate and rhythm continuouslyfor PVCs, which may result fromdrug’s stimulatory effect on heart’s conductionsystem, and sinus tachycardia,which results from positive chronotropiceffect of beta stimulation and mayincrease heart rate by 5 to 15 beats/minute.• Monitor hemodynamic parameters, suchas central venous pressure, pulmonaryartery wedge pressure, and cardiac output,as indicated, to assess drug’s effectiveness.WARNING Monitor serum potassium levelto check for hypokalemia, a rare result ofbeta 2 stimulation that causes electrolyteimbalance.• Monitor urine output hourly, as appropriate,to check for improved renal blood flow.• Dobutamine isn’t indicated for long-termtreatment of heart failure because it maynot be effective and may increase the riskof hospitalization and death.PATIENT TEACHING•Explain the need for frequent hemodynamicmonitoring.docusate calcium(dioctyl calciumsulfosuccinate)Albert Docusate (CAN), DC Softgels,Docucal-P, Doxidan (CAN), Pro-Cal-Sof,Sulfolax, Surfakdocusate potassium(dioctyl potassiumsulfosuccinate)Diocto-K, Kasofdocusate sodium(dioctyl sodiumsulfosuccinate)Afko-Lube, Afko-Lube Lax, Bilax,Colace, Colax, Correctol Stool SoftenerSoft Gels, Dialose, Diocto, Dioeze,

DOK, D.O.S. Softgels, Ex-Lax LightFormula (CAN), Modane Soft,Regulax SS, SilaceClass and CategoryChemical class: Anionic surfactantTherapeutic class: Laxative, stool softenerPregnancy category: CIndications and Dosages To treat constipationCAPSULES (DOCUSATE CALCIUM)Adults and adolescents. 240 mg at bedtimeuntil bowel movements are normal.Children age 6 and over. 50 to 150 mg atbedtime.CAPSULES, LIQUID, SYRUP, TABLETS (DOCUSATESODIUM)Adults and adolescents. 50 to 500 mg atbedtime.Children ages 6 to 12. 40 to 120 mg at bedtime.Children ages 3 to 6. 20 to 60 mg at bedtime.Children under age 3. 10 to 40 mg at bedtime.CAPSULES, TABLETS (DOCUSATE POTASSIUM)Adults and adolescents. 100 mg t.i.d. untilbowel movements are normal.Children age 6 and over. 100 mg at bedtime.Route Onset Peak DurationP.O. 24–72 hr Unknown UnknownMechanism of ActionActs as a surfactant that softens stool bydecreasing surface tension between oil andwater in feces. This action lets more fluidpenetrate stool, forming a softer fecal mass.ContraindicationsFecal impaction; hypersensitivity to docusatesalts or their components; intestinalobstruction; nausea, vomiting, or othersymptoms of appendicitis; undiagnosedabdominal painInteractionsDRUGSmineral oil: Increased mineral oil absorption,increased risk of toxicitytetracycline: Decreased tetracycline absorptionAdverse ReactionsCNS: Dizziness, syncopeCV: PalpitationsGI: Abdominal cramps and distention,diarrhea, nausea, perianal irritation, vomitingMS: Muscle weaknessNursing ConsiderationsWARNING Expect long-term or excessive useof docusate to cause dependence on laxativesfor bowel movements, electrolyteimbalances, osteomalacia, steatorrhea, andvitamin and mineral deficiencies.• Assess for laxative abuse syndrome, especiallyin women with depression, personalitydisorders, or anorexia nervosa.PATIENT TEACHING• Tell patient not to use docusate when shehas abdominal pain, nausea, or vomiting.• Advise patient to take docusate with a fullglass of water or milk.• To help prevent constipation, encouragepatient to increase fiber intake, exerciseregularly, and drink 6 to 8 glasses (240 ml/glass) of water daily.• Instruct patient to notify prescriber aboutrectal bleeding; symptoms of electrolyteimbalances, such as dizziness, light-headedness,muscle cramping, and weakness;and unrelieved constipation.dofetilideTikosyndofetilide 337Class and CategoryChemical class: MethanesulfonanilidederivativeTherapeutic class: Class III antiarrhythmicPregnancy category: CIndications and Dosages To convert symptomatic atrial fibrillationor flutter to normal sinus rhythm orto maintain normal sinus rhythm inpatients converted from symptomaticatrial fibrillation or flutterCAPSULESAdults. Initial: 500 mcg b.i.d. for patientswith creatinine clearance above 60 ml/min/1.73 m 2 . Maintenance: Dosage based onQTc interval. If, 2 to 3 hr after initial dose,QTc interval increase is 15% of baseline orless, initial dose given b.i.d. Maximum:500 mcg b.i.d.D

338dofetilideDOSAGE ADJUSTMENT Initial dose reducedto 250 mcg b.i.d. if creatinine clearance is40 to 60 ml/min/1.73 m 2 and to 125 mcgb.i.d. if clearance is 20 to 39 ml/min/1.73 m 2 , as prescribed. If, 2 to 3 hr after initialdose, QTc interval has increased by atleast 15% or is more than 500 milliseconds(msec) (550 msec in patients with ventricularconduction abnormalities), dosagedecreased by 50%, as prescribed. However,for patients receiving lowest initial dose of125 mcg b.i.d., dosage reduced to 125 mcgdaily, as prescribed. During next four doses(given every 2 to 3 hr, as prescribed), if QTcinterval increases to more than 500 msec(550 msec in patients with ventricular conductionabnormalities), expect to discontinuedrug, as prescribed.Route Onset Peak DurationP.O. Unknown 2 hr 4 hrMechanism of ActionSelectively blocks potassium channels inmyocardial cell membranes involved in cardiacrepolarization. By blocking potassiumchannels, dofetilide prolongs ventricularrefractoriness (widens QT interval), effectiverefractory period, and action potentialduration. These actions terminate or preventreentrant tachyarrhythmias, such asatrial fibrillation, atrial flutter, and ventriculartachycardia.ContraindicationsCardiac conduction disturbances withoutan artificial pacemaker; congenital oracquired QT prolongation syndrome; concurrenttherapy with cimetidine, hydrochlorothiazide,ketoconazole, trimethoprim,or verapamil; hypersensitivity to dofetilideor its components; severe renal impairment(creatinine clearance less than 20 ml/min/1.73 m 2 )InteractionsDRUGSamiloride, cimetidine, co-trimoxazole, ketoconazole,megestrol, metformin, triam-terene,trimethoprim: Possibly increased blooddofetilide levelazole antifungals, diltiazem, nefazodone, norfloxacin,protease inhibitors, quinine, selectiveserotonin reuptake inhibitors, zafirlukast:Possibly increased blood dofetilide level andrisk of dofetilide toxicitybepridil, cisapride, macrolide antibiotics,phenothiazines, tricyclic antidepressants:Possibly prolonged QT intervalclass I and III antiarrhythmics, especiallyamiodarone: Possibly prolonged QT intervaland increased risk of dofetilide-inducedproarrhythmiasdiuretics (potassium-depleting): Increasedrisk of torsades de pointes in patients withhypokalemia or hypomagnesemiahydrochlorothiazide, verapamil: Possiblyincreased blood dofetilide level andincreased risk of torsades de pointesFOODSgrapefruit juice: Increased dofetilide levelACTIVITIESmarijuana use: Increased dofetilide levelAdverse ReactionsCNS: Cerebral ischemia, dizziness, facial orflaccid paralysis, headache, insomnia, paresthesia,slurred speech, stroke, syncopeCV: AV block, bradycardia, cardiac arrest,chest pain, edema, MI, tachycardia, ventriculararrhythmias (including torsades depointes and ventricular tachycardia)GI: Abdominal pain, diarrhea, hepatic dysfunction,nauseaMS: Back pain, muscle weaknessRESP: Cough, dyspnea, respiratory tractinfectionSKIN: Jaundice, rashOther: Angioedema, flulike symptoms,weight gainNursing ConsiderationsWARNING If patient has previously receivedamiodarone, be aware that dofetilideshouldn’t be started until blood amiodaronelevel is less than 0.3 mcg/ml oruntil amiodarone has been withdrawn forat least 3 months.• Evaluate and document QTc intervalbefore and during dofetilide therapy.• Place patient on continuous ECG monitoringfor at least 3 days, as ordered, duringdofetilide therapy.WARNING If patient does not convert tonormal sinus rhythm within 24 hours ofstarting dofetilide, expect possible synchronizedelectrical cardioversion.• Be prepared to reevaluate renal functionand QTc interval every 3 months, asordered, during dofetilide therapy.

• When switching to dofetilide from class Ior class III antiarrhythmics, or after withdrawingantiarrhythmic treatment, monitorcontinuous ECG for at least 30 hours,as ordered.• If patient requires a drug that may interactwith dofetilide, expect to discontinuedofetilide, as prescribed, for 2 or moredays before starting the other drug.WARNING Monitor laboratory test resultsfor hypokalemia or hypomagnesemia,especially in patients taking diuretics,because of the increased risk of dofetilideinducedtorsades de pointes.• Monitor women often for adverse reactions,including prolonged QTc intervaland torsades de pointes; they have 12% to18% lower renal clearance of drug thanmen and therefore a greater risk of adversereactions.PATIENT TEACHING• Advise patient to swallow dofetilide capsuleswith water.• Instruct patient to avoid drinking grapefruitjuice while taking this drug.• Inform patient that she may be hospitalizedfor at least 3 days if dofetilide dosageis increased.• Teach patient to measure pulse rate andblood pressure during dofetilide therapy.•Urge patient to report chest discomfort,fluttering, or palpitations immediately.• Advise patient to consult prescriber beforeusing any OTC drugs, nutritional supplements,or herbal products.• Instruct patient to keep follow-upappointments to monitor heart rhythm.dolasetron mesylateAnzemetClass and CategoryChemical class: Carboxylate monomethanesulfonateTherapeutic class: AntiemeticPregnancy category: BIndications and Dosages To prevent nausea and vomiting due tochemotherapyORAL SOLUTION, TABLETSAdults and children over age 16. 100 mgwithin 1 hr before chemotherapy.Adverse ReactionsCNS: HeadacheCV: Cardiac arrest, hypertension, hypotension,MI, ventricular fibrillation and tachydolasetronmesylate 339Children ages 2 to 16. 1.8 mg/kg within 1 hrbefore chemotherapy. Maximum: 100 mg.I.V. INJECTIONAdults and children over age 16. 1.8 mg/kgor 100 mg as a single dose within 30 minbefore chemotherapy.Children ages 2 to 16. 1.8 mg/kg as a singledose within 30 min before chemotherapy.Maximum: 100 mg. To prevent postoperative nausea andvomitingORAL SOLUTION, TABLETSAdults and children over age 16. 100 mgwithin 2 hr before surgery.Children ages 2 to 16. 1.2 mg/kg within2 hr before surgery. Maximum: 100 mg.I.V. INJECTIONAdults and children over age 16. 12.5 mg15 min before end of anesthesia.Children ages 2 to 16. 0.35 mg/kg 15 minbefore end of anesthesia. Maximum:12.5 mg/dose. To treat postoperative nausea and vomitingI.V. INJECTIONAdults and children over age 16. 12.5 mgas single dose as soon as symptoms develop.Children ages 2 to 16. 0.35 mg/kg as singledose as soon as symptoms develop.Maximum: 12.5 mg/dose.Mechanism of ActionWith its active metabolite hydrodolasetron,prevents activation of serotonin 5-HT 3receptors located peripherally on vagalnerve terminals and centrally in chemoreceptortrigger zone, thereby decreasing thevomiting reflex.ContraindicationsHypersensitivity to dolasetron or componentsInteractionsDRUGSatenolol: Possibly decreased dolasetronclearancecimetidine: Possibly increased blooddolasetron levelrifampin: Possibly decreased blood dolasetronlevelD

340donepezil hydrochloridecardia, wide-complex tachycardiaGI: DiarrheaSKIN: RashOther: Injection site painNursing Considerations• Expect to give up to 100 mg of dolasetronI.V. in 30 seconds or to dilute it in normalsaline solution, D 5 W, dextrose 5% in halfnormal(0.45) saline solution, or lactatedRinger’s solution and infuse for up to15 minutes, as prescribed.• Flush I.V. line with compatible solutionbefore and after drug administration.• Expect to prepare an oral solution ofdolasetron for patients unable to swallowtablets by diluting injection solution withapple or apple-grape juice.WARNING Assess patient for ECG changes,including prolonged PR, QTc, and QTintervals and widened QRS complex.PATIENT TEACHING• For children or patients who have troubleswallowing, explain that oral solution canbe prepared by diluting injection form ofdrug with apple or apple-grape juice.•Inform patient that oral solution may berefrigerated for up to 48 hours but shouldbe discarded after 2 hours at room temperature.donepezilhydrochlorideAriceptClass and CategoryChemical class: Piperidine derivativeTherapeutic class: AntidementiaPregnancy category: CIndications and Dosages To treat dementia of Alzheimer’s typeORAL SOLUTION, TABLETSAdults. Initial: 5 mg at bedtime. After 4 to6 wk, dosage increased to 10 mg at bedtime,as indicated. Maximum: 10 mg daily.Mechanism of ActionReversibly inhibits acetylcholinesterase andimproves acetylcholine’s concentration atcholinergic synapses. Raising acetylcholinelevel in the cerebral cortex may improvecognition. Donepezil becomes less effectiveas Alzheimer’s disease progresses and numberof intact cholinergic neurons declines.ContraindicationsHypersensitivity to donepezil, piperidinederivatives, or their componentsInteractionsDRUGSanticholinergics: Possibly interference withactivity of these drugscarbamazepine, dexamethasone, phenobarbital,phenytoin, rifampin: Increaseddonepezil elimination ratecholinergic agonists, neuromuscular blockers:Possibly synergistic effects of these drugsketoconazole, quinidine: Inhibited donepezilmetabolismNSAIDs: Possibly increased gastric acidsecretion and increased risk of GI bleedingAdverse ReactionsCNS: Abnormal gait, agitation, anxiey,asthenia, depression, dizziness, dream disturbances,fatigue, fever, headache, hostility,insomnia, nervousness, seizures, somnolence,syncope, tremorCV: Abnormal ECG, bradycardia, chestpain, edema, heart failure, hypertension,hypotensionEENT: PharyngitisENDO: HyperglycemiaGI: Abdominal pain, anorexia, constipation,diarrhea, dyspepsia, gastroenteritis, fecalincontinence, nausea, vomitingGU: Cystitis, glycosuria, hematuria, urinaryfrequency or incontinence, UTIHEME: Anemia, hemorrhageMS: Arthralgia, back pain, elevated creatinekinase level, muscle spasmsRESP: Bronchitis, increased cough, pneumoniaSKIN: Ecchymosis, eczema, pruritus, rash,ulcerationOther: Angioedema, dehydration, elevatedalkaline phosphatase or lactate dehydrogenaselevel, flu syndrome, weight lossNursing Considerations• Use donepezil cautiously in patients withbladder obstruction because drug’s weakperipheral cholinergic effect couldobstruct outflow.• Use drug cautiously in patients with asthma,COPD, or other pulmonary disordersbecause it has weak affinity for peripheral

cholinesterase, which may increase bronchoconstrictionand bronchial secretions.• If patient has cardiac disease, monitorheart rate and rhythm for bradycardia,which may result from increased vagaltone caused by drug’s inhibition ofperipheral cholinesterase. Reduced heartrate may be especially significant if patienthas sick sinus syndrome, bradycardia, orother supraventricular arrhythmia.• Take safety precautions if patient is dizzyor has other adverse CNS reactions.PATIENT TEACHING• Advise patient to take donepezil justbefore going to bed.• Inform her that drug may be taken with orwithout food.• Instruct patient to avoid hazardous activities,such as driving, until drug’s CNSeffects are known. Urge her to take safetyprecautions to prevent falling if she hasadverse reactions, such as dizziness.• If patient has a history of peptic ulcer diseaseor gastric irritation, explain that drugmay aggravate these conditions by increasinggastric acid secretion.• Caution patient to avoid NSAIDs duringtherapy because of risk of GI bleeding.Urge her to notify prescriber immediatelyif she notices black, tarry stools.dopaminehydrochlorideIntropin, Revimine (CAN)Class and CategoryChemical class: CatecholamineTherapeutic class: Cardiac stimulant, vasopressorPregnancy category: Cdopamine hydrochloride 341Indications and Dosages To correct hypotension that’s unresponsiveto adequate fluid volume replacementor occurs as part of shock syndromecaused by bacteremia, chroniccardiac decompensation, drug overdose,MI, open-heart surgery, renal failure,trauma, or other major systemic illnesses;to improve low cardiac outputI.V. INFUSIONAdults. 0.5 to 3 mcg/kg/min for vasodilationof renal arteries; 2 to 10 mcg/kg/minfor positive inotropic effects and increasedcardiac output; 10 mcg/kg/min, increasedgradually according to patient’s response,for increased systolic and diastolic bloodpressures.DOSAGE ADJUSTMENT Initial dosage reducedto 10% of usual amount if patient has takenMAO inhibitor in previous 2 to 3 wk.Children. 1 to 5 mcg/kg/min increasedgradually in increments of 2.5 to 5mcg/kg/min to achieve desired results.Maximum: 20 mcg/kg/min.Route Onset Peak DurationI.V. In 5 min Unknown Up to 10 minMechanism of ActionStimulates dopamine 1 (D 1 ) and dopamine 2(D 2 ) postsynaptic receptors. D 1 receptorsmediate vasodilation in renal, mesenteric,coronary, and cerebral blood vessels. D 2receptors inhibit norepinephrine release. Inhigher doses, dopamine also stimulatesalpha 1 and alpha 2 receptors, causing vascularsmooth-muscle contraction.At doses of 0.5 to 3 mcg/kg/min, thisnaturally occurring catecholamine mainlyaffects dopaminergic receptors in renal,mesenteric, coronary, and cerebral vessels,resulting in vasodilation, increased renalblood flow, improved GFR, and increasedurine output. At doses of 2 to 10 mcg/kg/min, dopamine stimulates beta 1 -adrenergicreceptors, increasing cardiac output whilemaintaining dopaminergic-induced vasodilation.At doses of 10 mcg/kg/min or more,alpha-adrenergic agonism takes over, causingincreased peripheral vascular resistanceand renal vasoconstriction.IncompatibilitiesDon’t add dopamine to 5% sodium bicarbonate,alkaline I.V. solutions, oxidizingagents, or iron salts.ContraindicationsPheochromocytoma, uncorrected ventricularfibrillation, ventricular tachycardia, andother tachyarrhythmiasInteractionsDRUGSalpha blockers, haloperidol, loxapine, phenothiazines,thioxanthenes: AntagonizedD

342dopamine hydrochlorideperipheral vasoconstriction with high dosesof dopamineanesthetics, such as chloroform, enflurane,halothane, isoflurane, and methoxyflurane:Increased risk of severe atrial and ventriculararrhythmiasantihypertensives, diuretics used as antihypertensives:Possibly decreased antihypertensiveeffects of these drugsbeta blockers: Antagonized beta receptor–mediated inotropic effects of dopaminedigitalis glycosides: Possibly increased risk ofarrhythmias and additive inotropic effectsdiuretics: Possibly increased diuretic effectsof dopamine or diureticdoxapram: Possibly increased vasopressoreffects of dopamine or doxapramergot alkaloids: Enhanced peripheral vasoconstrictionguanadrel, guanethidine: Possibly decreasedhypotensive effects of these drugs andpotentiated vasopressor response todopamine, resulting in hypertension andarrhythmiaslevodopa: Increased risk of arrhythmiasMAO inhibitors: Prolonged and intensifiedcardiac stimulation and vasopressor effectmaprotiline, tricyclic antidepressants:Possibly potentiated cardiovascular andvasopressor effects of dopamine, resultingin arrhythmias, hyperpyrexia, or severehypertensionmecamylamine, methyldopa: Possiblydecreased hypotensive effects of these drugsand enhanced vasopressor effect ofdopaminemethylphenidate: Possibly potentiated vasopressoreffect of dopaminenitrates: Possibly decreased antianginaleffects of nitrates; possibly decreased vasopressoreffect of dopamine, resulting inhypotensionoxytocic drugs: Possibly severe hypertensionphenoxybenzamine: Possibly antagonizedperipheral vasoconstriction of dopamine,causing hypotension and tachycardiaphenytoin: Possibly sudden bradycardia andhypotensionrauwolfia alkaloids: Possibly decreased hypotensiveeffects of these drugssympathomimetics: Possibly increasedadverse cardiovascular and other effectsthyroid hormones: Increased risk of coronaryinsufficiencyAdverse ReactionsCNS: HeadacheCV: Angina, bradycardia, hypertension, hypotension,palpitations, peripheral vasoconstriction,sinus tachycardia, ventriculararrhythmiasGI: Nausea, vomitingRESP: DyspneaSKIN: Extravasation with tissue necrosisNursing Considerations• If possible, avoid giving dopamine topatients with occlusive vascular disease,such as atherosclerosis, Buerger’s disease,diabetic endarteritis, or Raynaud’s disease,because of risk of decreased peripheral circulation.• Use drug cautiously in patients with cardiacdisease, particularly coronary arterydisease, because dopamine increasesmyocardial oxygen demand. Also use drugcautiously in patients allergic to sulfites,which are contained in some forms ofdopamine.• Inspect parenteral solution for particlesand discoloration before administration.• Dilute dopamine concentrate with a compatibleI.V. solution before administering.Typical dilution is 400 mg in 250 ml toyield 1.6 mg/ml. Don’t exceed 3.2 mg/ml.• If patient has hypovolemia, ensure adequatefluid resuscitation before givingdrug.• Give drug by I.V. infusion using an infusionpump.WARNING When infusion rate exceeds20 mcg/kg/min, monitor patient for excessivevasoconstriction and loss of renalvasodilating effects. Avoid using an infusionrate above 50 mcg/kg/min.• If you must infuse more than 20 mcg/kg/min of dopamine to maintain blood pressure,expect to infuse norepinephrine asprescribed.• To avoid extravasation and tissue necrosis,administer infusion through a centralcatheter. If you must give drug via peripheralline, inspect site often for signs ofextravasation and necrosis. If you detectsuch signs, start a new I.V. line for dopamineinfusion, discontinue previous I.V.line, and notify prescriber immediately.• If drug extravasates, expect to give 5 to10 mg phentolamine diluted in 10 to 15 ml

normal saline solution, as prescribed.Phentolamine infiltrates directly into areato antagonize vasoconstriction and minimizesloughing and tissue necrosis.• Titrate dopamine gradually to minimizehypotension, especially after a high infusionrate.• Monitor blood pressure continuously withan intra-arterial line, as indicated.• Place patient on continuous ECG monitoring,and assess heart rate and rhythmfor arrhythmias.• Monitor patient’s hemodynamic parameters,such as central venous pressure, pulmonaryartery wedge pressure, and cardiacoutput, as indicated, to assess effectivenessof dopamine therapy.• Monitor urine output hourly as appropriateto assess patient for improved renalblood flow.PATIENT TEACHING• Explain the need for frequent hemodynamicmonitoring.doripenemDoribaxClass and CategoryChemical class: CarbapenemTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat complicated intra-abdominalinfections caused by Escherichia coli,Klebsiella pneumoniae, Pseudomonasaeruginosa, Bacteroides caccae, B. fragilis,B. thetaiotaomicron, B. uniformis,B. vulgatus, Streptococcus intermedius,S. constellatus, and Peptostreptococcusmicros and complicated UTIs, includingpyelonephritis caused by E. coli, K.pneumoniae, Proteus mirabilis, P.aeruginosa, and Acinetobacter baumanniiI.V. INFUSIONAdults. 500 mg infused over 1 hr every 8 hrfor 5 to 14 days. May switch to oral therapyif improvement after 3 days.DOSAGE ADJUSTMENT For patients withimpaired renal function or creatinine clearanceof 30 to 50 ml/min/1.73 m 2 , dosagereduced to 250 mg infused over 1 hr everydoripenem 3438 hr. For creatinine clearance of 10 to30 ml/min/1.73 m 2 , dosage reduced to250 mg infused over 1 hr every 12 hr.Route Onset Peak DurationI.V. Unknown 1 hr 8 hrMechanism of ActionInhibits cell wall synthesis in susceptiblebacteria. Doripenem inactivates multiplepenicillin-binding proteins essential in cellwall synthesis to cause cell death.IncompatibilitiesDon’t mix doripenem with other drugs oradd to solutions containing other drugsbecause of potential for incompatibility.ContraindicationsHistory of anaphylactic reactions to betalactams;hypersensitivity to doripenem, itscomponents or other carbapenemsInteractionsDRUGSdivalproex sodium, valproic acid: Decreasedeffectiveness of valproic acid with possibleloss of seizure controlprobenecid: Increased plasma concentrationsof doripenemAdverse ReactionsCNS: Headache, seizureCV: PhlebitisEENT: Oral candidiasisGI: Diarrhea, liver enzyme elevation, nauseaGU: VaginitisHEME: Leukopenia, neutropeniaSKIN: Dermatitis, erythema, erythemamultiforme, macular or papular eruptions,pruritus, rash, Stevens Johnson Syndrome,toxic epidermal necrolysis, urticariaOther: AnaphylaxisNursing Considerations• Use cautiously in patients with a history ofhypersensitivity to cephaloporins or penicillinsbecause cross sensitivity may occur.• Constitute vial with 10 ml sterile water forinjection or normal saline solution, andgently shake to form a suspension. Withdrawsuspension using a syringe with a21G needle and add it to an infusion bagcontaining 100 ml normal saline solutionor 5% dextrose. Gently shake until clear. Ifadministering reduced dosage of 250 mg,D

344doxapram hydrochlorideremove 55 ml of prepared solution frominfusion bag and discard before infusion.• Be aware that upon constitution, suspensionin the vial must be diluted within1 hour. Once drug is diluted in infusionsolution, drug stored at room temperaturemust be used within 8 hours if mixed innormal saline solution and within 4 hoursif mixed in 5% dextrose. If infusion solutionis refrigerated, it must be used within24 hours or discarded.• Monitor patient closely for evidence ofhypersensitivity, especially if patient hasmultiple allergies, because serious andoccasionally fatal hypersensitivity reactionshave occurred in patients receivingbeta-lactam antibiotics. If an allergic reactionoccurs, discontinue drug immediately,notify prescriber, and expect to administeremergency treatment such as epinephrine,oxygen, I.V. fluids, I.V. antihistamines, corticosteroids,and pressor amines, asordered, and provide airway management.• Assess patient’s bowel pattern daily; severediarrhea may be caused by Clostridiumdifficile. If suspected, expect to stop drugand provide treatment as prescribed.PATIENT TEACHING• Instruct patient to report any evidence ofallergic reaction, such as rash, hives, itchingor trouble breathing.• Advise patient to report diarrhea if severeor persistent.doxapramhydrochlorideDopramClass and CategoryChemical class: Pyrrolidinone derivativeTherapeutic class: Respiratory stimulantPregnancy category: BIndications and Dosages To stimulate respiration in COPDrelatedacute respiratory insufficiencyI.V. INFUSIONAdults and adolescents. 1 to 2 mg/mintitrated according to respiratory response.Maximum: 3 mg/min for up to 2 hr. To treat respiratory depression afteranesthesiaI.V. INFUSIONAdults and adolescents. 5 mg/min untildesired response occurs and then reducedto 1 to 3 mg/min. Maximum: Cumulativedose of 4 mg/kg or 300 mg.I.V. INJECTIONAdults and adolescents. 0.5 to 1 mg/kg,repeated every 5 min, if needed. Maximum:1.5 mg/kg as a single dose or 2 mg/kg every5 min.Route Onset Peak DurationI.V. 20–40 sec 1–2 min 5–12 minMechanism of ActionActivates peripheral carotid, aortic, andother chemoreceptors to stimulate respiration,resulting in increased tidal volumeand respiratory rate. Doxapram also mayincrease respiratory rate and tidal volumeby directly stimulating the respiratory centerin the medulla oblongata.IncompatibilitiesTo avoid precipitation and gas formation,don’t mix doxapram with alkaline solutions,such as aminophylline, sodium bicarbonate,or 2.5% thiopental.ContraindicationsAge less than 1 month; cerebral edema;head injury; hypersensitivity to doxapramor its components; mechanical disorders ofventilation, including acute bronchial asthma,flail chest, muscle paresis, obstruction,pneumothorax, and pulmonary fibrosis;pulmonary embolism; seizure disorder;severe cardiovascular disorder; severehypertension; stroke; uncompensated heartfailureInteractionsDRUGSchloroform, cyclopropane, enflurane, halothane,isoflurane, methoxyflurane, trichloroethylene:Possibly adverse myocardial effectsif doxapram given within 10 minutes ofthese drugsCNS stimulants: Possibly excessive CNSstimulation, with arrhythmias, insomnia,irritability, nervousness, or seizuresMAO inhibitors, sympathomimetics:Additive vasopressor effectsskeletal muscle relaxants: Masked residualeffects of muscle relaxants

Adverse ReactionsCNS: Disorientation, dizziness, headacheCV: Arrhythmias, including sinus tachycardia;hypertensionGI: Diarrhea, hiccups, nausea, vomitingGU: Urine retentionRESP: Bronchospasm, cough, dyspneaSKIN: DiaphoresisOther: Injection site pain, redness, swelling,and thrombophlebitisNursing Considerations• Avoid giving doxapram to patients receivingmechanical ventilation.• Maintain a patent airway, and assess foroptimal oxygenation before giving drug.• Monitor I.V. insertion site for extravasationand signs of thrombophlebitis orlocal skin irritation.• If hypertension or dyspnea develops suddenly,stop infusion as directed.• Assess patient for early signs and symptomsof overdose, including enhanceddeep tendon reflexes, skeletal musclehyperactivity, and tachycardia.PATIENT TEACHING• Explain the need for frequent pulse andblood pressure monitoring.doxazosin mesylateCardura, Cardura-1 (CAN),Cardura-2 (CAN), Cardura-4 (CAN)Class and CategoryChemical class: Quinazoline derivativeTherapeutic class: Antihypertensive, benignprostatic hyperplasia therapeutic agentPregnancy category: CIndications and Dosages To manage hypertensionTABLETSAdults. Initial: 1 mg daily. Doubled every1 to 2 wk, if needed to achieve desiredblood pressure. Maximum: 16 mg daily. To treat benign prostatic hyperplasia(BPH)TABLETSAdults. Initial: 1 mg daily. Doubled every1 to 2 wk, if needed, based on signs andsymptoms. Maximum: 8 mg daily.Mechanism of ActionCompetitively inhibits alpha 1 -adrenergicdoxazosin mesylate 345receptors in the sympathetic nervous system,causing peripheral vasodilation andreduced peripheral vascular resistance. Thisaction increases heart rate and decreasesblood pressure, especially when the patientstands. Doxazosin also relaxes smooth muscleof the bladder neck, prostate, andprostate capsule, which reduces urethralresistance and pressure and urinary outflowresistance.Route Onset Peak DurationP.O. 1–2 hr* 2–6 hr† 24 hr†ContraindicationsHypersensitivity to doxazosin, prazosin, terazosin,or their componentsInteractionsDRUGSantihypertensives, diuretics, phosphodiesterase-5inhibitors: Enhanced hypotensiveeffectscimetidine: Possibly increased blood doxazosinleveldopamine: Antagonized vasopressor effectof high-dose dopamineephedrine, metaraminol, methoxamine,phenylephrine: Possibly decreased vasopressoreffects of these drugsepinephrine: Possibly severe hypotensionand tachycardiaNSAIDs: Possibly loss of hypotensive activityfrom sodium or fluid accumulationAdverse ReactionsCNS: Dizziness, drowsiness, headache,nervousness, restlessness, vertigoCV: Arrhythmias, including sinus tachycardia;first-dose orthostatic hypotension; palpitations;peripheral edemaEENT: Intraoperative floppy iris syndrome,rhinitisGI: NauseaRESP: DyspneaNursing Considerations• Don’t give drug to hypotensive patients.• Use doxazosin cautiously in patients withhepatic disease (because normal dosagemay cause exaggerated effects) and in elderlypatients (because hypotensiveresponse may be more pronounced).* For hypertension; in 2 wk for BPH.† For hypertension; unknown for BPH.D

346doxepin hydrochlorideWARNING Monitor patient for orthostatichypotension (which may cause syncope)early in therapy, especially after exerciseand in patients with hypovolemia.• Monitor blood pressure for 2 to 6 hoursafter first dose and with each increasebecause orthostatic hypotension commonlyoccurs at this time. Adjust dose as prescribed,based on standing blood pressure.• Carefully monitor patients with renal diseasefor exaggerated effects, such as firstdoseorthostatic hypotension.• Monitor urination, checking for difficultyurinating and urine retention, to assessdrug’s effects on BPH.PATIENT TEACHING• Inform patient that she may take doxazosinin the morning or evening and withfood, if desired.• Instruct patient to change position slowlyto minimize orthostatic hypotension.• Advise patient to avoid standing for longperiods, exercising, using alcohol, andgoing outside in hot weather; these activitiesmay worsen orthostatic hypotension.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.doxepinhydrochlorideNovo-Doxepin (CAN), Sinequan,Triadapin (CAN)Class and CategoryChemical class: Dibenzoxepin derivativeTherapeutic class: AntidepressantPregnancy category: Not ratedIndications and Dosages To treat mild to moderate depression oranxietyCAPSULES, ORAL SOLUTIONAdults and adolescents. 75 to 150 mg dailyat bedtime. Maximum: 150 mg daily. To treat mild to moderate depression oranxiety with organic diseaseCAPSULES, ORAL SOLUTIONAdults and adolescents. 25 to 50 mg daily. To treat severe depression or anxietyCAPSULES, ORAL SOLUTIONAdults and adolescents. 50 mg t.i.d., graduallyincreased to 300 mg daily, as indicated.Mechanism of ActionMay block serotonin and norepinephrinereuptake by adrenergic nerves. In this way,the tricyclic antidepressant raises serotoninand norepinephrine levels at nerve synapses,which may elevate mood and reducedepression.Route Onset Peak DurationP.O. 2–3 wk Unknown UnknownIncompatibilitiesDon’t mix doxepin solution with carbonatedbeverages or grape juice.ContraindicationsAcute recovery phase of MI; concurrent useof MAO inhibitor; glaucoma; hypersensitivityto doxepin, other tricyclic antidepressants,or their components; urine retentionInteractionsDRUGSamantadine, anticholinergics, antidyskinetics,antihistamines: Possibly intensified anticholinergiceffects, causing confusion, hallucinations,and nightmaresanticonvulsants: Possibly lowered seizurethreshold and decreased effects of thesedrugsantithyroid drugs: Possibly increased risk ofagranulocytosisbarbiturates, carbamazepine: Increased doxepinmetabolism, decreased blood doxepinlevel, possibly lowered seizure thresholdbupropion, clozapine, cyclobenzaprine, haloperidol,loxapine, maprotiline, molindone,phenothiazines, thioxanthenes: Possibly prolongedand intensified sedative and anticholinergiceffects of either drug, possiblyincreased risk of seizurescimetidine, flecainide, phenothiazines,propafenone, quinidine, selective serotoninreuptake inhibitors, tricyclic antidepressants:Increased blood doxepin level from inhibitedsystemic clearance, resulting in increasedrisk of toxicityclonidine, guanadrel, guanethidine:Increased risk of hypertension, especiallyduring second week of doxepin therapyCNS depressants: Possibly potentiated CNSdepression, hypotension, and respiratorydepressioncorticosteroids: Possibly worsened depression

direct-acting sympathomimetics, such as epinephrineand norepinephrine: Potentiatedeffects of these drugsdisulfiram: Possibly transient deliriumfluoxetine: Possibly increased blood doxepinlevelMAO inhibitors: Possibly hyperpyrexia, hypertension,seizures, and deathoral anticoagulants: Possibly increased anticoagulanteffects of these drugspimozide: Increased risk of arrhythmiasprobucol: Possibly prolonged QT interval,increased risk of ventricular tachycardiathyroid hormones: Possibly increased therapeuticand toxic effects of both drugstolazamide: Possibly severe hypoglycemiaACTIVITIESalcohol use: Possibly enhanced CNS depression,hypotension, and respiratory depressionAdverse ReactionsCNS: Confusion, delirium, dream disturbances,drowsiness, fatigue, hallucinations,headache, nervousness, parkinsonism, restlessness,sedation, seizures, suicidal ideation(children and teens), tremorCV: ECG changes, orthostatic hypotension,palpitationsEENT: Blurred vision, dry mouth, taste perversionGI: Constipation, diarrhea, heartburn, ileus,increased appetite, nausea, vomiting,GU: Decreased libido, ejaculation disordersSKIN: Diaphoresis, jaundiceOther: Weight gainNursing Considerations• If desired, mix oral solution in 120 ml ofwater; milk; or orange, grapefruit, tomato,or pineapple juice.• Expect to observe adverse reactions withina few hours after giving drug.• Evaluate patient for therapeutic response,such as decreased anxiety, apprehension,depression, fear, guilt, somatic symptoms,and worry; increased energy; and morerestful sleep.WARNING Monitor children and teensclosely for evidence of suicidal thinkingand behavior because doxepin increasesthe risk in these groups.• Keep in mind that abrupt withdrawal ofdoxepin after prolonged therapy can causecholinergic rebound effects, includingdiarrhea, nausea, and vomiting.• Plan to discontinue drug, as prescribed,several days before elective surgery toavoid hypertension.• Monitor elderly patients for parkinsonism,especially with high-dose therapy.• Be alert for seizures. Patients with seizuredisorder may need increased anticonvulsantdosage to maintain seizure control.• For patients with asthma or sulfite sensitivity,doxepin tablets may aggravate asthmaor cause allergic reactions because theycontain sulfites.• Follow diabetic patient’s serum glucoselevel closely; drug may alter glucosemetabolism.• If patient takes a thyroid hormone, bealert for increased responses to both drugsand, possibly, exaggerated drug-inducedeffects, such as arrhythmias and CNSstimulation. Untreated hypothyroidismprevents adequate response to therapy.PATIENT TEACHINGWARNING Alert parents to watch their childor teen closely for abnormal thinking orbehavior and increased aggression or hostility.Stress importance of notifying prescriberabout unusual changes.• Instruct patient to avoid alcohol duringdoxepin therapy because mental alertnessmay decrease.• Advise diabetic patient to measure serumglucose level more often than usual.doxercalciferolHectoroldoxercalciferol 347Class and CategoryChemical class: Fat-soluble vitamin DanalogueTherapeutic class: AntihyperparathyroiddrugPregnancy category: BIndications and Dosages To reduce elevated intact parathyroidhormone (iPTH) serum level whenmanaging secondary hyperparathyroidismin patients undergoing chronichemodialysisCAPSULESAdults. Initial: 10 mcg 3 times/wk (aboutD

348doxercalciferolevery other day) before, during, or afterdialysis. Maintenance: If iPTH level isdecreased by 50% and above 300 picograms(pg)/ml, dosage increased by 2.5 mcg at 8-wk intervals, as needed. If iPTH level is150 to 300 pg/ml, initial dosage maintained.If iPTH level is less than 100 pg/ml, drugstopped for 1 wk and then restarted at adose at least 2.5 mcg less than previousdose. Maximum: 20 mcg 3 times/wk for atotal of 60 mcg/wk. To reduce elevated iPTH blood levelwhen managing secondary hyperparathyroidismin patients with stage 3or 4 chronic renal diseaseCAPSULESAdults. 1 mcg daily. Maintenance: If iPTHlevel exceeds 70 pg/ml for stage 3 or 110 pg/ml for stage 4, dosage increased by 0.5 mcgat 2-wk intervals, as needed. If iPTH level is35 to 70 pg/ml for stage 3 or 70 to 110 pg/ml for stage 4, dosage is maintained. IfiPTH level is less than 35 pg/ml for stage 3or less than 70 pg/ml for stage 4, drug isstopped for 1 wk and then restarted at adose at least 0.5 mcg lower than previousdose. Maximum: 3.5 mcg daily.Mechanism of ActionUndergoes hepatic conversion to an activemetabolite (1,25-dihydroxyvitamin D 2[1,25-dihydroxyergocalciferol]), whichincreases intestinal absorption of dietarycalcium and renal tubular reabsorption ofurinary calcium. Together with parathyroidhormone, doxercalciferol also mobilizes calciumfrom bone. These effects serve tomaintain blood calcium levels in patientswith chronic renal failure, which in turnprevents hyperparathyroidism.In patients with renal failure, decreasedmetabolic activation of vitamin D in thekidneys leads to chronic hypocalcemia. Theparathyroid gland compensates by increasingPTH secretion, but renal failure preventsit from achieving a normal serum calciumlevel. Thus, secondary hyperparathyroidismdevelops. Because doxercalciferoldoesn’t require renal conversion to form itsactive metabolite, it can regulate the serumcalcium level and thus suppress PTH secretionand reduce its serum level in patientswith chronic renal failure. An elevated PTHlevel in these patients leads to metabolicbone disease, such as renal osteodystrophy.ContraindicationsEvidence of vitamin D toxicity, hypersensitivityto doxercalciferol or its components,risk or history of hypercalcemia or hyperphosphatemiaInteractionsDRUGSantacids that contain magnesium: Possiblyadditive drug effects and increased risk ofhypermagnesemiacholestyramine, mineral oil, orlistat, otherdrugs that affect lipid absorption: Possiblydecreased doxercalciferol absorptionglutethimide, phenobarbital: Possiblyincreased doxercalciferol metabolism andrisk of adverse reactionserythromycin, ketoconazole: Possibly inhibiteddoxercalciferol metabolism anddecreased effectivenessvitamin D and its analogues: Possibly additiveeffects, resulting in increased adverseeffects, such as hypercalcemiaAdverse ReactionsCNS: Depression, dizziness, headache,insomnia, malaise, paresthesiaCV: Bradycardia, chest pain, peripheraledemaEENT: RhinitisENDO: Oversuppression of iPTHGI: Anorexia, constipation, indigestion,nausea, vomitingHEME: AnemiaMS: HypertoniaRESP: Cough, dyspneaSKIN: PruritusOther: Dehydration, hypercalcemia, hypercalciuria,hyperphosphatemia, weight gainNursing ConsiderationsWARNING Be aware that patients who takevitamin D should not also take doxercalciferolbecause they may develop severevitamin D toxicity and hypercalcemia.• Be alert for signs and symptoms of vitaminD toxicity and hypercalcemia inpatients receiving high-dose or long-termdoxercalciferol therapy. Early signs andsymptoms include bone pain, constipation,dry mouth, headache, metallic taste,myalgia, nausea, somnolence, vomiting,and weakness. Late signs and symptomsinclude albuminuria, anorexia, arrhythmias,azotemia, conjunctivitis (calcific),decreased libido, elevated AST and ALT

levels, elevated BUN level, generalized vascularcalcification, hypercholesterolemia,hypertension, hyperthermia, irritability,mild metabolic acidosis, nephrocalcinosis,nocturia, pancreatitis, photophobia, polydipsia,polyuria, pruritus, rhinorrhea, andweight loss.• Keep emergency equipment readily availablein case patient develops toxicity.• Expect to monitor patient’s blood iPTH,calcium, and phosphorus levels beforestarting drug and weekly early in therapy.• For patients with renal failure who arehaving hemodialysis, oral calcium-basedor other non–aluminum-containing phosphatebinders and a low-phosphate diettypically are used to control serum phosphoruslevel. An elevated serum phosphoruslevel worsens secondary hyperparathyroidismand may decrease doxercalciferol’seffectiveness in reducing blood iPTH level.• After doxercalciferol therapy starts, expectto decrease dosage of phosphate binders tocorrect persistent mild hypercalcemia.Expect to increase dosage to correct persistentmild hyperphosphatemia.• Avoid giving magnesium-containingantacids with doxercalciferol if patientreceives long-term hemodialysis becausedoing so may lead to hypermagnesemia.PATIENT TEACHING• Urge patient who takes doxercalciferol tofollow strict low-phosphorus diet and totake calcium supplement, as prescribed, tomaintain serum calcium level. Stress thatdiet and calcium-based phosphate bindershould provide 1.5 to 2 g of calcium daily.• Explain importance of periodic follow-upblood work to measure drug effectiveness.Tell the patient that it may take severalmonths to reach optimal PTH suppression.• Warn patient not to take other forms ofvitamin D with doxercalciferol and to askprescriber before taking any OTC drug.• Advise patient to contact prescriber immediatelyif early signs or symptoms of toxicity,such as headache or nausea, develop.doxycycline calcium(contains 50 mg of base per 5 ml of oralsuspension)Vibramycindoxycycline hyclate(contains 50 or 100 mg of base per capsule,100 mg of base per delayed-releasecapsule, 100 mg of base per tablet, and100 or 200 mg of base per injection vial)Alti-Doxycycline (CAN),Apo-Doxy (CAN), Doryx,Doxycin (CAN), Vibramycin, Vibra-Tabsdoxycyclinemonohydrate(contains 50 or 100 mg of base per capsuleand 25 mg of base per 5 ml of oral suspension)Monodox, Vibramycindoxycycline 349Class and CategoryChemical class: Oxytetracycline derivativeTherapeutic class: AntibioticPregnancy category: DIndications and Dosages To treat cutaneous, GI, or inhalationanthraxCAPSULES, DELAYED-RELEASE CAPSULES, ORALSUSPENSION, TABLETS, I.V. INFUSIONAdults, adolescents, and children weighingmore than 45 kg (99 lb). 100 mg (base)every 12 hr for 60 days.Children weighing less than 45 kg. 2.2 mg/kg (base) every 12 hr for 60 days. To treat inflammatory lesions (papulesand pustules) of rosaceaAdults. 40 mg once daily in morning To treat endocervical, rectal, and urethralinfections caused by ChlamydiatrachomatisCAPSULES, DELAYED-RELEASE CAPSULES, ORALSUSPENSION, TABLETSAdults and children over age 8 weighingmore than 45 kg. 100 mg (base) b.i.d. for7 days. Maximum: 300 mg (base) daily.Children weighing 45 kg or less. 2.2 mg(base)/kg b.i.d. on day 1 and then 2.2 to4.4 mg (base)/kg daily or 1.1 to 2.2 mg(base)/kg b.i.d.I.V. INFUSIONAdults and children over age 8 weighingmore than 45 kg. 200 mg (base) once dailyor 100 mg (base) every 12 hr on day 1 andthen 100 to 200 mg (base) once daily orD

350doxycycline50 to 100 mg (base) every 12 hr. Maximum:300 mg (base) daily.Children weighing 45 kg or less. 4.4 mg(base)/kg once daily or 2.2 mg (base)/kgevery 12 hr on day 1 and then 2.2 to 4.4 mg(base)/kg once daily or 1.1 to 2.2 mg(base)/kg every 12 hr. To treat epididymo-orchitis caused by C.trachomatis or Neisseria gonorrhoeaeor nongonococcal urethritis caused by C.trachomatis or Ureaplasma urealyticumCAPSULES, DELAYED-RELEASE CAPSULES, ORALSUSPENSION, TABLETSAdults and children over age 8 weighingmore than 45 kg. 100 mg (base) b.i.d. for atleast 10 days. Maximum: 300 mg (base)/day.Children weighing 45 kg or less. 2.2 mg(base)/kg b.i.d. on day 1 and then 2.2 to4.4 mg (base)/kg once daily or 1.1 to 2.2 mg(base)/kg b.i.d.I.V. INFUSIONAdults and children over age 8 weighingmore than 45 kg. 200 mg (base) once dailyor 100 mg (base) every 12 hr on day 1 andthen 100 to 200 mg (base) once daily or50 to 100 mg (base) every 12 hr. Maximum:300 mg (base) daily.Children weighing 45 kg or less. 4.4 mg(base)/kg once daily or 2.2 mg (base)/kgevery 12 hr on day 1 and then 2.2 to 4.4 mg(base)/kg once daily or 1.1 to 2.2 mg(base)/kg every 12 hr. To prevent malariaCAPSULES, DELAYED-RELEASE CAPSULES, ORALSUSPENSION, TABLETSAdults and children over age 8 weighingmore than 45 kg. 100 mg (base) daily starting1 to 2 wk before travel, continued dailyduring travel, and then daily for 4 wk aftertravel ends. Maximum: 300 mg (base) daily.Children over age 8. 2 mg (base)/kg dailystarting 1 to 2 days before travel, continueddaily during travel, and daily for 4 wk aftertravel ends. Maximum: 100 mg (base) daily. To treat early syphilis in penicillinallergicpatientsCAPSULES, DELAYED-RELEASE CAPSULES, ORALSUSPENSION, TABLETSAdults and children over age 8 weighingmore than 45 kg. 100 mg (base) b.i.d. for2wk.Maximum: 600 mg (base) daily.Children weighing 45 kg or less. 2.2 mg(base)/kg b.i.d. on day 1 and then 2.2 to4.4 mg (base)/kg once daily or 1.1 to 2.2 mg(base)/kg b.i.d.I.V. INFUSIONAdults and children over age 8 weighingmore than 45 kg. 150 mg (base) every 12 hrfor at least 10 days. Maximum: 300 mg(base) daily.Children weighing 45 kg or less. 4.4 mg(base)/kg once daily or 2.2 mg (base)/kgevery 12 hr on day 1 and then 2.2 to 4.4 mg(base)/kg once daily or 1.1 to 2.2 mg(base)/kg every 12 hr. To treat syphilis of more than 1 year’sduration in penicillin-allergic patientsCAPSULES, DELAYED-RELEASE CAPSULES, ORALSUSPENSION, TABLETSAdults and children over age 8 weighingmore than 45 kg. 100 mg (base) b.i.d. for4wk.Maximum: 300 mg (base) daily.I.V. INFUSIONAdults and children over age 8 weighingmore than 45 kg. 150 mg (base) every 12 hrfor at least 10 days. Maximum: 300 mg(base) daily.Children weighing 45 kg or less. 4.4 mg(base)/kg once daily or 2.2 mg (base)/kgevery 12 hr on day 1 and then 2.2 to 4.4 mg(base)/kg once daily or 1.1 to 2.2 mg(base)/kg every 12 hr. To treat all other infections caused bysusceptible organismsCAPSULES, DELAYED-RELEASE CAPSULES, ORALSUSPENSION, TABLETSAdults and children over age 8 weighingmore than 45 kg. 100 mg (base) every 12 hron day 1 and then 100 mg (base) once dailyor 50 mg (base) b.i.d. For severe infections,100 mg (base) continued every 12 hr.Maximum: 300 mg (base) daily.Children weighing 45 kg or less. 2.2 mg(base)/kg b.i.d. on day 1 and then 2.2 to4.4 mg (base)/kg once daily or 1.1 to 2.2 mg(base)/kg b.i.d.I.V. INFUSIONAdults and children over age 8 weighingmore than 45 kg. 200 mg (base) once dailyor 100 mg (base) every 12 hr on day 1 andthen 100 to 200 mg (base) once daily or50 to 100 mg (base) every 12 hr. Maximum:300 mg (base) daily.Children weighing 45 kg or less. 4.4 mg(base)/kg once daily or 2.2 mg (base)/kgevery 12 hr on day 1 and then 2.2 to 4.4 mg(base)/kg once daily or 1.1 to 2.2 mg(base)/kg every 12 hr.

Mechanism of ActionExerts a bacteriostatic effect against a widevariety of gram-positive and gram-negativeorganisms. Doxycycline is more lipophilicthan other tetracyclines, which allows it topass more easily through the bacterial lipidbilayer, where it binds reversibly to 30Sribosomal subunits. Bound doxycyclineblocks the binding of aminoacyl transferRNA to messenger RNA, thus inhibitingbacterial protein synthesis.ContraindicationsHypersensitivity to any tetracyclineInteractionsDRUGSantacids that contain aluminum, calcium,magnesium, or zinc; calcium supplements;choline and magnesium salicylates; iron salts;laxatives that contain magnesium: Decreaseddoxycycline absorption and effectsbarbiturates, carbamazepine, phenytoin:Increased clearance and decreased effects ofdoxycyclinecholestyramine, colestipol: Decreased doxycyclineabsorptiondigoxin: Increased bioavailability of digoxin,possibly leading to digitalis toxicityoral anticoagulants: Possibly increased hypoprothrombinemiceffects of these drugsoral contraceptives: Decreased effectivenessof estrogen-containing oral contraceptives,increased risk of breakthrough bleedingpenicillins: Inhibited bactericidal actionpenthrane: Possibly increased risk of fatalrenal toxicitysodium bicarbonate: Altered doxycyclineabsorption from increased gastric pHFOODSdairy products, other foods high in calcium oriron: Decreased doxycycline absorptionAdverse ReactionsCNS: ParesthesiaCV: PhlebitisEENT: Black “hairy” tongue, glossitis,hoarseness, oral candidiasis, pharyngitis,stomatitis, tooth discolorationGI: Anorexia; bulky, loose stools; diarrhea;dysphagia; enterocolitis; epigastric distress;esophageal ulceration; hepatotoxicity; nausea;pseudomembranous colitis; rectal candidiasis;vomitingGU: Anogenital lesions, dark yellow orbrown urine, elevated BUN level, vaginaldoxycycline 351candidiasisHEME: Eosinophilia, hemolytic anemia,neutropenia, thrombocytopenia,thrombocytopenic purpuraSKIN: Dermatitis, photosensitivity, rash,urticariaOther: Anaphylaxis, injection site phlebitisNursing Considerations• Avoid giving doxycycline to breastfeedingwomen because of the risk of enamelhypoplasia, inhibited linear skeletalgrowth, oral and vaginal candidiasis, photosensitivityreactions, and tooth discolorationin breastfeeding infant.• Avoid giving drug to children under age 8,if possible; it may cause discoloration andenamel hypoplasia of developing teeth.• Use oral suspension cautiously in patientsallergic to sulfites because it contains sodiummetabisulfite.• Expect to adjust dosage for patients whohave hepatic disease to avoid drug accumulation.WARNING Don’t give doxycycline by I.M. orsubcutaneous route.• Give doxycycline without regard to meals.Food and milk may delay absorption, butthey don’t significantly reduce it.• Observe patient often for injection sitephlebitis, a common adverse reaction toI.V. administration.• Monitor liver function test results asappropriate to detect hepatotoxicity.• Expect oral or parenteral doxycycline toincrease risk of oral, rectal, or vaginal candidiasis—especiallyin elderly or debilitatedpatients and those on prolonged therapy—bychanging the normal balance ofmicrobial flora.• Monitor patient closely for diarrhea,which may indicate pseudomembranouscolitis. If diarrhea occurs, notify prescriberand expect to withhold doxycycline.Expect to treat pseudomembranous colitiswith fluids, electrolytes, protein, and anantibiotic effective against Clostridium difficile.PATIENT TEACHING• Instruct patient not to take doxycyclinejust before bed because it may not dissolveproperly when she’s recumbent and maycause esophageal burning and ulceration.• Instruct patient taking doxycycline forrosacea to take the capsule in the morningD

352dronabinolon an empty stomach.• Advise patient to avoid dairy products;foods high in calcium or iron; antacidscontaining aluminum, calcium, or magnesium;bismuth subsalicylate; and ironcontainingproducts during therapy.• Caution patient not to take bismuth subsalicylatewhile taking doxycycline becausedoxycycline absorption will be reduced.• Instruct patient to drink plenty of fluidswhile taking doxycycline to reduce the riskof esophageal burning and ulceration.• Inform patient that her urine may becomedark yellow or brown during therapy.• Urge patient to avoid sun exposure andultraviolet light as much as possible duringtherapy and to use sunscreen or sunblockas needed. If patient develops phototoxicity,such as skin eruption, tell her tostop drug and notify prescriber.• Advise patients who take an oral contraceptiveto use an additional contraceptivemethod during therapy.• If patient is being treated for a sexuallytransmitted disease, explain that her partnermay need treatment as well.• Tell patient to notify prescriber immediatelyabout anorexia, epigastric distress,nausea, or vomiting during therapy.• Urge patient to report watery, bloodystools to prescriber immediately, even upto 2 months after drug therapy has ended.• Alert female patients that doxycycline mayincrease risk of vaginal candidiasis. Tellher to notify prescriber if she developsvaginal itching or discharge.• Advise patient taking doxycycline formalaria prevention to start taking drug1 to 2 days before traveling to the regionand continue for 4 weeks after leaving thearea. Note that the total length of therapyshouldn’t exceed 4 months.dronabinol(delta-9-tetrahydrocannabinol,THC)MarinolClass, Category, and ScheduleChemical class: Synthetic tetrahydrocannabinolTherapeutic class: Antiemetic, appetitestimulantPregnancy category: CControlled substance schedule: IIIndications and Dosages To prevent nausea and vomiting causedby chemotherapy and unresponsive toother antiemeticsCAPSULESAdults. 5 mg/m 2 1 to 3 hr before and 2 to4 hr after chemotherapy, increased by2.5 mg/m 2 , p.r.n. Maximum: 15 mg/m 2 /dose or a total of 4 to 6 doses daily. To stimulate appetite in cancer andAIDS patientsCAPSULESAdults. Initial: 2.5 mg b.i.d. before lunchand supper, increased p.r.n. Maximum:20 mg daily in divided doses.DOSAGE ADJUSTMENT Dosage reduced to2.5 mg before supper or at bedtime forpatients who can’t tolerate 5 mg daily.Route Onset Peak DurationP.O. Unknown Unknown 24 hr orlonger*Mechanism of ActionMay exert antiemetic effect by inhibitingthe vomiting control mechanism in themedulla oblongata. As the main psychoactivesubstance in marijuana (Cannabis sativaL.), dronabinol’s effects may be mediatedby cannabinoid receptors in neural tissues.ContraindicationsHypersensitivity to dronabinol, its components,sesame oil, or marijuanaInteractionsDRUGSanticholinergics, antihistamines: Possiblyincreased risk of tachycardiaapomorphine: Possibly potentiated CNSdepression, possibly decreased emeticresponse with prior use of dronabinolCNS stimulants (such as amphetamines),and CNS depressants (such as benzodiazepines):Additive CNS effectssympathomimetics: Possibly enhancedhypertension, tachycardia, and otheradverse cardiovascular effects* For appetite stimulant effects; unknownfor antiemetic effects.

ACTIVITIESalcohol use: Additive CNS depressant effectsAdverse ReactionsCNS: Amnesia, anxiety, ataxia, confusion,delusions, depression, dizziness, drowsiness,euphoria, fatigue, hallucinations, irritability,mood changes, nervousness, seizures, sleepdisturbanceCV: Orthostatic hypotension, palpitations,sinus tachycardiaGI: Nausea, vomitingOther: Physical and psychological dependenceNursing ConsiderationsWARNING Dronabinol shouldn’t be discontinuedabruptly; if it is, withdrawal syndromemay occur.• Use cautiously in patients with history ofseizures because drug may lower seizurethreshold. Notify prescriber of seizuresimmediately, and expect to stop drug.• Patients under age 45 may tolerate drugbetter than those over age 45.• Watch for adverse reactions that mimicpsychosis, such as hallucinations and, possibly,acute anxiety, especially at high doses.• Anticipate higher risk of cardiovascularreactions, such as increased heart rate andblood pressure changes (especially orthostatichypotension), at higher doses.WARNING Expect tolerance to drug todevelop over time, especially if patient hassmoked marijuana.• Be aware that short-term, low-dose therapydoesn’t typically lead to physical andpsychological dependence, which mayoccur with long-term, high-dose therapy.• Expect drug to alter REM sleep pattern,even after therapy stops.PATIENT TEACHING• Caution patient not to stop drug abruptlybecause withdrawal symptoms may occur.• Urge patient not to use alcohol while takingdronabinol because it may enhanceCNS depression.• Instruct patient to rise slowly to sitting orstanding position to minimize effects oforthostatic hypotension.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Inform patient that sleep pattern may beadversely affected during therapy and forsometime afterward.dronedaroneMultaqContraindicationsBradycardia less than 50 beats/minute; concurrentuse of drugs or herbal products thatprolong QT interval, such as class I and IIIantiarrhythmics, phenothiazine antipsychotics,oral macrolide antibiotics (selected),and tricyclic antidepressants; concurrentuse of strong CYP3A inhibitors, suchas clarithromycin, cyclosporine, ketoconazole,itraconazole, nefazodone, ritonavir,telithromycin, and voriconazole; hypersensitivityto dronedarone or its components;nursing mothers; NYHA Class IV heart failureor NYHA Class II-III heart failure witha recent decompensation requiring hospitalizationor referral to a specialized heartfailure clinic; pregnancy; QTc Bazett intervalof 500 ms or greater or a PR intervalgreater than 280 ms; second- or thirddronedarone353Class and CategoryChemical class: Benzofuran derivativeTherapeutic class: AntiarrhythmicPregnancy category: XIndications and Dosages To reduce risk of cardiovascular hospitalizationin patients with paroxysmalor persistent atrial fibrillation or flutter,with a recent episode of atrial fibrillationor flutter and associated cardiovascularrisk factors (i.e., age over 70 yearsor presence of hypertension, diabetes,prior cerebrovascular accident, left atrialdiameter 50 mm or more or left ventricularejection fraction less than 40%),who are in sinus rhythm or who will becardiovertedTABLETSAdults. 400 mg twice daily, with morningand evening mealsRoute Onset Peak DurationP.O. Unknown 3–6 hr UnknownMechanism of ActionAlthough specific effect on heart rhythm isunknown, dronedarone possesses propertiesof all four Vaughn-Williams antiarrhythmicclasses.D

354Indications and Dosages To reduce nausea and vomiting aftersurgery or diagnostic procedures whenother treatments are ineffectiveI.V. OR I.M. INJECTIONAdults and adolescents. Dosage individualizedup to a maximum initial dose of2.5 mg I.M. or slow I.V. Additional 1.25 mgmay be given to achieve desired effect ifpotential benefit outweighs risk.Children ages 2 to 12. Dosage individualdroperidoldegree atrioventricular block or sick sinussyndrome (except when used in with afunctioning pacemaker); severe hepaticimpairment (Child-Pugh Class C)InteractionsDRUGScalcium channel blockers: Possibly increaseddronedarone effects on conductioncalcium channel blockers, such as diltiazem,nifedipine, and verapamil; CYP3A substrateswith narrow therapeutic rang,e such assirolimus and tacrolimu; CYP2D6 substrates,such as beta blockers, selective serotoninreuptake agents, and tricyclic antidepressant;statins, such as simvastain: Increased effectsof these drugs with possibly increased riskof adverse reactionsclass I and III antiarrhythmics, macrolideantibiotics, phenothiazinees, tricyclic antidepressants:Possibly increased QT intervalCYP3A inducers, such as carbamazepine,phenobarbital, phenytoin, rifampin, St. John’swort: Decreased dronedarone effectsCYP3A inhibitors, such as clarithromycin,cyclosporine, ketoconazole, itraconazole, nefazodone,ritonavir, telithromycin, andvoriconazole: Increased dronedarone effectsdigoxin and other P-gP substrates: Increasedeffect of these drugs with risk of toxicity;increased risk of adverse GI reactionsdiltiazem, verapamil: Increased dronedaroneeffectpotassium-depleting diuretics: Increased riskof hypokalemia and hypomagnesemiaFOODSgrapefruit juice: Increased dronedaroneeffectsAdverse ReactionsCNS: AstheniaCV: Bradycardia, heart failure, prolongedQT intervalGI: Abdominal pain, diarrhea,dyspepsia,nausea, vomitingGU: Increased serum creatinine levelsSKIN: Allergic dermatitis, dermatitis,eczema, photosensitivity, pruritus, rashNursing Considerations• Check that patient has stopped taking anydrug contraindicated with dronedarone, asprescribed, before giving first dose.• Monitor patient for evidence of heart failure,such as weight gain, dependentedema, or increasing shortness of breath.If present, notify prescriber; dronedaronemay need to be discontinued.• Monitor patient’s PR and QT interval, asordered, to see if conduction is delayed. Ifso, notify prescriber immediately.Dronedarone will need to be stopped.• Monitor patient’s serum creatinine levels,as ordered. Elevation may occur rapidly,plateau after 7 days, and usually isreversible after therapy stops. However, ifserum creatinine level increases, be awarethat this increased value should be used asthe patient’s new baseline.PATIENT TEACHING• Inform patient that dronedarone must betaken with a meal.• Warn patient that dronedarone should notbe taken with grapefruit juice.• Urge patient to contact prescriber if hedevelops evidence of heart failure, such asweight gain, dependent edema, or increasingshortness of breath, because dronedaronemay need to be discontinued.• Inform women of childbearing age of needfor contraception if sexually active becausedrug is contraindicated during pregnancyand breastfeeding. If pregnancy occurs,she should notify prescriber immediately.• Tell patient to inform all prescribers thathe is taking dronedarone and to checkwith prescriber before taking any newlyprescribed drug, OTC product, or herbalproduct with dronedarone.droperidolInapsineClass and CategoryChemical class: Butyrophenone derivativeTherapeutic class: AntiemeticPregnancy category: C

ized to a maximum initial dose of 0.1 mg/kg. Additional dose may be given to achievedesired effect if potential benefit outweighsrisk.DOSAGE ADJUSTMENT Initial dosage reducedfor elderly, debilitated, or critically illpatients because of the increased risk ofhypotension and excessive sedation.Route Onset Peak DurationI.V., I.M. 3–10 min In 30 min 2–4 hrMechanism of ActionProduces sedation by blocking postsynapticdopamine receptors in limbic system.Droperidol may reduce nausea by blockingdopamine receptors in chemoreceptor triggerzone in reticular formation of themedulla oblongata. It also may produceantiemetic effects by attaching to postsynapticgamma-amino-butyric acid(GABA) receptors in the chemoreceptortrigger zone.ContraindicationsHypersensitivity to droperidol or its components,known or suspected prolonged QTinterval (including congenital long-QT syndrome)InteractionsDRUGSamoxapine, haloperidol, loxapine, metoclopramide,metyrosine, molindone, olanzapine,phenothiazines, pimozide, rauwolfia alkaloids,risperidone, tacrine, thioxanthenes:Possibly increased risk of severe extrapyramidalreactionsanesthetics: Possibly hypotension andperipheral vasodilationantiarrhythmics (class I or III), antidepressants,antimalarials, benzodiazepines, diuretics,I.V. opioids, laxatives, MAO inhibitors,volatile anesthetics, and other drugs that prolongQT interval (such as some antihistamines):Increased risk of serious adverseeffects of droperidol, such as prolonged QTinterval and arrhythmiasantihypertensives: Possibly orthostatic hypotensionbromocriptine, levodopa: Possibly inhibitedactions of these drugsCNS depressants: Additive CNS depressionepinephrine: Possibly paradoxical reductionof blood pressureNursing ConsiderationsWARNING Use droperidol cautiously inpatients over age 65 and in patients withalcoholism, bradycardia, heart failure,hypokalemia, hypomagnesemia, parkinsonism,or preexisting QT-interval prolongationbecause they’re at increased risk forprolonged QT interval and potentiallyfatal adverse reactions. Patients who takedrugs that prolong the QT interval, suchas some antiarrhythmics and benzodiazepines,and patients who take drugs thatmay cause an electrolyte imbalance, suchas diuretics and laxatives, are also atincreased risk.• Expect a 12-lead ECG to be performed onall patients before droperidol administrationto verify the absence of prolonged QTinterval. Monitor ECG continuously for2 to 3 hours after administering drug. Alsomonitor serum electrolyte levels to detectelectrolyte imbalances.• Use droperidol cautiously in patients withcardiac disease, who may not be able tocompensate for drug’s hypotensive effect.Monitor vital signs, including blood pressure,frequently. Be aware that hypertensionand tachycardia may occur in patientswith a history of pheochromocytoma.• Expect altered level of consciousness tolast up to 12 hours after drug is given.Expect dosage to be reduced if patient istaking an opioid analgesic.• If drug causes extrapyramidal reactions,such as restlessness, dystonia, and oculogyriccrisis, expect to administer an antidroperidol355propofol: Possibly decreased antiemeticeffect of both drugsACTIVITIESalcohol use: Additive CNS depressionAdverse ReactionsCNS: Anxiety, drowsiness, dystonia, restlessnessCV: Cardiac arrest, hypertension, hypotension,potentially fatal arrhythmias (such astorsades de pointes and ventricular tachycardia),prolonged QT interval, sinus tachycardiaEENT: Fixed upward position of eyeballs,laryngospasmMS: Spasms of tongue, face, neck, and backmusclesRESP: BronchospasmD

356drotrecogin alfacholinergic, such as benztropine ordiphenhydramine. Be sure to maintain apatent airway and oxygenation.• If patient develops severe hypotension,expect to give phenylephrine. If hypotensionis related to hypovolemia, expect toadminister fluids.PATIENT TEACHING• Advise patient to immediately report palpitationsor faintness, which may indicatean abnormal cardiac rhythm.• Instruct patient to ask for help withambulation on first postoperative daybecause altered consciousness may last upto 12 hours.• Caution patient to avoid drinking alcohol,taking CNS depressants, driving, andoperating machinery for 24 hours afterreceiving droperidol.drotrecogin alfa(activated)(recombinant humanactivated protein C)XigrisClass and CategoryChemical class: Serine protease glycoproteinTherapeutic class: Anti-inflammatory, antithrombolyticPregnancy category: CIndications and Dosages To reduce risk of death in patients withsevere sepsis in acute organ dysfunctionI.V. INFUSIONAdults. 24 mcg/kg/hr for 96 hr.Mechanism of ActionInterferes with a number of body responsesto severe sepsis, including increased thrombingeneration and fibrin formation,impaired fibrinolysis, and systemic inflammation.Drotrecogin alfa produces antithromboticeffect by inhibiting factors Vaand VIIIa and indirect profibrinolytic effectby inhibiting plasminogen activatorinhibitor-1 and limiting generation of activatedthrombin-activatable fibrinolysisinhibitor.Drotrecogin may produce antiinflammatoryeffect by inhibiting productionof human tumor necrosis factor andother cytokines, preventing leukocyte adhesionto selectins, and limiting thrombininducedinflammatory responses in themicrovascular endothelium.IncompatibilitiesDon’t infuse any drugs or solutions exceptD 5 W, normal saline solution, lactatedRinger’s solution, or dextrose and salinemixtures through drotrecogin alfa I.V. line.ContraindicationsActive internal bleeding; evidence of cerebralherniation; hemorrhagic stroke in thepast 3 months; hypersensitivity to drotrecoginalfa or its components; intracranial orintraspinal surgery or severe head traumain the past 2 months; intracranial neoplasmor lesion; presence of epidural catheter;trauma with an increased risk of lifethreateningbleedingInteractionsDRUGSabciximab, eptifibatide, and other glycoproteinIIb/IIIa inhibitors; aspirin and otherplatelet inhibitors; heparin; oral anticoagulants;thrombolytics: Increased risk of bleedingAdverse ReactionsCNS: Intracranial hemorrhageCV: Intrathoracic bleedingGI: GI, intra-abdominal, or retroperitonealbleedingGU: Genitourinary bleedingHEME: Prolonged APTTSKIN: EcchymosisNursing Considerations• Be aware that drotrecogin alfa is used onlyfor patients with severe sepsis who are athigh risk for death, as determined by anAcute Physiology and Chronic HealthEvaluation (APACHE) II score, a methodof assessing mortality risk. Patients withonly single-organ dysfunction who arerecovering from recent surgery may not becandidates for drotrecogin alfa despite anadequate APACHE II score.• Reconstitute 5-mg and 20-mg vials byslowly adding 2.5 ml or 10 ml sterile waterfor injection, respectively, to yield 2 mg/ml. Gently swirl—don’t shake—vial untilpowder is completely dissolved. Use

immediately or store for up to 3 hours at59° to 86° F (15° to 30° C).• Add reconstituted drug to normal salinesolution by directing stream to side of bagto minimize agitation. Gently invert bag tomix; don’t shake. Dilute to final concentrationof 100 to 200 mg/ml if drug will begiven by I.V. infusion pump or 100 to1,000 mg/ml if by syringe pump. Infusionbag should not be transported by amechanical delivery system, such as a tubedelivery system, between pharmacy andnursing unit.• Prime infusion set for 15 minutes at a flowrate of 5 ml/hour when infusing less than200 mg/ml at less than 5 ml/hour. Use preparedI.V. solution within 12 hours.• Give drotrecogin alfa through a dedicatedI.V. line or lumen of a multilumen centralvenous catheter. Don’t infuse any drugs orsolutions except D 5 W, normal saline solution,lactated Ringer’s solution, or dextroseand saline mixtures through the same line.• Be aware that total duration of the drotrecoginalfa infusion must equal96 hours, even if you need to interrupt itfor a period. For example, if you calculatethat infusion should end on 5 p.m. Friday,but then have to stop to give the patientblood for 2 hours on Thursday, add those2 hours to your estimated completiontime, which would then be 7 p.m. Friday.WARNING Monitor patient closely forbleeding; if it occurs, stop drotrecogin alfainfusion immediately and notify prescriber.Patients at increased risk includethose with chronic severe hepatic disease,intracranial arteriovenous malformationor aneurysm, known bleeding diathesis, GIbleeding in previous 6 weeks, or ischemicstroke in previous 3 months; those receivingconcurrent therapeutic heparin(15 units/kg/hour or more); those whohave received thrombolytic therapy in previous3 days, aspirin at more than 650 mgdaily, other platelet inhibitors in previous7 days, or oral anticoagulants or glycoproteinIIb/IIIa inhibitors in previous 7 days;those with any other condition in whichbleeding would constitute a significanthazard or be difficult to manage becauseof its location; and those with a plateletcount less than 30,000 10 6 /L or PT (asINR) greater than 3.0.duloxetine hydrochloride 357• Expect to discontinue drotrecogin alfa2 hours before an invasive surgical orother procedure that poses a risk of bleedingand to resume administration immediatelyafter uncomplicated, less-invasiveprocedures or 12 hours after major invasiveprocedures or surgery at the same rateof 24 mg/kg/hour, as prescribed.• Be aware that drotrecogin alfa may prolongAPTT during administration; PTmay need to be used to monitor coagulopathystatus during treatment.• Before using drotrecogin alfa, refrigerate itat 36° to 46° F (2° to 8° C); don’t freeze it.Protect from heat and direct sunlight.PATIENT TEACHING• Teach patient about adverse reactions todrotrecogin alfa, including bleeding fromgums or nose and increased bruising.Instruct her to immediately report anysigns of bleeding.• Reassure patient that she’ll be monitoredclosely throughout therapy.duloxetinehydrochlorideCymbaltaClass and CategoryChemical: Selective serotonin and norepinephrinereuptake inhibitorTherapeutic: Antidepressant, neuropathicpain relieverPregnancy category: CIndications and Dosages To treat major depressive disorderE.R. CAPSULESAdults. 20 mg b.i.d. Alternatively, 60 mgonce daily or 30 mg b.i.d. To relieve neuropathic pain associatedwith diabetic peripheral neuropathyE.R. CAPSULESAdults. 60 mg daily. To treat generalized anxiety disorderE.R. CAPSULESAdults. Initial: 30 or 60 mg once daily,increased in 30-mg increments weekly, asneeded. Maximum: 120 mg once daily. To treat fibromyalgiaE.R. CAPSULESAdults. Initial: 30 mg daily for 1 wk; thenD

358duloxetine hydrochlorideincreased to 60 mg daily.Mechanism of ActionInhibits neuronal serotonin, norepinephrine,and dopamine reuptake to potentiateserotonergic and noradrenergic activity inthe CNS. These activities may elevate moodand inhibit pain signals stemming fromperipheral nerves adversely affected bychronically elevated serum glucose level.Route Onset Peak DurationP.O. Unknown 6 hr UnknownContraindicationsHepatic insufficiency, hypersensitivity toduloxetine or its components, uncontrolledangle-closure glaucoma, use within 14 daysof MAO inhibitor therapyInteractionsDRUGSamiodarone, celecoxib, cimetidine, erythromycin,fluoxetine, fluvoxamine, haloperidol,ketoconazole, methadone, paroxetine, quinidine,quinolones, ritonavir: Increased bloodduloxetine levelamiodarone, amitriptyline, desipramine, flecainide,haloperidol, imipramine,methadone, nortriptyline, phenothiazines,propafenone, ritonavir, thioridazine:Increased blood levels of these drugsaspirin, NSAIDs, warfarin: Possiblyincreased risk of bleedingCNS drugs: Increased effect of duloxetineMAO inhibitors: Serious, sometimes fatal,autonomic instability, hyperthermia,myoclonus, rigidityplasma protein binders (warfarin, phenytoin):Increased free concentration of thesedrugs and increased risk of adverse reactionsserotonergic drugs: Increased risk of serotoninsyndromeACTIVITIESalcohol use: Increased risk of hepatotoxicityAdverse ReactionsCNS: Abnormal dreams, aggression, agitation,anger, anxiety, asthenia, chills, dizziness,extrapyramidal disorder, fatigue, fever,hallucinations, headache, insomnia,migraine, nervousness, neuroleptic malignantsyndrome, parasthesia, restless legssyndrome, serotonin syndrome, somnolence,suicidal ideation, syncope, tremor,vertigoCV: Hypertension, hypertensive crisis,orthostatic hypotension, palpitations,paresthesia, peripheral edema, supraventriculararrhythmiaEENT: Blurred vision, dry mouth, glaucoma,nasopharyngitis, pharyngitis, tastealterationENDO: Hot flashes, hyperglycemiaGI: Abdominal pain, anorexia, cholestaticjaundice, constipation, diarrhea, elevatedliver enzymes, flatulence, hepatitis, hepatotoxicity,indigestion, jaundice, nausea,upper abdominal pain, vomitingGU: Abnormal orgasm, decreased libido,erectile or ejaculatory dysfunction, urinaryfrequency, UTIHEME: Bleeding episodes, leukopenia,thrombocytopeniaMS: Arthralgia, back pain, extremity pain,muscle cramp, myalgiaRESP: Cough, upper respiratory tract infectionSKIN: Diaphoresis, erythema multiforme,pruritus, rash, Stevens-Johnson syndrome,urticariaOther: Anaphylaxis, angioedema, hyponatremia,weight lossNursing Considerations• Avoid giving duloxetine to patients withsevere renal impairment or end-stage renaldisease that requires hemodialysis becauseblood drug levels increase significantly inthese patients. Also avoid duloxetine inpatients with hepatic insufficiency becausedrug is metabolized by the liver.• Use duloxetine cautiously in patients withdelayed gastric emptying because drug’senteric coating resists dissolution until itreaches an area where pH exceeds 5.5.• Give duloxetine cautiously to patients witha history of mania, which it may activate.Also give cautiously to patients with aseizure disorder because drug effects aren’tknown in these patients.• Obtain patient’s baseline blood pressurebefore duloxetine therapy starts, and assessit periodically thereafter for changes. Iforthostatic hypotension occurs duringtherapy, notify prescriber and anticipatethat drug may need to be discontinued.• Monitor patient’s serum sodium level,especially if patient is elderly, is taking a

diuretic, or has volume depletion, becausedrug may lower serum sodium level.• Monitor patient’s hepatic function, asordered, because drug may increase therisk of hepatotoxicity.• If patient takes duloxetine for depression(especially if he’s a child or an adolescent),watch closely for evidence of suicidalthinking or behavior, especially when therapystarts or dosage changes.• Avoid stopping duloxetine therapy abruptly,if possible, because withdrawal symptomssuch as dizziness, nausea, headacle,fatigue, paresthesia, vomiting, irritability,nightmares, insomnia, diarrhea, anxiety,hyperhidrosis, and vertigo may occur.Taper dosage gradually, as ordered.WARNING Monitor patient for serotoninsyndrome, characterized by agitation,chills, confusion, diaphoresis, diarrhea,fever, hyperactive reflexes, poor coordination,restlessness, shaking, talking or actingwith uncontrolled excitement, tremor, andtwitching. In its most severe form, serotoninsyndrome can resemble neurolepticmalignant syndrome, which includes ahigh fever, muscle rigidity, autonomicinstability with possible fluctuations invital signs, and mental status changes.PATIENT TEACHING• Tell patient to take capsule whole and notto chew it, crush it, or sprinkle contentson food or liquids because doing so altersenteric coating and may affect drugabsorption.• Inform patient that full effect of duloxetinemay take weeks to occur; stress theimportance of continuing to take the drugas directed.• Caution patient against excessive alcoholconsumption while taking duloxetinebecause it may increase risk of hepaticdysfunction.• Advise patient not to stop duloxetineabruptly because adverse reactions mayoccur. Explain that drug will be stoppedgradually.• Instruct patient to notify prescriber if anyserious or troublesome adverse effectsdevelop.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to rise from a lying or sittingposition slowly to minimize drug’seffect on lowering blood pressure.• If patient takes duloxetine for depression,urge caregivers to watch closely for evidenceof suicidal tendencies, especially ifpatient is a child or an adolescent andespecially when therapy starts or dosagechanges.• Instruct female patients of childbearingpotential to notify prescriber if they are,could be, or wish to become pregnant;duloxetine therapy may cause adversereactions in neonates exposed to it duringthe third trimester.dutasterideAvodartdutasteride 359Class and CategoryChemical class: Synthetic 4-azasteroidcompoundTherapeutic class: Benign prostatic hyperplasiaagentPregnancy category: XIndications and Dosages To treat symptomatic benign prostatichyperplasia (BPH); as adjunct withtamsulosin therapy to treat symptomaticBPHCAPSULESAdult men. 0.5 mg daily.ContraindicationsChildren; women; hypersensitivity to dutasteride,its components, or other 5-alphareductase inhibitorsInteractionsDRUGScimetidine, ciprofloxacin, diltiazem, ketoconazole,ritonavir, verapamil, and otherCYP3A4 inhibitors: Risk of decreased dutasteridemetabolism and enhanced effectsAdverse ReactionsCNS: DizzinessENDO: Gynecomastia, increased serumtestosterone and thyroid-stimulating hormonelevelsGU: Decreased ejaculatory volume,decreased libido, impotenceSKIN: Localized edema, pruritus, rash, seriousskin reactions, urticariaENDO: AngioedemaD

360dyphyllineTestosteroneTestosteroneMechanism of ActionDutasteride reduces prostate glandenlargement by inhibiting conversion oftestosterone to its active metabolite,5-alpha dihydrotestosterone (DHT).DHT is the main hormone that stimulatesprostate cells to grow. As men age,they may become more sensitive to DHT,resulting in excessive growth of prostaticcells and enlargement of the prostate.This condition, benign prostatic hyperplasia,may cause urinary hesitancy, urinaryurgency, and nocturia.Two forms of the intracellular enzyme 5-alpha-reductase (5-R types 1 and 2) inliver, prostate, and skin, convert testosteroneto DHT, as shown below left.Dutasteride, a dual 5-R inhibitor, deactivatesboth forms. When 5-R is inhibitedby dutasteride, production of DHT issuppressed, as shown below right. Withless circulating DHT, the prostate glandshrinks and symptoms improve.DutasterideDutasteride5α-R5α-RCellCellDHTDHTDHT DHTBloodBloodvesselvesselDHT DHTNursing ConsiderationsWARNING Be aware that dutasteride isabsorbed through the skin. If you arefemale and pregnant or of childbearingage, do not handle dutasteride capsulewhen administering it to a patient.• Patient should be evaluated for other urologicconditions, including prostate cancer,before dutasteride therapy starts.• Expect patient to undergo a digital rectalexamination of the prostate before andperiodically during dutasteride therapy.• Anticipate need to obtain a new baselineprostate-specific antigen (PSA) value after3 to 6 months of dutasteride treatmentbecause drug can decrease PSA concentrationby 40% to 50%.PATIENT TEACHINGWARNING Urge patient and female partnersto use reliable contraceptive method duringdutasteride therapy because semen ofmen who take drug can harm male fetuses.Caution women and children againsthandling capsules.• Advise patient to inform prescriber if hehas liver disease.• Explain how to take drug properly, andadvise patient to follow instructions thataccompany drug. Instruct him to swallowcapsule whole and to notify pharmacist ifcapsules are cracked or leaking.• Inform patient that drug may decreaseejaculatory volume and libido and maycause impotence.• Instruct patient to postpone blood donationsfor 6 months after final dose to avoidtransmitting dutasteride to a pregnantwoman during a blood transfusion.• Urge patient to have periodic follow-upappointments.dyphyllineDilor, LufyllinClass and CategoryChemical class: Xanthine derivative

Therapeutic class: BronchodilatorPregnancy category: CIndications and Dosages To prevent or relieve bronchospasmfrom acute and chronic bronchial asthma,chronic bronchitis, and emphysemaELIXIR, TABLETSAdults. Up to 15 mg/kg every 6 hr.I.M. INJECTIONAdults. Initial: 500 mg. Maintenance: 250 to500 mg every 2 to 6 hr, as needed.Mechanism of ActionMay cause bronchodilation by inhibitingphosphodiesterase enzymes. These enzymesnormally inactivate cyclic adenosinemonophosphate (cAMP) and cyclic guanosinemonophosphate (cGMP), which areresponsible for bronchial smooth-musclerelaxation. Drug also may foster calciumtranslocation, prostaglandin antagonism,catecholamine stimulation, and adenosinereceptorantagonism.ContraindicationsHypersensitivity to dyphylline, xanthines,or their components; peptic ulcer disease;seizure disorder (unless controlled by anticonvulsanttherapy)InteractionsDRUGSbeta blockers: Possibly inhibited bronchodilationby dyphyllineephedrine: Possibly increased frequency ofinsomnia, nausea, and nervousnesshydrocarbon inhalation anesthetics: Possiblyincreased risk of ventricular arrhythmiasprobenecid: Possibly decreased renal excretionof dyphyllinesucralfate: Possibly adsorption of dyphyllineif drugs given within 2 hours of each otherAdverse ReactionsCNS: Headache, insomnia, irritability, nervousness,seizures, tremorCV: Arrhythmias, hypotension, tachycardiaGI: Diarrhea, gastroesophageal reflux, nausea,vomitingGU: Increased diuresisNursing Considerations• Inspect I.M. form of dyphylline for precipitate.If present, discard drug and obtain anew ampule.• Give oral drug at least 1 hour after mealsdyphylline 361for best absorption. However, if drug causesGI distress, give it with food if prescribed.• Don’t give parenteral drug by I.V. route.• Evaluate for therapeutic response, includingdecreased respiratory rate and effort.• Assess for signs of dyphylline toxicity,including seizures and ventricular tachycardia.PATIENT TTEACHING• Instruct patient to take oral dyphyllinewith a full glass of water and on an emptystomach to promote absorption.• Advise patient to consult prescriber abouttaking drug with food if she experiencesGI distress.D

E FecallantideKalbitorClass and CategoryChemical class: 60-amino-acid proteinTherapeutic class: Kallikrein inhibitorreplacementPregnancy category: CIndications and Dosages To treat acute attacks of hereditaryangioedema in patients age 16 and olderSUBCUTANEOUS INJECTIONAdults. 30 mg (3 ml) given in divided dosesof 10 mg (1 ml) each and repeated, if needed,within 24 hr.Route Onset Peak DurationP.O. 24–50 min 2–3 hr UnknownMechanism of ActionBlocks conversion of kininogen to bradykininby binding to plasma kallikrein.Without bradykinin, the inflammatorypathway is not initiated and signs andsymptoms of angioedema are relieved.The kallikrein-kinin system is a complexproteolytic cascade that initiates the inflammatoryand coagulation pathways throughconversion of kininogen to bradykinin bykallikrein. In hereditary angioedema, normalregulation of plasma kallikrein activityand the classical complement cascade is notpresent because of the absence of a kallikreininhibitor. This allows kininogen to beconverted to bradykinin unchecked, resultingin an excessive amount of bradykinincirculating in plasma. Bradykinin is avasodilator that may be responsible for thesymptoms of hereditary angioedema suchas swelling, inflammation, and pain.ContraindicationsHypersensitivity to ecallantide or its componentsAdverse ReactionsCNS: Fatigue, fever, headacheEENT: Nasopharyngitisecallantide 363GI: Diarrhea, nausea, upper abdominalpain, vomitingRESP: Upper respiratory infectionSKIN: PruritusOther: Anaphylaxis; antibody formation toecallantide; injection site reactions such asbruising, erythema, irritation, pain, pruritus,and uriticariaNursing Considerations• Ecallantide must be administered in a settingequipped to treat life-threateninghypersensitivity reactions.• Refrigerate ecallantide and protect fromlight until time of administration.• Using aseptic technique, withdraw 1 ml(10 mg) from 10-mg vial using a largeboreneedle. Then, change needle on thesyringe to a 27G subcutaneous needle.Repeat procedure for remaining two vialsin dose pack.• Give three injections of ecallantide subcutaneouslyinto skin of abdomen, thigh, orupper arm. The injections may be in thesame or different anatomic locationsbecause there is no need for site rotation.However, the sites should be separatedfrom each other by at least 5 cm (2 in).Also, don’t use any site where signs andsymptoms of the attack are located.WARNING Monitor patient closely forhypersensitivity reactions, including anaphylaxis,especially within 1 hour ofadministration. Signs and symptoms maybe similar to those of a hereditary angioedemaattack. Immediately report chestpain, flushing, pharyngeal edema, pruritus,rhinorrhea, sneezing, nasal congestion,throat irritation, urticaria, wheezing, andhypotension, and be prepared to provideemergency supportive care, as ordered.PATIENT TEACHING• Explain that a dose requires three injectionsand that it may be repeated within24 hours if needed.• Stress importance of reporting any unusualsigns and symptoms immediately afterreceiving ecallantide, such as wheezing,shortness of breath, cough, chest tightness,trouble breathing, dizziness, fainting, fastor weak heartbeat, nervousness, swellingof throat or tongue, throat tightness,hoarse voice, trouble swallowing, runnynose or sneezing, reddening of face, itching,hives or feeling warm.EF

364eflornithine hydrochloride; eletriptan hydrobromideeflornithinehydrochloride(alpha-difluoromethylornithine,DFMO)OrnidylClass and CategoryChemical class: DifluoromethylornithineTherapeutic class: AntiprotozoalPregnancy category: CIndications and Dosages To treat the meningoencephalitic stage ofTrypanosoma brucei gambiense infection(sleeping sickness)I.V. INFUSIONAdults. 100 mg/kg given over at least45 min every 6 hr for 14 days.Route Onset Peak DurationI.V. Unknown 4–6 hr UnknownMechanism of ActionInhibits the enzyme ornithine decarboxylase,which is needed for decarboxylation ofornithine. This process is the first step inpolyamine synthesis, which is needed forprotozoal cell division and differentiation.IncompatibilitiesDon’t give eflornithine with any other drug.ContraindicationsHypersensitivity to eflornithine or its componentsAdverse ReactionsCNS: Asthenia, dizziness, headache, seizuresEENT: Hearing lossGI: Abdominal pain, anorexia, diarrhea,vomitingHEME: Anemia, eosinophilia, leukopenia,myelosuppression, thrombocytopeniaOther: Alopecia, facial edemaNursing Considerations• Plan to reduce eflornithine dosage as prescribed,based on renal function. Monitorcreatinine clearance in patients with renaldysfunction.• Before infusion, dilute eflornithine concentratewith sterile water for injection.Using strict aseptic technique, withdrawthe contents of a 100-ml vial and inject25 ml into each of four I.V. diluent bagsthat contain 100 ml of sterile water. Theresulting solution contains 40 mg/ml ofeflornithine (5,000 mg of eflornithine in125 ml total volume).• Store bags of diluted eflornithine at 4° C(39° F) to reduce the risk of contamination.Use diluted drug within 24 hours.• Expect to monitor the patient’s CBC,including platelet count, before eflornithinetreatment, twice weekly duringtreatment, and weekly after treatmentstops until the patient’s hematologic valuesreturn to baseline.• Take infection-control and bleeding precautionsbecause drug may cause myelosuppression.Adjust dosage or stop therapyas prescribed, based on severity.• Take seizure precautions during eflornithinetherapy.• Consult prescriber about the need for serialaudiography, if appropriate.• Store undiluted vials of eflornithine atroom temperature, and protect from freezingand light.PATIENT TEACHING• Stress need for follow-up visits because riskof relapse lasts 24 months after treatment.• Teach patient how to follow infectioncontroland bleeding precautions if myelosuppressionoccurs.• Warn patient about risk of seizures; adviseagainst performing potentially hazardousactivities during therapy.eletriptanhydrobromideRelpaxClass and CategoryChemical class: Serotonin 5-HT 1D –receptoragonistTherapeutic class: Antimigraine agentPregnancy category: CIndications and Dosages To relieve acute migraine attacks with orwithout auraTABLETSAdults. Initial: 20 or 40 mg as a single dose.Repeated in 2 hr, as needed and ordered.

Maximum: 40 mg as single dose, 80 mgdaily.Mechanism of ActionMay stimulate 5-HT 1 receptors, causingselective vasoconstriction of inflamed anddilated cranial blood vessels in carotid circulation,which decreases carotid arterialblood flow and relieves acute migraines.ContraindicationsBibasilar or hemiplegic migraine, cardiovasculardisease (significant), cerebrovascularsyndromes (stroke, transient ischemicattack), hepatic impairment (severe),hypersensitivity to eletriptan or components,ischemic bowel disease, ischemic orvasospastic coronary artery disease (CAD),peripheral vascular disease, uncontrolledhypertension, use within 24 hours ofanother serotonin 5-HT 1 –receptor agonistor ergot-type drug, use within 72 hours of apotent CYP3A4 inhibitorInteractionsDRUGSclarithromycin, ketoconazole, itraconazole,nefazodone, nelfinavir, ritonavir, troleandomycinand other potent CYP3A4 inhibitors:Increased metabolism of eletriptan anddecreased blood eletriptan levelergot-containing drugs, 5-HT 1 -receptor agonists:Possibly additive or prolonged vasoconstrictiveeffectsfluoxetine, fluvoxamine, paroxetine, sertraline:Increased risk of weakness, hyperreflexia,and incoordinationAdverse ReactionsCNS: Asthenia, dizziness, headache, paresthesia,somnolence, tiredness, weaknessCV: Chest tightness, pain, or pressure; coronaryartery vasospasm; hypertension, MI ormyocardial ischemia (transient); ventricularfibrillation or tachycardiaEENT: Dry mouth, throat tightnessGI: Abdominal pain, cramps, discomfort, orpressure; dysphagia; indigestion; nauseaSKIN: FlushingOther: Feeling of warmth, pain, or pressureNursing Considerations• Ensure that patients who are at risk forCAD undergo a satisfactory CV evaluationbefore you administer the first dose ofeletriptan and that they have a periodic reevaluationof their cardiac status duringintermittent long-term therapy.• Obtain an ECG immediately after firstdose of drug in patients who have CV riskfactors but who have had a satisfactory CVevaluation because of the drug’s potentialto cause coronary vasospasm.• Evaluate patient for CV signs and symptomsafter administration of eletriptanand notify prescriber if they occur. Expectdrug to be withheld, as ordered, whilepatient undergoes an extensive CVworkup, and discontinued if abnormalitiesare detected.• Monitor patient’s blood pressure duringtherapy because of drug’s potential toincrease blood pressure.PATIENT TEACHING• Advise patient to take eletriptan as soon aspossible after onset of migraine symptoms.• Urge patient to contact prescriber andavoid taking drug if headache symptomsaren’t typical.• Advise against exceeding prescribed dose.• Instruct patient to seek emergency care forchest, jaw, or neck tightness after takingdrug because these may indicate adverseCV reactions; subsequent doses mayrequire ECG monitoring.• Urge patient to report palpitations.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise yearly ophthalmic examinationsduring prolonged eletriptan therapy.• Instruct patient to inform prescriber of alldrugs he’s taking, including OTC productsand herbal remedies.eltrombopagolaminePromactaeltrombopag olamine 365Class and CategoryChemical class: Biphenyl hydrazoneTherapeutic class: Platelet formation inducerPregnancy category: CIndications and Dosages To treat thrombocytopenia in patientswith chronic immune (idiopathic)thrombocytopenic purpura and aninsufficient response to corticosteroids,EF

366eltrombopag olamineimmunoglobulins, or splenectomyTABLETSAdults. Initial: 50 mg daily, increased asneeded to maintain a platelet count of50 10 9 /L. Platelet counts usually increasein 1 to 2 wk. Maximum: 75 mg daily.DOSAGE ADJUSTMENT For patients of EastAsian ancestry or patients with moderate tosevere hepatic impairment, starting dose of25 mg daily.Route Onset Peak DurationP.O. Unknown 2–6 hr UnknownMechanism of ActionInteracts with the transmembrane domainof the thrombopoietin receptor to signalcascades that induce proliferation and differentiationof megakaryocytes from bonemarrow progenitor cells. This actionincreases platelet production, which isabnormally low in patients with thrombocytopenicpurpura.ContraindicationsHypersensitivity to eltrombopag or its componentsInteractionsDRUGSacetaminophen, atorvastatin, benzylpenicillin,fluvastatin, methotrexate, nateglinide,NSAIDs, opioids, pravastatin, repaglinide,rifampin, rosuvastatin: Possibly increasedrisk of adverse reactions related to excessiveexposure to these drugsantacids and mineral supplements containingaluminum, calcium, iron, magnesium, selenium,or zinc: Decreased eltrombopag absorptionciprofloxacin, fluvoxamine, gemfibrozil,omep-razole, rifampin, trimethoprim:Increased risk of eltrombopag-inducedadverse reactionsFOODSall foods, especially dairy: Decreased absorptionof eltrombopagACTIVITIESsmoking: Increased risk of eltrombopaginducedadverse reactions and possiblydecreased eltrombopag efficacyAdverse ReactionsCNS: Headache, paresthesiaEENT: Cataract, conjunctival hemorrhageGI: Abdominal pain, dyspepsia, elevatedliver enzymes, hepatotoxicity, nausea, vomitingGU: MenorrhagiaHEME: Hemorrhage, thrombocytopeniaMS: Fatigue, myalgiaSKIN: EcchymosisNursing Considerations• Eltrombopag should be used only to treatchronic immune (idiopathic) thrombocytopeniapurpura and not any other kind ofthrombocytopenia because of the risk ofhematologic malignances.• Eltrombopag can be used only through arestricted distribution program called,Promacta Cares. Patient, pharmacy, andprescriber must all be enrolled beforetherapy begins.• Use cautiously in patients with hepaticimpairment because drug may cause hepatotoxicity.• Monitor liver enzymes and bilirubin level,as ordered, before starting eltrombopag,every 2 weeks during dosage adjustment,and monthly once dose is stable. If abnormalitiesoccur, repeat testing within 3 to5 days and then weekly until liver enzymesreturn to baseline. Expect to discontinuedrug if alanine aminothransferase levelincreases to three or more times the uppernormal limit, progresses or persists for 4or more weeks, or is accompanied by anincrease in direct bilirubin or clinicalsymptoms of liver injury.• Obtain baseline CBC, including plateletcount and peripheral blood smears, beforestarting eltrombopag therapy, weekly untilstable, and monthly thereafter, as ordered,because thrombopoietin receptor agonists(the same class as eltrombopag) havecaused bone marrow fibrosis.• Patient should have a baseline eye examination,as ordered, before starting eltrombopagand periodically throughout therapy,because drug may cause cataracts.• Dosage adjustments are based on plateletcount response and are not used to normalizeplatelet counts in order to preventor minimize thrombotic complications.• Give eltrombopag 1 hour before or2 hours after the patient has eaten.Separate doses of other drugs by at least 4hours to prevent drug interactions.• Do not administer more than one dose of

eltrombopag within any 24-hour period.• Expect to discontinue drug if improvementdoesn’t occur within 4 weeks atmaximum dose of 75 mg daily.• Monitor patient for hematologic malignanciesbecause eltrombopag stimulatesthrombopoietin receptor on the surface ofhematopoietic cells, which increases risk ofmalignancies.• Monitor patient for increased bleedingafter stopping eltrombopag becausethrombocytopenia may worsen, increasingbleeding risk, especially if patient is onanticoagulants or antiplatelet therapy. Ifbleeding occurs, obtain weekly CBC,including platelet count, for at least4 weeks after therapy stops, and providesupportive care, as indicated and ordered.PATIENT TEACHING• Inform patient that, before eltrombopagtherapy can begin, he must be enrolled inthe Promacta Cares program, which providescomprehensive education about thedrug.• Urge patient to tell prescriber about allhealth conditions and all prescribed drugs,OTC drugs, herbs, and supplements taken.• Instruct patient to take eltrombopag on anempty stomach with a full glass of water1 hour before or 2 hours after a meal andto separate use of other drugs by at least4 hours because food and certain drugs(such as antacids and iron and vitaminsupplements) may interfere with eltrombopagabsorption.• Instruct patient to take drug at the sametime every day because no more than onedose should be taken within any 24-hourperiod.• Urge patient to report any adverse reactionsto prescriber and to keep all appointmentsfor blood work and follow-up.enalapril maleateVasotecenalaprilatVasotec I.V.Class and CategoryChemical class: Dicarbocyl-containing ACEinhibitorenalapril maleate 367Therapeutic class: AntihypertensivePregnancy category: C (first trimester),D (later trimesters)Indications and Dosages To control hypertensionTABLETSAdults. Initial: 5 mg daily, increased after1 to 2 wk, as needed. Maintenance: 10 to40 mg once daily or in divided doses b.i.d.Children. 0.08 mg/kg daily, titrated accordingto blood pressure response up to 5 mgdaily. Maximum: 0.58 mg/kg/dose or40 mg/dose.I.V. INJECTIONAdults. 1.25 mg every 6 hr.DOSAGE ADJUSTMENT Initial dose 2.5 mgP.O. or 0.625 mg I.V. for patients who havesodium and water depletion from diuretictherapy, are receiving diuretics, or have acreatinine clearance below 30 ml/min/1.73 m 2 . If response to I.V. dose is inadequateafter 1 hr, I.V. dose of 0.625 mg isrepeated and therapy continued at 1.25 mgevery 6 hr. To treat heart failureTABLETSAdults. Initial: 2.5 mg once or twice daily,increased after 1 to 2 wk, as needed.Maintenance: 5 to 40 mg once daily or individed doses b.i.d. To treat asymptomatic left ventriculardysfunctionTABLETSAdults. Initial: 2.5 mg b.i.d., increased to20 mg daily in divided doses.DOSAGE ADJUSTMENT Initial dosage reducedto 2.5 mg daily and, if possible, diureticdosage reduced in patients who have aserum sodium level below 130 mEq/L or aserum creatinine level above 1.6 mg/dl.Route Onset Peak DurationP.O. 1 hr 4–6 hr About 24 hrI.V. 15 min 1–4 hr About 6 hrMechanism of ActionMay reduce blood pressure by affecting therenin-angiotensin-aldosterone system. Byinhibiting angiotensin-convering enzyme(ACE), enalapril:• prevents conversion of angiotensin I toangiotensin II, a potent vasoconstrictorthat also stimulates the adrenal cortex toEF

368enalapril maleatesecrete aldosterone• may inhibit renal and vascular productionof angiotensin II• decreases the serum angiotensin II leveland increases serum renin activity, whichdecreases aldosterone secretion and slightlyincreases serum potassium level andfluid loss• decreases vascular tone and blood pressure• inhibits aldosterone release, which reducessodium and water reabsorption andincreases their excretion, further reducingblood pressure.ContraindicationsHistory of angioedema from previous ACEinhibitor; hypersensitivity to enalapril, enalaprilat,or their componentsInteractionsDRUGSallopurinol, bone marrow depressants (suchas amphotericin B and methotrexate), procainamide,systemic corticosteroids: Possiblyincreased risk of fatal neutropenia or agranulocytosiscyclosporine, potassium-sparing diuretics,potassium supplements: Increased risk ofhyperkalemiadiuretics, other antihypertensives: Additivehypotensive effectslithium: Increased blood lithium level andlithium toxicityNSAIDs: Possibly reduced antihypertensiveeffects of enalapril and enalaprilatsodium aurothiomalate: Increased risk ofnitritoid reactions, such as facial flushing,nausea, vomiting, and hypotensionsympathomimetics: Possibly reduced therapeuticeffects of enalapril and enalaprilatFOODSpotassium-containing salt substitutes:Increased risk of hyperkalemiaACTIVITIESalcohol use: Possibly additive hypotensiveeffectAdverse ReactionsCNS: Ataxia, confusion, depression, dizziness,dream disturbances, fatigue, headache,insomnia, nervousness, peripheral neuropathy,somnolence, stroke, syncope, vertigo,weaknessCV: Angina, arrhythmias, cardiac arrest, hypotension,MI, orthostatic hypotension,palpitations, pulmonary embolism andinfarction, Raynaud’s phenomenonEENT: Blurred vision, conjunctivitis, dryeyes and mouth, glossitis, hoarseness, lacrimation,loss of smell, pharyngitis, rhinorrhea,stomatitis, taste perversion, tinnitusENDO: GynecomastiaGI: Abdominal pain, anorexia, constipation,diarrhea, hepatic failure, hepatitis, ileus,indigestion, melena, nausea, pancreatitis,vomitingGU: Flank pain, impotence, oliguria, renalfailure, UTIMS: Muscle spasmsRESP: Asthma, bronchitis, bronchospasm,cough, dyspnea, pneumonia, pulmonaryedema, pulmonary infiltrates, upper respiratorytract infectionSKIN: Alopecia, diaphoresis, erythemamultiforme, exfoliative dermatitis, flushing,pemphigus, photosensitivity, pruritus, rash,Stevens-Johnson syndrome, toxic epidermalnecrolysis, urticariaOther: Anaphylaxis, angioedema, herpeszoster, hyperkalemiaNursing Considerations• Use enalapril and enalaprilat cautiously inpatients with impaired renal function.Avoid giving drug to children with a GFRless than 30 ml/min/1.73 m 2 .• For children who can’t swallow tablets,consult with prescriber and pharmacistabout preparing an oral suspension fromtablets as directed by manufacturer.• Administer each I.V. dose over at least5 minutes.• Measure patient’s blood pressure immediatelyafter first dose and frequently for atleast 2 hours thereafter. If hypotensionrequires a dosage reduction, monitorblood pressure frequently for 2 hours afterreduced dosage is administered and foranother hour after blood pressure has stabilized.• Monitor blood pressure regularly duringtherapy. If hypotension develops, placepatient in a supine position and expect togive I.V. normal saline solution or othervolume expander as prescribed.• Monitor patient’s heart rate and rhythm.Expect to obtain repeated 12-lead ECGtracings.• Monitor laboratory test results to checkhepatic and renal function, leukocytecount, and serum potassium level.

• Monitor patient closely for angioedema ofthe face, lips, tongue, glottis, larynx, andlimbs. For angioedema of the face andlips, stop drug and give an antihistamine,as prescribed. If tongue, glottis, or larynxis involved, assess patient for airwayobstruction and prepare to give epinephrine1:1,000 (0.3 to 0.5 ml) subcutaneouslyand maintain a patent airway.PATIENT TEACHING• Advise patient to take enalapril or enalaprilatat the same time each day.• Instruct patient not to split, crush, orchew tablets.• Inform patient that light-headedness andfainting may occur, especially during firstfew days of therapy. Advise him to changeposition slowly and avoid hazardous activitiesuntil drug’s CNS effects are known.• Inform patient that diarrhea, excessivesweating, vomiting, and other conditionsmay cause dehydration, which can lead todizziness, fainting, and very low bloodpressure during therapy. Urge sufficientfluid intake to prevent dehydration andrelated adverse reactions. If diarrhea orvomiting is severe or prolonged, instructpatient to notify prescriber.• Urge patient to immediately notify prescriberif angioedema and other adversereactions, including persistent dry cough,occur.• Advise patient to consult prescriber beforeusing salt substitutes, potassium supplements,or other drugs (including OTCdrugs) while taking drug.WARNING Caution women of childbearingage that they should use a reliable form ofcontraception and should notify prescriberimmediately if pregnancy is suspectedbecause enalapril may cause fetalharm and should be discontinued.enoxacinPenetrexClass and CategoryChemical class: FluoroquinoloneTherapeutic class: AntibioticPregnancy category: CIndications and Dosages To treat gonorrheaenoxacin 369TABLETSAdults. 400 mg as a single dose. To treat uncomplicated UTITABLETSAdults. 200 mg every 12 hr for 7 days. To treat complicated UTITABLETSAdults. 400 mg every 12 hr for 14 days.DOSAGE ADJUSTMENT Dosage reduced byhalf in patients with creatinine clearance of30 ml/min/1.73 m 2 or less.ContraindicationsHistory of tendinitis or tendon rupture,hypersensitivity to enoxacin or anyquinolone antibioticInteractionsDRUGSaluminum-, calcium-, or magnesiumcontainingantacids; didanosine (chewable orbuffered tablets); ferrous sulfate; magnesiumcontaininglaxatives; sucralfate; zinc:Interference with enoxacin absorption,decreased blood enoxacin levelbismuth: Decreased enoxacin bioavailability(by about 25% if given with or up to60 minutes after enoxacin)cyclosporine: Possibly increased blood cyclosporineleveldigoxin: Increased serum digoxin level andrisk of digitalis toxicityNSAIDs: Possibly increased risk of CNSstimulation and seizurestheophylline: Interference with theophyllinemetabolism, increased risk of theophyllinetoxicitywarfarin: Possibly increased anticoagulanteffect and increased risk of bleedingFOODScaffeine: Decreased caffeine clearance,increased adverse effects of caffeine,increased blood enoxacin levelAdverse ReactionsCNS: Dizziness, drowsiness, hallucinations,headache, insomnia, nervousness, seizures,vertigoEENT: Taste perversionGI: Abdominal pain, diarrhea, indigestion,nausea, pseudomembranous colitis, vomitingGU: VaginitisMS: Tendinitis, tendon ruptureSKIN: Photosensitivity, pruritus, rashOther: AnaphylaxisEF

370enoxacinMechanism of ActionNormally, the enzyme DNA gyrase isresponsible for unwinding and supercoilingbacterial DNA before replication, asNormal DNA DNA replicationshown at left. Enoxacin inhibits DNAgyrase, as shown at right, disrupting bacterialreplication and causing cell death.Inhibited DNA DNA replicationOriginal DNA DNAmoleculeNew New DNA DNAmoleculeDNA DNA gyraseNew New DNA DNAmoleculeEnoxacin inhibitingDNA DNA gyraseDNA DNA gyraseNew New DNA DNAblockedNursing Considerations• Be aware that enoxacin shouldn’t be givento a patient under age 18 because it maycause arthropathy.• Use drug cautiously in patients with a historyof or susceptibility to seizures.• Obtain a specimen for culture and sensitivitytests, as ordered, but expect to begintherapy before results are available.• Monitor patient closely for signs andsymptoms of anaphylaxis after first dose:shock, dyspnea, facial or laryngeal edema,loss of consciousness, paresthesia, pruritus,and urticaria. If they occur, stopenoxacin immediately, notify prescriber,and prepare to treat symptoms.• Ask if patient has a history of seizures.Take seizure and safety precautionsbecause drug may induce seizures andother adverse CNS reactions after a singledose.• Report severe or prolonged diarrhea,which may indicate pseudomembranouscolitis.• Watch for pain, inflammation, and tendonrupture, especially in shoulders, hands,and ankles.• If patient has gonorrhea, expect to obtaina serologic test for syphilis at diagnosisand 3 months after enoxacin therapy ends.PATIENT TEACHING• Stress the importance of taking the fullcourse of enoxacin exactly as prescribed,even if patient feels better before it’s finished.• Instruct patient to take drug at the sametimes each day—1 hour before or 2 hoursafter meals—with 8 oz of water.• Urge patient to avoid potentially hazardousactivities until CNS effects ofenoxacin are known.• Advise patient to notify prescriber ifsymptoms don’t improve within a fewdays.• Urge patient to drink plenty of fluids butto avoid caffeine during therapy.• Caution patient not to take aluminum-,calcium-, or magnesium-containingantacids; bismuth; didanosine (chewableor buffered tablets), if prescribed; or productsthat contain iron or zinc for 8 hoursbefore or 2 hours after taking enoxacin.• Tell patient to avoid direct sunlight, to usesunscreen and wear protective clothingoutdoors, and to report photosensitivity.• Instruct patient to stop taking enoxacinand notify prescriber immediately if a rashor other allergic reaction develops.• Instruct patient to take a missed dose assoon as he remembers, unless it’s nearlytime for the next. Warn against doublingthe dose.• Tell patient to report tendon pain orinflammation, to stop enoxacin, and torest until tendinitis or tendon rupture isruled out.

enoxaparin sodiumLovenoxClass and CategoryChemical class: Low-molecular-weightheparinTherapeutic class: AntithromboticPregnancy category: BIndications and Dosages To prevent deep vein thrombosis (DVT)after hip or knee replacement and forcontinued prophylaxis after hospitalizationfor hip replacementSUBCUTANEOUS INJECTIONAdults. 30 mg every 12 hr, starting 12 to24 hr after surgery for up to 14 days. Or,40 mg daily, starting 9 to 15 hr after hipreplacement surgery. Prophylaxis: 40 mgdaily for 3 wk. To prevent DVT after abdominal surgeryfor patients with thromboembolicrisk factors (over age 40, obesity, generalanesthesia lasting longer than 30 minutes,cancer, or a history of DVT or pulmonaryembolism)SUBCUTANEOUS INJECTIONAdults. 40 mg daily, starting 2 hr beforesurgery and lasting 7 to 10 days. To prevent ischemic complications ofunstable angina and non–Q-wave MISUBCUTANEOUS INJECTIONAdults. 1 mg/kg every 12 hr with 100 to325 mg of aspirin daily for 2 to 8 days oruntil condition is stable.DOSAGE ADJUSTMENT Dosage reduced to30 mg daily if creatinine clearance is lessthan 30 ml/min/1.73 m 2 and patient isreceiving drug as prophylaxis in abdominal,hip, or knee replacement surgery or isacutely ill. Reduced to 1 mg/kg daily if creatinineclearance is less than 30 ml/min/1.73 m 2 and drug is given with aspirin toprevent ischemic complications of unstableangina and non–Q-wave MI, with warfarinas inpatient treatment for acute DVT withor without pulmonary embolism, or withwarfarin as outpatient treatment of acuteDVT without pulmonary embolism. To treat acute ST-segment–elevation MI(STEMI)I.V. INJECTION, THEN SUBCUTANEOUS INJECTIONAdults. 30 mg I.V. as a single dose, followedenoxaparin sodium 371by 1 mg/kg subcutaneously (maximum,100 mg for first two doses). Then, 1 mg/kgsubcutaneously every 12 hr.DOSAGE ADJUSTMENT If patient also receivesa thrombolytic, enoxaparin should be given15 to 30 min before and 30 min after fibrinolytictherapy starts. If patient has percutaneouscoronary intervention, give 0.3-mg/kg I.V. bolus if last enoxaparin dose wasgiven more than 8 hr before balloon inflation.Route Onset Peak DurationSubQ Unknown 3–5 hr Up to 24 hrMechanism of ActionPotentiates the action of antithrombin III, acoagulation inhibitor. By binding withantithrombin III, enoxaparin rapidly bindswith and inactivates clotting factors (primarilythrombin and factor Xa). Withoutthrombin, fibrinogen can’t convert to fibrinand clots can’t form.IncompatibilitiesDon’t mix enoxaparin with other I.V. fluidsor drugs.ContraindicationsActive major bleeding; hypersensitivity tobenzyl alcohol (if only the multidose vial isavailable), enoxaparin, heparin (includinglow-molecular-weight heparins), or porkproducts; thrombocytopenia and positiveantiplatelet antibody test while taking lowmolecular-weightheparinsInteractionsDRUGScefamandole, cefoperazone, cefotetan, plicamycin,valproic acid: Possibly increased riskof hemorrhageNSAIDs; oral anticoagulants; platelet aggregationinhibitors, such as aspirin, dipyridamole,sulfinpyrazone, and ticlopidine;thrombolytics, such as alteplase, anistreplase,streptokinase, and urokinase: Possiblyincreased risk of bleeding and of spinal orepidural hematomaAdverse ReactionsCNS: Confusion, epidural or spinalhematoma, fever, paralysis, strokeCV: Atrial fibrillation, congestive heart failure,hyperlipidemia, peripheral edemaEENT: EpistaxisEF

372enoxaparin sodiumGI: Bloody stools, diarrhea, elevated liverfunction test results, hematemesis, melena,nausea, vomitingGU: Hematuria, menstrual irregularitiesHEME: Anemia, hemorrhage, thrombocytopeniaRESP: Dyspnea, pneumonia, pulmonaryedema or embolismSKIN: Cutaneous vasculitis, ecchymosis,persistent bleeding or oozing from mucousmembranes or surgical wounds, pruritus,skin necrosis at injection site or distantfrom injection site, urticaria, vesiculobullousrashOther: Anaphylaxis; hyperkalemia; injectionsite erythema, hematoma, irritation,and painNursing Considerations• Use enoxaparin with extreme caution inpatients with a history of heparin-inducedthrombocytopenia or an increased risk ofhemorrhage, as from bacterial endocarditis;congenital or acquired bleeding disorder;active ulcerative or angiodysplastic GIdisease; hemorrhagic stroke; recent brain,spinal, or ophthalmologic surgery; or concurrenttreatment with a platelet inhibitor.• Use cautiously in those with bleedingdiathesis, diabetic retinopathy, hepatic orrenal impairment, recent GI ulceration orhemorrhage, or uncontrolled hypertension.Expect delayed elimination in elderlypatients and those with renal insufficiency.• Drug isn’t recommended for patients withprosthetic heart valves, especially pregnantwomen, because of risk of prosthetic valvethrombosis. If enoxaparin is needed, monitorpeak and trough anti-factor Xa levelsoften and adjust dosage as needed.• Use multidose vials cautiously in pregnantwomen because benzyl alcohol may crossthe placenta and cause fetal harm.• Don’t give drug by I.M. injection.WARNING If patient is receiving enoxaparinwith epidural or spinal anesthesia orspinal puncture, watch closely for developmentof spinal hematoma, which maycause long-term or permanent paralysis. Ifyou see evidence of neurologic impairment,such as changes in sensory or motorfunction, notify prescriber immediatelybecause urgent care is needed to minimizehematoma’s effect. Risk of spinal orepidural hematoma during enoxaparintherapy is increased by indwelling epiduralcatheters, concurrent use of other drugsthat affect hemostatis, a history of traumaticor repeated epidural or spinal punctures,or a history of spinal deformity orspinal surgery.• Expect to give drug with aspirin to patientwith unstable angina, STEMI, and non–QwaveMI. To minimize risk of bleedingafter vascular procedures, give enoxaparinat recommended intervals.• After percutaneous revascularization procedure,it is important to achieve hemostasisat the puncture site. A closure devicemay be removed right away; however, if amanual compression method is used, thesheath should be removed 6 hours afterlast enoxaparin dose. If enoxaparin therapywill continue, give next scheduled doseno sooner than 6 to 8 hours after sheathremoval.• Watch closely for bleeding. Notify prescriberimmediately if platelet count fallsbelow 100,000/mm 3 . Expect to stop drugand start treatment if patient has a thromboembolicevent, such as a stroke.•Test stool for occult blood, as ordered.• Keep protamine sulfate nearby in case ofaccidental overdose.• Check serum potassium level for elevation,especially in patients with renalimpairment or concurrent use of potassium-sparingdiuretics.PATIENT TEACHING• Advise patient to notify prescriber aboutadverse reactions, especially bleeding.• Instruct patient to seek immediate help forevidence of thromboembolism, such asneurologic changes and severe shortness ofbreath.• Stress the importance of complying withfollow-up visits with prescriber.• Teach patient or family member how togive enoxaparin at home, if needed. Showpatient how to give by deep subcutaneousinjection while lying down. Instruct himnot to expel air bubble from a prefilledsyringe to avoid losing some of the drug.Tell him to insert the entire needle into askin fold held between the thumb andforefinger. Remind him to alternate injectionsites between the left and rightanterolateral abdominal wall.• To minimize bruising, caution patient not

to rub the site after giving the injection.• Review safe handling and disposal ofsyringes and needles.entacaponeComtanClass and CategoryChemical class: COMT inhibitorTherapeutic class: AntidyskineticPregnancy category: CIndications and Dosages As adjunct to manage symptoms ofParkinson’s diseaseTABLETSAdults. 200 mg with each dose of carbidopaand levodopa. Maximum: 1,600 mg daily.Mechanism of ActionInhibits peripheral catechol-O-methyltransferase(COMT), the major metabolizingenzyme for levodopa. During levodopametabolism, COMT causes the formationof a levodopa metabolite that reduces theeffectiveness of levodopa. By inhibitingCOMT, entacapone leads to higher sustainedblood levels of levodopa and itsincreased availability for diffusion into theCNS, where it is converted to dopamine. Byreplenishing dopamine stores, entacaponeincreases dopaminergic stimulation in thebrain and reduces the symptoms of Parkinson’sdisease. Carbidopa is given withlevodopa because it inhibits the peripheraldistribution of levodopa, making more levodopaavailable for transport to the brain.ContraindicationsHypersensitivity to entacapone or its components,use within 14 days of nonselectiveMAO inhibitor therapyInteractionsDRUGSampicillin, chloramphenicol, cholestyramine,erythromycin, probenecid, rifampin:Decreased biliary excretion of entacaponeapomorphine, bitolterol, dobutamine, dopamine,epinephrine, isoetharine, isoproterenol,methyldopa, norepinephrine: Possiblyincreased heart rate, arrhythmias, andexcessive changes in blood pressureMAO inhibitors (nonselective): Possiblyinhibited entacapone metabolismNursing ConsiderationsWARNING Be aware that entacapone shouldnot be discontinued abruptly becausedoing so may precipitate signs and symptomsresembling those of neurolepticmalignant syndrome, such as fever, musclerigidity, altered level of consciousness,confusion, and elevated creatine kinaselevel. Patients may also experience a rapidreemergence of parkinsonian symptoms.• Monitor patient for drug-induced diarrheaduring first 4 to 12 weeks of therapy.• Help patient with activities as neededbecause drug may increase risk of orthostatichypotension or syncope.• Watch for worsening dyskinesia becauseentacapone potentiates dopaminergicadverse effects of levodopa.• Drug may be taken with selective MAOinhibitors, such as selegiline.• Assess patient for skin changes regularlybecause risk of melanoma is increased inthose with Parkinson’s disease. It isn’t clearwhether increased risk results from thedisease or drugs used to treat it.PATIENT TEACHING• Instruct patient to always take entacaponewith carbidopa and levodopa because ithas no antidyskinetic effect of its own.• Inform patient that dizziness and sleepinessare more common at beginning oftreatment, especially in those withhypotension.• Advise patient not to participate in potentiallyhazardous activities until drug’s CNSeffects are known, especially if he’s alsotaking CNS depressants.• If patient is scheduled for surgery, instructhim to inform surgeon and anesthesioloentacapone373Adverse ReactionsCNS: Agitation, anxiety, asthenia, dizziness,dyskinesia, fatigue, hallucinations, hyperkinesia,hypokinesia, somnolenceEENT: Dry mouthGI: Abdominal pain, constipation, diarrhea,indigestion, gastritis, nauseaGU: Brown-orange urineMS: Back painRESP: DyspneaSKIN: Diaphoresis, purpuraOther: Intense urges to perform certainacts, such as gambling or sexEF

374epinephrinegist about entacapone use before the prcedurebecause COMT inhibitors such asentacapone may interact with some drugsused in surgical procedures.• Caution patient that entacapone mayincrease adverse effects of carbidopa andlevodopa, such as nausea and uncontrolledmovements. If these adverse effects doincrease, advise him to contact prescriberimmediately because carbidopa and levodopadosage may need to be lowered.• Inform patient that urine may turnbrown-orange while he’s taking entacaponebut that this is a harmless effect.• Urge patient to have regular skin examinationsby a dermatologist or other qualifiedhealth professional.• Advise patient to notify prescriber aboutintense urges, including those for gamblingor sex. Dosage may need to bereduced or drug discontinued.epinephrine(adrenaline)Adrenalin, Adrenalin ChlorideSolution, Ana-Guard, Bronkaid Mist,Bronkaid Mistometer (CAN), EpiPen(CAN), EpiPen Auto-Injector, EpiPen Jr.(CAN), EpiPen Jr. Auto-Injector,Primatene MistepinephrinebitartrateAsthmahaler Mist, BronkaidSuspension MistracepinephrineAsthmaNefrin, MicroNefrin, Nephron,VaponefrinClass and CategoryChemical class: CatecholamineTherapeutic class: Antianaphylactic, bronchodilator,cardiac stimulant, vasopressorPregnancy category: CIndications and Dosages To treat bronchospasmINHALED SOLUTION (EPINEPRHINE)Adults and children age 4 and over. 1 to3 inhalations (10 drops) by hand-bulb nebulizerno more than every 3 hr.INHALED SOLUTION (RACEPINEPHRINE)Adults and children age 4 and over.3 inhalations of 0.5 ml (10 drops) by handbulbnebulizer, or 0.2 to 0.5 ml (4 to10 drops) of diluted solution given over15 min by jet nebulizer; repeated after 3 to4 hr, if needed.ORAL INHALED AEROSOL (EPINEPHRINE BITAR-TRATE)Adults and children age 4 and over.1 inhalation (160 mcg) repeated after 1 min,if needed; then repeated after at least 3 hr.ORAL INHALER (EPINEPHRINE)Adults and children age 4 and over.1 inhalation (200 to 275 mcg) repeatedafter at least 1 min, if needed; then repeatedafter at least 3 hr. To treat croupINHALED SOLUTION (RACEPINEPHRINE)Children. 0.05 ml/kg diluted to 3 ml innormal saline solution and given over15 min every 2 hr, as needed. Maximum:0.5 ml/dose. To treat anaphylaxisI.V. INFUSIONAdults and adolescents. 100 to 250 mcggiven slowly.I.M. OR SUBCUTANEOUS INJECTIONAdults and adolescents. 100 to 500 mcgrepeated every 10 to 15 min, as needed.Maximum: 1 mg/dose; three doses.Children. 10 mcg/kg repeated every 15 minfor three doses. Maximum: 300 mcg/dose. To treat severe anaphylactic shockI.V. INFUSIONAdults. 1 mcg/min titrated to 2 to 10 mcg/min for desired hemodynamic response. To treat cardiac arrestI.V. INJECTIONAdults. 0.5 to 1 mg every 3 to 5 min duringresuscitation.Children. 10 mcg/kg followed by 100 mcg/kg every 3 to 5 min, if needed. If two dosesproduce no response, subsequent doses areincreased to 200 mcg/kg every 5 min.Neonates. 10 to 30 mcg/kg every 3 to 5 min.Mechanism of ActionActs on alpha and beta receptors. This nonselectiveadrenergic agonist stimulates:• alpha 1 receptors, which constricts arteriesand may decrease bronchial secretions• presynaptic alpha 2 receptors, whichinhibits norepinephrine release by way of

negative feedback• postsynaptic alpha 2 receptors, which constrictsarteries• beta 1 receptors, which induces positivechronotropic and inotropic responses• beta 2 receptors, which dilates arteries,relaxes bronchial smooth muscles, increasesglycogenolysis, and prevents mast cellsfrom secreting histamine and other substances,thus reversing bronchoconstrictionand edema.Route Onset Peak DurationI.V., I.M. Rapid Unknown 1–2 minSubQ 5–10 min In 20 min ShortOral 1–5 min In 5–15 Up toinhalation min 3 hrIncompatibilitiesDon’t mix epinephrine with alkalies or oxidizingagents, including bromine, chlorine,chromates, iodine, metal salts (as fromiron), nitrites, oxygen, and permanganates,because these substances can destroy epinephrine.ContraindicationsCerebral arteriosclerosis, coronary insufficiency,counteraction of phenothiazineinducedhypotension, dilated cardiomyopathy,general anesthesia with halogenatedhydrocarbons or cyclopropane, hypersensitivityto epinephrine or its components,labor, angle-closure glaucoma, organicbrain damage, shock (nonanaphylactic)InteractionsDRUGSalpha-adrenergic blockers, drugs with alphaadrenergicaction, rapid-acting vasodilators:Blockage of epinephrine’s alpha-adrenergiceffect, possibly causing severe hypotensionand tachycardiaamyl nitrite, nitrates: Decreased antianginaleffectsantihypertensives, diuretics used to treathypertension: Decreased antihypertensiveeffectsbeta blockers: Mutual inhibition of therapeuticeffects, possibly severe hypertensionand cerebral hemorrhagechlorpheniramine, diphenhydramine, levothyroxine,MAO inhibitors, tricyclic antidepressants,tripelennamine: Possibly increasedAdverse ReactionsCNS: Anxiety, apprehensiveness, chills,fever, dizziness, drowsiness, hallucinations,headache, insomnia, light-headedness,nervousness, restlessness, seizures, stroke,temporary worsening of Parkinson’s disease,tremor, weaknessCV: Arrhythmias, including ventricular fibrillation;chest discomfort or pain; fast,irregular, or slow heartbeat; palpitations;severe hypertension; tachycardiaEENT: Blurred vision, dry mouth or throat,miosisENDO: Hyperglycemia in diabeticsGI: Anorexia, heartburn, nausea, vomitingGU: DysuriaMS: Muscle twitching, severe musclespasmsRESP: DyspneaSKIN: Cold skin, diaphoresis, ecchymosis,flushed or red face or skin, pallor, tissuenecrosisOther: Hyperkalemia; hypokalemia; injecepinephrine375effects of epinepherinedigoxin, diuretics, quinidine: Increased riskof arrhythmiasdihydroergotamine, ergoloid mesylates, ergonovine,ergotamine, methylergonovine,methysergide, oxytocin: Increased risk ofvasoconstriction, causing gangrene, peripheralvascular ischemia, or severe hypertensionergot alkaloids: Possibly reversed pressoreffects of epinephrinehydrocarbon inhalation anesthetics:Increased risk of severe atrial and ventriculararrhythmiasinsulin, oral antidiabetic drugs: Decreasedeffects of these drugsMAO inhibitors: Possibly increased vasopressoreffect of epinephrine and hypertensivecrisismaprotiline, tricyclic antidepressants:Potentiated cardiovascular effects of epinephrine,possibly causing arrhythmias,hyperpyrexia, severe hypertension, or tachycardiasympathomimetics: Additive CNS stimulation,increased cardiovascular effects ofeither drugthyroid hormones: Increased effects of eitherdrugxanthines: CNS stimulation and toxic effectsEF

376eplerenonetion site coldness, hypoaesthesia, pain, pallor,and stingingNursing Considerations• Use epinephrine with extreme caution inpatients with angina, arrhythmias, asthma,degenerative heart disease, or emphysema.Epinephrine’s inotropic effect equals thatof dopamine and dobutamine; itschronotropic effect exceeds that of both.• Use drug cautiously in elderly patients andthose with cardiovascular disease (otherthan listed above), diabetes mellitus, hypertension,hyperthyroidism, prostatic hypertrophy,and psychoneurologic disorders.• Be aware that some preparations containsulfites, which may cause allergic-typereactions. However, the presence of sulfitesin epinephrine should not deter its use ina patient with anaphylaxis, even if patientis sensitive to sulfites. Monitor patientclosely for adverse effects.• Dilute the 1:1,000 (1-mg/ml) solution ofparenteral epinephrine before I.V. use.• Shake suspension thoroughly before withdrawingdose; refrigerate it between uses.• Inspect epinephrine solution or suspensionbefore use. If it’s pink or brown, airhas entered a multidose vial. If it’s discoloredor contains particles, discard it. Alsodiscard unused portions of parenteral epinephrine.• For injection, rotate sites because repeatedinjections in the same site may cause vasoconstrictionand localized necrosis.• Be aware that drug shouldn’t be given byintra-arterial injection because markedvasoconstriction may cause gangrene.• Avoid giving injection into buttocks because drug may be less effective when giventhere, especially for treating anaphylaxis.• Monitor patient for potassium imbalances.Initially, hyperkalemia occurs when hepatocytesrelease potassium. Hypokalemiamay quickly follow as skeletal muscles takeup potassium.• To minimize insomnia, give last dose a fewhours before bedtime.WARNING To treat cardiac arrest, at leasttwice the peripheral I.V. dose of epinephrinemay be given by endotracheal instillation.Two dilutions are needed for thisregimen; use great caution to avoid makingmedication errors.PATIENT TEACHING• Warn patient not to exceed recommendeddosage or to shorten interval because ofthe risk of adverse reactions and tolerance.• Advise patient to notify prescriber ifsymptoms don’t improve or if theyimprove but then worsen.• Instruct patient to take the day’s last dosea few hours before bedtime to avoid insomnia.• Caution patient not to use inhalationsolution that is pink or brown or that containsparticles.• Teach patient how to use oral inhaler orinhalation solution, as needed.• If patient also uses an oral corticosteroidinhaler, instruct him to use epinephrineinhaler first, wait 5 minutes, and then usecorticosteroid inhaler to increase effectiveness.• Teach patient and family how to administerepinephrine subcutaneously in anemergency. Tell them to inject drug intoanterolateral aspect of the thigh, throughthe clothing if necessary. Explain thatsolution is light sensitive and should bestored in the carrying case and at roomtemperature. Tell them not to refrigeratedrug and to replace solution if it discolors.• Caution patient to avoid accidental injectingdrug into his fingers, hands, toes, orfeet because epinephrine is a strong vasoconstrictorand could cause loss of bloodflow to the area, resulting in gangrene. Ifaccidental injection occurs in any of theseareas, instruct patient to go immediatelyto nearest emergency room.• Advise patient to notify prescriber immediatelyif he has blurred vision, chest pain,trouble breathing, a fast or irregular heartbeat,or increased sweating.• Inform patient with diabetes that epinephrinemay cause hyperglycemia. Informpatient with Parkinson’s disease thatsymptoms my temporarily worsen but thisshould not deter use of drug.eplerenoneInspraClass and CategoryChemical class: Methyl ester

Therapeutic class: AntihypertensivePregnancy category: BIndications and Dosages To improve survival of stable patientswith left ventricular systolic dysfunctionand congestive heart failure after anacute MITABLETSAdults. Initial: 25 mg daily, increased to50 mg daily within 4 wk, if needed. To treat hypertension alone or withother antihypertensive drugsTABLETSAdults. Initial: 50 mg daily, increased to50 mg b.i.d. after 4 wk, if needed.DOSAGE ADJUSTMENT For patients takingweak CYP450 3A4 inhibitors, such aserythromycin, saquinavir, verapamil, andfluconazole, initial dosage reduced to 25 mgdaily.Mechanism of ActionBlocks the binding of aldosterone at itsmineralocorticoid receptor sites located inthe kidneys, heart, blood vessels, and brain.This action decreases blood pressure bypreventing aldosterone from inducing sodiumreabsorption and possibly other mechanismsthat contribute to raising blood pressure.ContraindicationsHyperkalemia (serum potassium levelgreater than 5.5. mEq/L); hypersensitivityto eplerenone or its components; renalinsufficiency (serum creatinine level greaterthan 2.0 mg/dl in men or 1.8 mg/dl inwomen or creatinine clearance less than50 ml/min/1.73 m 2 ); type 2 diabetes mellituscomplicated by microalbuminuria; useof potassium supplements, potassium-sparingdiuretics, or strong CYP3A4 inhibitors,such as ketoconazole or itraconazoleInteractionsDRUGSACE inhibitors, angiotensin II receptorantagonists: Increased risk of hyperkalemiaCYP450 3A4 inhibitors: Increased bloodlevel and effect of eplerenonelithium: Possibly lithium toxicityNSAIDs: Possibly reduced antihypertensiveeffect of eplerenoneFOODSgrapefruit: Possibly increased blood leveland effect of eplerenoneAdverse ReactionsCNS: Dizziness, fatigue, headacheCV: Angina pectoris, hypercholesterolemia,hypertriglyceridemia, MIENDO: Gynecomastia, mastodyniaGI: Abdominal pain, diarrhea, increasedliver enzyme levelsGU: Albuminuria, elevated BUN and serumcreatinine levels, vaginal bleedingRESP: CoughOther: Flulike symptoms, hyperkalemia,hyponatremia, increased uric acid levelNursing Considerations• Monitor patient’s blood pressure regularlyto evaluate eplerenone effectiveness.• Monitor patient’s serum potassium levelevery 2 weeks for the first month or two oftherapy and monthly thereafter, as ordered.• Be aware that patients who take an ACEinhibitor or an angiotensin II receptorantagonist during eplerenone therapy havean increased risk of hyperkalemia.PATIENT TEACHING• Caution patient not to use potassiumcontainingsupplements or salt substitutesbecause increased potassium levels canlead to serious adverse reactions toeplerenone.• Urge patient to tell all prescribers abouteplerenone use because of possible interactions.epoetin alfa(EPO, erythropoietinalfa, recombinanterythropoietin,r-HuEPO)Epogen, Eprex (CAN), Procritepoetin alfa 377Class and CategoryChemical class: 165–amino acid glycoproteinidentical to human erythropoietinTherapeutic class: AntianemicPregnancy category: CIndications and Dosages To treat anemia from renal failureI.V. OR SUBCUTANEOUS INJECTIONAdults and adolescents. Initial: 50 to100 units/kg 3 times/wk, increased byEF

378epoetin alfa25 units/kg after 8 wk if hematocrit hasn’trisen by 5 or 6 points or is below desiredrange (30% to 36%). Maintenance: Dosagegradually decreased by 25 units/kg at 4-wkintervals or longer to lowest dose that keepshematocrit at 30% to 36%. Maximum:300 units/kg 3 times/wk.Children on dialysis. 50 units/kg 3 times/wk; increased after 8 wk if hematocrit hasn’trisen by 5 or 6 points and is still belowdesired range of 30% to 36%. Maintenance:Dosage gradually decreased to lowest dosethat keeps hematocrit at 30% to 36%. To treat anemia in HIV-infectedpatients who take zidovudineI.V. OR SUBCUTANEOUS INJECTIONAdults with serum erythropoietin level of500 mU/ml or less who receive 4,200 mgor less of zidovudine/wk. Initial: 100 units/kg 3 times/wk, increased by 50 to 100 units/kg every 4 to 8 wk after 8 wk of therapy.Maintenance: Dosage gradually titrated tomaintain desired response, based on suchfactors as variations in zidovudine dosageand occurrence of infection or inflammation.Maximum: 300 units/kg 3 times/wk. To treat anemia from chemotherapySUBCUTANEOUS INJECTIONAdults. Initial: 150 units/kg 3 times/wk.Dosage decreased by 25% if hemoglobinlevel approaches 12 g/dl or increases morethan 1 g/dl in any 2-wk period. Dose withheldif hemoglobin exceeds 13 g/dl andresumed at 25% less than previous doseafter hemoglobin has fallen to 12 g/dl.Dosage increased to 300 units/kg 3 times/wk after 8 wk if response is inadequate.Maximum: 300 units/kg 3 times/wk. Or,40,000 units weekly. Dosage decreased by25% if hemoglobin level approaches 12 g/dlor increases more than 1 g/dl in any 2-wkperiod. Dose withheld if hemoglobin levelexceeds 13 g/dl and resumed at 25% lessthan previous dose after hemoglobin hasfallen to 12 g/dl. Dosage increased to60,000 units weekly after 8 wk if hemoglobinlevel has not increased at least 1 g/dlwithout RBC transfusion. To reduce the need for blood transfusionin anemic patients having surgerySUBCUTANEOUS INJECTIONAdults. 300 units/kg daily for 10 days beforesurgery, on day of surgery, and 4 days aftersurgery; or 600 units/kg/wk starting 3 wkbefore surgery for a total of 3 doses. Doseof 300 units/kg repeated on day of surgery.DOSAGE ADJUSTMENT For patients with anemiafrom renal failure, dosage temporarilyreduced or drug discontinued if hematocritreaches or exceeds 36%; drug is resumed ata lower dose when hematocrit returns todesired range. For patients with anemiafrom zidovudine use, therapy temporarilystopped if hematocrit reaches or exceeds40% and is resumed at a 25% lower dosewhen hematocrit returns to desired range.Route Onset Peak DurationI.V., In 2–6 wk In 2 mo AboutSubQ2 wkMechanism of ActionStimulates the release of reticulocytes fromthe bone marrow into the bloodstream,where they develop into mature RBCs.IncompatibilitiesDon’t mix epoetin alfa with any other drug.ContraindicationsHypersensitivity to human albumin orproducts made from mammal cells, uncontrolledhypertensionInteractionsDRUGSantihypertensives: Increased blood pressure(to hypertensive level), especially whenhematocrit rises rapidlyheparin: Increased heparin requirement inhemodialysis patientsiron supplements: Increased iron requirementand need for increased doseAdverse ReactionsCNS: Anxiety, asthenia, dizziness, fatigue,fever, headache, insomnia, paresthesia,seizures, strokeCV: Chest pain, deep vein thrombosis,edema, hypertension, MI, tachycardiaGI: Constipation, diarrhea, indigestion,nausea, vomitingGU: UTIHEME: PolycythemiaMS: Arthralgia, bone pain, muscle weaknessRESP: Cough, dyspnea, pulmonary congestion,upper respiratory tract infectionSKIN: Rash, pruritus, urticariaOther: Flulike symptoms, hyperkalemia,injection site reaction, trunk pain

Nursing Considerations• Use epoetin alfa cautiously in patients whohave conditions that could decrease ordelay response to drug, such as aluminumintoxication, folic acid deficiency, hemolysis,infection, inflammation, iron deficiency,malignant neoplasm, osteitis (fibrosacystica), or vitamin B 12 deficiency.• Also use drug cautiously in patients withcardiovascular disorders caused by hypertension,a history of porphyria or seizures,vascular disease, or a hematologic disorder,such as hypercoagulation, myelodysplasticsyndrome, or sickle cell disease.WARNING Multidose vial of epoetin containsbenzyl alcohol, which can cause afatal toxic syndrome in neonates andimmature infants characterized by CNS,respiratory, circulatory, and renal impairmentand metabolic acidosis.• Use lowest possible dose in cancer patientsbecause drug has shortened survival rateand increased tumor progression inpatients with certain types of cancers, suchas breast, non-small cell lung, head andneck, and lymphoid cancers. Drug shouldonly be used to treat anemia caused bymyelosuppressive chemotherapy in cancerpatients.• Don’t shake vial while preparing to avoiddenaturing glycoprotein, inactivating drug.• Discard unused portion of single-dose vialbecause it contains no preservatives.Discard unused portion of multidose vialafter 21 days.• Baseline hemoglobin level should be above10 but below 13 g/dl if drug is given topatient scheduled for surgery. Watch closelythroughout surgical period for deepvein thrombosis, especially in patients notreceiving prophylactic anticoagulation,because risk increases.WARNING Target hemoglobin shouldn’texceed 12 g/dl when treating anemia inpatients with chronic renal failure.Exceeding 12 g/dl increases risk of lifethreateningadverse cardiovascular effects.• Expect to increase heparin dose if patientreceives hemodialysis because epoetin alfacan increase the RBC volume, which couldcause clots to form in the dialyzer, hemodialysisvascular access, or both.• Expect to give an iron supplement (I.V.iron dextran, if needed) because ironrequirements rise when erythropoiesisconsumes existing iron stores.• Monitor drug effectiveness by checkinghematocrit, typically twice weekly until itstabilizes at 30% to 36%. After that, monitoringcan be less frequent.• Take seizure precautions.• Check hemoglobin and hematocrit levels,as ordered, with twice-weekly measurementsrecommended for chronic renalfailure patients and weekly measurementsrecommended for zidovudine-treatedHIV-infected and cancer patients.• Risk of hypertensive or thrombotic complicationsincreases if hematocrit risesmore than 4 points in 2 weeks.PATIENT TEACHING• Before epoetin alfa therapy starts, explainits serious adverse effects.• Teach patient how to administer drug andhow to dispose of needles properly.Caution him against reusing needles.• Advise patient that the risk of seizures ishighest during the first 90 days of epoetinalfa therapy. Urge him not to engage inhazardous activities during this time.• Stress the importance of complying withthe dosage regimen and keeping follow-upmedical appointments and appointmentsfor laboratory tests.• Encourage patient to eat iron-rich foods.• Review possible adverse reactions, andurge patient to notify prescriber if heexperiences chest pain, headache, hives,rapid heartbeat, rash, seizures, shortness ofbreath, or swelling.• Advise women of childbearing age to useeffective contraception during therapy ifpregnancy isn’t desired because mensesmay resume after epoetin alfa therapy.epoprostenolsodium(PGI 2 , PGX, prostacyclin)Flolanepoprostenol sodium 379Class and CategoryChemical class: Natural prostaglandinTherapeutic class: Antihypertensive,vasodilatorPregnancy category: BEF

380epoprostenol sodiumIndications and Dosages To provide long-term treatment of primarypulmonary hypertensionI.V. INFUSIONAdults. Initial: 2 nanograms/kg/min,increased by 2 nanograms/kg/min every15 min or longer until dose-limiting effectsoccur (abdominal, chest, or musculoskeletalpain; anxiety; bradycardia; dizziness; dyspnea;flushing; headache; hypotension; nausea;tachycardia; vomiting; or other adversereactions). Maintenance: Dosage reduced byat least 4 nanograms/kg/min by continuousinfusion.DOSAGE ADJUSTMENT Infusion rate adjustedbased on persistence, recurrence, or worseningof primary pulmonary hypertensionand dose-related adverse reactions.Mechanism of ActionDirectly relaxes vascular smooth musclesthrough its action as a natural prostaglandin.This results in arterial dilation andinhibition of platelet aggregation. Theseactions decrease pulmonary vascular resistance,increase cardiac index and oxygendelivery, and limit thrombus formation.IncompatibilitiesDon’t mix epoprostenol with otherparenteral solutions or drugs.ContraindicationsHypersensitivity to epoprostenol or itscomponents; long-term use in patients withheart failure caused by severe left ventricularsystolic dysfunction; pulmonary edemathat developed while establishingepoprostenol dosageInteractionsDRUGSanticoagulants, antiplatelet drugs, NSAIDs:Increased risk of bleedingantihypertensives, diuretics, vasodilators:Decreased blood pressureAdverse ReactionsCNS: Anxiety, chills, confusion, dizziness,fever, headache, nervousness, paresthesia,syncope, weaknessCV: Bradycardia, chest pain, hypotension,tachycardiaGI: Abdominal pain, diarrhea, nausea, vomitingHEME: Bleeding events, thrombocytopeniaMS: Arthralgia, jaw pain, myalgiaRESP: Dyspnea, hypoxiaSKIN: FlushingOther: Flulike symptoms, injection siteinfection and pain, sepsis, weight loss orgainNursing Considerations• Use epoprostenol cautiously in elderlypatients because they may have decreasedhepatic, renal, or cardiac function, orother diseases or may receive other drugsthat can interact with epoprostenol.• Reconstitute drug only with sterile diluentthat comes with package. Don’t dilutereconstituted epoprostenol.• To make 100 ml of reconstituted solutionat 3,000 nanograms/ml, dissolve contentsof 0.5-mg vial with 5 ml of diluent; withdraw3 ml and add diluent to make100 ml. To make 100 ml of solution at5,000 nanograms/ml, dissolve contents of0.5-mg vial with 5 ml of diluent; withdrawcontents and add diluent to make 100 ml.To make 100 ml of solution at10,000 nanograms/ml, dissolve contents oftwo 0.5-mg vials each with 5 ml of diluent;withdraw contents and add diluent tomake 100 ml. To make 100 ml of solutionat 15,000 nanograms/ml, dissolve contentsof 1.5-mg vial with 5 ml of diluent; withdrawcontents and add diluent to make100 ml.• Give continuous infusion through centralvenous catheter. Use peripheral I.V. infusiononly until central access established.• Use a small, lightweight, ambulatory infusionpump able to deliver 2 nanograms/kg/min. It should have alarms for occlusion,end of infusion, and low battery. Usea polyvinyl chloride, polypropylene, orglass reservoir. Keep a backup pump andinfusion set nearby to minimize disruptionsin delivery.• At room temperature, administer a singlecontainer of reconstituted solution over8 hours. For extended use at temperaturesabove 77° F (25° C), use a cold pouch withfrozen gel packs to keep drug at 36° to 46°F (2° to 8° C) for 12 hours.• After a new infusion rate has been established,monitor patient closely for adversereactions. Measure each blood pressurewith patient standing and supine. Also,monitor heart rate for several hours afterdosage adjustment.

• During prolonged infusion, watch fordose-related adverse reactions. If theydevelop, expect to decrease infusion by2 nanograms/kg/min every 15 minutes, asprescribed, until reactions resolve.• Avoid abrupt withdrawal or a sudden largereduction in infusion rate, which couldcause rebound pulmonary hypertension(asthenia, dizziness, dyspnea) or death.• Protect reconstituted drug from light, andrefrigerate for no more than 48 hours.Discard solution that has been frozen orbeen refrigerated for more than 48 hours.• Watch for evidence of bleeding, especiallyif patient has other risk factors for bleeding,because epoprostenol is a potentinhibitor of platelet aggregation.PATIENT TEACHING• Explain that epoprostenol is infused continuouslythrough permanent indwellingcentral venous catheter by infusion pump.• Stress that patient must commit to longtermtherapy, possibly for years.• Teach patient or caregiver how to reconstitutedrug, administer it, and care for thepermanent central venous catheter.• Urge patient to maintain prescribed infusionrate and to consult prescriber beforealtering it.• Caution patient that even brief interruptionsin drug delivery may cause rapidworsening of symptoms.• Instruct patient to notify prescriber ifadverse reactions occur.• Make sure patient or caregiver has readyaccess to emergency phone numbers.eprosartan mesylateTevetenClass and CategoryChemical class: Monomethanesulfonate,nonbiphenyl nontetrazole angiotensin IIreceptor antagonistTherapeutic class: AntihypertensivePregnancy category: Not ratedIndications and Dosages To control blood pressure in patientswith essential hypertensionTABLETSAdults. Initial: 600 mg daily. Maximum:800 mg once daily or in divided doses b.i.d.eprosartan mesylate; eptifibatide 381Mechanism of ActionBlocks the effects of angiotensin II (apotent vasoconstrictor that’s part of therenin-angiotensin-aldosterone system) byblocking its binding to angiotensin I receptorsin vascular smooth muscles, adrenalglands, and other tissues. This action haltsangiotensin II’s negative feedback on reninsecretion. Thus, circulating renin andangiotensin II levels rise and vascular resistancedeclines.ContraindicationsHypersensitivity to eprosartan or componentsAdverse ReactionsCNS: Depression, dizziness, drowsiness,fatigueCV: Angina pectoris, atrial fibrillation,bradycardia, extrasystole, hypertriglyceridemia,hypotension, palpitations, tachycardiaEENT: Pharyngitis, rhinitisGI: Abdominal painGU: Oliguria, UTIMS: Myalgia, rhabdomyolysisRESP: Cough, upper respiratory tract infectionNursing Considerations• Watch for excessive hypotension if patientreceives other cardiac drugs.• Expect maximum blood pressure responseafter about 3 weeks.• Be aware that, unlike ACE inhibitors,eprosartan doesn’t affect bradykininbreakdown and cause the characteristicACE cough.PATIENT TEACHING• Explain that maximum blood pressureresponse may not occur for 3 to 4 weeks.• Tell patient that drug may cause dizziness,drowsiness, or very low blood pressure.Urge him to rise slowly to upright position.eptifibatideIntegrilinClass and CategoryChemical class: Cyclic heptapeptideTherapeutic class: Platelet aggregationinhibitorPregnancy category: BEF

382eptifibatideIndications and Dosages To treat unstable angina and non–QwaveMII.V. INFUSIONAdults. Initial: 180 mcg/kg over 1 to 2 minas soon as possible after diagnosis.Maintenance: 2 mcg/kg/min by continuousinfusion starting immediately after initialdose and continuing until discharge orcoronary artery bypass grafting, up to 72 hr.DOSAGE ADJUSTMENT For patients withserum creatinine level of 2 to 4 mg/dl, initialdosage reduced to 135 mcg/kg over 1 to2 min and maintenance dosage to 0.5 mcg/kg/min by continuous infusion. Dosage discontinuedbefore coronary artery bypassgraft surgery or if platelet count is less than100,000/mm 3 . To prevent thrombosis related to percutaneoustransluminal coronary angioplasty(PTCA)I.V. INFUSIONAdults. Initial: 135 mcg/kg over 1 to 2 minimmediately before procedure.Maintenance: 0.5 mcg/kg/min by continuousinfusion beginning just after initialdose and continuing for 20 to 24 hr.Maximum: 96 hr of therapy.Route Onset Peak DurationI.V. Immediate In 15 min 4–8 hrMechanism of ActionReversibly inhibits platelet aggregation bypreventing fibrinogen, von Willebrand factor,and other adhesive ligands from bindingto glycoprotein IIb/IIIa receptors onactivated platelets. As a result, eptifibatidedisrupts final cross-linking stage of plateletaggregation—and thrombus formation.IncompatibilitiesDon’t administer eptifibatide through thesame I.V. line as furosemide.ContraindicationsActive bleeding or stroke during prior30 days, bleeding diathesis, dependency ondialysis, history of hemorrhagic stroke,hypersensitivity to eptifibatide, major surgeryduring previous 4 weeks, serum creatininelevel of 2 mg/dl or higher (for 180-mcg/kg dose or 2-mcg/kg/min infusion) or4 mg/dl or higher (for 135-mcg/kg dose or0.5-mcg/kg/min infusion), severe uncontrolledhypertension (systolic pressureabove 200 mm Hg, diastolic pressure above110 mm Hg), thrombocytopenia (plateletcount below 100,000/mm 3 )InteractionsDRUGSanticoagulants, clopidogrel, dipyridamole,NSAIDs, thrombolytics, ticlopidine: Additivepharmacologic effects, increased risk ofbleedingother platelet aggregation inhibitors (especiallyinhibitors of platelet receptor glycoproteinIIb/IIIa, such as abciximab): Increasedrisk of additive pharmacologic effectsAdverse ReactionsCNS: Intracranial hemorrhageCV: HypotensionGI: HematemesisGU: HematuriaHEME: Bleeding, decreased hemoglobinlevel, thrombocytopeniaOther: AnaphylaxisNursing Considerations• Expect to obtain APTT and PT as a baselineand hematocrit, platelet count, andhemoglobin and serum creatinine levelsbefore therapy.• Withdraw bolus dose of eptifibatide froma 10-ml (2 mg/ml) vial into a syringe.• Using vented I.V. infusion set, give continuousinfusion directly from the 100-ml(0.75 mg/ml) vial. Be sure to center thespike in the circle on top of vial stopper.• Expect to keep APTT between 50 and70 seconds or per facility protocol duringtherapy unless patient has PTCA.• If patient has PTCA, expect to maintainactivated clotting time between 200 and250 seconds during the procedure.• During therapy, avoid arterial and venouspunctures, I.M. injections, urinarycatheters, nasotracheal or nasogastric intubation,and use of noncompressible I.V.sites, such as subclavian and jugular veins.• Expect to discontinue eptifibatide andheparin and monitor patient closely ifplatelet count falls below 100,000/mm 3 .• Plan to stop drug, as prescribed, if patientundergoes coronary artery bypass surgery.PATIENT TEACHING• Instruct patient to immediately reportbleeding during eptifibatide therapy.• Reassure patient that he’ll be monitored

closely throughout therapy.• Advise patient to avoid activities that maylead to bruising and bleeding.ergoloid mesylates(dihydrogenated ergotalkaloids)Gerimal, Hydergine, Hydergine LCClass and CategoryChemical class: Dihydrogenated ergot alkaloidderivativeTherapeutic class: Antidementia adjunct,cerebral metabolic enhancerPregnancy category: Not ratedIndications and Dosages To treat age-related decline in mentalcapacityCAPSULES, ORAL SOLUTION, S.L. TABLETS, TABLETSAdults. 1 to 2 mg t.i.d.Route Onset Peak DurationP.O. 3 wk Unknown Unknownor moreMechanism of ActionMay increase cerebral metabolism, bloodflow, and oxygen uptake. These actions mayincrease neurotransmitter levels.ContraindicationsAcute or chronic psychosis, hypersensitivityto ergoloid mesylates or their componentsInteractionsDRUGSdelavirdine, efavirenz, indinavir, nelfinavir,saquinavir: Increased risk of ergotism(blurred vision, dizziness, and headache)dopamine: Increased risk of gangreneAdverse ReactionsCNS: Dizziness, headache, light-headedness,syncopeCV: Bradycardia, orthostatic hypotensionEENT: Blurred vision, nasal congestion,tongue soreness (with S.L. tablets)GI: Abdominal cramps, anorexia, nausea,vomitingSKIN: Flushing, rashNursing Considerations• Expect ergoloid mesylates to be prescribedergoloid mesylates; ergotamine tartrate 383only after a pathophysiologic cause formental decline has been ruled out.• Measure blood pressure and pulse rate andrhythm before therapy begins and monitorthem frequently during therapy.• If bradycardia or hypotension develops,expect to discontinue drug permanently.PATIENT TEACHING• Stress the importance of adhering to prescribeddosage and schedule.• Teach caregiver to place S.L. tablet underpatient’s tongue and withhold food, fluids,and cigarettes until tablet dissolves.• Instruct patient not to swallow S.L. tablets.• Advise caregiver to skip a missed dose andresume the regular dosing schedule. Warnagainst doubling the dose, and urge caregiverto notify prescriber if patient missestwo or more doses in a row.• Instruct caregiver to store drug in a tightlyclosed, light-resistant container.• Inform caregiver and family that drug maytake 3 to 4 weeks to produce its effects.• Stress the importance of follow-up care.ergotamine tartrateErgomar (CAN), Ergostat, Gynergen(CAN), Medihaler Ergotamine (CAN)Class and CategoryChemical class: Ergot alkaloidTherapeutic class: Vascular headachesuppressantPregnancy category: XIndications and Dosages To relieve vascular headaches, such asmigraine, migraine variants, and clusterheadachesS.L. TABLETSAdults. Initial: 2 mg at first sign of attackand repeated every 30 min, p.r.n.Maximum: 6 mg/day and no more thantwice/wk at least 5 days apart.TABLETSAdults. Initial: 1 to 2 mg at first sign ofattack, repeated every 30 min, p.r.n.Increased to 3 mg for subsequent attacks ifneeded and if lower dose was well tolerated.Maximum: 6 mg daily.ORAL INHALATION AEROSOLAdults. 1 (360-mcg) inhalation at first signof attack and repeated every 5 min, p.r.n.EF

384Indications and Dosages To treat moderate to severe infections,such as complicated intra-abdominalinfections due to Escherichia coli,Clostridium clostridioforme,Eubacterium lentum, Pepto-streptoertapenemsodiumMaximum: 2.16 mg daily and no more thantwice/wk at least 5 days apart.Route Onset Peak DurationP.O., S.L. Unknown 1–5 hr UnknownMechanism of ActionDirectly stimulates vascular smooth muscles,constricting arteries and veins anddepressing vasomotor centers in the brain.ContraindicationsCoronary artery disease, hypersensitivity toergot alkaloids, hypertension, impairedhepatic or renal function, malnutrition,peripheral vascular disease (Raynaud’s disease,severe arteriosclerosis, syphilitic arteritis,thromboangiitis obliterans, thrombophlebitis),pregnancy or risk of pregnancy,sepsis, severe pruritusInteractionsDRUGSbeta blockers: Increased risk of vasoconstrictionand, possibly, peripheral gangreneerythromycin, troleandomycin: Possiblyincreased risk of peripheral vasospasm andischemianitrates: Increased ergotamine effects,decreased antianginal effects of nitrates,increased risk of hypertensionsumatriptan: Possibly additive vasoconstrictionvasoconstrictors: Increased risk of dangeroushypertensionACTIVITIESsmoking: Possibly increased risk of peripheralvasoconstriction and ischemiaAdverse ReactionsCNS: Anxiety, confusion, dizziness, drowsiness,paresthesia, severe headacheCV: Chest pain, fast or slow heart rate,heart valve fibrosis, increased or decreasedblood pressure, MI, weak pulseEENT: Dry mouth, miosis, vision changesGI: Nausea, vomitingMS: Arm, back, or leg pain; muscle weaknessin legsSKIN: Cold, cyanotic, or pale feet or hands;pruritusOther: Edema of face, feet, fingers, or lowerlegs; physical dependenceNursing Considerations• Use ergotamine cautiously in elderlypatients.• If patient receives long-term therapy,monitor pain control; he may needincreasingly higher doses to obtain relief.• Notify prescriber at the first sign of vasospasmand expect to discontinue drug.PATIENT TEACHING• Teach patient to take a tablet at the firstsign of headache and to lie down in aquiet, dark room.• Instruct patient not to swallow S.L. tabletbut to let it dissolve under his tongue.Advise him not to drink, eat, or smokeuntil tablet has dissolved.• Stress the importance of adhering to prescribeddosage and schedule because ofdrug’s potential for dependence.• Warn patient not to smoke while takingergotamine (especially heavy smokers)because combining drug with nicotine,which also constricts vessels, may increaserisk of peripheral vascular ischemia.• Advise patient to notify prescriber if usualdoses fail to relieve headaches or ifheadache frequency or severity increases.• Urge patient to avoid alcohol because itworsens headaches. Also suggest thatpatient avoid excessive cold, which mayincrease peripheral vasoconstriction.• Instruct patient to notify prescriber if aninfection develops because severe infectionmay increase sensitivity to drug.• Advise patient to notify prescriber if heexperiences chest pain; numbness, pain, ortingling in fingers or toes; pulse ratechanges; swelling of face, feet, fingers, orlower legs; or vision changes.ertapenem sodiumInvanzClass and CategoryChemical class: Synthetic 1- methylcarbapenemTherapeutic class: AntibioticPregnancy category: B

coccus species, Bacteroides fragilis, B.distasonis, B. ovatus, B. thetaiotaomicron,or B. uniformis; complicated skinand skin-structure infections due toStaphylococcus aureus (methicillinsusceptiblestrains only), Streptococcuspyogenes, E. coli, or Peptostreptococcusspecies; community-acquired pneumoniadue to Streptococcus pneumoniae(penicillin-susceptible strains only,including cases with concurrent bacteremia),Haemophilus influenzae(beta-lactamase–negative strains only),or Moraxella catarrhalis; complicatedUTI (including pyelonephritis) due to E.coli (including cases with concurrentbacteremia) or Klebsiella pneumoniae;and acute pelvic infections (includingpostpartum endomyometritis, septicabortion, and postsurgical gynecologicinfections) due to Streptococcus agalactiae,E. coli, B. fragilis, Porphyromonasasaccharolytica, Peptostreptococcusspecies, or Prevotella biviaI.V. INFUSIONAdults and adolescents. 1 g daily, infusedover 30 min, for up to 14 days.Children ages 3 months to 13 years. 15 mg/kg b.i.d., infused over 30 min, for up to14 days. Maximum: 1 g daily.I.M. INJECTIONAdults and adolescents. 1 g daily for up to7 days.Children ages 3 months to 13 years. 15 mg/kg b.i.d. for up to 7 days. Maximum: 1 gdaily.DOSAGE ADJUSTMENT Dosage decreased to500 mg daily for patients with advancedrenal insufficiency (creatinine clearance lessthan or equal to 30 ml/min/1.73 m 2 ) orend-stage renal insufficiency (creatinineclearance less than or equal to 10 ml/min/1.73 m 2 ). For patients on hemodialysis whohave received 500 mg of ertapenem within6 hr of hemodialysis, supplemental dose of150 mg given after hemodialysis.Mechanism of ActionInhibits bacterial cell wall synthesis bybinding to specific penicillin-bindingproteins inside the cell wall. Penicillin-bindingproteins are responsible for varioussteps in bacterial cell wall synthesis. Bybinding to these proteins, ertapenem leadsto bacterial cell wall lysis.ertapenem sodium 385IncompatibilitiesDon’t mix ertapenem with other drugs.Don’t dilute it with solutions containingdextrose.ContraindicationsHypersensitivity to ertapenem, its components,or other drugs in the same class;hypersensitivity to local anesthetics (I.M.form only, because lidocaine hydrochloride1% is used as a diluent); patients who haveexperienced anaphylactic reactions to betalactamdrugsInteractionsDRUGSprobenecid: Increased ertapenem half-life,increased and prolonged blood ertapenemlevelvalproic acid: Possibly decreased serum valproicacid level and increased risk of breakthroughseizuresAdverse ReactionsCNS: Aggression, agitation, anxiety, asthenia,confusion, delirium, disorientation,dizziness, dyskinesia, fatigue, fever, hallucinations,headache, hypothermia, insomnia,mental changes, myoclonus, seizures, somnolence,stupor, tremorCV: Chest pain, edema, hypertension,hypotension, tachycardia, thrombophlebitisEENT: Nasopharyngitis, oral candidiasis,viral pharyngitisENDO: HyperglycemiaGI: Abdominal pain, acid regurgitation,Clostridium difficile colitis, constipation,diarrhea, elevated liver function test results,indigestion, nausea, small-intestine obstruction,vomitingGU: Dysuria, elevated serum creatininelevel, proteinuria, RBCs and WBCs inurine, UTI, vaginitisHEME: Anemia, decreased hematocrit,decreased WBC count, eosinophilia,increased WBC count, neutropenia, prolongedPT, thrombocytopenia, thrombocytosisMS: Leg painRESP: Atelectasis, cough, crackles, dyspnea,pneumonia, respiratory distress, upper respiratorytract infection, wheezingSKIN: Cellulitis, dermatitis, erythema,extravasation, pruritus, rashOther: Anaphylaxis; death; hyperkalemia;hypokalemia; infusion site induration, pain,EF

386erythromycinphlebitis, redness, swelling, or warmthNursing Considerations• Obtain sputum, urine, or other specimensfor culture and sensitivity testing, asordered, before giving ertapenem. Expectto start therapy before results are available.• When preparing drug for I.V. use, reconstitute1 g with 10 ml of sterile water forinjection, 0.9% sodium chloride injection,or bacteriostatic water for injection. Don’tuse solutions that contain dextrose. Shakewell to dissolve. Immediately transferreconstituted drug to 50 ml normal salinesolution. Use within 6 hours if stored atroom temperature, 24 hours if refrigeratedat 5° C (41° F). Don’t freeze. Give I.V.infusion over 30 minutes.• Inspect drug for particles and discolorationafter reconstitution.• For I.M. injection, reconstitute 1 g of drugwith 3.2 ml of 1% lidocaine hydrochlorideinjection (without epinephrine). Shakethoroughly to form solution. Use within 1hour after preparation. Withdraw contentsof vial and inject deep into a large musclemass such as the gluteal muscle.WARNING Don’t give reconstituted I.M.solution by I.V. route because of possibleadverse reaction to lidocaine hydrochlorideinjection used to reconstitutedrug.• Monitor patient closely for a life-threateninganaphylactic reaction. Patients with ahistory of hypersensitivity to penicillin,cephalosporins, other beta-lactams, orother allergens are at increased risk.WARNING If ertapenem triggers an anaphylacticreaction, stop drug, notify prescriberimmediately, and provide appropriatetherapy. Anaphylaxis requires immediatetreatment with epinephrine as well as airwaymanagement and administration ofoxygen and I.V. corticosteroids, as needed.• Be aware that patients with a history ofseizures, other CNS disorders that predisposethem to seizures (such as brainlesions), or compromised renal functionmay be at increased risk for seizures.Administer anticonvulsant, as ordered.• Monitor patient for diarrhea during andfor at least 2 months after drug therapy;diarrhea may signal pseudomembranouscolitis caused by Clostridium difficile. Ifdiarrhea occurs, notify prescriber andexpect to withhold ertapenem and treatwith fluids, electrolytes, protein, and anantibiotic effective against C. difficile.• Be aware that because ertapenem is excretedin breast milk, its use by nursing mothersis carefully evaluated.PATIENT TEACHING• Instruct patient receiving ertapenem toimmediately report signs of anaphylaxis,such as rash, itching, or shortness ofbreath; or signs of superinfection, such assevere diarrhea or white patches on tongueor in mouth.• Urge patient to tell prescriber about diarrheathat’s severe or lasts longer than 3days. Remind patient that watery orbloody stools can occur 2 or more monthsafter antibiotic therapy and can be serious,requiring prompt treatment.erythromycin(contains 250, 333, or 500 mg of base perdelayed-release capsule, delayed-releasetablet, or tablet)Apo-Erythro (CAN), E-Mycin, Erybid(CAN), ERYC, Ery-Tab, Ilotycin, Novo-Rythro Encap (CAN), PCEerythromycinestolate(contains 250 mg of base per capsule ortablet, or 125 or 250 mg of base per 5 mlof oral suspension)Ilosone, Novo-Rythro (CAN)erythromycinethylsuccinate(contains 1 g of base per 1.6 g of oral suspensionor tablet)Apo-Erythro-ES (CAN), E.E.S., EryPed,Erythro, Novo-Rythro (CAN)erythromycingluceptate(contains 500 or 1,000 mg of base pervial)Ilotycin

erythromycinlactobionate(contains 500 or 1,000 mg of base pervial)Erythrocinerythromycinstearate(contains 125 or 250 mg of base per 5 mlof oral suspension, or 250 or 500 mg ofbase per tablet)Apo-Erythro-S (CAN), Erythrocin,Erythrocot, My-E, Novo-Rythro (CAN),WintrocinClass and CategoryChemical class: MacrolideTherapeutic class: Antiacne agent, antibioticPregnancy category: BIndications and Dosages To treat mild to moderate upper respiratorytract infections caused byHaemophilus influenzae,Streptococcus pneumoniae, orStreptococcus pyogenes (group A betahemolyticstreptococcus)CAPSULES, CHEWABLE TABLETS, DELAYED-RELEASECAPSULES, DELAYED-RELEASE TABLETS, ORALSUSPENSION, TABLETS, I.V. INFUSIONAdults. 250 to 500 mg (base) every 6 hr for10 days.Children. 250 to 500 mg (base) q.i.d. or20 to 50 mg (base)/kg daily in divided dosesfor 10 days. For H. influenzae infections,erythromycin ethylsuccinate is administeredwith 150 mg/kg daily of sulfisoxazole.Maximum: Adult dosage, or 6 g daily forerythromycin ethylsuccinate. To treat lower respiratory tract infectionscaused by S. pneumoniae or S.pyogenes (group A beta-hemolyticstreptococcus)CAPSULES, CHEWABLE TABLETS, DELAYED-RELEASECAPSULES, DELAYED-RELEASE TABLETS, ORALSUSPENSION, TABLETS, I.V. INFUSIONAdults. 250 to 500 mg (base) every 6 hr for10 days.Children. 250 to 500 mg (base) q.i.d. or20 to 50 mg (base)/kg daily in divided doseserythromycin 387for 10 days. Maximum: Adult dosage. To treat respiratory tract infectionscaused by Mycoplasma pneumoniaeCAPSULES, CHEWABLE TABLETS, DELAYED-RELEASECAPSULES, DELAYED-RELEASE TABLETS, ORALSUSPENSION, TABLETS, I.V. INFUSIONAdults. 500 mg (base) every 6 hr for 5 to10 days or up to 3 wk for severe infections. To treat mild to moderate skin and softtissueinfections caused by S. pyogenesor Staphylococcus aureusCAPSULES, CHEWABLE TABLETS, DELAYED-RELEASECAPSULES, DELAYED-RELEASE TABLETS, ORALSUSPENSION, TABLETS, I.V. INFUSIONAdults. 250 mg (base) every 6 hr or 500 mg(base) every 12 hr for 10 days. Maximum:4 g (base) daily.Children. 250 to 500 mg (base) q.i.d. or20 to 50 mg (base)/kg daily in divided dosesfor 10 days. Maximum: Adult dosage. To treat acne vulgarisDELAYED-RELEASE CAPSULES, DELAYED-RELEASETABLETS, TABLETSAdults and adolescents. Initial: 250 mg(base) every 6 hr, 333 mg (base) every 8 hr,or 500 mg (base) every 12 hr for 4 wk.Maintenance: 333 to 500 mg (base) daily. To treat pertussis (whooping cough)caused by Bordetella pertussisCAPSULES, CHEWABLE TABLETS, DELAYED-RELEASECAPSULES, DELAYED-RELEASE TABLETS, ORALSUSPENSION, TABLETS, I.V. INFUSIONChildren. 500 mg (base) q.i.d. or 40 to50 mg (base)/kg daily in divided doses for5 to 14 days. To treat diphtheriaCAPSULES, CHEWABLE TABLETS, DELAYED-RELEASECAPSULES, DELAYED-RELEASE TABLETS, ORALSUSPENSION, TABLETS, I.V. INFUSIONAdults and children. 500 mg (base) every6 hr for 10 days. To treat erythrasmaCAPSULES, CHEWABLE TABLETS, DELAYED-RELEASECAPSULES, DELAYED-RELEASE TABLETS, ORAL SUS-PENSION, TABLETS, I.V. INFUSIONAdults and children. 250 mg (base) t.i.d.for 21 days. To treat intestinal amebiasisCAPSULES, CHEWABLE TABLETS, DELAYED-RELEASECAPSULES, DELAYED-RELEASE TABLETS, ORALSUSPENSION, TABLETS, I.V. INFUSIONAdults. 250 mg (base) every 6 hr for 10 to14 days.Children. 30 to 50 mg (base)/kg daily inEF

388erythromycindivided doses for 10 to 14 days To treat pelvic inflammatory diseasecaused by Neisseria gonorrhoeaeCAPSULES, CHEWABLE TABLETS, DELAYED-RELEASECAPSULES, DELAYED-RELEASE TABLETS, ORALSUSPENSION, TABLETS, I.V. INFUSIONAdults. 500 mg (base) I.V. every 6 hr for3 days and then 250 mg (base) P.O. or I.V.every 6 hr for 7 days. To treat conjunctivitis in newbornsI.V. INFUSIONNeonates. 50 mg (base)/kg daily in 4 divideddoses for 14 days. To treat pneumonia in neonatesI.V. INFUSIONNeonates. 50 mg (base)/kg daily in divideddoses for 21 days. To treat urogenital infections causedby Chlamydia trachomatis duringpregnancyCAPSULES, CHEWABLE TABLETS, DELAYED-RELEASECAPSULES, DELAYED-RELEASE TABLETS, ORALSUSPENSION, TABLETSAdults. 500 mg (base) on an empty stomachevery 6 hr for 7 days; or 250 mg (base)on an empty stomach every 6 hr for at least14 days. To treat nongonococcal urethritis oruncomplicated urethral, endocervical,or rectal infections caused by C. trachomatisCAPSULES, CHEWABLE TABLETS, DELAYED-RELEASECAPSULES, DELAYED-RELEASE TABLETS, ORALSUSPENSION, TABLETSAdults. 500 mg (base) every 6 hr for 7 days.If patient can’t tolerate high doses, 250 mg(base) every 6 hr for 14 days. To treat primary syphilisCAPSULES, CHEWABLE TABLETS, DELAYED-RELEASECAPSULES, DELAYED-RELEASE TABLETS, ORALSUSPENSION, TABLETSAdults. 20 to 40 g (base) in divided dosesover 10 to 15 days. To treat Legionnaire’s diseaseCAPSULES, CHEWABLE TABLETS, DELAYED-RELEASECAPSULES, DELAYED-RELEASE TABLETS, ORALSUSPENSION, TABLETS,I.V. INFUSIONAdults. 1 to 4 g (base) daily in divideddoses for 10 to 14 days. To treat rheumatic feverCAPSULES, CHEWABLE TABLETS, DELAYED-RELEASECAPSULES, DELAYED-RELEASE TABLETS, ORALSUSPENSION, TABLETS, I.V. INFUSIONAdults. 250 mg (base) every 12 hr. To prevent bacterial endocarditis inpatients with penicillin allergy who plandental or upper respiratory tract surgeryCAPSULES, CHEWABLE TABLETS, DELAYED-RELEASECAPSULES, DELAYED-RELEASE TABLETS, ORALSUSPENSION, TABLETS, I.V. INFUSIONAdults. 1 g (base) given 1 to 2 hr beforeprocedure and then 500 mg (base) 6 hrafter initial dose.Children. 20 mg (base)/kg given 2 hr beforeprocedure and then 10 mg (base)/kg 6 hrafter initial dose. To treat listeriosisCAPSULES, CHEWABLE TABLETS, DELAYED-RELEASECAPSULES, DELAYED-RELEASE TABLETS, ORALSUSPENSION, TABLETS, I.V. INFUSIONAdults. 250 mg (base) every 6 hr or 500 mg(base) every 12 hr. Maximum: 4 g (base)daily.Mechanism of ActionBinds with the 50S ribosomal subunit ofthe 70S ribosome in many types of aerobic,anaerobic, gram-positive, and gram-negativebacteria. This action inhibits RNAdependentprotein synthesis in bacterialcells, causing them to die.ContraindicationsAstemizole, cisapride, pimozide, or terfenadinetherapy; hypersensitivity to erythromycin,macrolide antibiotics, or their components;hepatic disease (erythromycinestolate)InteractionsDRUGSalfentanil: Decreased alfentanil clearance,prolonged alfentanil actionastemizole, cisapride, terfenadine: Increasedrisk of cardiotoxicity, torsades de pointes,ventricular tachycardia, and deathatorvastatin, lovastatin, pravastatin, simvastatin:Increased risk of rhabdomyolysiscarbamazepine, valproic acid: Possibly inhibitedmetabolism of these drugs, increasingtheir blood levels and risk of toxicitychloramphenicol, lincomycins: Antagonizedeffects of these drugscyclosporine: Increased risk of nephrotoxicitydigoxin: Increased serum digoxin level andrisk of digitalis toxicitydiltiazem, verapamil: Increased risk of lifethreateningcardiac eventsergotamine: Decreased ergotamine metabolism,increased risk of vasospasm from

ergotamine usehepatotoxic drugs: Increased risk of hepatotoxicitymidazolam, triazolam: Increased pharmacologiceffects of these drugsoral contraceptives: Failed contraception,hepatotoxicityototoxic drugs: Increased risk of ototoxicityif patient with impaired renal functionreceives high doses of erythromycinpenicillins: Interference with bactericidaleffects of penicillinssildenafil: Increased effects of sildenafilwarfarin: Prolonged PT and risk of hemorrhage,especially in elderly patientsxanthines (except dyphylline): Increasedserum theophylline level and risk oftheophylline toxicityACTIVITIESalcohol use: Increased alcohol level (by40%) with I.V. erythromycinAdverse ReactionsCNS: Fatigue, fever, malaise, weaknessCV: Prolonged QT interval, torsades depointes, ventricular arrhythmiasEENT: Hearing loss, oral candidiasisGI: Abdominal cramps and pain, diarrhea,hepatotoxicity, nausea, pseudomembranouscolitis, vomitingGU: Vaginal candidiasisMS: New or aggravated myasthenia gravissyndromeSKIN: Erythema, jaundice, pruritus, rashOther: Fluid overload (from I.V. infusion),injection site inflammation and phlebitisNursing Considerations• Use erythromycin cautiously in patientswith impaired hepatic function becausedrug is metabolized by the liver.• Use erythromycin cautiously in elderlypatients, especially those with renal orhepatic dysfunction, because these patientsare at increased risk of hearing loss andtorsades de pointes. They’re also atincreased risk of bleeding if taking an oralanticoagulant.• Before giving first erythromycin dose,expect to obtain body fluid or tissue samplefor culture and sensitivity testing.• Reconstitute parenteral form beforeadministration. Add at least 10 ml ofpreservative-free sterile water for injectionto each 500-mg vial or at least 20 ml oferythromycin 389diluent to each 1-g vial.• For prolonged infusion, expect to infuse abuffered solution up to 24 hours afterdilution.• For intermittent infusion, dilute dose in100 to 250 ml normal saline solution orD 5 W if needed; give slowly over 20 to60 minutes.• When giving I.V. erythromycin gluceptate,dilute the solution if needed to 1 g/L innormal saline solution or D 5 W injectionfor slow, continuous infusion. Dilutedsolution remains potent for 7 days ifrefrigerated.• When giving I.V. erythromycin lactobionate,dilute the solution if needed to 1 to5 mg/ml in normal saline solution, lactatedRinger’s solution, or other electrolytesolution for slow, continuous infusion.Diluted solution remains potent for14 days if refrigerated and for 24 hours atroom temperature.• Be aware that infusions prepared in piggybackinfusion bottles stay potent for30 days if frozen, 24 hours if refrigerated,or 8 hours at room temperature. Don’tstore infusions prepared in the ADDvantagesystem.• Don’t use diluent with benzyl alcohol ifparenteral erythromycin is for a neonate.It may cause a fatal toxic syndrome ofCNS depression, hypotension, metabolicacidosis, renal failure, respiratory problems,and, possibly, seizures and intracranialhemorrhage.• Periodically monitor liver function testresults to detect hepatotoxicity, which ismost common with erythromycin estolate.Signs typically appear within 2 weeks aftercontinuous therapy starts and resolvewhen it stops.• Assess hearing regularly, especially in elderlypatients and those who receive 4 g ormore daily or have hepatic or renal disease.Hearing impairment begins 36 hoursto 8 days after treatment starts and usuallybegins to improve 1 to 14 days after itstops.• During I.V. therapy, watch for evidence offluid overload, such as acute dyspnea andcrackles.• Monitor infants for vomiting or irritabilitywith feeding because infantile hypertrophicpyloric stenosis has been reported.EF

390InteractionsDRUGSaspirin, NSAIDs, warfarin: Possiblyincreased risk of bleedingcarbamazepine: Possibly increased clearanceof escitalopramcimetidine: Possibly increased plasma escitalopramlevelCNS drugs: Additive CNS effectslithium: Possible enhancement of the seroescitalopramoxalate• Assess myasthenia gravis patients forweakness because drug may aggravate it.Keep in mind that myasthenic syndromemay arise in patients previously undiagnosedwith myasthenia gravis.• Watch closely for signs and symptoms ofsuperinfection. If they occur, notify prescriberand expect to stop drug and provideappropriate therapy.• Monitor patient for diarrhea during andfor at least 2 months after erythromycintherapy; diarrhea may signal pseudomembranouscolitis caused by Clostridium difficile.If diarrhea occurs, notify prescriberand expect to withhold drug and treatwith fluids, electrolytes, protein, and anantibiotic effective against C. difficile.• If patient receives an order for urine catecholamineanalysis, notify prescriberbecause erythromycin interferes with fluorometricmeasurement of urine catecholamines.PATIENT TEACHING• Urge patient to complete prescribed therapy,even if he feels better before it’s finished.• Tell patient to notify prescriber if symptomsworsen or don’t improve after a fewdays.• Teach patient how to administer prescribedform of erythromycin. Instructhim to swallow capsules or tablets whole.For an oral suspension, teach him to usethe calibrated measuring device providedto ensure accurate doses. Remind him toshake the suspension before measuring adose.• Advise patient to take oral form of erythromycinwith a full glass of water on anempty stomach (except erythromycin ethylsuccinate,which is better absorbed withfood).• If GI distress occurs, instruct patient totake oral form with food.• Instruct patient to promptly notify prescriberif he develops allergic reactions,hearing changes, or signs of hepatic dysfunction.• Urge patient to tell prescriber about diarrheathat’s severe or lasts longer than3 days. Remind patient that watery orbloody stools can occur 2 or more monthsafter antibiotic therapy and can be serious,requiring prompt treatment.escitalopramoxalateLexaproClass and CategoryChemical class: Pure S enantiomer ofracemic bicyclic phthalane derivativecitalopramTherapeutic class: AntidepressantPregnancy category: CIndications and Dosages To treat generalized anxiety disorder ormajor depressionORAL SOLUTION, TABLETSAdults. Initial: 10 mg daily in morning orevening, increased to 20 mg daily after 1 ormore wk, as needed. To treat major depressionORAL SOLUTION, TABLETSAdults. Initial: 10 mg daily, morning orevening, increased to 20 mg daily after1 wk, as needed.Adolescents ages 12 to 17. Initial: 10 mgdaily, morning or evening, increased to20 mg daily after 3 wk, as needed.DOSAGE ADJUSTMENT Dosage shouldn’texceed 10 mg daily for elderly patients andthose with hepatic impairment.Mechanism of ActionInhibits reuptake of the neurotransmitterserotonin by CNS neurons, thereby increasingthe amount of serotonin available innerve synapses. An elevated serotonin levelmay result in elevated mood and reduceddepression.ContraindicationsHypersensitivity to escitalopram, citalopramor its components; use within 14 daysof MAO inhibitor therapy

tonergic effects of escitalopramMAO inhibitors: Possibly hyperpyreticepisodes, hypertensive crisis, serotonin syndrome,and severe seizuresmetoprolol: Increased plasma metoprolollevels with decreased cardioselectivity ofmetoprololnaratriptan, sumatriptan, zolmitriptan:Possibly weakness, hyperreflexia, and incoordinationSt. John’s wort: Increased risk of serotoninsyndromesibutramine: Increased risk of serotoninsyndromeACTIVITIESalcohol use: Possibly increased cognitive andmotor effects of alcoholAdverse ReactionsCNS: Abnormal gait, acute psychosis,aggression, akathisia, delirium, dizziness,dyskinesia, dystonia, extrapyramidal effects,fatigue, headache, hypomania, insomnia,lethargy, mania, myoclonus, neurolepticmalignant syndrome, paresthesia, seizures,serotonin syndrome, somnolence, suicidalideationCV: Atrial fibrillation, cardiac failure, deepvein or phlebitis thrombosis, hypotension,MI, prolonged QT interval, thrombosis,torsades de pointes, ventricular arrhythmiasEENT: Diplopia, dry mouth, glaucoma,nystagmus, rhinitis, sinusitis, toothache,visual hallucinationsENDO: Diabetes mellitus, hyperprolactinemia,syndrome of inappropriate ADHsecretionGI: Abdominal pain, constipation,decreased appetite, diarrhea, flatulence, GIbleeding or hemorrhage, hepatic necrosis,hepatitis, indigestion, nausea, pancreatitis,rectal hemorrhage, vomitingGU: Acute renal failure, anorgasmia,decreased libido, ejaculation disorders,impotence, priapismHEME: Bleeding, decreased prothrombintime, hemolytic anemia, leukopenia, thrombocytopeniaMS: Neck or shoulder pain, rhabdomyolysisRESP: Pulmonary embolismSKIN: Ecchymosis, erythema multiforme,increased sweating, photosensitivity,Stevens-Johnson syndrome, toxic epidermalnecrolysis, urticariaOther: Anaphylaxis, angioedema, flulikesymptoms, hyponatremiaescitalopram oxalate 391Nursing Considerations• Use escitalopram cautiously in patientswith history of mania or seizures, patientswith severe renal impairment, and thosewith diseases or conditions that producealtered metabolism or hemodynamicresponses.• Monitor patient—especially elderlypatient—for hypoosmolarity of serum andurine and for hyponatremia (headache,trouble contentrating, impaired memory,weakness, unsteadiness) because they maymay indicate escitalopram-induced syndromeof inappropriate ADH secretion.• Watch for signs of misuse or abuse, suchas development of tolerance, increasingdosage without approval, and drug-seekingbehavior; drug’s potential for physicaland psychological dependence isunknown.• Monitor patient for bleeding, especially ifpatient is also taking aspirin, an NSAID, oran anticoagulant. Bleeding can range fromecchymoses, hemtomas, epitaxis andpetechiae to life-threatening hemorrhages.• Expect prescriber to reassess patient periodicallyto determine the continued needfor therapy and evaluate dosage.• If patient (particularly a child or an adolescent)takes escitalopram for depression,watch closely for suicidal tendencies, especiallywhen therapy starts or dosagechanges, because depression may worsentemporarily.• If escitalopram will be stopped, expect totaper dosage to avoid serious adverse reactions.PATIENT TEACHING• Inform patient that alcohol use isn’t recommendedduring escitalopram therapybecause it may decrease his ability to thinkclearly and perform motor skills.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient that drug shouldn’t betaken with citalopram hydrobromidebecause of potentially additive effects.• Tell patient that improvement may not benoticed for 1 to 4 weeks after therapybegins. Emphasize the importance of continuingtherapy as prescribed.• If patient (particularly a child or an adolescent)takes drug for depression, urgeEF

392esmolol hydrochloridecaregivers to watch closely for suicidal tendencies,especially when therapy starts ordosage changes.• Warn patient not to stop taking drugabruptly. Explain that gradual taperinghelps to avoid withdrawal symptoms.• Urge patient to inform prescriber of anyOTC drugs he takes because of potentialfor interactions.• Review signs and symptoms of hyponatremia,and instruct patient to report themto prescriber.• Warn patient that escitalopram increasesbleeding risk if taken with aspirin, anNSAID, or an anticoagulants and thatbleeding events could range from mild tosevere. Tell patient to seek emergency carefor serious or prolonged bleeding.esmololhydrochlorideBreviblocClass and CategoryChemical class: Beta blockerTherapeutic class: Antiarrhythmic, antihypertensivePregnancy category: CIndications and Dosages To treat supraventricular tachycardiaI.V. INFUSIONAdults. Loading: 500 mcg/kg over 1 min.Maintenance: If response to loading dose isadequate after 5 min, 50 mcg/kg/mininfused for 4 min. If response is inadequateafter 5 min, another 500 mcg/kg may begiven over 1 min followed by 100 mcg/kg/min for 4 min. Sequence repeated, as needed,until adequate response occurs, increasingmaintenance dosage by 50 mcg/kg/minat each step. Maximum: 200 mcg/kg/minfor 48 hr.Children. 50 mcg/kg/min titrated every10 min up to 300 mcg/kg/min. To treat intraoperative and postoperativetachycardia and hypertensionI.V. INFUSIONAdults. Initial: 250 to 500 mcg/kg over1 min. Maintenance: 50 mcg/kg/mininfused over 4 min. If response is inadequateafter 5 min, another 250 to 500 mcg/kg may be given over 1 min followed by100 mcg/kg/ min for 4 min. Sequencerepeated, as needed, up to 4 times, increasingby 50 mcg/kg/min each time.Maximum: 200 mcg/kg/min for 48 hr.DOSAGE ADJUSTMENT Loading doses omitted,increments decreased to 25 mcg/kg/min, and titration intervals increased to10 min as heart rate approaches desiredlevel or if blood pressure decreases toomuch.Route Onset Peak DurationI.V. Immediate Unknown 10–20 minMechanism of ActionInhibits stimulation of beta 1 receptorsmainly in the heart, which decreases cardiacexcitability, cardiac output, and myocardialoxygen demand. Esmolol also decreasesrenin release from kidneys, which helpsreduce blood pressure.IncompatibilitiesDon’t mix esmolol with 5% sodiumbicarbonate injection.ContraindicationsCardiogenic shock, hypersensitivity to betablockers, overt heart failure, second- orthird-degree heart block, sinus bradycardiaInteractionsDRUGSantihypertensives: Possibly hypotensioninsulin, oral antidiabetics: Possibly maskingof signs and symptoms of hypoglycemiacaused by these drugsMAO inhibitors: Possibly severe hypertensionif esmolol is given within 14 days ofdiscontinuing MAO inhibitor therapyneuromuscular blockers: Possibly potentiatedand prolonged action of these drugsphenytoin: Possibly increased cardiacdepressionreserpine: Possibly bradycardia andhypotensionsympathomimetics, xanthine derivatives:Possibly inhibited therapeutic effects ofboth drugsAdverse ReactionsCNS: Anxiety, confusion, depression, dizziness,fatigue, fever, headache, syncopeCV: Bradycardia, chest pain, decreasedperipheral circulation, heart block,

hypotensionGI: Nausea, vomitingRESP: Dyspnea, wheezingSKIN: Diaphoresis, flushing, pallorOther: Infusion site pain, redness, andswellingNursing Considerations•Use esmolol cautiously if patient hassupraventricular arrhythmias withdecreased cardiac output, hypotension, orother hemodynamic compromise or istaking drugs that decrease peripheralresistance or myocardial filling, contractility,or impulse generation.• Also use drug cautiously in patients withimpaired renal function because drug isexcreted by the kidneys. Patients with endstagerenal disease have an increased riskof adverse reactions.• Avoid giving esmolol for intraoperative orpostoperative hypertension caused byhypothermia-induced vasoconstriction.• Expect to give lowest possible dose topatients with allergies, asthma, bronchitis,or emphysema. If patient develops broncho-spasm,expect to discontinue infusionimmediately and give a beta 2 -stimulatingdrug, as ordered.• Don’t give 250 mg/ml (2,500 mg/10 ml)dosage strength by direct I.V. push. Diluteit to a 10-mg/ml infusion by first removing20 ml from 500 ml of a compatible I.V.solution, such as D 5 W or dextrose 5% innormal saline solution, and then adding5 g of esmolol to the solution.• Use diluted solution within 24 hours ifstored at room temperature.• Use 100-mg vial (prediluted to 10 mg/ml)for loading dose. For 70-kg (154-lb)patient, loading dose for 500 mcg/kg/minis 3.5 ml.• Monitor blood pressure and heart rateoften during therapy. Hypotension canoccur at any dose but usually is dose related.It typically reverses within 30 minutesafter dose is decreased or infusion stopped.• Inspect site often for thrombophlebitis(pain, redness, swelling at site). Infusion of20 mg/ml is more likely to cause seriousvein irritation than 10 mg/ml.Extravasation of 20 mg/ml may cause aserious local reaction and skin necrosis.Don’t give more than 10 mg/ml into asmall vein or using a butterfly catheter.esomeprazole magnesium 393PATIENT TEACHING• Urge patient to report adverse reactionsimmediately.• Reassure patient that his blood pressure,heart rate, and response to therapy will bemonitored throughout esmolol therapy.esomeprazolemagnesiumNexium, Nexium I.V.Class and CategoryChemical class: Substituted benzimidazoleTherapeutic class: AntiulcerativePregnancy category: BIndications and Dosages To treat gastroesophageal reflux disease(GERD)DELAYED-RELEASE CAPSULESAdults. 20 to 40 mg daily for 4 to 8 wk;may be repeated for another 4 to 8 wk ifulcer hasn’t healed. Maintenance: 20 mgdaily for up to 6 mo.Adolescents ages 12 to 17. 20 or 40 mgonce daily for up to 8 wk.Children ages 1 to 11. 10 mg once daily forup to 8 wk.DOSAGE ADJUSTMENT For children weighing20 kg (44 lb) or more and being treated forhealing of erosive esophagitis in GERD,dosage may be increased to 20 mg oncedaily for 8 wk, if needed. To treat GERD in a patient with a historyof erosive esophagitis who can’t takethe drug by mouthI.V. INFUSION, I.V. INJECTIONAdults. 20 to 40 mg daily infused for no lessthan 3 min (I.V. injection) or 10 to 30 min(I.V. infusion). As adjunct to treat duodenal or gastriculcer associated with HelicobacterpyloriDELAYED-RELEASE CAPSULESAdults. 40 mg daily with amoxicillin1,000 mg b.i.d. and clarithromycin 500 mgb.i.d. for 10 days. To reduce the risk of gastric ulcer formationin patients who are receiving continuousNSAID therapy and who eitherare over age 60 or have a history of gastriculcerEF

394esomeprazole magnesiumDELAYED-RELEASE CAPSULESAdults. 20 to 40 mg daily for up to 6 mo. To treat pathological hypersecretory conditions,including Zollinger-Ellison syndromeDELAYED-RELEASE CAPSULESAdults. 40 mg b.i.d.DOSAGE ADJUSTMENT For patients withsevere hepatic insufficiency, maximum20 mg daily.Mechanism of ActionInterferes with gastric acid secretion byinhibiting the hydrogen-potassium-adenosinetriphosphatase (H -K -ATPase)enzyme system, or proton pump, in gastricparietal cells. Normally, the proton pumpuses energy from hydrolysis of ATPase todrive H and chloride (Cl ) out of parietalcells and into the stomach lumen inexchange for potassium (K ), which leavesthe stomach lumen and enters parietal cells.After this exchange, H and Cl combinein the stomach to form hydrochloric acid(HCl). Esomeprazole irreversibly inhibitsthe final step in gastric acid production byblocking exchange of intracellular H andextracellular K , thus preventing H fromentering the stomach and additional HClfrom forming.IncompatibilitiesDon’t give esomeprazole with any otherdrug through the same I.V. site or tubing.ContraindicationsHypersensitivity to esomeprazole or itscomponentsInteractionsDRUGSantimicrobials: Increased esomeprazole levelatazanavir, nelfinavir: Decreased blood levelsof these drugsdiazepam: Possibly increased diazepam leveldigoxin, iron salts, ketoconazole: Possiblydecreased absorption of these drugssaquinavir: Increased plasma saquinavirlevel with increased toxicityvoriconazole: Increased esomeprazole exposureand risk of adverse effectswarfarin: Possibly increased INR and PT,leading to abnormal bleedingFOODSall foods: Decreased bioavailability ofesomeprazoleAdverse ReactionsCNS: Agitation, aggression, depression,dizziness, headache, hallucinations, hepaticencephalopathyEENT: Blurred vision, dry mouth, mucosaldiscoloration, sinusitis, stomatitis, taste disturbanceENDO: GynecomastiaGI: Abdominal pain; Barrett’s esophagus;benign polyps or nodules; candidiasis; constipation;diarrhea; duodenitis; dyspepsia;esophagitis; esophageal stricture, ulceration,or varices; flatulence; gastric ulcer; gastritis;hepatic failure; hepatitis; jaundice; nausea;pancreatitisGU: Interstitial nephritisHEME: Agranulocytosis, pancytopeniaMS: Muscle weakness, myalgiaRESP: Bronchospasm, respiratory tractinfectionSKIN: Alopecia, diaphoresis, erythemamultiforme, photosensitivity, pruritus,Stevens-Johnson syndrome, toxic epidermalnecrolysisOther: Anaphylaxis, infusion site redness orpruritusNursing Considerations• Give oral esomeprazole at least 1 hourbefore meals because food decreasesbioavailability.WARNING If patient takes drug with amoxicillinor clarithromycin for H. pylori–related ulcer, severe diarrhea may indicatepseudomembranous colitis. Obtain stoolcultures, as ordered.• Always flush I.V. line with normal salinesolution injection, lactated Ringer’s injection,or 5% dextrose injection before andafter giving esomeprazole intravenously.• For I.V. injection, reconstitute powderwith 5 ml of normal saline solution injectionand give as a bolus dose over 3 ormore minutes. Once reconstituted, drugmay be stored at room temperature for upto 12 hours.• For I.V. infusion, reconstitute powder with5 ml of normal saline solution injection,lactated Ringer’s injection, or 5% dextroseinjection. Further dilute reconstitutedsolution to make a final volume of 50 ml,and infuse over 10 to 30 minutes.Reconstituted drug may be stored at roomtemperature up to 6 hours if mixed with5% dextrose injection or up to 12 hours if

mixed with normal saline solution or lactatedRinger’s injection.• Be aware that patient receiving I.V.esomeprazole should be switched to oralform as soon as possible.PATIENT TEACHING• If patient has trouble swallowingesomeprazole capsules, tell him to opencapsule and sprinkle pellets into a tablespoonof cool applesauce. Tell him not tochew pellets and to discard any unusedpellets.• Urge patient to tell prescriber if he takesantacids.estazolamClass, Category, and ScheduleChemical class: BenzodiazepineTherapeutic class: Sedative-hypnoticPregnancy category: XControlled substance schedule: IVIndications and Dosages To treat insomniaTABLETSAdults. 1 to 2 mg at bedtime.DOSAGE ADJUSTMENT Starting dose 0.5 mgfor small or debilitated elderly patients.Route Onset Peak DurationP.O. Unknown Unknown 6–8 hrMechanism of ActionMay potentiate effects of gamma-aminobutyricacid (GABA) and other inhibitoryneurotransmitters by binding to specificbenzodiazepine receptors in limbic and corticalareas of CNS. By binding to thesereceptors, estazolam increases GABA’sinhibitory effects and blocks cortical andlimbic arousal.ContraindicationsAcute angle-closure glaucoma; hypersensitivityto estazolam, other benzodiazepines,or their components; pregnancy; psychosisInteractionsDRUGSbarbiturates, carbamazepine, phenytoin,rifampin: Possibly decreased estazolam levelcarbamazepine: Possibly increased bloodestazolam 395carbamazepine levelcimetidine, diltiazem, disulfiram, erythromycin,fluoxetine, fluvoxamine, isoniazid,itraconazole, ketoconazole, nefazodone, oralcontraceptives, propoxyphene, ranitidine, verapamil:Possibly increased blood level andimpaired hepatic metabolism of estazolamclozapine: Possibly cardiac arrest or respiratorydepressionCNS depressants: Possibly potentiated CNSdepressionlevodopa: Possibly decreased therapeuticeffects of levodopaFOODSgrapefruit juice: Possibly increased bloodlevel and impaired hepatic metabolism ofdrugACTIVITIESalcohol use: Possibly potentiated CNSdepressionAdverse ReactionsCNS: Amnesia, anxiety, ataxia, confusion,delusions, depression, dizziness, drowsiness,euphoria, headache, hypokinesia, irritability,malaise, nervousness, slurred speech,tremorCV: Chest pain, palpitations, tachycardiaEENT: Blurred vision, dry mouth, increasedsalivation, photophobiaGI: Abdominal pain, constipation, diarrhea,nausea, thirst, vomitingGU: Libido changesRESP: Respiratory depressionSKIN: DiaphoresisOther: Physical or psychological dependenceNursing Considerations• Use estazolam with extreme caution inpatients with a history of drug or alcoholabuse because of risk of addiction. Expectto give drug for no more than 12 weeks.• Use cautiously in elderly or debilitatedpatients and those with depression orimpaired hepatic, renal, or respiratoryfunction.• Expect to stop drug gradually to preventwithdrawal symptoms. Avoid stoppingabruptly if patient has history of seizures.• Monitor respiratory status, especially inpatients with respiratory compromise,who are at increased risk for respiratorydepression.• If patient takes estazolam for depression,EF

396estradiolwatch for suicidal tendencies, especiallywhen therapy starts or dosage changes.PATIENT TEACHING• Warn patient not to exceed prescribedtime because of risk of addiction.• Because estazolam can reduce alertness,advise patient to avoid hazardous activitiesuntil CNS effects of the drug are known.• Advise patient not to drink alcohol or takeother CNS depressants during therapybecause of the risk of additive effects.• Warn elderly and debilitated patients andthose with impaired hepatic or renal functionabout risk of excessive sedation ormental impairment and need to reportthem.• If patient takes 2-mg dosage for a longtime, warn against stopping drug abruptly.estradiolEstrace, Estrasorb, Estring, Estrogel,Evamist, Vagifemestradiol acetateFemring, Femtraceestradiol cypionatedepGynogen, Depo-Estradiol,Depogen, Dura-Estrin, E-Cypionate,Estragyn LA 5, Estro-Cyp, Estrofem,Estro-L.A.estradioltransdermal systemAlora, Climara, Esclim, Estraderm,Estrasorb, Estrogel, FemPatch,Menostar, Vivelle, Vivelle-Dotestradiol valerateClinagen LA 40, Delestrogen, Dioval40, Dioval XX, Duragen-20, Estra-L 40,Estro-Span, Femogex (CAN), GynogenL.A. 20, Gynogen L.A. 40, Menaval-20,Valergen 10, Valergen 20, Valergen 40ethinyl estradiolEstinylClass and CategoryChemical class: Estrogen derivative, steroidhormoneTherapeutic class: Antineoplastic, antiosteoporoticagent, ovarian hormonereplacementPregnancy category: XIndications and Dosages To treat menopausal symptomsTABLETS (ESTRADIOL)Adult menopausal and postmenopausalwomen. Starting on day 5 of a cycle, 0.5 to2 mg daily in cycles of 3 wk on, 1 wk off.Adult postmenopausal women with intactuterus receiving progestin. 0.5 to 2 mgdaily with daily progestin. Or, 0.5 to 2,mgdaily on days 1 through 25 of a 28-daycycle, with progestin starting day 12 or 16and continuing through day 25 of the cycle;then no drugs on days 26 through 28, asprescribed.VAGINAL RING (ESTRADIOL ACETATE [FEMRING])Adult women. One ring (0.05 mg or 0.1 mgof estradiol/24 hr) inserted into upper thirdof vaginal vault and replaced every 3 mo.TABLETS (ESTRADIOL ACETATE [FEMTRACE])Adult menopausal and postmenopausalwomen. Initial: 0.45 mg daily.May beincreased to 0.9 mg daily and then 1.8 mgdaily as needed.TABLETS (ETHINYL ESTRADIOL)Adult menopausal and postmenopausalwomen. 0.02 to 0.05 mg daily in cycles of3 wk on, 1 wk off.Adult postmenopausal women with intactuterus receiving progestin. 0.02 to 0.05 mgdaily with daily progestin; or 0.02 to0.05 mg daily on days 1 through 25 of a 28-day cycle, with progestin starting day 12 or16 and continuing through day 25; then nodrugs on days 26 through 28, as prescribed.DOSAGE ADJUSTMENT Dosage may bereduced to less than 1 mg daily (estradiol)or 0.05 mg daily (ethinyl estradiol) forpatients with only vaginal or vulvar symptoms.I.M. INJECTION (ESTRADIOL CYPIONATE IN OIL)Adult women. 1 to 5 mg as a single doseevery 3 to 4 wk as needed.I.M. INJECTION (ESTRADIOL VALERATE IN OIL)Adult women. 10 to 20 mg every 4 wk asneeded.TRANSDERMAL (ALORA, ESTRADERM, VIVELLE,VIVELLE-DOT)Adult menopausal and postmenopausal

women. Initial: 0.025 to 0.05 mg daily incycles of 3 wk on, 1 wk off. One patchapplied to trunk or buttocks and replacedtwice/wk (every 3 to 4 days). Adjust dosageto control symptoms, as prescribed.TRANSDERMAL (CLIMARA)Adult women. Initial: 0.025 mg daily. Onepatch applied to trunk or buttocks, replacedevery wk. Titrate dosage to control symptoms,as prescribed. Schedule will be cyclicunless patient has had a hysterectomy.TRANSDERMAL (ESCLIM)Adult women. Initial: 0.025 mg daily. Onepatch applied to upper arm, upper thigh, orbuttocks and replaced twice/wk (every 3 to4 days). Adjust dosage to control symptoms,as prescribed. Use a cyclic schedule,as prescribed, unless patient has had a hysterectomy.TRANSDERMAL (ESTRASORB)Adult women. 3.48 g daily in morning. Halfof dose (1 pouchful) applied to one thighand rubbed over entire thigh and calf for3 min, repeated on other thigh and calf.TRANSDERMAL (ESTROGEL)Adult women. 1.25 g daily applied in thinlayer from wrist to shoulder on inside andoutside of one arm.TRANSDERMAL (FEMPATCH)Adult women. Initial: 0.025 mg daily. Onepatch applied to buttocks and replacedevery wk. If symptoms aren’t relieved after4 to 6 wk, increased to two patches everywk, as prescribed. Follow a cyclic schedule,as prescribed, unless patient has had a hysterectomy.TRANSDERMAL MIST (EVAMIST)Adult women. Initial: 1.53 mg (1 spray)once daily in the morning. Dosage may beincreased to 3.06 mg (2 sprays) once dailyin the morning and then to 4.59 mg(3 sprays) once daily in the morning asneeded. To treat menopausal symptoms as combinationtherapy in patients with anintact uterusTRANSDERMAL ESTRADIOL (ALORA, ESTRADERM,VIVELLE, VIVELLE-DOT), IN COMBINATION WITHESTRADIOL AND NORETHINDRONE ACETATE(COMBIPATCH)Adult women. 0.05 mg daily estradiol-onlytransdermal system applied for first 14 daysof 28-day cycle and replaced twice/wk,according to product directions. Estradiolestradiol 397and norethindrone acetate transdermal systemapplied for remaining 14 days of 28-day cycle and replaced twice/wk during thisperiod. To treat postmenopausal vaginal andurogenital symptomsVAGINAL CREAM (ESTRACE)Adult women. Initial: 2 to 4 g (200 to400 mcg) daily for 1 to 2 wk. Then, dosagegradually reduced to half of initial dose, asprescribed, for 1 to 2 wk. Maintenance: 1g(100 mcg) daily 1 to 3 times/wk for 3 wk,followed by 1 wk of no drugs. Repeat cyclicallyas needed.VAGINAL RING (ESTRING)Adult women. One ring (7.5 mcg of estradiol/24hr) inserted into upper third ofvaginal vault and replaced every 3 mo.VAGINAL RING (FEMRING)Adult women. One ring (0.05 or 0.1 mg ofestradiol/24 hr) inserted into upper third ofvaginal vault and replaced every 3 mo.INTRAVAGINAL TABLETS (VAGIFEM)Adult women. Initial: 10-mcg tablet dailyfor 2 wk, followed by 1 tablet twice weekly.Dosage increased to 25 mcg, as needed. To prevent osteoporosis secondary toestrogen deficiency due to either naturalor surgical menopauseTABLETS (ESTRADIOL)Adult women. At least 0.5 mg daily cyclicallyor continuously, adjusted as needed tocontrol concurrent menopausal symptoms,as prescribed.TABLETS (ETHINYL ESTRADIOL)Adult women. At least 0.02 mg daily cyclicallyor continuously, as prescribed.TRANSDERMAL (ALORA, VIVELLE-DOT)Adult women. Initial: 0.025 mg daily continuously.One patch applied to lowerabdomen or buttocks and replaced twice/wk. Adjust dosage to control symptoms andmaintain bone density, as prescribed.TRANSDERMAL (CLIMARA)Adult women. Initial: 0.025 mg daily. Onepatch applied to trunk or buttocks andreplaced every wk. Adjust dosage to controlsymptoms, as prescribed. Follow a cyclicschedule, as prescribed, unless patient hashad a hysterectomy.TRANSDERMAL (ESTRADERM)Adult women. Initial: 0.05 mg daily. Onepatch applied to trunk or buttocks andreplaced twice/wk. Adjust dosage to controlEF

398Mechanism of ActionIncreases the rate of DNA and RNA synthesisin cells of female reproductive organs,pituitary gland, hypothalamus, and othertarget organs. In the hypothalamus, estrogensreduce release of gonadotropin-releasinghormone, which decreases pituitaryrelease of follicle-stimulating hormone andluteinizing hormone. In women, these horestradiolsymptoms, as prescribed. Follow a cyclicschedule, as prescribed, unless patient hashad a hysterectomy.TRANSDERMAL (MENOSTAR)Adult women. Initial: 0.014 mg daily. Onepatch applied to lower abdomen andreplaced every wk. Follow a cyclic schedule,as prescribed, unless patient has had a hysterectomy. To treat estrogen deficiency due tooophorectomy, primary ovarian failure,or female hypogonadismTABLETS (ESTRADIOL)Adult women. 0.5 to 2 mg daily continuouslyor in cycles of 3 wk on, 1 wk off.TABLETS (ETHINYL ESTRADIOL)Adult women. For primary ovarian failureor oophorectomy, 0.05 mg t.i.d. initially,then 0.05 mg daily after a few weeks, cyclicallyor continuously. For female hypogonadism,0.05 mg once daily to t.i.d. for first2 wk of a theoretical menstrual cycle. Aprogestin may be added, as prescribed, duringlast half of cycle to help induce menses.I.M. INJECTION (ESTRADIOL CYPIONATE IN OIL)Adult women. 1.5 to 2 mg every mo (forfemale hypogonadism only).I.M. INJECTION (ESTRADIOL VALERATE IN OIL)Adult women. 10 to 20 mg every mo asneeded.TRANSDERMAL (ALORA, ESTRADERM, VIVELLE)Adult women. Initial: 0.05 mg daily. Onepatch applied to trunk or buttocks andreplaced twice/wk. Titrate dosage to controlsymptoms, as prescribed. Follow a cyclicschedule, as prescribed, unless patient hashad a hysterectomy.TRANSDERMAL (CLIMARA)Adult women. Initial: 0.05 mg daily. Onepatch applied to trunk or buttocks andreplaced every wk. Adjust dosage to controlsymptoms, as prescribed. Follow a cyclicschedule, as prescribed, unless patient hashad a hysterectomy.TRANSDERMAL (ESCLIM)Adult women. Initial: 0.025 mg daily. Onepatch applied to upper arm, upper thigh, orbuttocks and replaced twice/wk (every 3 to4 days). Adjust dosage to control symptoms,as prescribed. Follow a cyclic schedule,as prescribed, unless patient has had ahysterectomy.TRANSDERMAL (FEMPATCH)Adult women. Initial: 0.025 mg. One patchapplied to buttocks and replaced every wk.If symptoms aren’t relieved after 4 to 6 wk,increased to two patches every wk, as prescribed.Follow a cyclic schedule unlesspatient has had a hysterectomy. To treat dysfunctional uterine bleedingfrom hormonal imbalance in patientswith hypoplastic or atrophic endometriumand without uterine diseaseTRANSDERMAL (CLIMARA)Adult women. Initial: 0.05 mg daily. Onepatch applied to trunk or buttocks andreplaced every wk. Adjust dosage to controlsymptoms, as prescribed. Follow a cyclicschedule, as prescribed.TRANSDERMAL (FEMPATCH)Adult women. Initial: 0.025 mg daily. Onepatch applied to buttocks and replacedevery wk. If symptoms aren’t relieved after4 to 6 wk, increased to two patches everywk, as prescribed. Follow a cyclic schedule,as prescribed. To provide palliative treatment for inoperable,progressive breast cancer inselected men and postmenopausalwomenTABLETS (ESTRADIOL)Adults. 10 mg t.i.d. for at least 3 mo.TABLETS (ETHINYL ESTRADIOL)Adults. 1 mg t.i.d. for at least 3 mo. To treat advancing, inoperable prostatecancerTABLETS (ESTRADIOL)Adult men. 1 to 2 mg b.i.d. or t.i.d., adjustedor continued, as prescribed, according topatient response.TABLETS (ETHINYL ESTRADIOL)Adult men. 0.15 to 3 mg daily, adjusted orcontinued, as prescribed, according topatient response.I.M. INJECTION (ESTRADIOL VALERATE)Adult men. 30 mg every 1 to 2 wk, adjustedor continued, as prescribed, according topatient response.

mones are required for normal genitourinaryand other essential body functions.At the cellular level, estrogens increasecervical secretions, cause endometrial cellproliferation, and improve uterine tone.Estrogen replacement helps maintain genitourinaryfunction and reduces vasomotorsymptoms when estrogen productiondeclines as a result of menopause, surgicalremoval of ovaries, or other estrogen deficiencystates. Estrogen replacement alsohelps prevent osteoporosis by inhibitingbone resorption.In men, estrogens inhibit pituitarysecretion of luteinizing hormone anddecrease testicular secretion of testosterone.These actions may decrease prostate tumorgrowth and lower the level of prostate-specificantigen (PSA).ContraindicationsActive deep vein thrombosis, pulmonaryembolism, or history of these conditions;active or recent (within past year) arterialthromboembolic disease, such as stroke orMI; hepatic dysfunction or disease; hypersensitivityto estradiol, ethinyl estradiol, ortheir components; hypersensitivity to tartrazinedye (contained in 0.02-mg estradioland ethinyl estradiol tablets); known orsuspected breast cancer or history of breastcancer except in appropriately selectedpatients being treated for metastatic disease;known or suspected estrogen-dependentcancer; pregnancy; undiagnosed abnormalgenital bleedingInteractionsDRUGSaminocaproic acid: Possibly increased hypercoagulabilitycaused by aminocaproic acidbarbiturates, carbamazepine, hydantoins,rifabutin, rifampin: Possibly reduced activityof estradiolbromocriptine: Possibly decreased therapeuticeffects of bromocriptinecalcium: Possibly increased calcium absorptioncorticosteroids: Increased therapeutic andtoxic effects of corticosteroidscyclosporine: Increased risk of hepatotoxicityand nephrotoxicitydidanosine, lamivudine, zalcitabine: Possiblypancreatitishepatotoxic drugs, such as isoniazid: Increasedestradiol 399risk of hepatitis and hepatotoxicityoral antidiabetic drugs: Decreased therapeuticeffects of these drugssomatrem, somatropin: Possibly acceleratedepiphyseal maturationtamoxifen: Possibly decreased therapeuticeffects of tamoxifenthyroid hormone replacement: Decreasedeffectivenessvitamin C: Decreased metabolism and possiblyincreased adverse effects of estradiolwarfarin: Decreased anticoagulant effectFOODSgrapefruit juice: Decreased estradiol metabolismand possibly increased adverse effectsACTIVITIESsmoking: Increased risk of stroke, pulmonaryembolism, thrombophlebitis, andtransient ischemic attackAdverse ReactionsCNS: Dementia, depression, dizziness,headache, migraine headache, stokeCV: Hypertension, MI, peripheral edema,pulmonary embolism, thromboembolism,thrombophlebitisEENT: Intolerance of contact lenses, retinalvascular thrombosis, vision changesENDO: Breast enlargement, pain, tenderness,or tumors; gynecomastia; hyperglycemiaGI: Abdominal cramps or pain, anorexia,bowel obstruction (vaginal ring), constipation,diarrhea, elevated liver function testresults, enlargement of hepatic hemangiomas,gallbladder disease or obstruction,hepatitis, increased appetite, nausea, pancreatitis,vomitingGU: Amenorrhea, breakthrough bleeding,cervical erosion, clear vaginal discharge,decreased libido (males), dysmenorrhea,endometrial cancer, impotence, increasedlibido (females), ovarian cancer, pelvic pain,prolonged or heavy menstrual bleeding,ring adherence, testicular atrophy, vaginalcandidiasis, worsening of endometriosisMS: ArthralgiaSKIN: Acne, alopecia, hirsutism, jaundice,melasma, oily skin, purpura, rash, seborrhea,urticariaOther: Angioedema, folic acid deficiency,hypercalcemia (in metastatic bone disease),toxic shock syndrome (vaginal ring), weightgainEF

400estradiolNursing ConsiderationsWARNING Be aware that estradiol (Estrace)and ethinyl estradiol (Estinyl) are distinctand separate products and that their dosingisn’t equivalent.• Use estradiol cautiously in patients withasthma, chorea, diabetes mellitus, epilepsy,migraine headaches, porphyria, systemiclupus erythematosus, or hepatic hemangiomasbecause estradiol may worsenthese disorders.• Administer oral preparations with orimmediately after food to decrease nausea.• For I.M. injection of estradiol cypionate orestradiol valerate, roll vial and syringebetween palms to evenly disperse drug.Use at least a 21G needle because of viscosityof oil-based solution. Use a dry,sterile syringe. Inject deep into upperouter quadrant of gluteal muscle. Aspiratebefore injection to avoid injection into ablood vessel.• Be aware that, in patients who are convertingfrom oral estrogen to transdermal system,oral estrogen should be stopped1 week before skin patches are applied.• Expect to begin prophylaxis treatmentagainst osteoporosis at the start ofmenopause.• Be aware that estrogen therapy should begiven cyclically or combined with a proges-tinfor 10 to 14 days per month inwomen with an intact uterus to minimizethe risk of endometrial hyperplasia.WARNING Be aware that severe hypercalcemiamay occur in patients with bonemetastasis due to breast cancer becauseestrogens influence the metabolism of calciumand phosphorus. Monitor for toxiceffects of increased calcium absorption inpatients who are predisposed to hypercalcemiaor nephrolithiasis.WARNING Assess patient for possible contactlens intolerance or changes in vision orvisual acuity because estrogens can causekeratoconus, leading to increased curvatureof the cornea. Be prepared to discontinuedrug immediately, as prescribed, if patientexperiences sudden partial or completeloss of vision or sudden onset of diplopia,migraine, or proptosis.• Monitor PT test results of patients receivingwarfarin for loss of anticoagulanteffect because estrogens increase productionof clotting factors VII, VIII, IX, and Xand promote platelet aggregation.• Watch for elevated liver function testresults because estrogens may worsen suchconditions as acute intermittent or variegatehepatic porphyria.• Closely monitor patient’s blood pressure.A few patients may experience a substantialincrease in blood pressure as an indiosyncraticreaction to estrogen. Monitorpatients who already have hypertensionfor increases in blood pressure becauseestrogens may cause fluid retention. Alsomonitor patients with asthma, heart disease,migraines, renal disease, or seizuredisorder for exacerbation of these conditions.• Watch for peripheral edema or mildweight gain because estrogens can causesodium and fluid retention.• Frequently monitor serum glucose level inpatients who have diabetes mellitusbecause estrogens may decrease insulinsensitivity and alter glucose tolerance.WARNING Expect to stop estrogen therapyin any woman who develops signs orsymptoms of cancer; cardiovascular disease,such as stroke, MI, pulmonaryembolism, or venous thrombosis; ordementia.• Be aware that exogenous estradiol andprogestins may worsen mood disorders,including depression. Monitor patient foranxiety, depression, dizziness, fatigue,insomnia, or mood changes.• Assess skin for melasma (tan or brownpatches), which may develop on forehead,cheeks, temples, and upper lip. Thesepatches may persist after drug is stopped.• Check patient’s triglyceride level routinelybecause, in patients with hypertriglyceridemia,estrogen therapy may increaseserum triglyceride level enough to causepancreatitis and other complications.• Monitor serum PSA level in patients withinoperable prostate cancer to determine ifpatient is responding to hormone therapy.If patient responds (usually within 3months), expect therapy to continue untildisease is significantly advanced.• Monitor thyroid function test results inpatients with hypothyroidism becauselong-term use of ethinyl estradiol maydecrease effectiveness of thyroid therapy.

• Expect to stop estrogen therapy severalweeks before patient undergoes major surgery,as prescribed, because certain proceduresare associated with prolongedimmobilization and therefore pose a riskof thromboembolism.• If patient takes thyroid hormone replacementtherapy, monitor her for increasedsigns and symptoms of hypothyroidismbecause estradiol may increase thyroidbinding globulin levels, which may makethe patient’s current dose of thyroid hormoneinsufficient.PATIENT TEACHING• Before therapy starts, inform patient ofrisks involved in estrogen therapy, such asincreased risk of breast, endometrial, orovarian cancer; cardiovascular disease;dementia (if age 65 or over); gallbladderdisease; and vision abnormalities.• Advise patient to remain recumbent for atleast 30 minutes after applying estradiolvaginal cream. Inform her that she mayuse a sanitary napkin (but not a tampon)to protect clothing after application.• Teach patient proper application and useof transdermal patch. Instruct her not toapply patch to breasts, waistline, or otherareas where it may not adhere properly.Advise her to rotate application sites atleast weekly and to remove old patchbefore applying new one. If patch falls off,instruct her to reapply it to another areaor to apply a new patch and continue theoriginal treatment schedule. Caution hernot to expose patch to sun for long periods.Explain that she may bathe whilewearing the patch.• Teach patient to apply Estrogel to clean,dry skin of one arm, using applicator.Stress importance of transferring all of thegel from applicator to arm. Tell patient tospread gel as thinly as possible over entireinside and outside of arm from wrist toshoulder. Advise her to wash her handswith soap and water afterward and toavoid fire and smoking until gel has driedbecause it’s flammable. Tell patient neverto apply gel to breasts. Warn that gel isalcohol-based and that patient shouldavoid fire, flame, or smoking until gel hasdried.• Inform patient that each pouch ofEstrasorb contains half of daily dose.estradiol 401Instruct her to apply emulsion to clean,dry skin on top of thigh and to rub it intoentire thigh and calf for 3 minutes. Tellher to rub any excess emulsion onto herbuttocks. Then, advise her to repeat procedureon her other thigh and calf using thesecond pouch. Tell her to wash her handswith soap and water after the applicationand to dress only after affected areas aredry.• Teach patient proper use of estradiol vaginalring. Instruct her to insert ring inupper third of vagina, to keep it there for90 days, and then to remove it and insert anew ring. Or she may remove it during the90-day dosage period, rinse it with lukewarm(not hot or boiling) water, and reinsertit as needed for personal hygiene.Remind patient that she shouldn’t be ableto feel the ring when it’s in place. If shedoes, she should use a finger to push thering farther into her vagina. If vaginal wallulcertation or erosion occurs, suggest thatpatient leave ring out and not replace ituntil healing is complete to keep ring fromadhering to healing tissue.• Instruct patient using estradiol vaginalring to remove ring immediately and contactprescriber if she develops fever, nausea,vomiting, diarrhea, muscle pain, dizziness,faintness, or a sunburn rash on faceor body that may suggest a rare but seriousbacterial infection called toxic shocksyndrome. Also ugre patient to seekprompt medical care if ring becomesattached to vaginal wall (rare), makingremoval difficult.• Instruct patient prescribed transdermalEvamist to prime the pump of a newdevice before the first dose by holding thecontainer upright with the cover in placeand spraying 3 sprays. Then, to deliver adose, she should spray the mist on theinner aspect of her forearm starting nearthe elbow. Instruct her to let the mist dryfor 2 minutes and to not wash the area forat least 30 minutes.• Inform patient receiving estradiol treatmentthat she should have an annualpelvic examination to screen for cervicaldysplasia.• Tell patient who has an intact uterus andis prescribed transdermal Menostar thatshe will need to receive progestin for 14EF

402estrogens (conjugated)days every 6 to 12 months and have anendometrial biopsy yearly.estrogens(conjugated)C.E.S. (CAN), Congest (CAN), Premarin,Premarin Vaginal Cream, SyntheticConjugated Estrogens A (SCE-A)Vaginal Creamestrogens(conjugated) andmedroxyprogesteronePremphase, Premprosynthetic estrogens,A (conjugated)Cenestinsynthetic estrogens,B (conjugated)EnjuviaClass and CategoryChemical class: Estrogen derivative, steroidhormoneTherapeutic class: Antiosteoporotic agent,ovarian hormone replacementPregnancy category: XIndications and Dosages To treat moderate to severe vasomotormenopausal symptomsTABLETS (CENESTIN, PREMARIN)Adults. 0.3 to 1.25 mg daily (Cenestin,Premarin) or cyclically 25 days on, 5 daysoff (Premarin only). Dosage increased asneeded to control symptoms.TABLETS (ENJUVIA)Adults. 0.625 mg daily. Dosage increased asneeded to control symptoms.TABLETS (PREMPRO)Adults. 0.3 mg conjugated estrogens and1.5 mg medroxyprogesterone daily.Increased up to 0.625 mg conjugated estrogensand 5 mg medroxyprogesterone dailyas needed.TABLETS (PREMPHASE)Adults. 0.625 mg conjugated estrogens dailyon days 1 through 14 and combinationproduct (0.625 mg conjugated estrogensand 5 mg medroxyprogesterone) on days15 through 28. To treat vaginal and vulvar atrophyTABLETS (CENESTIN, PREMARIN)Adults. 0.3 to 1.25 mg daily (Cenestin,Premarin) or cyclically 25 days on, 5 daysoff (Premarin only). Dosage increased asneeded to control symptoms.TABLETS (PREMPRO)Adults. 0.3 mg conjugated estrogens and1.5 mg medroxyprogesterone daily.Increased up to 0.625 mg conjugated estrogensand 5 mg medroxyprogesterone dailyas needed.TABLETS (PREMPHASE)Adults. 0.625 mg conjugated estrogens dailyon days 1 through 14 and combinationproduct (0.625 mg conjugated estrogensand 5 mg medroxyprogesterone) on days15 through 28. To treat atrophic vaginitis and vaginaland vulvar atrophyVAGINAL CREAM (PREMARIN)Adults. 0.5 to 2 g daily in cycles of 3 wk on,1 wk off. To treat moderate to severe vaginal drynessand pain with intercourse andsymptoms of vulvar and vaginal atrophyin menopauseTABLETS (ENJUVIA)Adults. 0.3 mg daily.VAGINAL CREAM (PREMARIN)Adults. 0.5 g twice/wk. Or, 0.5 g daily for21 days followed by 7 days off, with cyclerepeated every 28 days.VAGINAL CREAM (SCE-A)Adults. 1 g daily for 1 wk, followed by 1 gtwice/wk. To prevent postmenopausal osteoporosisTABLETS (CENESTIN, PREMARIN)Adults. 0.625 mg daily continuously or incycles of 25 days on, 5 days off.TABLETS (PREMPRO)Adults. 0.3 mg conjugated estrogens and1.5 mg medroxyprogesterone daily.Increased to 0.625 mg conjugated estrogensand 5 mg medroxyprogesterone daily asneeded.TABLETS (PREMPHASE)Adults. 0.625 mg conjugated estrogens daily

on days 1 through 14 and combinationproduct (0.625 mg conjugated estrogensand 5 mg medroxyprogesterone) on days15 through 28. To provide palliative treatment foradvanced androgen-dependent prostatecancerTABLETS (PREMARIN)Adults. 1.25 to 2.5 mg t.i.d. To provide palliative treatment formetastatic breast cancerTABLETS (PREMARIN)Adults. 10 mg t.i.d. for 3 mo or longer. To treat dysfunctional uterine bleedingI.V. INFUSION, I.M. INJECTION (PREMARIN)Adults. 25 mg, repeated in 6 to 12 hr ifneeded. To treat estrogen deficiency fromoophorectomy or primary ovarian failureTABLETS (PREMARIN)Adults. 1.25 mg daily in cycles of 3 wk on,1 wk off. To treat female hypogonadismTABLETS (PREMARIN)Adults. 0.3 to 0.625 mg daily in cycles of3 wk on, 1 wk off. Increased as neededevery 6 to 12 mo.Mechanism of ActionIncrease the rate of DNA and RNA synthesisin the cells of female reproductiveorgans, hypothalamus, pituitary glands, andother target organs. In the hypothalamus,estrogens reduce the release ofgonadotropin-releasing hormone, whichdecreases pituitary release of follicle-stimulatinghormone and luteinizing hormone.In women, these hormones are required fornormal genitourinary and other essentialbody functions. At the cellular level, estrogensincrease cervical secretions, causeendometrial cell proliferation, and increaseuterine tone. Estrogen replacement helpsmaintain genitourinary function andreduce vasomotor symptoms when estrogenproduction declines from menopause, surgicalremoval of ovaries, or other estrogendeficiency. Estrogen also helps preventosteoporosis by keeping bone resorptionfrom exceeding bone formation.In men, estrogens inhibit pituitarysecretion of luteinizing hormone anddecrease testicular secretion of testosterone.These actions may decrease prostate tumorgrowth and lower the level of prostate-specificantigen.estrogens (conjugated) 403ContraindicationsActive deep vein thrombosis, pulmonaryembolism, or history of these conditions;active or recent (within past year) arterialthromboembolic disease such as stroke orMI; hepatic dysfunction or disease; hypersensitivityto estrogens or their components;known or suspected breast cancer orhistory of breast cancer; known or suspectedestrogen-dependent cancer; pregnancy;undiagnosed abnormal genital bleedingIncompatibilitiesDon’t combine I.V. estrogens with acidsolutions, ascorbic acid, and proteinhydrolysate because they’re incompatible.InteractionsDRUGSaminocaproic acid: Possibly increased levelof hypercoagulability caused by aminocaproicacidbarbiturates, carbamazepine, hydantoins,rifabutin, rifampin: Possibly reduced activityof estrogen and medroxyprogesteronebromocriptine: Possibly interference withbromocriptine’s therapeutic effectscalcium: Possibly increased calcium absorptioncorticosteroids: Increased therapeutic andtoxic effects of corticosteroidscyclosporine: Increased risk of hepatotoxicityand nephrotoxicitydidanosine, lamivudine, zalcitabine: Possiblypancreatitishepatotoxic drugs (such as isoniazid): Increasedrisk of hepatitis and hepatotoxicityoral antidiabetic drugs: Decreased therapeuticeffects of these drugssomatrem, somatropin: Possibly acceleratedepiphyseal maturationtamoxifen: Possibly interference withtamoxifen’s therapeutic effectsthyroid hormone replacement: Decreasedeffectivenesswarfarin: Decreased anticoagulant effectACTIVITIESsmoking: Increased risk of stroke, pulmonaryembolism, thrombophlebitis, andtransient ischemic attackAdverse ReactionsCNS: Asthenia, dementia, depression, dizziness,growth benign meningioma,EF

404estrogens (conjugated)headache, insomnia, migraine headache,mood disturbance, nervousness, paresthesia,strokeCV: Hypertension, MI, peripheral edema,thromboembolism, thrombophlebitis,vasodilationEENT: Intolerance of contact lenses,pharyngitis, retinal vascular thrombosis,rhinitis, sinusitisENDO: Breast enlargement, pain, tenderness,or tumors; gynecomastia (men); hotflashes; hyperglycemiaGI: Abdominal cramps or pain, anorexia,cholestatic jaundice, constipation, diarrhea,flatulence, gallbladder disease or obstruction,hepatic hemangioma enlargement,hepatitis, increased appetite, ischemic colitis,nausea, pancreatitis, vomitingGU: Amenorrhea, breakthrough bleeding,cervical erosion, clear vaginal discharge,decreased libido (men), dysmenorrhea,endometrial cancer or hyperplasia, impotence,increased libido (women), leukorrhea,ovarian cancer, prolonged or heavymenstrual bleeding, testicular atrophy, uterineleiomyomata enlargement, vaginal candidiasis,vaginitis, vaginal site reactions(vaginal administration only) such as burning,irritation, and genital pruritusMS: Arthralgias, back painRESP: Bronchitis, increased cough, pulmonaryembolismSKIN: Acne, alopecia, chloasma, erythemamultiforme, erythema nodosum, hemorrhagiceruption, hirsutism, melasma, oilyskin, pruritus, purpura, rash, seborrhea,urticariaOther: Anaphylaxis, angioedema, flu syndrome,folic acid deficiency, hypercalcemia(in metastatic bone disease), weight gainNursing Considerations• Use conjugated estrogens cautiously inpatients with severe hypocalcemia becausea sudden increase in serum calcium levelmay cause adverse reactions.• Reconstitute conjugated estrogens withnormal saline solution, dextrose, or invertsugar solution and use within a few hours.Discard solution that contains precipitate.WARNING Monitor serum calcium level todetect severe hypercalcemia in patientswith bone metastasis from breast cancer.• Watch for elevated liver function testresults because estrogen and progestinsmay worsen such conditions as acute intermittentor variegate hepatic porphyria.• Assess hypertensive patients for increasesin blood pressure because estrogens maycause fluid retention.• Monitor patients with asthma, diabetesmellitus, endometriosis, heart disease,lupus erythematosus, migraine headaches,renal disease, or seizure disorder for worseningof these conditions.• If patient takes warfarin, assess PT for lossof anticoagulant effects because estrogensincrease production of clotting factors andpromote platelet aggregation.• Expect to stop drug during periods ofimmobilization, 4 weeks before electivesurgery, and if jaundice develops.WARNING Expect to stop estrogen combinationtherapy in any woman who developssigns or symptoms of cancer; cardiovasculardisease, such as MI, pulmonaryembolism, venous thrombosis, or stroke;or dementia.• Check triglyceride level routinely because,in hypertriglyceridemia, estrogen therapymay increase triglycerides enough to causepancreatitis and other complications.• If patient takes thyroid hormone replacementtherapy, monitor her for increasedsigns and symptoms of hypothyroidismbecause estrogen may increase thyroidbinding globulin level, which may makethe patient’s current dose of thyroid hormoneinsufficient.• Estrogen may worsen mood disorders,including depression. Monitor patient fordepression, fatigue, insomnia, or moodchanges.PATIENT TEACHING• Explain the risks of estrogen therapy,including increased risk of breast,endometrial, or ovarian cancer; cardiovasculardisease; dementia; and gallbladderdisease.• Instruct patient how to use vaginal creamand to cleanse plunger by removing itfrom barrel and washing it with mild soapand warm water after each use.• Urge patient to immediately report breakthroughbleeding to prescriber.• Instruct patient to perform monthly breastself-examination and to comply with allprescribed follow-up examinations.• Warn female patient that long-term use

may increase risk of dementia, heart disease,stroke, gallbladder disease, and breastor endometrial cancer.• Inform patient that estrogen vaginalcream may alter effectiveness of condoms,diaphragms, or cervical caps made of latexor rubber.eszopicloneLunestaClass, Category, and ScheduleChemical class: Pyrrolopyrazine derivativeof cyclopyrrolone classTherapeutic class: Sedative-hypnoticPregnancy category: CControlled substance schedule: IVIndications and Dosages To treat insomniaTABLETSAdults. Initial: 2 mg immediately at bedtime.May be increased to 3 mg at bedtime,as needed. Maintenance: 3 mg at bedtime.DOSAGE ADJUSTMENT For elderly patientswho have trouble falling asleep or patientswith severe hepatic impairment, dosagedecreased to 1 mg at bedtime. For elderlypatients who have trouble staying asleep,dosage may be increased to 2 mg at bedtime.Route Onset Peak DurationP.O. Unknown 1 hr UnknownMechanism of ActionMay potentiate effects of the inhibitoryneurotransmitter gamma-aminobutyricacid (GABA) by binding close to or withbenzodiazepine receptors in limbic and corticalareas of the CNS. By binding to thesereceptor sites and areas, eszopicloneincreases GABA’s inhibitory effects andblocks cortical and limbic arousal, therebyinducing and maintaining sleep.ContraindicationsHypersensitivity to eszopiclone or its componentsInteractionsDRUGSclarithromycin, itraconazole, ketoconazole,eszopiclone 405nefazodone, nelfinavir, ritonavir, troleandomycin:Increased eszopiclone levelrifampin: Decreased eszopiclone levelACTIVITIESalcohol use: Additive effect on psychomotorperformanceAdverse ReactionsCNS: Agitation, anxiety, bizarre behaviorsuch as sleep driving, confusion, depersonalization,depression, dizziness, hallucinations,headache (including migraine), nervousness,neuralgia, somnolence, unusualdreamsCV: Chest pain, peripheral edemaEENT: Dry mouth, taste perversionENDO: GynecomastiaGI: Diarrhea, hepatitis, indigestion, nausea,vomitingGU: Decreased libido, dysmenorrhea, UTIRESP: Asthma, respiratory tract infectionSKIN: Pruritus, rashOther: Generalized pain, heat stroke, viralinfectionNursing Considerations• Use eszopiclone cautiously in patients withsevere mental depression or reduced respiratoryfunction; drug may intensify mentaldepression and lead to respiratory depression.PATIENT TEACHING• Instruct patient not to exceed prescribedeszopiclone dosage and not to stop drugabruptly because withdrawal symptomsmay occur.• Because eszopiclone can reduce alertness,advise patient to take drug immediatelybefore bedtime and to avoid potentiallyhazardous activities until drug’s CNSeffects are known.• Urge patient to avoid alcohol and CNSdepressants because of additive effects.• Advise woman of childbearing age to notifyprescriber if she becomes or intends tobecome pregnant during therapy.• Explain that sleep may be disturbed forthe first few nights after therapy.• Warn patient and caregiver that somepatients have performed bizarre activitiesafter taking drug, such as driving the car,preparing and eating food, making phonecalls, or having sex while not fully awakeand often with no memory of the event.These episodes usually occur in patientsEF

406etanerceptwho have taken the drug with alcohol orother CNS depressant or who have exceededthe recommended dose. If such anepisode occurs, the prescriber should benotified and eszopiclone therapy discontinuedimmediately.etanerceptEnbrelClass and CategoryChemical class: Dimeric recombinanthuman p75 tumor necrosis factor receptorTherapeutic class: Disease-modifying antirheumatoiddrugPregnancy category: BIndications and Dosages To reduce signs and symptoms ofrheumatoid or psoriatic arthritis, slowstructural damage in active arthritis,and improve physical function inpatients with psoriatic arthritis, alone orin combination with methotrexateSUBCUTANEOUS INJECTIONAdults. 50 mg once/wk on same day eachwk. To reduce signs and symptoms of activeankylosing spondylitisSUBCUTANEOUS INJECTIONAdults. 50 mg once/wk on same day eachwk. To reduce signs and symptoms of juvenilerheumatoid arthritisSUBCUTANEOUS INJECTIONChildren ages 4 to 17. 0.4 mg/kg twice/wk3 to 4 days apart for 3 to 7 mo. Or, 0.8 mg/kg once/wk on same day each wk for 3 to7 mo. Maximum: 25 mg twice/wk or 50 mgweekly. To treat chronic moderate-to-severeplaque psoriasis in candidates for systemictherapy or phototherapySUBCUTANEOUS INJECTIONAdults. Initial: 50 mg twice/wk 3 to 4 daysapart for 3 mo; then reduced to 50 mg/wk. To reduce signs and symptoms of moderatelyto severely active polyarticularjuvenile idiopathic arthritisSUBCUTANEOUS INJECTIONChildren ages 2 to17. 0.8 mg/kg/wk.Maximum: 50 mg/wk.IncompatibilitiesDon’t combine etanercept with other drugs.ContraindicationsHypersensitivity to etanercept, hamster protein,or their components; sepsis or risk of itInteractionsDRUGScyclophosphamide: Possibly increased risk ofmalignancysulfasalazine: Possibly decreased neutrophilcountAdverse ReactionsCNS: Asthenia, chills, dizziness, fever,headache, multiple sclerosis, seizuresCV: Congestive heart failure, hypertension,hypotension, peripheral edemaEENT: Optic neuritis, pharyngitis, rhinitis,sinusitisGI: Abdominal abscess, abdominal pain,autoimmune hepatitis, cholecystitis, diarrhea,gastroenteritis, indigestion, nausea,noninfectious hepatitis, vomitingGU: PyelonephritisHEME: Aplastic anemia, neutropenia, pancytopeniaMS: Osteomyelitis, septic arthritis, transversemyelitisRESP: Bronchitis, cough, pneumonia, upperrespiratory tract infectionSKIN: Cellulitis, foot abscess, leg ulceration,pruritus, rash, urticariaOther: Angioedema; injection site edema,erythema, itching, and pain; malignancy,such as leukemia or lymphoma; sepsis; varicellainfectionNursing Considerations• Screen patient for latent tuberculosis witha tuberculin skin test before starting etanercepttherapy. If test is positive, expect togive treatment, as ordered, before startingetanercept. Also screen patient for hepatitisB. If present, expect etanercept therapyto be withdrawn because antirheumatictherapies like etanercept may reactivatehepatitis B.• Use cautiously in patients with a history ofrecurrent infection, underlying conditionsthat may predispose them to infections, oran existing chronic, latent, or localizedinfection because etanercept increasestheir risk of infection.• Use cautiously in patients with COPD, and

etanercept 407Mechanism of ActionEtanercept reduces joint inflammationfrom rheumatoid arthritis by bindingwith tumor necrosis factor (TNF), acytokine, or protein, that plays an importantrole in normal inflammatory andimmune responses.In rheumatoid arthritis, the immuneand inflammatory process triggers releaseof TNF, mainly from macrophages. TNFthen binds to TNF receptors on cellmembranes, as shown below left. Thisaction renders TNF biologically activeand triggers a cascade of inflammatoryevents that results in increased inflammationof the synovial membrane, release ofdestructive lysosomal enzymes, and furtherjoint destruction.Etanercept binds to TNF and preventsit from binding with TNF receptors onthe cell membranes, as shown belowright. This action renders bound TNFbiologically inactive, prevents TNF-mediatedcellular responses, and significantlyreduces inflammatory activity.MacrophageEFCell membraneTNFTNFreceptorEtanerceptbound to TNFInflammationmonitor respiratory status closely becauseetanercept therapy may increase patient’srisk of adverse respiratory reactions.• Use cautiously in patients with preexistingor recent onset CNS demyelinating disordersbecause drug may worsen these conditions.Also use cautiously in patientswith heart failure because drug may worsenit.• Tumor necrosis factor antagonists shouldn’tbe given with etanercept because doingso increases the risk of serious infection.WARNING Don’t use the diluent providedwith etanercept (bacteriostatic water forinjection, USP, with 0.9% benzyl alcohol)for patients who have benzyl alcoholhypersensitivity. Instead, use sterile waterfor injection for these patients.WARNING If you have a latex allergy, don’thandle needle cover of diluent syringebecause it contains dry natural rubber.• When giving etanercept to children, don’tuse the 25-mg prefilled syringe if the childweighs less than 31 kg (68 lb). The 50-mgprefilled syringe or SureClick autoinjectormay be used for children who weigh 63 kg(138 lb) or more.WARNING Expect to stop etanercept ifpatient develops sepsis.• Avoid giving live-virus vaccines to patientswho are taking etanercept because drugdecreases immune response and increasesrisk of secondary transmission of vaccinevirus.• Monitor immunosuppressed patients forevidence of acute or chronic infection,including chills, fever, and tachycardia,because etanercept decreases defensesagainst infection. It also increases the riskof developing malignant tumors.• Continue giving corticosteroids, NSAIDs,and other analgesics, as prescribed, duringetanercept therapy.• Malignancies, especially lymphomas andleukemias, have been reported rarely inpatients taking tumor necrosis factor

408ethacrynic acidblockers such as etanercept. Children, adolescents,and patients with rheumatoidarthritis, especially those with very activedisease, are at greatest risk. Monitor closely.PATIENT TEACHING• Inform patient that etanercept is given bya small injection under the skin, and teachhim proper injection technique if needed.• If patient will take 50-mg dose, explainthat a prefilled syringe is available to eliminatethe need to mix or draw up drug.• If patient will take less than 50-mg dose orprefers not to use prefilled syringe, advisehim to use drug as soon as possible afterdissolving powder. Dissolved powder maybe kept in refrigerator for up to 6 hoursafter mixing and then should be discarded.• Instruct patient to rotate injection sitesamong thigh, stomach, and upper armsand to avoid areas that are tender, red,bruised, or hard. Advise him to keep eachsite at least 10 away from a previous site.• Urge patient to use needles and syringesonce and discard in puncture-proof container.• Caution patient that the risk of malignanciessuch as leukemia and lymphoma maybe higher in those who take etanercept,especially children and adolescents. Tellhim to seek medical attention promptlyfor any suspicious signs and symptoms.• Urge patient to consult prescriber immediatelyif he develops an infection becausedrug may decrease the body’s infectionfightingability.• Caution patient who hasn’t had chickenpoxto contact prescriber right away if he’sexposed because he may develop a moreserious infection.• Urge patient to seek immediate emergencycare if he develops a persistent fever, bruising,bleeding, or pallor while taking drug.ethacrynic acidEdecrinethacrynate sodiumEdecrinClass and CategoryChemical class: Ketone derivative ofanyloxyacetic acidTherapeutic class: DiureticPregnancy category: BIndications and Dosages To promote diuresis in heart failure;hepatic cirrhosis; renal disease; ascites ofshort duration caused by cancer, idiopathicedema, or lymphedema; andedema in children (excluding infantswith congenital heart disease or nephroticsyndrome)ORAL SOLUTION, TABLETSAdults. Initial: 50 to 100 mg daily as a singledose or in divided doses. Dosageincreased by 25 to 50 mg daily, if needed.Maintenance: 50 to 200 mg daily.Maximum: 400 mg daily.Children (except infants). Initial: 25 mgdaily. Dosage increased in 25-mg incrementsdaily, if needed.I.V. INFUSIONAdults. Initial: 50 mg or 0.5 to 1 mg/kg.Dose repeated in 2 to 4 hr, if needed, thenevery 4 to 6 hr based on patient response.In an emergency, dose repeated every 1 hr,if needed. Maximum: 100 mg as singledose.Route Onset Peak DurationP.O. 30 min 2 hr 6–8 hrI.V. 5 min 15–30 min 2 hrMechanism of ActionProbably inhibits the sulfhydryl-catalyzedenzyme systems that cause sodium andchloride resorption in the proximal anddistal tubules and the ascending limb of theloop of Henle. These inhibitory effectsincrease urinary excretion of sodium, chloride,and water, causing profound diuresis.Drug also increases the excretion of potassium,hydrogen, calcium, magnesium, bicarbonate,ammonium, and phosphate.ContraindicationsAnuria; hypersensitivity to ethacrynic acid,ethacrynate sodium, sulfonylureas, or theircomponents; infancy; severe diarrheaInteractionsDRUGSACE inhibitors, antihypertensives: Possiblyhypotensionaminoglycosides: Increased risk of ototoxicityamiodarone: Increased risk of arrhythmias

amphotericin B: Increased risk of electrolyteimbalances, nephrotoxicity, and ototoxicityanticoagulants, thrombolytics: Possiblypotentiated anticoagulation and risk ofhemorrhagecorticosteroids: Increased risk of gastrichemorrhagedigoxin: Increased risk of digitalis toxicityinsulin, oral antidiabetic drugs: Possiblyincreased serum glucose level and decreasedtherapeutic effects of these drugslithium: Increased risk of lithium toxicityneuromuscular blockers: Possibly increasedneuromuscular blockadeNSAIDs: Possibly decreased effects of ethacrynicacidsympathomimetics: Possibly interferencewith hypotensive effects of ethacrynic acidand ethacrynate sodiumACTIVITIESalcohol use: Possibly potentiated hypotensiveand diuretic effects of ethacrynic acidand ethacrynate sodiumAdverse ReactionsCNS: Confusion, fatigue, headache, malaise,nervousnessCV: Orthostatic hypotensionEENT: Blurred vision, hearing loss, ototoxicity(ringing or buzzing in ears), sensationof fullness in ears, yellow visionENDO: Hyperglycemia, hypoglycemiaGI: Abdominal pain, anorexia, diarrhea,dysphagia, GI bleeding (I.V. form), nausea,vomitingGU: Hematuria (I.V. form), interstitial nephritis,polyuriaHEME: Agranulocytosis, severe neutropenia,thrombocytopeniaSKIN: RashOther: Hyperuricemia, hypochloremicalkalosis, hypokalemia, hypomagnesemia,hyponatremia, hypovolemia, infusion siteirritation and painNursing ConsiderationsWARNING Give ethacrynic acid and ethacrynatesodium cautiously in patients withadvanced hepatic cirrhosis, especiallythose with a history of electrolyte imbalanceor hepatic encephalopathy; bothforms of drug may lead to lethal hepaticcoma.• Dilute ethacrynate sodium with D 5 W ornormal saline solution for I.V. infusion.ethacrynic acid 409Discard unused portion after 24 hours.• Don’t use diluted ethacrynate sodiumthat’s cloudy or opalescent.• Infuse I.V. ethacrynate sodium slowly over30 minutes.• Weigh patient daily, and assess him forsigns and symptoms of electrolyte imbalancesand dehydration.• Monitor blood pressure and fluid intakeand output, and check laboratory testresults.• Report significant changes. Prescriber mayreduce dosage or temporarily stop drug.• If hypokalemia develops, administerreplacement potassium, as ordered.• Monitor serum glucose level frequently,especially if patient has diabetes mellitus;both forms of drug may cause hyperglycemiaor hypoglycemia.• Notify prescriber if patient experienceshearing loss, vertigo, or ringing, buzzing,or sense of fullness in his ears. Drug mayneed to be discontinued.PATIENT TEACHING• Instruct patient to take the last dose ofethacrynic acid several hours before bedtimeto avoid sleep interruption fromdiuresis. If patient receives once-daily dosing,advise him to take the dose in themorning to avoid sleep disturbance causedby nocturia.• Suggest that patient take ethacrynic acidwith food or milk to reduce the likelihoodof GI distress.• Advise patient to change position slowly tominimize effects of orthostatic hypotension,especially if he also takes an antihypertensive.• Unless contraindicated, urge patient to eatmore high-potassium foods and to take apotassium supplement, if prescribed, toprevent hypokalemia.• Caution patient not to drink alcohol,stand for prolonged periods, or exerciseduring hot weather because these activitiesmay exacerbate orthostatic hypotension.• Instruct patient to notify prescriber if hehas diarrhea; buzzing, fullness, or ringingin his ears; hearing loss; severe nausea;vertigo; or vomiting. Drug may need to bediscontinued.• Remind diabetic patients to check theirserum glucose levels often for changes.EF

410ethambutol hydrochlorideethambutolhydrochlorideEtibi (CAN), MyambutolClass and CategoryChemical class: Diisopropylethylenediamide derivativeTherapeutic class: AntitubercularPregnancy category: CIndications and Dosages As adjunct to treat tuberculosis andatypical mycobacterial infections causedby Mycobacterium tuberculosisTABLETSAdults and adolescents who haven’treceived previous antituberculotic therapy.15 mg/kg daily.Adults and adolescents who have receivedantituberculotic therapy. 25 mg/kg daily;after 60 days, decreased to 15 mg/kg daily.Mechanism of ActionMay suppress bacterial multiplication byinterfering with RNA synthesis in susceptiblebacteria that are actively dividing.ContraindicationsHypersensitivity to ethambutol or its components,inability to report changes invision, optic neuritisInteractionsDRUGSantacids that contain aluminum hydroxide:Decreased absorption of ethambutolother neurotoxic drugs: Increased risk ofneurotoxicity, such as optic and peripheralneuritisAdverse ReactionsCNS: Burning sensation or weakness inarms and legs, confusion, disorientation,dizziness, fever, headache, malaise, paresthesia,peripheral neuritisEENT: Blurred vision, decreased visual acuity,eye pain, optic neuritis, red-green colorblindnessGI: Abdominal pain, anorexia, hepatic dysfunction,nausea, vomitingHEME: Leukopenia, neutropenia, thrombocytopeniaMS: Arthralgia, gouty arthritis, joint painRESP: Pulmonary infiltratesSKIN: Dermatitis, erythema multiforme,pruritus, rashOther: Anaphylaxis, hypersensitivity syndrome(rash or exfoliative dermatitis,eosinophilia, and one of the following: hepatitis,pneumonitis, nephritis, myocarditis,pericarditis), lymphadenopathyNursing Considerations• Expect prescriber to refer patient for anophthalmologic examination that includestests for visual fields, acuity, and red-greencolor blindness before taking ethambutoland monthly thereafter. This is especiallylikely if therapy is prolonged or dosageexceeds 15 mg/kg daily.WARNING Notify prescriber immediately ifpatient develops vision changes, andexpect ethambutol to be stopped if theyoccur.• Expect to give the patient at least oneother antituberculotic with ethambutol, asprescribed, because bacteria may becomeresistant quickly to a single drug.• Monitor laboratory test results for changesin liver function or for increased serumuric acid level if patient has gouty arthritisor impaired renal function. Notify prescriberof any abnormalities.• Obtain a monthly sputum specimen, asordered, to check bacteriologic response insputum-positive patient.• Knowthat successful ethambutol therapytypically takes 6 to 12 months but maytake years.PATIENT TEACHING• Teach patient to recognize possible adversereactions to ethambutol.• Advise patient to take drug with food if heexperiences adverse GI reactions.• Instruct patient to take a missed dose assoon as he remembers, unless it’s nearlytime for the next dose, but not to doubledose.• Explain that ethambutol therapy may lastmonths or years and that compliance isessential.• Advise patient to notify prescriber if noimprovement occurs within 3 weeks ofstarting ethambutol therapy; if bothersomeor severe adverse reactions occur; ifhis vision changes; or if a rash, fever, orjoint pain (possible hypersensitivity)develops.

ethchlorvynolPlacidylClass, Category, and ScheduleChemical class: Chlorinated tertiaryacetylenic carbinolTherapeutic class: Sedative-hypnoticPregnancy category: CControlled substance schedule: IVIndications and Dosages To provide short-term relief frominsomniaCAPSULESAdults. 0.5 to 1 g at bedtime for no longerthan 1 wk.Route Onset Peak DurationP.O. 15–60 min Unknown 5 hrMechanism of ActionExerts sedative-hypnotic, muscle relaxant,and anticonvulsant effects possibly bydepressing the reticular activating system.ContraindicationsHypersensitivity to ethchlorvynol or itscomponents, porphyriaInteractionsDRUGSCNS depressants, tricyclic antidepressants:Increased CNS depressionoral anticoagulants: Decreased anticoagulanteffectsACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Ataxia, dizziness, facial numbness,fatigue, light-headedness, syncope,unsteadiness, weaknessCV: HypotensionEENT: Blurred vision, unpleasant aftertasteGI: Epigastric pain, indigestion, nausea,vomitingHEME: ThrombocytopeniaSKIN: Jaundice, rash, urticariaOther: Physical and psychological dependenceNursing Considerations• If patient awakens too early after taking0.5 or 0.75 g of ethchlorvynol at bedtime,ethchorvynol; ethionamide 411ask prescriber if he may take a single supplementaldose of 200 mg.• Assess for signs of addiction if patient hastaken drug for 2 weeks or longer.• Be aware that ethchlorvynol shouldn’t begiven for longer than 1 week. If patient hasreceived prolonged therapy, expect to discontinuedrug gradually to prevent withdrawalsymptoms. Notify prescriber if youdetect evidence of withdrawal, such asdiaphoresis, hallucinations, irritability,muscle twitching, nausea, nervousness,restlessness, seizures, sleep disturbance,tremor, vomiting, and weakness.PATIENT TEACHING• Caution patient not to exceed prescribeddosage or dosing frequency because ofethchlorvynol’s habit-forming potential.Instruct him not to use drug for morethan 1 week.• Advise patient to take ethchlorvynol withfood or milk to minimize adverse GI reactions.• If patient has taken long-term ethchlorvynoltherapy, warn against stopping drugabruptly; advise him to contact prescriberfor guidelines to reduce dosage.• Direct patient to avoid alcohol and otherCNS depressants during ethchlorvynoltherapy because they increase the risk ofadverse reactions.• Advise patient to avoid potentially hazardousactivities until drug’s CNS effects areknown.ethionamideTrecator-SCClass and CategoryChemical class: Thiamide analogue ofisonicotinic acidTherapeutic class: AntituberculoticPregnancy category: Not ratedIndications and Dosages As adjunct to treat tuberculosisTABLETSAdults. 0.5 to 1 g daily in divided dosesevery 8 to 12 hr, together with other antituberculotics.Maximum: 1 g daily.Children. 15 to 20 mg/kg daily in divideddoses every 8 to 12 hr, together with otherantituberculotics. Maximum: 750 mg daily.EF

412ethosuximideMechanism of ActionMay inhibit peptide synthesis, resulting inbacteriostatic action against Mycobacteriumtuberculosis.ContraindicationsHypersensitivity to ethionamide or its components,severe hepatic damageInteractionsDRUGScycloserine: Increased risk of adverse CNSeffects, especially seizuresother neurotoxic drugs: Increased risk ofneurotoxicity, such as optic and peripheralneuritisAdverse ReactionsCNS: Burning or pain in arms and legs,clumsiness, confusion, depression, mentalor mood changes, paresthesia, unsteadinessCV: Orthostatic hypotensionEENT: Blurred vision, eye pain, increasedsalivation, metallic taste, optic neuritis,stomatitis, vision lossENDO: Goiter, hypoglycemia, hypothyroidismGI: Anorexia, hepatitis, nausea, vomitingSKIN: Jaundice, rashNursing Considerations• Use ethionamide cautiously in patientswith a history of hypersensitivity to isoniazid,niacin, pyrazinamide, or chemicallyrelated drugs; these ptients also may behypersensitive to ethionamide.• Expect to give another antituberculoticwith ethionamide to decrease the risk ofdevelopment of bacterial resistance.• Also plan to give pyridoxine to prevent orminimize peripheral neuritis (burning,numbness, pain, or tingling in hands andfeet), especially if patient has already hadisoniazid-induced peripheral neuritis.• Monitor liver function test results, andassess for signs of impaired function, suchas hepatitis and jaundice.• Question patient regularly about visionchanges. Notify prescriber about blurredvision, eye pain, or loss of vision or acuity.• Monitor compliance; treatment may needto continue for 1 to 2 years or indefinitely.PATIENT TEACHING• Advise patient to take ethionamide withfood if adverse GI reactions occur.• Instruct patient to take a missed dose assoon as he remembers unless it’s nearlytime for the next dose. Caution him not todouble the dose.• Encourage patient to notify prescriber ifno improvement occurs within 3 weeks; ifbothersome or severe adverse reactionsoccur; if his vision changes; or if he hasburning, numbness, pain, or tingling inhis hands and feet.• Inform patient that therapy may have tocontinue for months or years and thatcompliance is essential.ethosuximideZarontinClass and CategoryChemical class: Succinimide derivativeTherapeutic class: AnticonvulsantPregnancy category: Not ratedIndications and Dosages To manage absence seizures in a patientwho also has generalized tonic-clonicseizuresCAPSULES, SYRUPAdults and children age 6 and over. Initial:500 mg daily. Maintenance: Increased by250 mg every 4 to 7 days until control isachieved with minimal adverse reactions.Children ages 3 to 6. Initial: 250 mg daily.Maintenance: Increased by 250 mg every4 to 7 days until control is achieved withminimal adverse reactions.Mechanism of ActionElevates the seizure threshold and reducesthe frequency of attacks by depressing themotor cortex and elevating the threshold ofCNS response to convulsive stimuli.ContraindicationsHypersensitivity to ethosuximide, succinimides,or their componentsInteractionsDRUGScarbamazepine, phenobarbital, phenytoin,primidone: Possibly decreased blood ethosuximidelevelCNS depressants: Possibly increased CNSdepressionhaloperidol: Possibly decreased blood haloperidollevel

loxapine, MAO inhibitors, maprotiline,molindone, phenothiazines, pimozide, tricyclicantidepressants: Possibly loweredseizure threshold and reduced therapeuticeffect of ethosuximidevalproic acid: Increased or decreased bloodethosuximide levelACTIVITIESalcohol use: Possibly increased CNS depressionAdverse ReactionsCNS: Aggressiveness, ataxia, decreased concentration,dizziness, drowsiness, euphoria,fatigue, headache, hyperactivity, irritability,lethargy, nightmares, sleep disturbance, suicidalideationEENT: Gingival hypertrophy, myopia,tongue swellingGI: Abdominal and epigastric pain, abdominalcramps, anorexia, diarrhea, hiccups,indigestion, nausea, vomitingGU: Increased libido, microscopic hematuria,vaginal bleedingHEME: Agranulocytosis, aplastic anemia,eosinophilia, leukopenia, pancytopeniaSKIN: Erythematous and pruritic rash, hirsutism,Stevens-Johnson syndrome, systemiclupus erythematosus, urticariaOther: Hypersensitivity reaction, weightlossNursing Considerations• Use ethosuximide with extreme caution inpatients with hepatic or renal disease.• Give other anticonvulsants concurrently,as prescribed, to control generalized tonicclonicseizures.• Monitor CBC and platelet count andassess for signs of infection, such as cough,fever, and pharyngitis. Also routinely evaluateliver and renal function test results.• Take safety precautions because drug maycause adverse CNS reactions, such asdizziness and drowsiness.• Monitor patient closely for evidence ofsuicidal thinking or behavior, especiallywhen therapy starts or dosage changes.PATIENT TEACHING• Stress the importance of complying withethosuximide regimen.• Advise patient to take a missed dose assoon as he remembers unless it’s nearlytime for the next dose. Warn him not todouble the dose.• Instruct patient not to engage in potentiallyhazardous activities until drug’s CNSeffects are known.• Caution patient not to stop taking drugabruptly; doing so increases the risk ofabsence seizures.• Urge caregivers to watch patient closely forevidence of suicidal tendencies, especiallywhen therapy starts or dosage changes,and to report any concerns immediately toprescriber.• Encourage female patient who becomespregnant while taking ethosuximide toenroll in the North American antiepilepticdrug pregnancy registry by calling 1-888-233-2334. Explain that this registry is collectinginformation about the safety ofantiepileptic drugs during pregnancy.ethotoinPeganoneethotoin 413Class and CategoryChemical class: Hydantoin derivativeTherapeutic class: AnticonvulsantPregnancy category: DIndications and Dosages To treat tonic-clonic and simple orcomplex partial seizures as initial oradjunct therapy, or when other drugsare ineffectiveTABLETSAdults and adolescents. Initial: 0.5 to 1 gon the first day in four to six divided doses,increased over several days until desiredresponse is reached. Maintenance: 2 to 3 gdaily in four to six divided doses.Maximum: 3 g daily.Children. Initial: Up to 750 mg daily, basedon weight and age, in 4 to 6 divided doses,adjusted as needed and tolerated.Maintenance: 0.5 to 1 g daily in 4 to6 divided doses. Maximum: 3 g daily.DOSAGE ADJUSTMENT For debilitatedpatients, initial dosage lowered to reduce therisk of adverse reactions.Mechanism of ActionLimits the spread of seizure activity and thestart of new seizures by:• regulating voltage-dependent sodium andcalcium channels in neuronsEF

414ethotoin• inhibiting calcium movement across neuronalmembranes• enhancing sodium-potassium adenosinetriphosphatase activity in neurons andglial cells.These actions may result from ethotoin’sability to slow the recovery rate of inactivatedsodium channels.ContraindicationsHematologic disorders; hepatic dysfunction;hypersensitivity to ethotoin, phenytoin,other hydantoins, or their componentsInteractionsDRUGSacetaminophen: Increased risk of hepatotoxicitywith long-term acetaminophen useamiodarone: Possibly increased blood ethotoinlevel and risk of toxicityantacids: Possibly decreased ethotoin effectivenessbupropion, clozapine, loxapine, MAOinhibitors, maprotiline, phenothiazines,pimozide, thioxanthenes: Possibly loweredseizure threshold and decreased therapeuticeffects of ethotoin; possibly intensified CNSdepressant effects of these drugschloramphenicol, cimetidine, disulfiram, fluconazole,isoniazid, methylphenidate, metronidazole,omeprazole, phenylbutazone, ranitidine,salicylates, sulfonamides, trimethoprim:Possibly impaired metabolism of thesedrugs and increased risk of ethotoin toxicitycorticosteroids, cyclosporine, digoxin, disopyramide,doxycycline, furosemide, levodopa,mexiletine, quinidine: Decreased therapeuticeffects of these drugsdiazoxide: Possibly decreased therapeuticeffects of both drugsestrogens, progestins: Decreased effects ofthese drugs, increased blood ethotoin levelfolic acid, leucovorin: Increased ethotoinmetabolism, decreased seizure controlhaloperidol: Possibly lowered seizure threshold,decreased ethotoin effects, anddecreased blood haloperidol levelinsulin, oral antidiabetic drugs: Possiblyincreased blood glucose level and decreasedtherapeutic effects of these drugslidocaine: Increased lidocaine metabolism,leading to reduced concentrationmethadone: Possibly increased methadonemetabolism and withdrawal symptomsmolindone: Possibly lowered seizure thresholdand impaired absorption and decreasedtherapeutic effects of ethotoinoral anticoagulants: Possibly impairedmetabolism of these drugs and increasedrisk of ethotoin toxicity; possibly increasedanticoagulant effect initially, but decreasedeffect with prolonged therapyoral contraceptives that contain estrogen andprogestin: Possibly breakthrough bleedingand decreased contraceptive effectivenessrifampin: Possibly decreased therapeuticeffects of ethotoinstreptozocin: Possibly decreased therapeuticeffects of streptozocinsucralfate: Possibly decreased ethotoinabsorptiontricyclic antidepressants: Possibly loweredseizure threshold and decreased therapeuticeffects of ethotoin; possibly decreased bloodlevel of tricyclic antidepressantsvalproic acid: Possibly decreased ethotoinlevel, increased valproic acid levelvitamin D analogues: Decreased vitamin Danalogue activity; risk of anticonvulsantinducedrickets and osteomalaciaxanthines: Possibly inhibited ethotoinabsorption and increased clearance of xanthinesACTIVITIESalcohol use: Possibly decreased ethotoineffectiveness, increased CNS depressionAdverse ReactionsCNS: Clumsiness, confusion, drowsiness,excitement, peripheral neuropathy, sedation,slurred speech, stuttering, suicidalideation, tremorEENT: NystagmusGI: Constipation, diarrhea, nausea, vomitingHEME: Agranulocytosis, leukopenia,thrombocytopeniaSKIN: Rash, Stevens-Johnson syndrome,toxic epidermal necrolysisOther: Lymphadenopathy, systemic lupuserythematosusNursing Considerations• Obtain CBC and differential before treatmentand monthly for first few months ofethotoin therapy, as ordered.WARNING Ethotoin shouldn’t be stoppedabruptly because of risk of status epilepticus.Plan to reduce dosage gradually orsubstitute another drug, as prescribed.

• Monitor patient for signs and symptomsof infection or unusual bleeding becauseethotoin may cause hematologic toxicity.• Because of ethotoin’s potential for hepatotoxicity,monitor liver function test resultsand expect drug to be discontinued if testresults are abnormal.• Notify prescriber immediately and expectethotoin to be stopped and replaced withanother drug if patient has decreased bloodcounts, enlarged lymph nodes, or rash.• Be aware that ethotoin may be substitutedfor phenytoin without loss of seizure controlif patient develops severe gingivalhyperplasia or other adverse reactions.Expect ethotoin dosage to be 4 to 6 timesgreater than phenytoin dosage.• Institute and maintain seizure precautionsaccording to facility protocol.• Monitor patient closely for evidence ofsuicidal thinking or behavior, especiallywhen therapy starts or dosage changes.PATIENT TEACHING• Instruct patient to take ethotoin exactly asprescribed and not to stop it abruptly.• Advise patient to take drug with food toenhance absorption and reduce adverse GIeffects.• Advise patient to report easy bruising,epistaxis, fever, malaise, petechiae, or sorethroat to prescriber immediately.• Instruct patient to keep medical appointmentsto monitor drug effectiveness andcheck for adverse reactions. Explain theneed for periodic laboratory tests.• Urge patient to avoid alcohol during ethotointherapy.• Caution patient to avoid hazardous activitiesuntil drug’s adverse effects are known.• Encourage patient to wear or carry medicalidentification indicating his diagnosisand drug therapy.• Urge caregivers to watch patient closely forevidence of suicidal tendencies, especiallywhen therapy starts or dosage changes,and to report any concerns immediately toprescriber.• Encourage female patient who becomespregnant while taking ethotoin to enroll inthe North American antiepileptic drugpregnancy registry by calling 1-888-233-2334. Explain that this registry is collectinginformation about the safety ofantiepileptic drugs during pregnancy.ContraindicationsEsophageal abnormalities that delay gastricemptying, such as achalasia and stricture;hypersensitivity to etidronate, bisphosphoetidronatedisodium 415etidronate disodiumDidronelClass and CategoryChemical class: BisphosphonateTherapeutic class: Antihypercalcemic agent,bone resorption inhibitorPregnancy category: B (oral), C (parenteral)Indications and Dosages To treat Paget’s disease of bone (osteitisdeformans)TABLETSAdults. 5 to 10 mg/kg daily for up to 6 mo,or 11 to 20 mg/kg daily for up to 3 mo. To prevent and treat heterotopic ossificationafter total hip replacementTABLETSAdults. 20 mg/kg daily for 1 mo before surgeryand then 20 mg/kg daily for 3 mo aftersurgery for a total of 4 mo of treatment. To prevent and treat heterotopic ossificationafter spinal cord injuryTABLETSAdults. 20 mg/kg daily for 2 wk and then10 mg/kg daily for 10 wk for a total of12 wk of treatment. To treat moderate to severe hypercalcemiacaused by cancerI.V. INFUSIONAdults. Initial: 7.5 mg/kg daily infused overat least 2 hr for 3 to 7 successive days. Oraletidronate may begin at 20 mg/kg/day for30 days on the day after last infusion.DOSAGE ADJUSTMENT Dosage reduced inrenal impairment. Drug not given if serumcreatinine level exceeds 5 mg/dl.Mechanism of ActionInhibits normal and abnormal bone resorptionby reducing bone turnover and slowingthe remodeling of pagetic or heterotopicbone. Etidronate also decreases theelevated cardiac output seen in Paget’s diseaseof bone and reduces local increases inskin temperature. It also inhibits the abnormalbone resorption that may occur withcancer and reduces the amount of calciumthat enters the blood from resorbed bone.EF

416etodolacnates, or their components; severe renalimpairmentInteractionsDRUGSantacids that contain aluminum, calcium, ormagnesium; vitamin and mineral supplementsthat contain aluminum, calcium, iron,or magnesium: Decreased etidronateabsorptionFOODShigh-calcium food (such as milk and otherdairy products): Decreased etidronateabsorptionAdverse ReactionsEENT: Altered taste, metallic tasteGI: Diarrhea, elevated liver function testresults, nauseaGU: NephrotoxicityMS: Bone fractures, bone pain, osteonecrosisof jawOther: HypocalcemiaNursing Considerations• Use etidronate cautiously in patients withupper GI problems such as Barrett’sesophagus, dysphagia, other esophagealdiseases, gastritis, duodenitis, or ulcersbecause drug may cause local irritation ofthe upper GI mucosa.• Anticipate starting etidronate as soon aspossible after spinal cord injury, preferablybefore signs of heterotopic ossification.• Expect etidronate not to inhibit healing ofspinal fractures, affect prosthesis, or disrupttrochanter attachment when usedafter total hip replacement.• Give oral form 2 hours before meals toprevent decreased absorption.• Dilute parenteral form in at least 250 mlof normal saline solution.• Give parenteral form slowly over at least2 hours.• Store diluted parenteral solution at roomtemperature for up to 48 hours.WARNING Watch for hypocalcemia ifpatient receives parenteral form for morethan 3 days.• When treating hypercalcemia, expect tocontinue giving drug for up to 90 days ifserum calcium level remains withinacceptable range.• Monitor patient for adverse esophagealeffects such as esophagitis, esophagealulcers, and esophageal erosions that mayoccur with bleeding, as well as gastric andduodenal ulcers, because these adverseeffects have occurred with other oralbiphosphonates.• Risk of severe adverse esophageal reactionsincreases in patients who lie down aftertaking drug, who fail to swallow it with afull glass of water, or who continue to takedrug after developing symptoms ofesophageal irritation.• Make sure patient has had a dental checkupbefore having an invasive dental proceduresduring etidronate therapy, especiallyif he has cancer; is receiving chemotherapy,head or neck radiation, or a corticosteroid;or has poor oral hygiene becausethe risk of osteonecrosis is increased inthese patients.PATIENT TEACHING• Instruct patient to take etidronate tabletson an empty stomach—2 hours beforemeals, antacids, or calcium supplements.Urge him to drink a full glass of waterwith tablets and to avoid taking drug withmilk or other high-calcium foods.• Tell patient to take a missed dose as soonas he remembers as long as 2 hours haveelapsed since his last meal. Instruct himnot to eat for another 2 hours. Warnagainst doubling the dose.• Inform patient with Paget’s disease that hisresponse to etidronate may be slow andmay continue for months after treatment.etodolacLodine, Lodine XLClass and CategoryChemical class: Pyranoindoleacetic acidderivativeTherapeutic class: Analgesic, antiinflammatoryPregnancy category: CIndications and Dosages To manage osteoarthritisCAPSULES, TABLETSAdults. Initial: 800 to 1,200 mg daily individed doses. Maintenance: 600 to1,200 mg daily in divided doses. Maximum:1,200 mg daily for patients weighing 60 kg(132 lb) or more; 20 mg/kg daily for thoseless than 60 kg.

E.R. TABLETSAdults. 400 to 1,000 mg daily. To relieve mild to moderate painCAPSULES, TABLETSAdults. Initial: 400 mg and then 200 to400 mg every 6 to 8 hr. Maximum:1,200 mg daily for patients weighing 60 kgor more; 20 mg/kg/day for patients weighingless than 60 kg.Route Onset Peak DurationP.O. 30 min 1–2 hr 4–12 hrMechanism of ActionBlocks the activity of cyclooxygenase, theenzyme needed for prostaglandin synthesis.Prostaglandins, important mediators of theinflammatory response, cause local vasodilationwith swelling and pain. By inhibitingcyclooxygenase and prostaglandins, thisNSAID causes inflammatory symptoms andpain to subside.ContraindicationsAngioedema, asthma, bronchospasm, nasalpolyps, rhinitis, or urticaria induced byaspirin, iodides, or NSAIDs; coronaryartery bypass graft surgery; hypersensitivityto etodolac or its componentsInteractionsDRUGSACE inhibitors: Possibly decreased hypotensiveeffects of these drugsacetaminophen (long-term use): Increasedrisk of adverse renal effectsantacids: Decreased blood etodolac levelantiplatelets, oral anticoagulants, thrombolytics:Prolonged PT (with warfarin),increased risk of bleedingcidofovir: Possibly nephrotoxicitycorticosteroids: Increased risk of adverse GIeffectscyclosporine: Increased nephrotoxic effects,increased blood cyclosporine leveldigoxin: Increased blood digoxin level andrisk of digitalis toxicityinsulin, oral antidiabetic drugs: Increasedrisk of hypoglycemialithium: Increased blood lithium level and,possibly, toxicityloop diuretics: Possibly decreased effects ofloop diureticsmethotrexate: Increased risk of methotrexatetoxicityetodolac 417phenylbutazone: Possibly altered etodolacclearancesalicylates: Decreased blood etodolac level,increased risk of adverse GI effectswarfarin: Synergistic bleeding effectsACTIVITIESalcohol use, smoking: Increased risk ofadverse GI effectsAdverse ReactionsCNS: Asthenia, chills, depression, dizziness,drowsiness, fatigue, fever, insomnia, irritability,malaise, nervousness, seizures, somnolence,syncope, strokeCV: Edema, heart failure, hypertension, MI,palpitations, tachycardia, vasculitisEENT: Blurred vision, deafness, loss oftaste, photophobia, tinnitusENDO: Hyperglycemia in diabeticsGI: Abdominal pain or distention, anorexia,constipation, diarrhea, diverticulitis, dyspepsia,dysphagia, elevated liver functiontest results, esophagitis, flatulence, gastritis,gastroenteritis, gastroesophageal reflux disease,GI bleeding and ulceration, GI perforation,hemorrhoids, hepatic failure, hepatitis,hiatal hernia, indigestion, melena, nausea,pancreatitis, peptic ulcer, perforation ofstomach or intestines, stomatitis, vomitingGU: Dysuria, elevated serum creatinine level,hematuria, renal failure or insufficiency,renal papillary necrosis, urinary frequencyHEME: Agranulocytosis, aplastic anemia,easy bruising, hemolytic anemia, leukopenia,neutropenia, pancytopenia, thrombocytopeniaMS: Arthralgia, muscle painRESP: Asthma, bronchospasm, pulmonaryinfiltrate with eosinophilia, respiratorydepressionSKIN: Erythema multiforme, exfoliativedermatitis, flushing, leukocytoclastic vasculitis,pruritus, Stevens-Johnson syndrome,toxic epidermal necrolysis, urticaria,vesiculobullous or other rashOther: Anaphylaxis, angioedema, lymphadenopathy,sepsisNursing Considerations• Assess patient’s hydration status and rehydrate,if needed and as ordered, beforestarting etodolac therapy.• Use etodolac with extreme caution inpatients with a history of ulcer disease orGI bleeding because NSAIDs increase theEF

418Indications and Dosages Adjunct treatment to improve blood gluexenatiderisk of GI bleeding and ulceration. Expectto use etodolac for the shortest time possiblein these patients. Also use withextreme caution in patients with advancedrenal disease because etodolac is eliminatedmainly by the kidneys.• Be aware that serious GI tract ulceration,bleeding, and perforation may occur withoutwarning symptoms. Elderly patents areat greater risk. To minimize risk, give drugwith food. If GI distress occurs, withholddrug and notify prescriber immediately.• Use etodolac cautiously in patients withhypertension, and monitor blood pressureclosely throughout therapy. Drug maycause hypertension or worsen it.WARNING Monitor patient closely forthrombotic events, including stroke andMI, because NSAIDs increase the risk.• Especially if patient is elderly or takingetodolac long-term, watch for less commonbut serious adverse GI reactions,including anorexia, constipation, diverticulitis,dysphagia, esophagitis, gastritis, gastroenteritis,gastroesophageal reflux disease,hemorrhoids, hiatal hernia, melena,stomatitis, and vomiting.• Monitor liver function test results. Rarely,elevated levels may progress to severehepatic reactions, including fatal hepatitis,hepatic necrosis, and hepatic failure.• Monitor BUN and serum creatinine levelsin patients with heart failure, hepatic dysfunction,or impaired renal function;those taking diuretics or ACE inhibitors;and elderly patients because drug maycause renal failure.• Monitor CBC for decreased hemoglobinlevel and hematocrit because drug mayworsen anemia.WARNING If patient has bone marrow suppressionor is receiving antineoplastic drugtherapy, monitor laboratory results(including WBC count), and watch forevidence of infection because anti-inflammatoryand antipyretic actions of etodolacmay mask it, such as fever and pain.• Assess patient’s skin routinely for rash orother signs of hypersensitivity reactionbecause etodolac and other NSAIDs maycause serious skin reactions without warning,even in patients with no history ofNSAID hypersensitivity Stop drug at firstsign of reaction and notify prescriber.• If patient also takes acetaminophen, monitorfluid intake and output and BUN andserum creatinine levels for signs of adverserenal reactions.PATIENT TEACHING• Tell patient to take etodolac with food orafter meals if adverse GI reactions occur.• Caution him to avoid aspirin or aspirincontainingproducts while taking drug.• Advise patient not to smoke or drink alcoholduring therapy because these activitiesincrease the risk of adverse GI reactions.• Inform patient that he may experiencedizziness or drowsiness.• Instruct him to notify prescriber immediatelyabout blood in urine, easy bruising,itching, rash, swelling, or yellow eyes orskin.• Caution pregnant patient not to takeetodolac or other NSAIDs during the thirdtrimester because drug may cause prematureclosure of the ductus arteriosus.• Explain that etodolac may increase the riskof serious adverse cardiovascular reactions;urge patient to seek immediatemedical attention for possible reactions,chest pain, shortness of breath, weakness,and slurring of speech.• Tell patient that etodolac therapy also mayincrease the risk of serious adverse GIreactions; stress the importance of seekingimmediate medical attention for suchsigns and symptoms as epigastric orabdominal pain, indigestion, black or tarrystools, or vomiting blood or material thatlooks like coffee grounds.• Explain the possibility of rare but seriousskin reactions. Urge patient to seek immediatemedical attention for rash, blisters,itching, fever, or other indications ofhypersensitivity.exenatideByettaClass and CategoryChemical class: Amino acid peptide amideTherapeutic class: Antidiabetic drugPregnancy category: C

cose levels in patients with type 2 diabetesmellitus who are taking metformin,a sulfonylurea, a thiazolidinedione,or a combination of metforminand a sulfonylurea or metformin and athiazolidinedione but have not achievedadequate glucose controlSUBCUTANEOUS INJECTIONAdults. Initial: 5 mcg b.i.d., given within60 min before morning and evening meals.After 1 mo, increased as needed to 10 mcgb.i.d., given within 60 min before morningand evening meals. Adjunct treatment to diet and exerciseto improve blood glucose levels inpatients with type 2 diabetes mellitusSUBCUTANEOUS INJECTIONAdults. Initial: 5 mcg b.i.d., given within60 min before morning and evening meals.After 1 mo, increased as needed to 10 mcgb.i.d., given within 60 min before morningand evening meals.Route Onset Peak DurationSubQ Immediate 2.1 hr UnknownContraindicationsHypersensitivity to exenatide or its components,ketoacidosis, type 1 diabetes mellitusexenatide 419InteractionsDRUGSoral antidiabetics: Increased risk of hypoglycemiaoral drugs: May decrease rate and extent ofabsorption of these drugswarfarin: Possibly increased INR withincreased risk of bleedingAdverse ReactionsCNS: Asthenia, dizziness, headache, jitteriness,somnolenceCV: Chest painEENT: Decreased tasteENDO: HypoglycemiaGI: Abdominal distention or pain, anorexia,constipation, diarrhea, dyspepsia, flatulence,gastroesophageal reflux, indigestion, nausea,pancreatitis (including life-threatening hemorrhagicor necrotizing), vomitingGU: Decreased renal functionRESP: Chronic hypersensitivity pneumonitisSKIN: Diaphoresis, pruritus, rash, urticariaOther: Anaphylaxis, angioedema, antiexenatideantibodies, dehydration, elevatedanti-exenatide antibody level, injection sitereactions, weight lossNursing Considerations• Exenatide isn’t recommended for patientsEFMechanism of ActionNormally, when serum glucose level rises, insulin is secreted within 10 minutes. Thisfirst-phase insulin response is absent in patients with type 2 diabetes. Exenatide, anincretin mimetic, restores the first-phase insulin response and improves the second-phase response that immediatelyfollows. It does so bypromoting incretins that spurinsulin synthesis and releasefrom beta cells by bindingand activating human GLP-1receptors to reduce fastingand postprandial serum glucoselevels.The drug also suppressesinappropriately elevatedglucagon secretion. Lowerserum glucagon level leads todecreased hepatic glucoseoutput and decreased insulindemand. It also slows gastricemptying and thus the rise ofserum glucose level.Absorbedinto bloodstreamExenatideinjectedSmallintestine:glucoseabsorptionslowedFood ingestedLiver:glucose outputdecreasedPancreas:insulin outputincreased

420ezetimibewith severe GI disease, patients with creatinineclearance less than 30 ml/ min/1.73 m 2 , or patients having dialysisbecause of adverse GI or renal effects.• Use exenatide cautiously in a renal transplantpatient or patient with moderaterenal disease when dosage is increasedfrom 5 mcg to 10 mcg. Monitor renalfunction throughout therapy, and notifyprescriber of abnormalities.• If patient also takes a sulfonylurea, the sulfonylureadosage may need to bedecreased to reduce the risk of hypoglycemia.Usually, no dosage adjustment isneeded for a patient taking metformin.• Administer drug into patient’s thigh,abdomen, or upper arm.• Monitor patient’s blood glucose level. Ifcontrol decreases despite the patient’s bestefforts, drug may need to be discontinuedbecause of the possibility that anti-exenatideantibodies have formed.• Monitor patient for evidence of acute pancreatitis,such as persistent, severe abdominalpain accompanied by vomiting, especiiallywhen drug is started or dosageincreased. Notify prescriber, and expect tostop exenatide and give supportive care.PATIENT TEACHING• Teach patient how to give a subcutaneousinjection and how to use pen injector.• Inform patient that exenatide may beadministered in the thigh, abdomen, orupper arm. Stress the need to rotate injectionsites.• Stress the need to use drug within 60 minutesbefore morning and evening meals orthe two main meals of the day, about 6hours or more apart, never after a meal.• If patient misses a dose, tell him to resumetreatment with the next scheduled dose.• Advise patient that drug should look clearand colorless. Caution against using prefilledpen device in which solution lookscloudy or colored or contains particles.• Instruct patient to check expiration dateon the vial and not to use drug if date haspassed.• Advise patient to refrigerate drug beforefirst use and protect it from light. Afterfirst use, drug may be stored at room temperatureof 77° F (25° C) or less.• Tell patient to discard pen injector 30 daysafter initial use, even if some drug is left.• Alert patient that pen doesn’t come withneedles and that he’ll need to buy them.• Warn patient that nausea may occur at thebeginning of therapy.• Inform patient taking a sulfonylurea to bealert for hypoglycemic reactions becauserisk increases with both drugs. Reviewways to treat such reactions, and tellpatient to alert prescriber if they occuroften or are severe.• Instruct female patient of childbearingpotential to tell her prescriber if she is,could be, or is planning to become pregnant.• Tell patient to seek emergency care forpersistent, severe abdominal pain andvomiting.• Caution patient that exenatide doesn’treplace diet and exercise measures.ezetimibeZetiaClass and CategoryChemical class: AzetidinoneTherapeutic class: AntihypercholesterolemicPregnancy category: CIndications and Dosages To treat heterozygous familial and nonfamilialhypercholesterolemia orhomozygous sitosterolemia; as adjunctwith HMG-CoA reductase inhibitors totreat heterozygous familial and nonfamilialhypercholesterolemia; with fenofibrateto treat mixed hyperlipidemia andwith atorvastatin or simvastatin to treatpatients with homozygous familialhypercholesterolemiaTABLETSAdults. 10 mg daily.ContraindicationsActive hepatic dysfunction, hypersensitivityto ezetimibe or its componentsInteractionsDRUGScholestyramine: Reduced effects ofezetimibecyclosporine: Increased blood cyclosporineand ezetimibe levelsfenofibrate, gemfibrozil: Increased blood ezetimibelevel

famotidine 421Mechanism of ActionReduces blood cholesterol by inhibitingits absorption through the small intestine.Normally, in the intestinal lumen,lipids break down to cholesterol andother substances that create smallerdroplets called micelles, as shown belowleft. The micelles enter intestinal epithelialcells called enterocytes, where theycombine with triglycerides, cholesterol,and other substances to form chylomicrons.Chylomicrons then pass through tothe lymphatic system to be carried to theblood.Ezetimibe blocks cholesterol absorptioninto enterocytes and keeps cholesterolfrom moving through the intestinalwall, as shown below right. Reduced cholesterolabsorption from the intestinedecreases chylomicron and LDL cholesterolcontent.EFAdverse ReactionsCNS: Depression, dizziness, fatigue,headache, paresthesiaCV: Chest painEENT: Pharyngitis, sinusitisGI: Abdominal pain, cholelithiasis, cholecystitis,diarrhea, elevated liver function testresults, hepatitis, nausea, pancreatitisHEME: ThrombocytopeniaMS: Arthralgia, back or limb pain, elevatedCK level, myalgia, myopathy, rhabdomyolysisRESP: Cough, upper respiratory tract infectionSKIN: Erythema multiforme, rash, urticariaOther: Anaphylaxis, angioedema, influenza,viral infectionNursing Considerations• Monitor liver function test results beforeand during ezetimibe therapy, as ordered.• Know that you should give ezetimibe2 hours before or 4 hours after giving bileacid sequestrant, cholestyramine, orcolestipol.PATIENT TEACHING• Direct patient to follow a low-cholesteroldiet as an adjunct to ezetimibe therapy.Recommend weight loss and exercise programs,as appropriate.• If patient also takes a bile acid sequestrant,tell him to take ezetimibe either 2 hoursbefore or at least 4 hours after it to preventdrug interactions.• Advise patient to report unexplained musclepain, tenderness, or weakness.famotidineAct (CAN), Apo-Famotidine (CAN),Dyspep HB (CAN), Gen-Famotidine(CAN), Mylanta-AR, Novo-Famotidine(CAN), Nu-Famotidine (CAN), Pepcid,Pepcid AC, Pepcid RPDClass and CategoryChemical class: Thiazole derivativeTherapeutic class: Antiulcer agent, gastricacid secretion inhibitorPregnancy category: BIndications and Dosages To provide short-term treatment of

422famotidineactive duodenal ulcerORAL SUSPENSION, TABLETS (CHEWABLE, ORALDISINTEGRATING, AND REGULAR)Adults and adolescents. 40 mg daily at bedtimeor 20 mg b.i.d.Children. 0.5 mg/kg daily as a single dose atbedtime or in divided doses b.i.d.I.V. INFUSION OR INJECTIONAdults and adolescents over age 16. 20 mgevery 12 hr, infused over 15 to 30 min orinjected over at least 2 min.Children ages 1 to 16. Initial: 0.25 mg/kgevery 12 hr, infused over 15 to 30 min orinjected over at least 2 min. Maximum:40 mg daily. To prevent recurrence of duodenal ulcerORAL SUSPENSION, TABLETS (CHEWABLE, ORALDISINTEGRATING, AND REGULAR)Adults and adolescents. 20 mg daily atbedtime. To provide short-term treatment foractive, benign gastric ulcerORAL SUSPENSION, TABLETS (CHEWABLE, ORALDISINTEGRATING, AND REGULAR)Adults and adolescents. 40 mg daily at bedtime.Children. 0.5 mg/kg daily as a single dose atbedtime or in divided doses b.i.d.I.V. INFUSION OR INJECTIONAdults and adolescents over age 16. 20 mgevery 12 hr.Children ages 1 to 16. Initial: 0.25 mg/kgevery 12 hr. Maximum: 40 mg daily. To treat gastroesophageal reflux disease(GERD)ORAL SUSPENSION, TABLETS (CHEWABLE, ORALDISINTEGRATING, AND REGULAR)Adults and adolescents. 20 mg b.i.d. for upto 6 wk.Children weighing more than 10 kg (22 lb).1 to 2 mg/kg daily in divided doses b.i.d.Children weighing less than 10 kg. 1 to2 mg/kg daily in divided doses t.i.d.ORAL SUSPENSIONInfants age 4 months to 1 year. 0.5 mg/kgdaily in divided doses b.i.d. for up to 8 wk.Infants age 3 months or less. 0.5 mg/kgdaily for up to 8 wk.I.V. INFUSION OR INJECTIONChildren ages 1 to 16. Initial: 0.25 mg/kgevery 12 hr. Maximum: 40 mg daily. To treat esophagitis caused by gastroesophagealrefluxORAL SUSPENSION, TABLETS (CHEWABLE, ORALDISINTEGRATING, AND REGULAR)Adults and adolescents. 20 to 40 mg b.i.d.for up to 12 wk. To treat gastric hypersecretory conditions,such as Zollinger-Ellison syndromeORAL SUSPENSION, TABLETS (CHEWABLE, ORALDISINTEGRATING, AND REGULAR)Adults and adolescents. Initial: 20 mgevery 6 hr. Dosage adjusted, if needed,based on patient response.I.V. INFUSION OR INJECTIONAdults and adolescents. 20 mg every 12 hr. To prevent heartburn and indigestionTABLETS (CHEWABLE, ORAL DISINTEGRATING, ANDREGULAR)Adults and adolescents. 10 mg 1 hr beforeeating. Maximum: 20 mg every 24 hr. To treat heartburn and indigestionTABLETS (CHEWABLE, ORAL DISINTEGRATING, ANDREGULAR)Adults and adolescents. 10 mg at onset ofsymptoms. Maximum: 20 mg every 24 hrfor up to 2 wk unless prescribed otherwise.DOSAGE ADJUSTMENT Oral or parenteraldosage reduced or dosing interval increased(to 36 to 48 hr), if needed, in patients withrenal insufficiency and creatinine clearanceof 49 ml/min/1.73 m 2 or less.Route Onset Peak DurationP.O. 1 hr 1–4 hr 10–12 hrI.V. In 30 min 0.5–3 hr 10–12 hrContraindicationsHypersensitivity to famotidine, other H 2 -receptor antagonists, or their componentsInteractionsDRUGSantacids, sucralfate: Possibly decreasedabsorption of famotidinebone marrow depressants: Increased risk ofblood dyscrasiasitraconazole, ketoconazole: Possiblydecreased absorption of these drugsACTIVITIESalcohol use: Possibly increased blood alcohollevelAdverse ReactionsCNS: Agitation (infants), anxiety, asthenia,confusion, depression, dizziness, fatigue,fever, hallucinations, headache, insomnia,

famotidine 423Mechanism of ActionIn normal digestion, parietal cells in thegastric epithelium secrete hydrogen (H+)ions, which combine with chloride ions(Cl – ) to form hydrochloric acid (HCl), asshown below left. However, HCl caninflame, ulcerate, and perforate gastricand intestinal mucosa normally protectedby mucus. Famotidine, an H 2 -receptorantagonist, reduces HCl formation bypreventing histamine from binding withH 2 receptors on the surface of parietalcells, as shown below right. By doing so,drug helps prevent peptic ulcers fromforming and helps heal existing ones.Parietal cellHistamineH 22 receptorH + +Cl Cl - -HClHistamineFamotidineEFmental or mood changes, paresthesia,seizures, somnolenceCV: Arrhythmias, AV block, palpitationsEENT: Dry mouth, laryngeal edema, tastealteration, tinnitusGI: Abdominal pain, anorexia, cholestaticjaundice, constipation, diarrhea, elevatedliver enzymes, hepatitis, nausea, vomitingGU: Decreased libidoHEME: Agranulocytosis, aplastic anemia,leukopenia, neutropenia, pancytopenia,thrombocytopeniaMS: Arthralgia, muscle crampsRESP: Bronchospasm, dyspnea, interstitialpneumonia, wheezingSKIN: Acne, alopecia, dry skin, erythemamultiforme, exfoliative dermatitis, flushing,jaundice, pruritus, rash, Stevens-Johnsonsyndrome, toxic epidermal necrolysis,urticariaOther: Anaphylaxis, angioedema, facial edema,hyperuricemiaNursing Considerations• Shake famotidine oral suspension vigorouslyfor 5 to 10 seconds before administration.• Dilute injection form (2 ml) with normalsaline solution or other solution to 5 to10 ml; give I.V. injection over at least2 minutes. Or dilute in 100 ml of D 5 Wand infuse over 15 to 30 minutes. Orinfuse premixed injection (20 mg/50 mlnormal saline solution) over 15 to 30 minutes.WARNING Be aware that Pepcid AC chewabletablets contain aspartame, which canbe dangerous for patients who havephenylketonuria.PATIENT TEACHING• Instruct patient to store famotidine oralsuspension at room temperature (below86° F [30° C]) and to protect it from freezing.Tell her to shake the bottle vigorouslyfor 5 to 10 seconds after adding water andright before use.• Advise patient who uses Pepcid RPD tostore drug in unopened package. For eachdose, instruct her to open blister pack withdry hands, place a tablet on her tongue, letit dissolve, and swallow it with saliva.• If patient uses chewable tablets, instructher to chew them thoroughly before swallowing.• If patient also takes antacids, instruct herto wait 30 to 60 minutes after takingfamotidine, if possible, before takingantacid.• Caution patient to avoid alcohol andsmoking during famotidine therapybecause they irritate the stomach and candelay ulcer healing.• Advise patient to notify prescriber if she

424febuxostatdevelops pain or has trouble swallowing orif she has bloody vomit or black stools.• Caution patient not to take famotidinewith other acid-reducing products.febuxostatUloricClass and CategoryChemical class: Non-purine xanthineoxidase inhibitorTherapeutic class: AntigoutPregnancy category: CIndications and Dosages To treat chronic hyperuricemia inpatients with goutTABLETSAdults. Initial: 40 mg once daily, increasedafter 2 wk to 80 mg once daily, if needed.Route Onset Peak DurationP.O. 2–3 days 1–1.5 hr UnknownMechanism of ActionInhibits the action of xanthine oxidase, thekey enzyme responsible for purine breakdown.Xanthine oxidase catalyzes conversionof xanthine to uric acid, therebyincreasing uric acid levels. High uric acidlevels cause gout attacks. Inhibiting xanthineoxidase causes uric acid levels to drop,decreasing the risk of gout attack.ContraindicationsConcurrent use of azathioprine, mercaptopurine,or theophylline; hypersensitivityto febuxostat or its componentsInteractionsDRUGSazathioprine, mercaptopurine, theophylline:Possibly increased serum levels of thesedrugs, leading to toxicityAdverse ReactionsCNS: Dizziness, hemiparesis, lacunarinfarction, stroke, transient ischemic attackCV: Angina, chest pain or discomfort, ECGabnormalities, MIEENT: Blurred vision, deafness, epistaxis,nasal dryness, paranasal sinus hypersecretion,pharyngeal edema, sneezing, taste disturbance,throat irritation, tinnitusENDO: Breast pain, gynecomastia, hotflashes, hypoglycemiaGI: Diarrhea, dyspepsia, GI discomfort,hepatomegaly, liver function abnormalities,nausea, vomitingGU: Decreased libido, erectile dysfunction,hematuria, nephrolithiasis, pollakiuria, proteinuria,renal failure or insufficiency,urgencyHEME: Anemia, idiopathic thrombocytopenicpurpura, leukocytosis, leukopenia,neutropenia, pancytopenia, splenomegaly,thrombocytopeniaMS: Arthralgia, joint stiffness or swellingRESP: Upper respiratory tract infectionSKIN: Dermatitis, ecchymosis, eczema,flushing, hair color or growth changes,hyperhidrosis, peeling skin, petechiae, photosensitivity,rashOther: Gout flares, hypersensitivityNursing Considerations• Febuxostat therapy isn’t recommended forpatients in whom rate of urate formationis greatly increased, as in malignancy andits treatment or Lesch-Nyhan syndrome.• Monitor patient’s serum uric acid level, asprescribed, to determine drug effectiveness.Expect it to take about 2 weeks foruric acid level to be therapeutically altered.Dose may be increased from 40 mg to80 mg daily if target serum uric acid levelfails to fall below 6 mg/dl.• Monitor patient for gout flares, which mayoccur after therapy is started because ofchanging serum uric acid levels that resultin mobilization of urate from tissuedeposits. Expect prescriber to order anNSAID or colchicine when febuxostattherapy starts. If patient has a gout flareupduring treatment, notify prescriber,and expect symptoms to be managed.Know that febuxostat therapy usually isn’tdiscontinued during this time.• Monitor patient for evidence of cardiovascularthrombosis, such as acute MI orstroke, because drug may increase patient’srisk of developing these disorders.• Monitor patient’s liver enzyme levels, asordered, especially 2 and 4 months aftertherapy starts and periodically thereafter.PATIENT TEACHING• Inform patient that a gout attack mayoccur when febuxostat therapy starts and

that NSAIDs or colchicine may be prescribed,usually along with febuxostat, toprevent it.• Instruct patient to seek emergency careimmediately for signs or symptoms of aheart attack or stroke.• Tell patient that periodic blood tests willbe needed to determine drug’s effectivenessand to detect adverse effects.felbamateFelbatolClass and CategoryChemical class: DicarbamateTherapeutic class: AnticonvulsantPregnancy category: CIndications and Dosages To treat partial seizures in patients whodon’t respond to other drugsORAL SUSPENSION, TABLETSAdults and adolescents over age 14. Initial:1,200 mg daily in divided doses t.i.d. orq.i.d. Dosage increased over several weeksbased on patient response. Maximum:3,600 mg daily.Children ages 2 to 14. Initial: 15 mg/kgdaily in divided doses t.i.d. or q.i.d. Dosageincreased over several weeks based onpatient response. Maximum: 3,600 mg dailyor 45 mg/kg daily. As adjunct to treat generalized or partialseizures associated with Lennox-Gastautsyndrome in childrenORAL SUSPENSION, TABLETSChildren ages 2 to 14. Initial: 15 mg/kgdaily in divided doses t.i.d. or q.i.d. whiledecreasing other anticonvulsant drugs by20% to control their blood levels.Felbamate dosage increased by 15 mg/kgdaily every wk. Maximum: 3,600 mg dailyor 45 mg/kg daily.DOSAGE ADJUSTMENT Dosage reduced by50% in patients with renal impairment.Mechanism of ActionMay exert anticonvulsant effects by antagonizingthe amino acid glycine. Whenglycine binds to N-methyl-D-aspartate(NMDA) receptors in the CNS, the frequencyat which receptor-gated calcium ionchannels open is increased—an importantfelbamate 425factor in initiating seizures. Felbamate mayraise the seizure threshold by blockingNMDA receptors so glycine can’t bind tothem.ContraindicationsHepatic dysfunction; history of blooddyscrasias; hypersensitivity to felbamate,other carbamates, or their componentsInteractionsDRUGScarbamazepine: Decreased blood carbamazepinelevel and increased felbamateclearance, resulting in decreased bloodfelbamate levelfosphenytoin, phenytoin: Increased bloodphenytoin level and increased felbamateclearance, resulting in decreased bloodfelbamate levelmethsuximide: Increased adverse effects ofmethsuximideoral contraceptives: Possibly decreased effectivenessof oral contraceptivesphenobarbital: Decreased blood felbamatelevel, increased blood phenobarbital leveland risk of adverse effectsvalproic acid: Increased blood valproic acidlevel and increased risk of adverse effectsAdverse ReactionsCNS: Abnormal gait, aggressiveness, agitation,anxiety, dizziness, drowsiness, fever,headache, insomnia, mood changes, suicidalideation, tremorEENT: Altered taste, diplopia, rhinitisGI: Abdominal pain, anorexia, constipation,diarrhea, elevated liver function test results,hepatic failure, indigestion, nausea, vomitingHEME: Aplastic anemia, leukopenia, pancytopenia,thrombocytopeniaRESP: Upper respiratory tract infectionSKIN: Photosensitivity, purpura, rashOther: Anaphylaxis, lymphadenopathy,weight lossNursing Considerations• Check liver function test results beforestarting felbamate, and expect to checkresults every 1 to 2 weeks during treatment.Notify prescriber immediately andexpect to stop drug if results are abnormal.• Plan to taper dosage by one-third every4 to 5 days as prescribed. If patientreceives adequate amounts of other anticonvulsantdrugs, felbamate may beEF

426felodipinestopped without tapering, if needed.WARNING Assess for signs of aplastic anemiaand bone marrow depression. Signsmay not appear until several months aftertherapy begins. Expect to stop felbamate ifbone marrow depression develops.• If patient receives adjunctive therapy,expect adverse reactions to resolve as otheranticonvulsant dosages decrease.• Monitor patient closely for evidence ofsuicidal thinking or behavior, especiallywhen therapy starts or dosage changes.PATIENT TEACHING• Direct patient to shake suspension beforeusing and to use a calibrated spoon orcontainer to measure each dose.• Instruct patient to store oral suspensionand tablets at room temperature.• Because drug may cause photosensitivity,urge patient to protect skin from sun andto avoid sunlamps and tanning booths.• Explain that dizziness and drowsiness mayoccur. Advise her to avoid hazardous activitiesuntil drug’s CNS effects are known.• Warn patient not to stop drug abruptly.• Advise patient to return for ordered liverfunction tests and to report yellow skin oreyes and dark urine to prescriber.• Instruct patient to tell prescriber if sheexperiences bleeding, infection, or fatigue.• Advise patient to carry medical identificationthat indicates condition and therapy.• Because felbamate decreases oral contraceptiveeffectiveness, discuss alternate contraceptivemethods.• Urge caregivers to watch patient closely forevidence of suicidal tendencies, especiallywhen therapy starts or dosage changes,and to report any concerns immediately.• Encourage female patient who becomespregnant while taking felbamate to enrollin the North American antiepileptic drugpregnancy registry by calling 1-888-233-2334. Explain that this registry is collectinginformation about the safety ofantiepileptic drugs during pregnancy.felodipinePlendil, Renedil (CAN)Class and CategoryChemical class: Dihydropyridine derivativeTherapeutic class: AntihypertensivePregnancy category: CIndications and Dosages To manage essential hypertension aloneor with other antihypertensivesE.R. TABLETSAdults. Initial: 5 mg daily. Dosage adjustedevery 2 wk to 2.5 to 10 mg daily based onpatient response.DOSAGE ADJUSTMENT Initial or maintenancedosage reduced, if needed, in patientswho are over age 65 or have impairedhepatic function.Route Onset Peak DurationP.O. 2–5 hr Unknown 16–24 hrMechanism of ActionMay slow the movement of extracellularcalcium into myocardial and vascularsmooth-muscle cells by deforming calciumchannels in cell membranes, inhibiting ioncontrolledgating mechanisms, and interferingwith calcium release from the sarcoplasmicreticulum. The effect of these actions isa decrease in intracellular calcium ions,which inhibits contraction of smooth-musclecells and dilates coronary and systemicarteries. As with other calcium channelblockers, felodipine’s actions result inincreased oxygen to the myocardium andreduced peripheral resistance, blood pressure,and afterload.ContraindicationsHypersensitivity to felodipine or its componentsInteractionsDRUGSanesthetics (hydrocarbon inhalation):Possibly hypotensionantihypertensives, prazocin: Increased risk ofhypotensionbeta blockers: Increased adverse effects ofbeta blockerscimetidine: Increased felodipine bioavailabilitydigoxin: Transiently increased blood digoxinlevel and risk of digitalis toxicityestrogens: Possibly increased fluid retentionand decreased felodipine effectslithium: Increased risk of neurotoxicityNSAIDs, sympathomimetics: Possibly

decreased therapeutic effect of felodipineprocainamide, quinidine: Increased risk ofprolonged Q-T intervaltacrolimus: Possibly increased blood tacrolimuslevel and risk of adverse effectsFOODSgrapefruit juice: Doubled felodipinebioavailabilityAdverse ReactionsCNS: Asthenia, dizziness, drowsiness,fatigue, headache, paresthesia, syncope,weaknessCV: Chest pain, hypotension, palpitations,peripheral edema, tachycardiaEENT: Gingival hyperplasia, pharyngitis,rhinitisGI: Abdominal cramps, constipation, diarrhea,indigestion, nauseaHEME: AgranulocytosisMS: Back painRESP: CoughSKIN: Flushing, rashNursing Considerations• Use felodipine cautiously in patients withheart failure or reduced ventricular function.• Monitor blood pressure during dosagetitration and throughout felodipine therapy,especially in elderly patients.• Felodipine bioavailability increases up totwofold when taken with grapefruit juice.WARNING Felodipine may cause severehypotension with syncope, which may leadto reflex tachycardia. This can precipitateangina in patients with coronary arterydisease or a history of angina.• Watch for signs of overdose, such as excessiveperipheral vasodilation, marked hypotensionand, possibly, bradycardia. If theyappear, place patient in supine positionwith legs elevated and give I.V. fluids, asordered. Expect to give I.V. atropine forbradycardia.PATIENT TEACHING• Instruct patient to swallow tablets wholeand not to crush or chew them.• Caution patient not to alter her intake ofgrapefruit juice during therapy.• Advise patient to store felodipine at roomtemperature and to protect it from light.• Instruct patient to monitor her pulse rateand blood pressure.• Teach patient how to minimize gingivalhyperplasia.• Advise patient to notify prescriber immediatelyif she has palpitations, pronounceddizziness, or swelling of hands or feet.fenofibrateLipofen, Tricorfenofibric acidTrilipixfenofibrate 427Class and CategoryChemical class: Aryloxisobutyric acidderivativeTherapeutic class: AntihyperlipidemicPregnancy category: CIndications and Dosages To treat primary hypercholesterolemiaor mixed hyperlipidemiaCAPSULESAdults. 200 mg daily.TABLETSAdults. 145 mg daily. To treat hypertriglyceridemia(Fredrickson types IV and V hyperlipidemia)CAPSULESAdults. Initial: 67 mg daily with food,increased as needed every 4 to 8 wk.Maximum: 201 mg daily with meals.TABLETSAdults. 48 to 145 mg daily, increased asneeded at 4- to 8-wk intervals. Maximum:145 mg daily.DOSAGE ADJUSTMENT For patients withmild to moderate renal impairment, initialdosage limited to 48 mg daily (tablets) or67 mg daily (capsules), with dosage increaseonly after drug’s therapeutic and renaleffects are known. For elderly patients,dosage limited to 48 mg daily (tablets) or67 mg daily (capsules). As adjunct to diet to treat severe hypertriglyceridemiaDELAYED-RELEASE CAPSULESAdults. Initial: 45 mg once daily, increased,as needed every 4- to 8-wk intervals.Maximum: 135 mg daily. As adjunct to diet to treat primaryhyperlipidemia or mixed dyslipidemia;as adjunct to diet and a HMG-CoAEF

428fenofibratereducatse inhibitor to treat mixed dyslipidemiaDELAYED-RELEASE CAPSULESAdults. 135 mg daily.DOSAGE ADJUSTMENT For patients withmild to moderate renal impairment or elderlypatients, initial dosage limited to 45 mgonce daily, with increase only after drug’stherapeutic and renal effects are known.Route Onset Peak DurationP.O. 6–8 wk Unknown UnknownMechanism of ActionMay increase the lipolysis of triglyceriderichlipoproteins and decrease the synthesisof fatty acids and triglycerides by enhancingthe activation of lipoprotein lipase andacyl-coenzyme A synthetase. Fenofibratealso may:• increase hepatic elimination of cholesterolas bile salts• promote the catabolism of larger, lessdense LDLs with a high-binding affinityfor cellular LDL receptors.ContraindicationsBreast-feeding; gallbladder disease; hypersensitivityto fenofibrate, fenofibric acid,choline fenofibrate, or their components;hepatic or severe renal impairmentInteractionsDRUGSbile acid sequestrants: Decreased fenofibrateabsorptioncyclosporine: Increased risk of nephrotoxicityHMG-CoA reductase inhibitors (atorvastatin,cerivastatin, fluvastatin, lovastatin,pravastatin, simvastatin): Increased risk ofmyopathy, rhabdomyolysis, and acute renalfailureoral anticoagulants: Risk of bleedingFOODSall foods: Increased fenofibrate bioavailabilitywhen given in capsule formAdverse ReactionsCNS: Asthenia, fatigue, headacheCV: Deep vein thrombosisEENT: RhinitisGI: Abdominal pain, cholelithiasis, cirrhosis,constipation, diarrhea, elevated liverfunction test results, hepatitis, nausea, pancreatitisGU: Increased serum creatinine level, renalfailureHEME: Agranulocytosis, anemia, decreasedhematocrit and hemoglobin levels, thrombocytopeniaMS: Arthralgia, back pain, muscle spasms,myopathy. myositis, rhabdomyolysisRESP: Pulmonary embolusSKIN: Rash, Stevens-Johnson syndrome,toxic epidermal necrolysis, urticariaOther: Flulike symptomsNursing Considerations• As ordered, stop drugs that increase serumtriglycerides, such as beta blockers, estrogens,and thiazides, and obtain baselinelipid levels before starting fenofibrate.• Give capsule form with a full glass ofwater with meals.• Administer drug 1 hour before or 4 hoursafter bile acid sequestrants.• Monitor results of liver and renal functiontests. If liver enzyme levels rise to morethan three times the upper limit of normaland persist, or if the patient develops gallstones,expect to stop drug.• Monitor serum triglyceride and cholesterollevels at 4- to 8-week intervals. If levelsdon’t decrease after 2 months at maximumdosage, expect to stop therapy.WARNING Monitor patient closely for acutehypersensitivity reactions, including severerash, and notify prescriber if they occur.Patient may need inpatient corticosteroids.• Assess blood counts periodically, asordered, during first 12 months of therapyto detect adverse hematologic effects.• Watch closely for evidence of deep veinthrombosis (pain, swelling, redness inextremity) or pulmonary embolus (suddenonset of anxiety, shortness of breath,restlessness) because risk is higher inpatients taking fenofibrate. Notify prescriberimmediately, and start emergencytreatment, as prescribed.PATIENT TEACHING• Stress that drug will be effective only ifpatient carefully follows prescriber’sinstructions about diet and exercise.• Instruct patient to take capsule form witha full glass of water and with food.• Instruct patient prescribed tablet form tostore the tablets in their original, desiccant-containingbottle and to avoid takingany chipped or broken tablets.

• Advise patient to have laboratory tests, asdirected, to determine drug’s effectiveness.They typically include liver function testsafter 3 to 6 months, hematocrit and hemoglobinlevels, and WBC counts periodicallyduring first year.• Urge patient to notify prescriber immediatelyabout chills, fever, or sore throat.Also urge her to tell prescriber aboutunexplained muscle pain, tenderness, orweakness, especially if accompanied byfatigue or fever.• Tell patient to seek emergency treatment ifhe develops pain, swelling, and redness inhis limb or sudden shortness of breath,anxiety, and restlessness.fenoldopammesylateCorlopamClass and CategoryChemical class: Dopamine agonistTherapeutic class: AntihypertensivePregnancy category: BIndications and Dosages To treat severe hypertension when rapid,but quickly reversible, emergency reductionof blood pressure is clinically indicated,including malignant hypertensionwith deteriorating end-organ functionI.V. INFUSIONAdults. Initial: 0.025 to 0.3 mcg/kg/min,individualized according to patient weightand desired effect. Usual: 0.01 to 1.6 mcg/kg/min. Maximum: 1.6 mcg/kg/min for upto 48 hr.Route Onset Peak DurationI.V. Rapid Unknown UnknownMechanism of ActionStimulates dopamine-1 postsynaptic receptors,which mediate renal and mesentericvasodilation. Vasodilation lowers bloodpressure and total peripheral resis-tancewhile increasing renal blood flow.ContraindicationsHypersensitivity to fenoldopam or its componentsfenoldopam mesylate 429InteractionsDRUGSantihypertensives: Additive hypotensiveeffectbeta blockers: Increased risk of hypotensiondopamine antagonists, metoclopramide:Possibly decreased effects of fenoldopamAdverse ReactionsCNS: Anxiety, headache, light-headednessCV: Hypotension, ST- and T-wave changes,tachycardiaEENT: Increased intraocular pressureGI: Abdominal pain, nauseaSKIN: Diaphoresis, flushingOther: Hypokalemia, injection site painNursing Considerations• Reconstitute by adding 40 mg fenoldopam(4 ml of concentrate) to 1,000 ml normalsaline solution or D 5 W, or 20 mg fenoldopam(2 ml of concentrate) to 500 ml normalsaline solution or D 5 W, or 10 mgfenoldopam (1 ml of concentrate) to250 ml normal saline solution or D 5 W toproduce a final fenoldopam concentrationof 40 mcg/ml.• Infuse through a mechanical infusionpump for proper control of infusion rate.• Expect to titrate fenoldopam dosage inincrements of 0.05 to 0.1 mcg/kg/min, asprescribed.• Expect to monitor heart rate and bloodpressure every 15 minutes during therapybecause most effect on blood pressureoccurs within 15 minutes of any dosagechange.• Be aware that patient may be started onoral antihypertensive therapy, as prescribed,any time after blood pressure isstable during fenoldopam infusion.• Discard any reconstituted solution notused within 24 hours.WARNING Assess patient for signs ofincreased myocardial oxygen demand,especially if patient has heart failure or ahistory of angina, because fenoldopammay produce a rapid decline in bloodpressure, resulting in symptomatichypotension and a dose-dependentincrease in heart rate.• Monitor serum potassium level becausefenoldopam decreases serum potassiumconcentrations, which may result inhypokalemia, exacerbate arrhythmias, orEF

430Adverse ReactionsCNS: Agitation, confusion, dizziness,drowsiness, headache, seizures, sleep disturbance,stroke, tremor, weaknessCV: Hypertension, MI, palpitations, peripheraledema, tachycardia, vasodilationEENT: Blurred vision, dry or sore mouth,hearing loss, tinnitusGI: Abdominal cramps, distention, andpain; anorexia; constipation; diarrhea;diverticulitis; dysphagia; esophagitis; flatulence;gastritis; gastroenteritis; gastroefenoprofencalciumprecipitate conduction abnormalities,especially in patients with cardiac disease.• Monitor patients with glaucoma orincreased intraocular pressure for changesin vision because drug may cause a dosedependentincrease in intraocular pressure.• Be alert for possible allergic- or anaphylactic-typereaction to sodium metabisulfite,a component of fenoldopam injection,especially in patients with asthma.PATIENT TEACHING• Inform patient that she’ll be switched toan oral antihypertensive once her bloodpressure is controlled.• Instruct patient to expect frequent monitoringof vital signs.fenoprofen calciumNalfonClass and CategoryChemical class: Propionic acid derivativeTherapeutic class: Analgesic, antiinflammatory,antirheumaticPregnancy category: Not ratedIndications and Dosages To manage mild to moderate painCAPSULES, TABLETSAdults. 200 mg every 4 to 6 hr, as needed. To relieve pain, stiffness, and swellingfrom rheumatoid arthritis or osteoarthritisCAPSULES, TABLETSAdults. 300 mg or 400 mg to 600 mg t.i.d.or q.i.d. Maximum: 3,200 mg daily.Route Onset Peak DurationP.O. 15–30 Unknown† 4–6 hr‡min*Mechanism of ActionBlocks the activity of cyclooxygenase, theenzyme needed for prostaglandin synthesis.* For analgesia; 2 days for antirheumaticeffects.† For analgesia; 2 to 3 wk for antirheumaticeffects.‡ For analgesia; unknown for antirheumaticeffects.Prostaglandins, important mediators of theinflammatory response, cause local vasodilationwith swelling and pain. Whencyclooxygenase is blocked and prostaglandinsinhibited, inflammatory symptomssubside. Prostaglandin inhibition alsorelieves pain because prostaglandins play arole in pain transmission from the peripheryto the spinal cord.ContraindicationsAngioedema, asthma, bronchospasm, nasalpolyps, rhinitis, or urticaria induced byaspirin, iodides, or NSAIDs; hypersensitivityto fenoprofen or its components; renalimpairment; severe hepatic impairmentInteractionsDRUGSacetaminophen: Increased risk of renalimpairment with concurrent long-term useantacids: Decreased fenoprofen effectivenessanticoagulants, cefamandole, cefoperazone,cefotetan, heparin, plicamycin, thrombolytics,valproic acid: Increased risk of bleedingantineoplastics: Increased adverse hematologiceffectscyclosporine: Increased risk of nephrotoxicitydiuretics, triamterene: Decreased effectivenessof these drugsglucocorticoids, NSAIDs, potassium supplements:Increased adverse GI effectsinsulin, oral antidiabetic drugs: Increasedrisk of hypoglycemialithium: Increased risk of lithium toxicitymethotrexate: Increased risk of methotrexatetoxicityphenobarbital: Possibly decreased eliminationhalf-life of fenoprofensalicylates: Increased risk of GI bleedingACTIVITIESalcohol use, smoking: Increased risk of GIbleeding

sophageal reflux disease; GI bleeding orulceration; hemorrhoids; hepatitis; hiatalhernia; indigestion; jaundice; liver failure;melena; nausea; perforation of stomach orintestines; vomitingGU: Acute renal failure, dysuria, interstitialnephritisHEME: Agranulocytosis, anemia, hemolyticanemia, leukopenia, neutropenia, pancytopeniaMS: Muscle spasms and twitching, myalgiaRESP: DyspneaSKIN: Diaphoresis, erythema, erythemamultiforme, exfoliative dermatitis, pruritus,Stevens-Johnson syndrome, toxic epidermalnecrolysis, urticariaOther: Anaphylaxis, angioedemafenoprofen calcium 431Nursing Considerations• Use fenoprofen with extreme caution inpatients with a history of ulcer disease orGI bleeding because NSAIDs such as fenoprofenincrease risk of GI bleeding andulceration. Expect to use fenoprofen forthe shortest time possible in these patients.• Serious GI tract ulceration, bleeding, andperforation may occur without warningsymptoms. Elderly patients are at greaterrisk. To minimize risk, give drug withfood. If GI distress occurs, withhold drugand notify prescriber immediately.• Use fenoprofen cautiously in patients withhypertension, and monitor blood pressureclosely throughout therapy. Drug maycause hypertension or worsen it.• Give drug with food, milk, or antacids todecrease adverse GI reactions.• Patients with rheumatoid arthritis mayneed higher doses than those withosteoarthritis to control their symptoms.WARNING If patient receives long-termtherapy, watch for signs of toxicity, such asagitation; blurred vision; coma; confusion;drowsiness; elevated BUN and serum creatininelevels; indigestion; nausea; rash;seizures; severe headache; slow, laboredbreathing; tinnitus; and vomiting.WARNING Monitor patient closely forthrombotic events, including MI andstroke, because NaSAIDs increase the risk.WARNING If patient has bone marrow suppressionor is receiving antineoplastic drugtherapy, monitor laboratory results(including WBC count), and watch forevidence of infection because anti-inflammatoryand antipyretic actions of fenoprofenmay mask signs and symptoms ofinfection, such as fever and pain.• Monitor patient—especially if she’s elderlyor receiving long-term fenoprofen therapy—forless common but serious adverseGI reactions, including anorexia, constipation,diverticulitis, dysphagia, esophagitis,gastritis, gastroenteritis, gastroesophagealreflux disease, hemorrhoids, hiatal hernia,melena, stomatitis, and vomiting.• Monitor patient’s liver function test resultsbecause, in rare cases, elevations mayprogress to severe hepatic reactions,including fatal hepatitis, liver necrosis, andhepatic failure.• Monitor BUN and serum creatinine levelsin elderly patients, patients taking diureticsor ACE inhibitors, and patients withheart failure, impaired renal function, orhepatic dysfunction because drug maycause renal failure.• Monitor CBC for decreased hemoglobinand hematocrit because drug may worsenanemia.• Assess patient’s skin regularly for signs ofrash or other hypersensitivity reactionbecause fenoprofen is an NSAID and maycause serious skin reactions without warning,even in patients with no history ofNSAID sensitivity. At first sign of reaction,stop drug and notify prescriber.PATIENT TEACHING• Advise patient to take fenoprofen withfood, milk, or antacids to minimize GIdistress. Also instruct her to take drugwith a full glass of water and to stayupright for 30 minutes afterward todecrease the risk of drug lodging in theesophagus and causing irritation.• Instruct patient to swallow drug wholeand not to crush, break, chew, or opencapsules.•Caution patient to avoid alcohol, aspirin,and other NSAIDs, unless prescribed,while taking fenoprofen.• If patient takes an anticoagulant, urge herto immediately report bleeding, includingbloody or tarry stools and bloody vomitus.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Explain that NSAIDs may increase the riskof serious adverse cardiovascular reactions;urge patient to seek immediateEF

432Mechanism of ActionBinds to opioid receptor sites in the CNS,altering perception of and emotionalresponse to pain by inhibiting ascendingpain pathways. Fentanyl may alter neurofentanylmedical attention if signs or symptomsarise, such as chest pain, shortness ofbreath, weakness, and slurring of speech.• Explain that fenoprofen also may increasethe risk of serious adverse GI reactions;stress the need to seek immediate medicalattention for such signs and symptoms asepigastric or abdominal pain, indigestion,black or tarry stools, or vomiting blood ormaterial that looks like coffee grounds.• Alert patient to the possibility of rare butserious skin reactions. Urge her to seekimmediate medical attention for rash, blisters,itching, fever, or other indications ofhypersensitivity.fentanyl citrateActiq, Onsolis, Sublimazefentanyltransdermal systemDuragesicfentanyliontophoretictransdermalIonsysClass, Category, and ScheduleChemical class: Opioid, phenylpiperidinederivativeTherapeutic class: Analgesic, anesthesiaadjunctPregnancy category: CControlled substance schedule: IIIndications and Dosages To provide surgical premedicationI.M. INJECTIONAdults. 0.05 to 0.1 mg 30 to 60 min beforesurgery. As adjunct to regional anesthesiaI.V. OR I.M. INJECTIONAdults. 0.05 to 0.1 mg I.M. or slow I.V. over1 to 2 min. To manage postoperative pain in postanesthesiacare unitI.M. INJECTIONAdults. 0.05 to 0.1 mg. Repeated in 1 to2 hr, if needed. To manage acute postoperative pain inhospitalized patients requiring opioidanalgesiaIONTOPHORETIC TRANSDERMALAdults. 40 mg on-demand, released over10 min. Maximum: Six 40-mcg doses/hourand eighty 40-mcg doses/24 hours for maximumof 72 hours. To treat breakthrough pain in cancerpatients who are receiving opioid therapyand have developed tolerance to itTRANSMUCOSAL LOZENGE (ACTIQ)Adults. Initial: 200 mcg placed betweencheek and gum for up to 15 min followedby second dose 15 min after first dose ends,if needed. Dosage increased according topatient’s needs.TRANSMUCOSAL SOLUBLE FILM (ONSOLIS)Adults. Initial: 200-mcg film sheet placedagainst inside of cheek per episode.Increased, as needed, by 200 mcg in eachsubsequent episode, with doses at least2 hours apart. Maximum: Four 200-mcgfilm sheets or one 1,200-mcg film sheetfour times daily. To relieve persistent moderate to severechronic pain that doesn’t respond to lesspotent drugs and requires around-theclockopioid administration for anextended timeTRANSDERMAL SYSTEMAdults and children age 2 and over. Initial:One 25-mcg/hr patch, replaced every 72 hr(or 48 hr, if needed). Dosage increased by12.5 mcg/hr, as needed, after first 72 hr andthen every 6 days. For more than 100 mcg/hr, more than one patch is used.DOSAGE ADJUSTMENT For elderly, cachectic,or debilitated patients, initial dosage shouldnot exceed 25 mcg/hr unless patient isalready receiving more than 135 mg of oralmorphine daily or an equivalent dose ofanother opioid. For patients receiving longtermopioid therapy, dosage adjusted basedon previous day’s drug requirement. Forcancer patients who need more than800 mcg/day for breakthrough pain, dosagealtered or another long-acting opioid given,as prescribed.

transmitter release from afferent nervesresponsive to painful stimuli, and it causesrespiratory depression by acting directly onrespiratory centers in the brain stem.Route Onset Peak DurationI.V. 1–2 min 3–5 min 30–60 minI.M. 7–15 min 20–30 min 1–2 hrTrans- 12–24 hr Unknown Over 72 hrdermalContraindicationsI.V. or I.M. form: Under age 2, asthma,myasthenia gravis, opioid hypersensitivityor intoleranceTransmucosal form: Acute or chronic pain,including postoperative painTransdermal form: Acute or postoperativepain, under age 12 (under age 18 if weightis less than 50 kg [110 lb]), dosage thatexceeds 25 mcg/hr at the start of therapy,hypersensitivity to fentanyl (or alfentanil,sufentanil, or adhesives), intermittent pain,treatment of mild to moderate pain responsiveto nonopioid drugsAll forms: Hypersensitivity to fentanyl (oralfentanil, sufentanil, or adhesives) or itscomponents, intermittent pain, opioid nontolerance,significant respiratory depression,treatment of mild to moderate painresponsive to nonopioid drugs, upper airwayobstructionInteractionsDRUGSamiodarone, amprenavir, aprepitant, clarithromycin,diltiazem, erythromycin, fluconazole,fosamprenavir, itraconazole, ketoconazole,nefazodone, nelfinavir, ritonavir, troleandomycin,verapamil: Possibly increasedopioid effect, leading to increased or prolongedadverse effects, including severe respiratorydepressionanticholinergics, antidiarrheals (such as loperamideand paregoric): Increased risk ofsevere constipationantihypertensives, diuretics: Possibly potentiatedhypotensionbenzodiazepines: Possibly reduced fentanyldose required for anesthesia inductionbuprenorphine: Possibly decreased therapeuticeffects of buprenorphineCNS depressants: Possibly increased CNSand respiratory depression and hypotensionAdverse ReactionsCNS: Agitation, amnesia, anxiety, asthenia,ataxia, confusion, delusions, depression,dizziness, drowsiness, euphoria, fever, hallucinations,headache, lack of coordination,light-headedness, nervousness, paranoia,sedation, seizures, sleep disturbance, slurredspeech, syncope, tremor, weakness, yawningCV: Asystole, bradycardia, chest pain,edema, hypotension, orthostatic hypotension,tachycardiaEENT: Blurred vision, dental caries, drymouth, gum line erosion, laryngospasm,rhinitis, sneezing, tooth lossGI: Anorexia, constipation, ileus, indigestion,nausea, vomitingGU: Anorgasmia, decreased libido, ejaculatorydifficulty, urinary hesitancy, urineretentionRESP: Apnea, depressed cough reflex, dyspnea,hypoventilation, respiratory depressionSKIN: Diaphoresis, exfoliative dermatitis,localized skin redness and swelling (withtransdermal form), pruritus, rashOther: Anaphylaxis, drug tolerance, physifentanyl433cytochrome P-450 inducers (such as rifampin,carbamazepine, and phenytoin):Possibly induced metabolism and increasedclearance of fentanylhydroxyzine: Possibly increased analgesiceffect of fentanyl and increased CNSdepression and hypotensionMAO inhibitors: Possibly unpredictable orfatal effects if taken within 14 daysmetoclopramide: Possibly antagonized effectof metoclopramide on gastric motilitynalbuphine, pentazocine: Possibly antagonizedanalgesic, respiratory depressant, andCNS depressant effects of fentanyl; possiblyadditive hypotensive and CNS and respiratorydepressant effects of both drugsnaloxone: Antagonized analgesic, hypotensive,CNS, and respiratory depressant effectsof fentanylnaltrexone: Possibly blocked therapeuticeffects of fentanylneuromuscular blockers: Possibly preventionor reversal of muscle rigidity by fentanylFOODSgrapefruit juice: Increased blood fentanyllevelACTIVITIESalcohol use: Increased CNS and respiratorydepression and hypotensionEF

434fentanylcal or psychological dependence with longtermuse, weight lossNursing ConsiderationsWARNING Fentanyl transdermal systemshould be used only in patients alreadyreceiving opioid therapy and with demonstratedopioid tolerance (taking for a weekor longer at least 60 mg of morphine daily,30 mg of oral oxycodone daily, 8 mg oforal hydromorphone daily, or an equianalgesicdose of another opioid), and requireat least a fentanyl dosage of 25 mcg perhour to manage their pain.• Use caution when titrating fentanyl dosagein elderly patients, especially using intravenousroute, because these patients aremore sensitive to the drug’s effects.• Use cautiously in patients at risk for opioidabuse, such as those with mental illnessor personal or family history of substanceabuse. Monitor patient throughouttherapy for fentanyl abuse or addiction.• To reduce skin irritation, spray the allergyinhaler triamcinolone on the patient’sskin, as prescribed, before applying a fentanylpatch.• Expect the blood fentanyl level to be prolongedif patient chews or swallows thetransmucosal form because drug isabsorbed slowly from GI tract.WARNING Never apply a transdermal patchif seal has been broken or patch has beencut, damaged, or changed because excessiveexposure could occur, resulting inpossibly fatal fentanyl overdose.• Be aware that 100 mcg of fentanyl isequivalent in potency to 10 mg of morphine.• To achieve optimum pain control with thelowest possible fentanyl dose, also plan togive a nonopioid analgesic, such as acetaminophen,as prescribed.WARNING Monitor patient’s respiratory statusclosely, especially during the first 24 to72 hours after therapy starts or dosageincreases, because severe hypoventilationmay occur without warning at any timeduring therapy.• To prevent withdrawal symptoms afterlong-term use, expect to taper drug dosagegradually, as prescribed.• Assess patient for withdrawal symptomsafter dosage reduction or conversion toanother opioid analgesic.• For patient with bradycardia, implementcardiac monitoring, as ordered, and assessheart rate and rhythm frequently duringfentanyl therapy because drug may furtherslow heart rate.WARNING Expect respiratory depressanteffects to last longer than analgesic effects.Also be prepared for residual drug topotentiate effects of subsequent doses.Residual drug can be detected for at least6 hours after I.V. dose and 17 hours afterother forms. Monitor patient closely for atleast 24 hours after therapy ends.WARNING Assess patient for evidence ofoverdose, such as cardiopulmonary arrest,hypoventilation, pupil constriction, respiratoryand CNS depression, seizures, andshock. Give naloxone (possibly in repeateddoses), as prescribed. Be prepared to assistwith endotracheal intubation and mechanicalventilation and to provide fluids.• Monitor blood glucose level of diabeticpatient receiving transdermal fentanylbecause each unit contains about 2 g ofsugar.WARNING Do not substitute Actiq orOnsolis for any other fentanyl product anddo not substitute for each other. Do notconvert dosage to or from other productson a mcg-per-mcg basis because doing somay result in a fatal overdose.PATIENT TEACHING• Instruct patient to avoid alcohol and otherCNS depressants during fentanyl therapyunless prescribed.• Advise patient not to stop taking drugunless directed by prescriber because withdrawalsymptoms may occur. Warn againstincreasing dose or frequency without consultingprescriber because drug can causedependency.• For transdermal form, instruct patient tochoose a site with intact (not irritated orirradiated) skin on a flat surface, such asthe chest, back, flank, or upper arm, and, ifappropriate, to clip, not shave, hair fromthe site and clean it with water (no soaps,lotions, oils, or alcohol). After site preparation,instruct patient to press patchfirmly in place with palm for 30 seconds,making sure edges are sealed. If patchloosens, tell her to tape edges down butnot cover the entire patch. If more thanone patch is needed, the edges shouldn’t

touch or overlap. Instruct patient toremove patch after 72 hours, fold it in halfwith adhesive sides together, and flush itdown the toilet. Remind her not to reuse asite for at least 3 days.• Warn patient never to apply transdermalpatch if seal has been broken or the patchhas been cut, damaged, or changed in anyway because drug may be released too rapidly.Also warn patient not to expose theapplication site and surrounding area todirect external heat sources, such as heatingpads or electric blankets, heat or tanninglamps, saunas, hot tubs, and heatedwater beds, while wearing the patch. Sheshould also avoid hot baths or sunbathingbecause increased body temperature mayincrease fentanyl release, resulting in apossible overdose. If she develops a feveror becomes overheated from strenuousexercise while wearing a patch, she shouldcontact the prescriber immediately.• For iontophoretic transdermal form,instruct patient to press button twice firmlywithin 3 seconds to release a dose. Anaudible tone will sound when a dose isactivated, and a red light will stay onthroughout the 10-minute administration.Explain that no more than six doses canbe given per hour and no more than 80doses per 24 hours. Tell the patient thatthe patch may be replaced once 80 dosesare released or 24 hours pass, but that 72hours is the maximum time the drug canbe delivered in this way.• For Actiq transmucosal form, instructpatient to open the package just before useand to save plastic cap for discarding theunused part of the lozenge. Tell her toplace lozenge between her cheek and gumand to suck, not chew, it for 15 minutes.Show her how to move lozenge from oneside of her mouth to the other using thehandle provided separately.• For Onsolis transmucosal form, instructpatient to wet inside of cheek with tongueor rinse his mouth with water. Tell him toopen package just before use and placeentire film sheet on the tip of a dry finger,pink side facing up. Then he should carefullyplace pink side of film against insideof cheek and press and hold it in place for5 seconds. Tell him not to drink anythingfor 5 minutes or eat for 30 minutes. Warnpatient not to cut or tear film before use.If he uses multiple film sheets, tell him toplace them in separately along sheek wall,not on top of each other.• Onsolis dosage increases must occur onlyin 200-mcg increments, must be done onlyin later pain episodes, and must be separatedby at least 2 hours from previousdose. If pain isn’t relieved within 30 minutes,tell him not to use another dose butto use a rescue drug instead. If dosageincrease is needed and continues to beneeded, tell patient to contact prescriberfor new dosage strength because eachepisode should be treated with one filmsheet of appropriate strength.• For transmucosal form, urge patient to seea dentist regularly, to brush teeth and flossafter each meal, and to avoid frequentconsumption of products high in sugarbecause of increased risk of dental caries.• For transmucosal form, inform diabeticpatient that each unit contains 2 g ofsugar. Instruct her to monitor her bloodglucose levels closely.• Remind patient to keep used and unuseddosage units out of reach of children andto dispose of drug properly. For buccaltablets, patient should flush leftover drugdown the toilet when no longer needed.• Caution patient that accidentally exposingothers to transdermal fentanyl could causeserious adverse reactions. If accidentalexposure occurs, the person shouldremove the patch, wash the area well withwater, and seek medical attention.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Tell patient to increase fiber and fluidintake, unless contraindicated, becausedrug may cause severe constipation. If itpersists or becomes severe, urge patient tonotify prescriber.ferrous saltsferrous fumarateferrous salts 435(contains 100 mg of elemental iron percapsule or per 5 ml of oral suspension, 33mg of elemental iron per chewable tabletor per 5 ml of oral suspension, 106 mg ofelemental iron per E.R. capsule, 15 mg ofEF

436ferrous saltselemental iron per 0.6 ml of oral solution,and 20 to 115 mg of elemental iron pertablet)Femiron, Feostat, Feostat Drops,Ferretts, Fumasorb, Fumerin,Hemocyte, Ircon, Neo-Fer (CAN),Nephro-Fer, Novofumar (CAN), Palafer(CAN), Span-FFferrous gluconate(contains 10 mg of elemental iron percapsule, 34 mg of elemental iron per 5 mlof elixir, 37 mg of elemental iron per E.R.tablet, 35 mg of elemental iron per 5 ml ofsyrup, and 34 to 38 mg of elemental ironper tablet)Apo-Ferrous Gluconate (CAN), Fergon,Ferralet, Ferralet Slow Release, Fertinic(CAN), Novoferrogluc (CAN), Simronferrous sulfate(contains 50 mg of elemental iron percapsule, 60 mg of elemental iron per driedcapsule, 30 to 50 mg of elemental iron perdried E.R. capsule, 50 mg of elementaliron per dried E.R. tablet, 65 mg of elementaliron per dried tablet, 44 mg of elementaliron per 5 ml of elixir, 60 to 65 mgof elemental iron per enteric-coatedtablet, 65 to 105 mg of elemental iron perE.R. tablet, 15 mg of elemental iron per0.6 ml of oral solution, 18 mg of elementaliron per 0.5 ml of oral solution, 25 mg ofelemental iron per ml of oral solution, 30or 60 mg of elemental iron per 5 ml oforal solution, and 39 to 65 mg of elementaliron per tablet)Apo-Ferrous Sulfate (CAN), Feosol,Feratab, Fer-gen-sol, Fer-In-SolCapsules, Fer-In-Sol Drops, Fer-In-SolSyrup, Fer-Iron Drops, Fero-Grad(CAN), Fero-Gradumet, Ferospace,Ferralyn Lanacaps, Ferra-TD, Mol-Iron, Novoferrosulfa (CAN), PMS-Ferrous Sulfate (CAN), Slow-Feiron, carbonyl(contains 50 mg of elemental iron percaplet)FeosolClass and CategoryChemical class: Trace element, mineralTherapeutic class: Antianemic, nutritionalsupplementPregnancy category: Not ratedIndications and Dosages To prevent iron deficiency based on U.S.and Canadian recommended dailyallowancesCAPLETS, CAPSULES, CHEWABLE TABLETS, DRIEDCAPSULES, DRIED E.R. CAPSULES, DRIED E.R.TABLETS, DRIED TABLETS, ELIXIR, ENTERIC-COATEDTABLETS, E.R. CAPSULES, E.R. TABLETS, ORALSOLUTION, ORAL SUSPENSION, SYRUP, TABLETSAdult men and children age 11 and over.10 mg (8 to 10 mg Canadian) elementaliron daily.Adult women and children age 11 andover. 10 to 15 mg (8 to 13 mg Canadian)elemental iron daily.Pregnant women. 30 mg (17 to 22 mgCanadian) elemental iron daily.Breast-feeding women. 15 mg (8 to 13 mgCanadian) elemental iron daily.Children ages 7 to 10. 10 mg (8 to 10 mgCanadian) elemental iron daily.Children ages 4 to 6. 10 mg (8 mgCanadian) elemental iron daily.Children from birth to age 3. 6 to 10 mg(0.3 to 6 mg Canadian) elemental irondaily. To replace iron in deficiency statesCAPLETS, CAPSULES, CHEWABLE TABLETS, DRIEDCAPSULES, DRIED E.R. CAPSULES, DRIED E.R.TABLETS, DRIED TABLETS, ELIXIR, ENTERIC-COATEDTABLETS, E.R. CAPSULES, E.R. TABLETS, ORALSOLUTION, ORAL SUSPENSION, SYRUP, TABLETSAdults and adolescents. 100 to 200 mg elementaliron t.i.d. for 4 to 6 mo.Children ages 2 to 12 weighing 30 to 50 kg(66 to 110 lb). 50 to 100 mg elemental irondaily in divided doses t.i.d. or q.i.d. for 4 to6 mo.Children ages 6 months to 2 years. Up to6 mg/kg elemental iron daily in divideddoses t.i.d. or q.i.d. for 4 to 6 mo.Infants under age 6 months. 10 to 25 mgelemental iron daily in divided doses t.i.d.or q.i.d. for 4 to 6 mo. To provide iron supplementation duringpregnancyCAPLETS, CAPSULES, CHEWABLE TABLETS, DRIEDCAPSULES, DRIED E.R. CAPSULES, DRIED E.R.TABLETS, DRIED TABLETS, ELIXIR, ENTERIC-COATED

TABLETS, E.R. CAPSULES, E.R. TABLETS, ORALSOLUTION, ORAL SUSPENSION, SYRUP, TABLETSPregnant women. 15 to 30 mg elementaliron daily during second and thirdtrimesters.DOSAGE ADJUSTMENT Dosage increased ifneeded for elderly patients, who may notabsorb iron as easily as younger adults do.Mechanism of ActionActs to normalize RBC production by bindingwith hemoglobin or by being oxidizedand stored as hemosiderin or aggregatedferritin in reticuloendothelial cells of theliver, spleen, and bone marrow. Iron is anessential component of hemoglobin, myoglobin,and several enzymes, includingcytochromes, catalase, and peroxidase. Ironis needed for catecholamine metabolismand normal neutrophil function.ContraindicationsHemochromatosis, hemolytic anemias,hemosiderosis, hypersensitivity to iron saltsor their components, other anemic conditionsunless accompanied by iron deficiencyInteractionsDRUGSacetohydroxamic acid: Reduced absorptionof both drugsantacids, calcium supplements: Decreasediron absorption and effectivenessascorbic acid (with doses of 200 mg or more):Increased iron absorptioncholestyramine, cimetidine: Decreased ironabsorptionciprofloxacin, enoxacin, etidronate, lomefloxacin,norfloxacin, ofloxacin, oral tetracyclines:Decreased effectiveness of thesedrugsdimercaprol: Possibly combination withiron in body to form a harmful chemicallevodopa: Possibly chelation with iron,decreasing levodopa absorption and bloodlevellevothyroxine: Decreased levothyroxineeffectiveness and, possibly, hypothyroidismmethyldopa: Decreased methyldopa absorptionand efficacypenicillamine: Decreased penicillamineabsorption because penicillamine chelatesheavy metalsvitamin E: Decreased vitamin E absorptionFOODScoffee; eggs; foods that contain bicarbonates,ferrous salts 437carbonates, oxalates, or phosphates; milk andmilk products; tea that contains tannic acid;whole-grain breads and cereals and otherhigh-fiber foods: Decreased iron absorptionand effectivenessACTIVITIESalcohol abuse (acute or chronic): Increasedserum iron levelAdverse ReactionsCNS: Dizziness, fever, headache, paresthesia,syncopeCV: Chest pain, tachycardiaEENT: Metallic taste, tooth discolorationGI: Abdominal cramps, constipation, epigastricpain, nausea, stool discoloration,vomitingHEME: Hemochromatosis, hemolysis,hemosiderosisRESP: DyspneaSKIN: Diaphoresis, flushing, rash, urticariaNursing Considerations• Give iron tablets and capsules with a fullglass of water or juice. Don’t crushenteric-coated tablets or open capsules.• Because iron solutions may stain teeth,dilute and administer with a straw or placedrops in back of patient’s throat. Mix theelixir form in water. Fer-In-Sol Drops orSyrup may be mixed with water or juice.• To maximize absorption, give iron salts1 hour before or 2 hours after meals. If GIirritation occurs, give with or just aftermeals.• Protect liquid form from freezing.• Be aware that at usual dosages, serumhemoglobin level usually normalizes inabout 2 months unless blood loss continues.Treatment lasts for 3 to 6 months tohelp replenish iron stores.WARNING Monitor patient for signs of ironoverdose, which may include abdominalpain, diarrhea (possibly bloody), nausea,severe vomiting, and sharp abdominalcramps. In case of iron toxicity or accidentaliron overdose (a leading cause of fatalpoisoning in children under age 6), givedeferoxamine, as prescribed. As few as 3adult iron tablets can cause serious poisoningin young children.• Don’t give antacids, coffee, tea, dairy products,eggs, or whole-grain cereals or breadswithin 1 hour before or 2 hours after iron.• Remember that unabsorbed iron turnsEF

438fesoterodine fumaratestool green or black and can mask bloodin stool. Check stool for occult blood, asordered.PATIENT TEACHING• Instruct patient not to chew any solidform of iron except for chewable tablets.• Inform patient that iron deficiency maycause decreased stamina, learning problems,shortness of breath, and tiredness.• To improve iron absorption, urge patientto eat lean red meat, chicken, turkey, andfish as well as foods rich in vitamin C(such as citrus fruits and fresh vegetables).• Urge patient to avoid foods that impairiron absorption, including dairy products,eggs, spinach, and high-fiber foods, suchas whole-grain breads and cereals andbran. Also advise her to avoid drinkingcoffee or tea within 1 hour of iron intake.• Caution patient not to take antacids orcalcium supplements within 1 hour beforeand 2 hours after taking iron supplement.• Inform patient that stool should becomedark green or black during therapy. Adviseher to notify prescriber if it doesn’t.• To minimize tooth stains from liquid iron,instruct patient to mix dose with water,fruit juice, or tomato juice and to drink itwith a straw. If patient must take liquidiron by dropper, direct her to place dropswell back on the tongue and to follow withwater or juice. Tell her that iron stains canbe removed by brushing with baking soda(sodium bicarbonate) or medicinal peroxide(hydrogen peroxide 3%).• Advise patient to consult prescriber beforetaking large amounts of iron for longerthan 6 months.• Warn patient about high risk of accidentalpoisoning, and urge her to keep ironpreparations out of the reach of children.fesoterodinefumarateToviazClass and CategoryChemical class: Muscarinic receptorantagonistTherapeutic class: AntispasmodicPregnancy category: CIndications and Dosages To treat overactive bladder with symptomsof urinary incontinence, urgency,and frequencyE.R. TABLETSAdults. Initial: 4 mg daily, increased to8 mg, as needed. Maximum: 8 mg daily.DOSAGE ADJUSTMENT For patients withsevere renal insufficiency or who are takingpotent CYP3A4 inhibitors (such as clarithromycin,itraconazole, and ketoconazole),dosage shouldn’t exceed 4 mg daily.Route Onset Peak DurationP.O. Unknown 5 hr UnknownMechanism of ActionExerts antimuscarinic (atropine-like) andpotent direct antispasmodic (papaverinelike)actions on smooth muscle in the bladder.The result is increased bladder capacityand a decreased urge to void. Fesoterodinehas an active metabolite that inhibits bladdercontraction and decreases detrussorpressure.ContraindicationsGastric retention, GI obstruction, hypersensitivityto fesoterodine or its components,ileus, pyloric stenosis, uncontrolled narrowangleglaucoma, urine retentionInteractionsDRUGSantimuscarinic agents: Possibly increasedanticholinergic effects; possibly alteredabsorption of oral drugs taken concurrentlypotent CYP3A4 inhibitors, such as clarithromycin,itraconazole, ketoconazole:Possibly increased serum fesoterodine leveland increased risk of adverse effectsFOODScaffeine: May aggravate bladder symptomsACTIVITIESalcohol use: Increased drowsinessAdverse ReactionsCNS: Drowsiness, insomniaCV: Angina, chest pain, peripheral edema,QT-interval prolongationEENT: Blurred vision; dry eyes, mouth, orthroatGI: Constipation, diverticulitis, dyspepsia,elevated liver enzymes, gastroenteritis, irritablebowel syndrome, nausea, upper

abdominal painGU: Dysuria, urine retention, UTIMS: Back painRESP: Cough, upper respiratory tract infectionSKIN: Decreased sweating, rashNursing Considerations• Use cautiously in patients with significantbladder outlet obstruction because fesoterodinecan cause urine retention.• Use cautiously in patients with myastheniagravis, decreased GI motility, and controllednarrow-angle glaucoma becausedrug can make these conditions worse.• Use cautiously in patients taking otherdrugs with anticholinergic effects, such asantihistamines.PATIENT TEACHING• Instruct patient to take drug exactly asprescribed.• Tell patient to take drug with a full glass ofwater and not to cut, crush, or chew tablets.• Explain that drug can cause adverse effectssuch as constipation and urine retention.If they occur and are severe or prolonged,patient should notify prescriber.• Advise patient to avoid alcohol consumptionduring fesoterodine therapy.• Tell patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Caution patient to avoid strenuous exerciseand excessive sun exposure because ofincreased risk of heatstroke.• Advise patient to limit caffeine consumptionduring drug therapy.• Explain that full benefits of fesoterodinetherapy may take 2 to 3 months.• Inform patient that chewing sugarlessgum or sucking hard candy (especiallylemon drops) may help ease dry mouth.filgrastim(granulocyte colonystimulatingfactor,rG-CSF)NeupogenClass and CategoryChemical class: Granulocyte colonystimulatingfactorTherapeutic class: Antineutropenic,hematopoietic stimulatorPregnancy category: Cfilgrastim 439Indications and Dosages To prevent infection after myelosuppressivechemotherapyI.V. INFUSIONAdults. 5 mcg/kg daily over 15 to 30 min.Increased, if needed, by 5 mcg/kg with eachchemotherapy cycle.SUBCUTANEOUS INJECTIONAdults. 5 mcg/kg daily for up to 2 wk.Increased, if needed, by 5 mcg/kg with eachchemotherapy cycle. To reduce duration of neutropenia afterbone marrow transplantationI.V. INFUSIONAdults. 10 mcg/kg daily over 4 hr or as acontinuous infusion over 24 hr.SUBCUTANEOUS INFUSIONAdults. 10 mcg/kg as a continuous infusionover 24 hr. To enhance peripheral blood progenitorcell collection in autologous hematopoieticstem cell transplantationSUBCUTANEOUS INFUSION OR INJECTIONAdults. 10 mcg/kg as continuous infusionover 24 hr or a single injection, starting4 days before first leukapheresis and continuinguntil last day of leukapheresis. To reduce occurrence and duration ofneutropenia in congenital neutropeniaSUBCUTANEOUS INJECTIONAdults. 6 mcg/kg b.i.d. To reduce the occurrence and durationof neutropenia in idiopathic or cyclicneutropeniaSUBCUTANEOUS INJECTIONAdults. 5 mcg/kg daily.DOSAGE ADJUSTMENT Dosage reduced forpatients whose absolute neutrophil countremains above 10,000/mm 3 .Route Onset Peak DurationI.V. In 5 min Unknown UnknownMechanism of ActionIs pharmacologically identical to humangranulocyte colony-stimulating factor, anendogenous hormone synthesized bymonocytes, endothelial cells, and fibroblasts.Filgrastim induces formation of neutrophilprogenitor cells by binding directlyto receptors on the surface of granulocytes,EF

440finasteridewhich then divide and differentiate. It alsopotentiates the effects of mature neutrophils,which reduces fever and the risk ofinfection raised by severe neutropenia.IncompatibilitiesDon’t mix filgrastim in vial or syringe withnormal saline solution because precipitatewill form.ContraindicationsHypersensitivity to filgrastim, its components,or proteins from Escherichia coliInteractionsDRUGSgrowth hormone: Increased bone marrowhematopoetic activitylithium: Increased neutrophil productionAdverse ReactionsCNS: Fever, headacheCV: Transient supraventricular tachycardiaGI: Splenic rupture, splenomegalyHEME: LeukocytosisMS: Arthralgia; myalgia; pain in arms, legs,lower back, or pelvisSKIN: Pruritus, rash, Sweet’s syndrome(acute febrile neutrophilic dermatosis)Other: Anaphylaxis, injection site pain andrednessNursing Considerations• Warm filgrastim to room temperaturebefore injection. Discard drug if storedlonger than 6 hours at room temperatureor 24 hours in refrigerator.• Withdraw only one dose from a vial; don’trepuncture the vial.• Don’t shake the solution.• For continuous infusion, dilute in D 5 W(not normal saline solution) to produceless than 15 mcg/ml.• For subcutaneous dose larger than 1 ml,divide and give in more than one site.• After chemotherapy, give drug over 15 to30 minutes. Don’t give within 24 hoursbefore or after cytotoxic chemotherapy.• Be aware that needle cover on single-useprefilled syringe contains dry natural rubberand may cause sensitivity reaction. Itshouldn’t be handled by allergic people.• Expect to monitor CBC, hematocrit, andplatelet count two or three times weekly.• Inform prescriber and expect to stop drugif leukocytosis develops or absolute neutrophilcount consistently exceeds10,000/mm 3 .• Anticipate decreased response to drug ifpatient has received extensive radiationtherapy or long-term chemotherapy.PATIENT TEACHING• Teach patient how to prepare, administer,and store filgrastim. Caution her not toreuse needle, syringe, or vial.• Advise patient prescribed single-use prefilledsyringe to notify prescriber if she hasan allergy to latex because needle covermay cause sensitivity reaction.• Provide patient with puncture-resistantcontainer for needle and syringe disposal.• Advise patient to promptly report pain inleft upper quadrant of abdomen orshoulder-tip pain.• Stress the importance of returning for follow-uplaboratory tests.finasteridePropecia, ProscarClass and CategoryChemical class: 4-Azasteroid compoundTherapeutic class: Benign prostatic hyperplasiaagent, hair growth stimulantPregnancy category: XIndications and Dosages To treat symptomatic benign prostatichyperplasia; to reduce the risk of symptomaticprogression of benign prostatichyperplasia when given with doxazocinTABLETSAdults. 5 mg daily. To treat male-pattern baldnessTABLETSAdults. 1 mg daily.Route Onset Peak DurationP.O.* Unknown 8 hr 24 hr†P.O.‡ In 3 mo Unknown UnknownMechanism of ActionInhibits 5-alpha reductase, an intracellularenzyme that converts testosterone to its* For benign prostatic hyperplasia.† With single-dose therapy; 2 wk withmultiple-dose therapy.‡ For male-pattern baldness.

metabolite (5-alpha dihydrotestosterone) inliver, prostate, and skin. The metabolite is apotent androgen partially responsible forbenign prostatic hyperplasia and hair loss.ContraindicationsAge (childhood), hypersensitivity to finasteride,sex (female)InteractionsDRUGStheophylline: Decreased theophylline levelAdverse ReactionsCNS: Asthenia, dizziness, headacheCV: Hypotension, peripheral edemaEENT: Lip swelling, rhinitisENDO: GynecomastiaGI: Abdominal pain, diarrheaGU: Decreased ejaculatory volume,decreased libido, impotence, testicular painMS: Back painRESP: DyspneaSKIN: Pruritus, rash, urticariaOther: AngioedemaNursing Considerations• Expect patient to have a digital rectalexamination of the prostate before andperiodically during finasteride therapy.PATIENT TEACHINGWARNING Urge patient and female partnersto use reliable contraception during therapybecause semen of men who take drugcan harm male fetuses. Caution womenand children not to handle broken tablets.• Explain how to take drug, and urge patientto follow instructions that accompany it.• Inform patient that drug may causedecreased ejaculatory volume, decreasedlibido, and impotence.• Urge patient to have periodic follow-up todetermine drug effectiveness.flavoxatehydrochlorideUrispasClass and CategoryChemical class: Flavone derivativeTherapeutic class: Urinary tractantispasmodicPregnancy category: BNursing Considerations• Monitor for eye pain if patient has glaucomabecause flavoxate’s anticholinergiceffects may worsen glaucoma.PATIENT TEACHING• Caution patient about possible dry mouthand photophobia. Advise her to wear sunglassesoutdoors, and suggest sugarlesscandy or gum, ice chips, sips of water, orsaliva substitute for dry mouth.• Advise patient to avoid hazardous activiflavoxatehydrochloride 441Indications and Dosages To relieve dysuria, nocturia, suprapubicpain, urinary frequency and urgency,and urinary incontinence caused by cystitis,prostatitis, urethrocystitis, or urethrotrigonitisTABLETSAdults and adolescents. 100 to 200 mgt.i.d. or q.i.d.Route Onset Peak DurationP.O. 55 min 112 min UnknownMechanism of ActionRelaxes muscles by cholinergic blockadeand counteracts smooth-muscle spasms inthe urinary tract.ContraindicationsAchalasia; GI hemorrhage; hypersensitivityto flavoxate or its components; obstructionof the duodenum, ileum, or pylorus;obstructive uropathies of the lower urinarytractInteractionsDRUGSbethanechol, metoclopramide: Possibly antagonizedGI motility effects of these drugsAdverse ReactionsCNS: Confusion, decreased concentration,dizziness, drowsiness, fever, headache, nervousness,vertigoCV: Palpitations, tachycardiaEENT: Accommodation disturbances,blurred vision, dry mouth, eye pain, photophobia,worsening of glaucomaGI: Constipation, nausea, vomitingGU: DysuriaHEME: Eosinophilia, leukopeniaSKIN: Decreased sweating, dermatoses,urticariaEF

442flecainide acetateties until CNS effects of flavoxate areknown.• Caution patient not to become overheatedor to take hot baths or saunas during therapybecause drug reduces sweating, whichcan lead to dizziness, fainting, or heatstroke.• Instruct patient to notify prescriber immediatelyif she experiences confusion,drowsiness, dysuria, headache, high fever,hives, nausea, nervousness, palpitations,rash, tachycardia, vertigo, vision problems,vomiting, or worsening dry mouth.flecainide acetateTambocorClass and CategoryChemical class: Benzamide derivativeTherapeutic class: Class IC antiarrhythmicPregnancy category: CIndications and Dosages To prevent and suppress recurrent lifethreateningventricular tachycardiaTABLETSAdults. Initial: 100 mg every 12 hr (every8 hr for some patients). Increased by 50 mgb.i.d. every 4 days, if needed, until responseoccurs. Maintenance: Up to 150 mg every12 hr. Maximum: 400 mg daily.DOSAGE ADJUSTMENT Initial dose reducedto 100 mg daily or 50 mg every 12 hr forpatients with creatinine clearance less than35 ml/min/1.73 m 2 . To prevent paroxysmal atrial fibrillationor flutter or paroxysmal supraventriculartachycardiaTABLETSAdults. Initial: 50 mg every 12 hr (every8 hr for some patients). Increased by 50 mgb.i.d. every 4 days, if needed, until responseoccurs. Maintenance: Up to 150 mg every12 hr. Maximum: 300 mg daily.Mechanism of ActionAchieves antiarrhythmic effect by inhibitingfast sodium channels of myocardial cellmembranes, which increase myocardialrecovery after repolarization, and bydepressing the upstroke of the actionpotential. Flecainide also produces its antiarrhythmiceffect by:• slowing intracardiac conduction, whichslightly increases the duration of theaction potential in atrial and ventricularmuscle, thus prolonging the PR interval,QRS complex, and QT interval• shortening the action potential of Purkinjefibers without affecting surroundingmyocardial tissue• inhibiting extracellular calcium influx (athigh doses)• stopping paroxysmal reentrant supraventriculartachycardias by acting on antegradepathways of dysfunctional AV conduction• decreasing conduction in accessory pathwaysin those with Wolff-Parkinson-Whitesyndrome.ContraindicationsCardiogenic shock, hypersensitivity to flecainideor its components, recent MI, rightbundle-branch block associated with lefthemiblock or second- or third-degree AVblock unless pacemaker is presentInteractionsDRUGSamiodarone: Increased blood flecainide levelbeta blockers, disopyramide, verapamil:Possibly myocardial depression andincreased blood levels of both drugscalcium channel blockers: Increased risk ofarrhythmiasdigoxin: Possibly increased blood digoxinlevelurinary acidifiers: Possibly increased flecainideelimination and decreased therapeuticeffectsurinary alkalinizers: Possibly decreased flecainideelimination and increased therapeuticeffectsFOODSacidic juices, foods that decrease urine pHbelow 5.0: Increased flecainide eliminationand decreased therapeutic effectsfoods that increase urine pH above 7.0, strictvegetarian diet: Decreased flecainide eliminationand increased therapeutic effectsACTIVITIESsmoking: Increased flecainide clearanceAdverse ReactionsCNS: Anxiety, depression, dizziness, drowsiness,fatigue, headache, light-headedness,tremor, weakness

CV: Arrhythmias, chest pain, heart failure,hypotensionEENT: Blurred visionGI: Abdominal pain, anorexia, constipation,hepatic dysfunction, nausea, vomitingRESP: DyspneaSKIN: RashNursing Considerations• Monitor urine pH at the start of flecainidetherapy.• Check blood pressure, fluid intake andoutput, and weight regularly during therapy.• Monitor trough flecainide level, as needed;therapeutic level is 0.2 to 1 mcg/ml.• Expect drug to cause mild to moderatenegative inotropic effects, minimal cardiovasculareffects, and no effect on bloodpressure, heart rate, and left ventricularfunction.WARNING Because hypokalemia or hyperkalemiamay interfere with flecainide’stherapeutic effects, monitor serum potassiumlevel before and during therapy andnotify prescriber immediately if potassiumimbalance develops. Also monitor for andnotify prescriber about prolonged PRinterval, QRS complex, or QT interval;chest pain; hypotension; and signs of heartfailure. Keep in mind that drug can causefatal proarrhythmias, which is why it isn’tconsidered a first-line antiarrhythmic.• Expect prolonged flecainide therapy toraise blood alkaline phosphatase level.PATIENT TEACHING• Instruct patient to take flecainide at regularintervals to keep a constant blood level.• Advise patient to take a missed dose assoon as she remembers if it’s within6 hours of the scheduled time.• Teach patient how to take her pulse, andinstruct her to record it daily, along withher weight. Advise her to bring record tofollow-up visits.• Encourage family members to obtaininstruction in basic cardiac life support.• Advise patient to notify prescriber immediatelyabout chest pain, difficulty breathing,and dizziness.• Caution patient not to stop taking flecainidesuddenly but to taper dosage graduallyaccording to prescriber’s instructions.fluconazoleDiflucanClass and CategoryChemical class: Triazole derivativeTherapeutic class: AntifungalPregnancy category: CMechanism of ActionDamages fungal cells by interfering with acytochrome P-450 enzyme needed to confluconazole443Indications and Dosages To treat oral and esophageal candidiasisORAL SUSPENSION, TABLETS, I.V. INJECTIONAdults and adolescents. 200 mg on day1 followed by 100 mg daily for at least2 (oral) or 3 (esophageal) wk after symptomsresolve.Children. 3 mg/kg daily for at least 2 (oral)or 3 (esophageal) wk and then for 2 wkafter esophageal symptoms resolve. To treat systemic candidiasisORAL SUSPENSION, TABLETS, I.V. INJECTIONAdults and adolescents. 400 mg on day1, followed by 200 mg daily for at least 4 wkand then for additional 2 wk after symptomsresolve. To treat cryptococcal meningitisORAL SUSPENSION, TABLETS, I.V. INJECTIONAdults and adolescents. 400 mg daily untilpatient responds to treatment, then 200 to400 mg daily for 10 to 12 wk after CSF cultureis negative. Maintenance: 200 mg dailyto suppress relapse.Children. 6 to 12 mg/kg daily for 10 to12 wk after CSF culture is negative. To prevent candidiasis after bone marrowtransplantationORAL SUSPENSION, TABLETS, I.V. INJECTIONAdults and adolescents. 400 mg daily startingseveral days before procedure if severeneutropenia is expected and continued for7 days after absolute neutrophil countexceeds 1,000/mm 3 . To treat vaginal candidiasisCAPSULES, ORAL SUSPENSION, TABLETSAdults. 150 mg as a single dose.DOSAGE ADJUSTMENT Dosage reduced forpatients with hepatic or renal impairment.Dosage reduced by 50% for patients withcreatinine clearance of 11 to 50 ml/min/1.73 m 2 .EF

444fluconazolevert lanosterol to ergosterol, an essentialpart of the fungal cell membrane.Decreased ergosterol synthesis causesincreased cell permeability, which allowscell contents to leak. Fluconazole also mayinhibit endogenous respiration, interactwith membrane phospholipids, inhibittransformation of yeasts to mycelial forms,inhibit purine uptake, and impair biosynthesisof triglycerides and phospholipids.IncompatibilitiesDon’t add fluconazole to I.V. bag that containsany other drug.ContraindicationsHypersensitivity to fluconazole or its componentsInteractionsDRUGSastemizole, terfenadine: Increased blood levelsof these drugsbenzodiazepines (short-acting): Possiblyincreased benzodiazepine level and psychomotoreffectscimetidine: Decreased fluconazole levelcisapride: Possibly increased QT interval,leading to torsades de pointescyclosporine: Increased cyclosporine levelglipizide, glyburide, tolbutamide: Increasedrisk of hypoglycemiahydrochlorothiazide: Increased fluconazolelevel from decreased excretionisoniazid, rifampin: Decreased fluconazoleeffectsnonsedating antihistamines: Increased bloodantihistamine level, increased risk of cardiotoxicityoral anticoagulants: Increased anticoagulanteffectsphenytoin: Increased phenytoin levelrifabutin: Increased rifabutin leveltheophylline: Increased theophylline levelzidovudine: Increased zidovudine levelAdverse ReactionsCNS: Chills, dizziness, drowsiness, fever,headache, seizuresCV: Prolonged QT interval, torsades depointesGI: Abdominal pain, anorexia, constipation,diarrhea, hepatic failure, nausea, vomitingHEME: Agranulocytosis, leukopenia,thrombocytopeniaSKIN: Exfoliative dermatitis, photosensitivity,pruritus, rashOther: Anaphylaxis, angioedemaNursing Considerations• Use fluconazole cautiously in patients withpotentially proarrhythmic conditionsbecause drug may prolong the QT interval,which can lead to life-threatening torsadesde pointes.• Expect to obtain BUN and serum creatininelevels and culture and sensitivity andliver function test results before therapystarts.• Refrigerate, but don’t freeze, fluconazoleoral suspension. Shake well before administering.• Discard I.V. solution that’s cloudy or containsprecipitate. Don’t infuse more than200 mg/hr or add supplemental drugs toinfusion.• Monitor hepatic and renal function periodicallyduring therapy, and notify prescriberif you detect signs of dysfunction.• Assess for rash every 8 hours during therapy,and notify prescriber if rash occurs.• If patient receives an oral anticoagulant,monitor coagulation test results and assesspatient for bleeding.• Monitor patient for symptoms of overdose,such as hallucinations and paranoia.If they occur, provide supportive treatment,gastric lavage, and, possibly,hemodialysis, which can reduce blood fluconazolelevel by half after about 3 hours.PATIENT TEACHING• Instruct patient to take fluconazole tabletsor oral suspension 30 minutes before or2 hours after meals. Inform her thattablets may be crushed for easier swallowingif needed.• Advise patient to complete entire course oftherapy, even if she feels better.• If patient takes an oral antidiabetic, urgeher to monitor blood glucose level oftenbecause of increased risk of hypoglycemia.• Alert patient that fluconazole may changethe taste of food.• Encourage patient to notify prescriberimmediately about diarrhea, headache,nausea, rash, right-upper-quadrantabdominal pain, yellow skin or whites ofeyes, or vomiting.• Suggest that breast-feeding patient consultprescriber because breast-feeding mayneed to be stopped during therapy.

fludrocortisoneacetateFlorinefClass and CategoryChemical class: GlucocorticoidTherapeutic class: MineralocorticoidreplacementPregnancy category: CIndications and Dosages To treat primary and secondary chronicadrenocortical insufficiencyTABLETSAdults and adolescents. Usual: 100 mcgdaily. Dosage may range from 100 mcgthree times/wk to 200 mcg daily.Children. 50 to 100 mcg daily. To treat salt-losing adrenogenital syndromeTABLETSAdults. 100 to 200 mcg daily.Children. 50 to 100 mcg daily.DOSAGE ADJUSTMENT Dosage reduced to50 mcg daily if transient hypertensiondevelops during therapy.Route Onset Peak DurationP.O. Unknown Unknown 1–2 daysMechanism of ActionEnhances sodium reabsorption, hydrogenand potassium excretion, and water retentionby the distal renal tubules, much likealdosterone, an endogenous mineralocorticoid.In large doses, fludrocortisone caninhibit endogenous adrenocortical secretion,thymic activity, and pituitary corticotropinexcretion. It also can promoteglycogen deposits in the liver and induce anegative nitrogen balance when proteinintake is deficient.ContraindicationsHypersensitivity to fludrocortisone, adrenocorticoids,or their components; systemicfungal infectionsfludrocortisone acetate 445InteractionsDRUGSdigoxin: Increased risk of digitalis toxicityand arrhythmias from hypokalemiaphenytoin, rifampin: Decreased fludrocortisoneeffectspotassium-wasting drugs, such as loop diureticsand amphotericin B: Increased risk ofsevere hypokalemiaAdverse ReactionsCNS: Dizziness, headache, mental changes,seizuresCV: Arrhythmias, heart failure, hypertension,peripheral edemaEENT: Cataracts (with long-term use),increased intraocular pressureENDO: Adrenal insufficiency, growth suppressionin children, hyperglycemiaGI: Anorexia, nausea, vomitingGU: Menstrual irregularitiesHEME: Easy bruisingMS: Arthralgia, muscle weakness, myalgia,osteoporosis (with long-term use), tendoncontracturesSKIN: Acne, diaphoresis, rash, urticariaOther: Hypokalemia, hypokalemic alkalosis,impaired wound healing, weight gainNursing Considerations• Monitor blood pressure, fluid status, andserum electrolyte levels periodically duringfludrocortisone therapy. Watch forsigns of heart failure, including adventitiousbreath sounds, peripheral edema,and weight gain.• Monitor for signs and symptoms of overdose,such as cardiomegaly, edema, excessiveweight gain, hypertension, andhypokalemia. These effects usually subsidea few days after therapy stops. Potassiumsupplementation may be needed.• Notify prescriber if patient has dizziness,headache, hypertension, hypokalemia,signs of infection, or weight gain.PATIENT TEACHING• Instruct patient to take a missed dose offludrocortisone as soon as she remembersif it’s within 12 hours of scheduled time.Warn against double-dosing. Advise her tonotify prescriber if she misses more thanone dose or if nausea or vomiting preventsher from taking drug.• Instruct patient to reduce dietary sodiumand to eat more potassium-rich foods duringtherapy.• Direct patient to weigh herself each morningbefore breakfast in clothes of similarweight and to notify prescriber if she gainsmore than 2 lb (0.9 kg) per day or 5 lbEF

446flumazenil(2.3 kg) per week. Instruct her to monitorhow tightly her rings and shoes fit.• Advise patient to notify prescriber aboutstressful events, such as dental extractions,emotional upset, illness, surgery, and trauma;dosage increase may be required.• Instruct patient to notify prescriber aboutdizziness, fever, fluid retention, headache,joint pain, irregular heart rate, muscleweakness, or palpitations.• Inform patient that drug may delaywound healing.• Caution patient not to stop taking drugabruptly but to taper dosage gradually, asprescribed.• Urge patient to wear or carry medicalidentification that documents corticosteroiduse.flumazenilAnexate (CAN), RomaziconClass and CategoryChemical class: ImidazobenzodiazepinederivativeTherapeutic class: Benzodiazepine antidotePregnancy category: CIndications and Dosages To reverse sedation from benzodiazepinetherapyI.V. INJECTIONAdults. 0.2 mg, repeated after 45 to 60 sec ifresponse is inadequate and then repeatedevery 1 min, if needed. If sedation recurs,regimen is repeated every 20 min or more.Maximum: 1 mg over 5 min or 3 mg over1 hr. To reverse benzodiazepine toxicity orsuspected overdoseI.V. INJECTIONAdults. 0.2 mg followed by 0.3 mg 30 to60 sec later if response is inadequate andthen 0.5 mg repeated every 1 min. If sedationrecurs, regimen is repeated every20 min. Maximum: 3 mg in 1-hr period.Mechanism of ActionAntagonizes CNS effects of benzodiazepinesby competing for their binding sites.ContraindicationsEvidence of tricyclic antidepressant overdose;hypersensitivity to flumazenil,benzodiazepines, or their components; useof benzodiazepine to control intracranialpressure, status epilepticus, or a potentiallylife-threatening conditionRoute Onset Peak DurationI.V. 1–2 min 6–10 min VariableInteractionsDRUGSbenzodiazepines: Benzodiazepine withdrawalsymptoms, including seizuresnonbenzodiazepine agonists: Loss of effectivenessof these drugstetracyclic or tricyclic antidepressant overdose:High risk of seizuresFOODSall foods: Increased flumazenil clearance (byhalf) with food ingestion during I.V. injectionAdverse ReactionsCNS: Agitation, anxiety, ataxia, confusion,dizziness, drowsiness, emotional lability,fatigue, headache, hypoesthesia, insomnia,paresthesia, resedation, seizures, tremor,vertigoCV: Hot flashes, hypertension, palpitationsEENT: Blurred vision, diplopia, dry mouthGI: Nausea, vomitingRESP: Dyspnea, hyperventilation, hypoventilationSKIN: Diaphoresis, flushing, rashOther: Injection site pain and thrombophlebitisNursing Considerations• Use flumazenil cautiously in patients withcardiac disease. Assess for increased stressor anxiety from benzodiazepine withdrawalbecause patient’s blood pressure mayrise.• Give flumazenil undiluted or diluted in asyringe with D 5 W, normal saline solution,or lactated Ringer’s solution. Administerover 15 to 30 seconds directly into tubingof a free-flowing compatible I.V. solution.Use a large vein, if possible, to minimizepain at site. Avoid extravasation becausedrug may irritate tissue.• Be aware that drug may cause signs ofbenzodiazepine withdrawal in drugdependentpatient. Also, abrupt awakeningfrom benzodiazepine overdose can cause

agitation, dysphoria, and increased adversereactions.• Be aware that benzodiazepine reversal maycause an anxiety or a panic attack forpatient with a history of these episodes.Expect to adjust dosage carefully.• Monitor patient for signs of resedationand hypoventilation for at least 2 hoursafter giving flumazenil because drug has ashort half-life. Be aware that patientshouldn’t be discharged until the risk ofresedation has resolved.PATIENT TEACHING• Caution patient to avoid alcohol and OTCdrugs for 10 to 24 hours after taking drug.• Advise patient to avoid hazardous activitiesfor 18 to 24 hours after discharge.• Inform patient and family that agitation,emotional lability, fear, and panic attack (ifpatient has a history of them) may occur.Tell them to seek medical care if patienthas depression, trouble breathing, flushing,hyperventilation, insomnia, palpitations,or tremor.• Because drug doesn’t always reverse postprocedureamnesia, provide writteninstructions or instructions to caregivereven if patient is alert.flunisolideAeroBid, AeroBid-M, Bronalide (CAN),Nasalide, Nasarel, Rhinalar (CAN)Class and CategoryChemical class: CorticosteroidTherapeutic class: Antiasthmatic, antiinflammatoryPregnancy category: Cflunisolide 447Indications and Dosages To provide maintenance treatment ofasthma, alone or with oral corticosteroidsINHALATION AEROSOLAdults and adolescents age 15 and over.500 mcg (2 inhalations) b.i.d. morning andevening. Maximum: 2,000 mcg daily(4 inhalations b.i.d.).Children ages 6 to 15. 500 mcg (2 inhalations)b.i.d. Maximum: 1,000 mcg daily. To relieve symptoms of seasonal orperennial rhinitisNASAL SOLUTIONAdults. 50 mcg (2 sprays) b.i.d. in each nostril.Maximum: 400 mcg daily (16 sprays).Children. 25 mcg (1 spray) t.i.d. in eachnostril. Maximum: 200 mcg daily (8 sprays).Route Onset Peak DurationInhalation In 4 wk Unknown UnknownNasal 3–7 days Unknown 4–6 hrMechanism of ActionInhibits cells involved in inflammatoryresponse, such as mast cells, eosinophils,basophils, lymphocytes, macrophages, andneutrophils. Also inhibits production ofchemical mediators, such as histamine,eicosanoids, leukotrienes, and cytokines.ContraindicationsHypersensitivity to flunisolide or its components,primary treatment of status asthmaticusor other asthma episodes thatrequire emergency care, recent nasal surgery(nasal form), untreated localized infectionof nasal mucosa (nasal form)Adverse ReactionsCNS: Anxiety, chills, depression, dizziness,headache, hyperactivity, insomnia, irritability,lethargy, mood changes, nervousness,tremor, vertigoCV: HypertensionEENT: Candidiasis (oral and throat), drymouth and throat, earache, eye infection,hoarseness, loss of smell or taste, mouthirritation, pharyngitis, rhinitis, sinusitis,sneezingGI: Abdominal pain, anorexia, constipation,diarrhea, flatulence, heartburn, increasedappetite, indigestion, nausea, vomitingGU: Menstrual irregularitiesHEME: EosinophiliaRESP: Bronchitis, dyspnea, pleurisy, pneumoniaSKIN: Acne, eczema, pruritus, rash,urticariaOther: Growth suppression (children),lymphadenopathyNursing Considerations• Use flunisolide cautiously in patients withocular herpes simplex, pulmonary tuberculosis,or untreated systemic bacterial,fungal, parasitic, or viral infection.• If patient receives an oral corticosteroid,expect to taper it slowly 1 week afterchanging to flunisolide. For patient whoEF

448Indications and Dosages To treat depressionCAPSULES, ORAL SOLUTION, TABLETS (PROZAC)Adults. Initial: 20 mg daily in the morning.Dosage increased every 4 to 8 wk as needed.Dosage greater than 20 mg daily givenb.i.d. morning and noon. Maximum: 80 mgdaily.Children and adolescents. Initial: 10 mgdaily. Increased after 1 wk to 20 mg daily.DOSAGE ADJUSTMENT For lower-weightchildren, dosage increased to 20 mg dailyonly if improvement insufficient after severalwk.DELAYED-RELEASE CAPSULES (PROZAC WEEKLY)Adults. 90 mg/wk, beginning 7 days afterlast 20-mg daily dose. To treat obsessive-compulsive disorderCAPSULES, ORAL SOLUTION, TABLETS (PROZAC)Adults. Initial: 20 mg daily in the morning.Dosage increased every 4 to 8 wk as needed.Dosage greater than 20 mg daily givenb.i.d. morning and noon. Maximum: 80 mgdaily.Children and adolescents. Initial: 10 mgdaily. Dosage increased after 2 wk to 20 mgdaily. Subsequent dosage increased, as needed,at intervals of at least several wk.Maintenance: 20 to 60 mg daily.DOSAGE ADJUSTMENT For lower-weight children,dosage should be increased above10 mg daily only if clinical improvementremains insufficient after several wk.Maintenance dosage for such patientsshould not exceed 30 mg daily. To treat moderate to severe bulimianervosaCAPSULES, ORAL SOLUTION, TABLETS (PROZAC)Adults. 60 mg daily in the morning. Somepatients may be prescribed a lower dose,which is titrated to 60 mg daily as tolerated. To treat panic disorder with or withoutagoraphobiaCAPSULES, ORAL SOLUTION, TABLETS (PROZAC)Adults. Initial: 10 mg daily. Dosageincreased in 1 wk to 20 mg daily, as needed.Maximum: 60 mg daily. To treat premenstrual dysmorphic disorderCAPSULES (SARAFEM)Adults. 20 mg daily. Dosage increased asneeded. Maximum: 80 mg daily.DOSAGE ADJUSTMENT Dose or frequencyreduced for patients with hepatic impairfluoxetinehydrochloridereceives prednisone, expect to reduce it byno more than 2.5 mg daily at weekly intervals,beginning at least 1 week after flunisolidetherapy starts.WARNING Assess patient switched from systemiccorticosteroid to flunisolide foradrenal insufficiency (fatigue, hypotension,lassitude, nausea, vomiting, weakness)during initial treatment and duringstress, trauma, surgery, infection, or otherelectrolyte-depleting conditions. Notifyprescriber immediately if signs or symptomsarise.• Monitor growth in children; corticosteroidsmay increase risk of growth suppression.PATIENT TEACHING• Teach patient how to use inhaler. Whenstarting a new canister, advise sprayingonce into the air (avoiding her eyes) tocheck for mist.• Instruct patient to gargle or rinse aftereach use of flunisolide to help preventmouth and throat dryness, relieve throatirritation, and prevent oropharyngealinfection.• Urge patient to contact prescriber if symptomshaven’t improved after 3 weeks.WARNING Caution patient not to use flunisolideto relieve acute bronchospasm.• If patient switches from an oral corticosteroidto flunisolide, advise her to carrymedical identification indicating the needfor supplemental systemic corticosteroidsduring stress or severe asthma attack.Advise her to ask prescriber how torespond to these problems.• Caution patient to avoid exposure tochickenpox and measles and to contactprescriber immediately if exposure occurs.fluoxetinehydrochlorideProzac, Prozac Weekly, SarafemClass and CategoryChemical class: PhenylpropylaminederivativeTherapeutic class: Antibulimic, antidepressant,antiobsessive-compulsivePregnancy category: C

ment or concurrent illness, those who takemultiple medications, and for elderlypatients.Route Onset Peak DurationP.O.* 1–6 wk† Unknown UnknownMechanism of ActionSelectively inhibits reuptake of the neurotransmitterserotonin by CNS neuronsand increases the amount of serotoninavailable in nerve synapses. An elevatedserotonin level may result in elevated moodand, consequently, reduced depression.ContraindicationsHypersensitivity to selective serotonin reuptakeinhibitors or their components, usewithin 14 days of MAO inhibitor therapy* Capsules, oral solution, and tablets.† For depression and bulimia; 5 wk forobsessive-compulsive disorder.fluoxetine hydrochloride 449InteractionsDRUGSalprazolam, diazepam: Possibly prolongedhalf-life of these drugsaspirin, NSAIDs, warfarin: Increased anticoagulantactivity and risk of bleedingastemizole: Increased risk of seriousarrhythmiasbuspirone: Decreased buspirone effectsclozapine, fluphenazine, haloperidol, maprotiline,trazodone: Increased risk of adverseeffectsCYP2D6-metabolized drugs, such as antiarrhythmics(especially flecainide, propafenone),selected antidepressants (tricyclics),antipyschotics (phenothiazines and mostatypicals), thioridazine, and vinblastine:Increased plasma levels of these drugs andincreased risk of serious adverse reactionslinezolid, lithium, serotonergics (such asamphetamines and other psychostimulants,antidepressants, and dopamine agonists), St.John’s wort, tramadol, triptans: Increasedrisk of serotonin syndromeMAO inhibitors: Possibly severe and lifethreateningadverse effectsphenytoin: Increased blood phenytoin leveland risk of toxicitypimozide: Possibly bradycardiasumatriptan: Increased risk of weakness,hyperreflexia, and difficulty with coordinationtryptophan: Increased risk of central andperipheral toxicityAdverse ReactionsCNS: Anxiety, chills, dream disturbances,drowsiness, fatigue, fever, headache, hypomania,insomnia, mania, nervousness, neurolepticmalignant syndrome, restlessness,seizures, serotonin syndrome, somnolence,suicidal ideation, tremor, vertigo, weakness,yawningCV: Hypotension, palpitationsEENT: Abnormal vision, dry mouth,pharyngitis, sinusitisENDO: Galactorrhea, gynecomastia, hypoglycemia,syndrome of inappropriate antidiuretichormone secretion (SIADH)GI: Anorexia, diarrhea, indigestion, nauseaGU: Decreased libido, ejaculation disorders,impotenceHEME: Altered platelet function, unusualbleedingMS: Arthralgia, myalgiaRESP: DyspneaSKIN: Diaphoresis, pruritus, rash, urticariaOther: Flulike symptoms, hyponatremia,weight lossNursing Considerations• Use fluoxetine cautiously in patients witha history of seizures.WARNING Avoid giving fluoxetine within 14days of an MAO inhibitor or startingMAO inhibitor therapy within 5 weeks ofdiscontinuing fluoxetine.• In patients taking fluoxetine for depression(especially children, adolescents, andyoung adults), watch closely for suicidaltendencies, particularly when therapystarts and dosage changes, because depressionmay worsen temporarily during thosetimes.• Monitor patient closely for evidence of GIbleeding, especially if patient takes anotherdrug known to increase the risk, such asaspirin, an NSAID, or warfarin.• Monitor patient—especially an elderlypatient—for hypoosmolarity of serum andurine and for hyponatremia (headache,difficulty concentrating, memory impairment,weakness, unsteadiness), which mayindicate fluoxetine-induced SIADH.• To discontinue, expect to taper drug, asordered, to minimnize adverse reactions.EF

450fluphenazineWARNING Monitor patient for possibleserotonin syndrome, characterized by agitation,chills, confusion, diaphoresis, diarrhea,fever, hyperactive reflexes, poor coordination,restlessness, shaking, talking oracting with uncontrolled excitement,tremor, and twitching, especially if patientis receiving another drug that raises serotoninlevel (such as dopamine agonist,MAO inhibitor, tryptophan, amphetamine,and other antidepressant or psychostimulant).In its most severe form,serotonin syndrome can resemble neurolepticmalignant syndrome, whichincludes a high fever, muscle rigidity, autonomicinstability, and possible fluctuationsin vital signs and mental status.• Monitor patient with diabetes mellitus foraltered blood glucose level because drugmay cause hypoglycemia during therapyand hyperglycemia when it stops. Expectto adjust dosage of antidiabetic drug, asprescribed.• Expect patient to be reevaluated periodicallyto determine continued need fortherapy.• When stopping fluoxetine therapy, expectto taper drug to minimize adverse reactions.PATIENT TEACHINGWARNING Tell patient that drug increasesrisk of serotonin syndrome, a rare butserious complication, especially whentaken with certain other drugs. Teachpatient to recognize its signs and symptoms,and advise her to notify prescriberimmediately if they occur.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes andparticularly if patient is a child, teenager,or young adult.• Caution patient to avoid hazardous activitiesuntil CNS effects of drug are known.• Caution against stopping fluoxetineabruptly because serious adverse effectsmay result.• Advise patient to consult prescriber beforetaking OTC or prescription drugs, if a rashor hives develop, or if she becomes orintends to become pregnant during therapy.• Inform patient that drug may take severalweeks to achieve full effects.fluphenazinedecanoateModecate (CAN), ModecateConcentrate (CAN), Prolixin DecanoatefluphenazineenanthateModiten Enanthate (CAN), ProlixinEnanthatefluphenazinehydrochlorideApo-Fluphenazine (CAN), Moditen HCl(CAN), Permitil, Permitil Concentrate,PMS Fluphenazine (CAN), Prolixin,Prolixin ConcentrateClass and CategoryChemical class: Phenothiazine,propylpiperazine derivativeTherapeutic class: AntipsychoticPregnancy category: Not ratedIndications and Dosages To control psychotic disordersELIXIR, ORAL SOLUTION, TABLETS (FLUPHENAZINEHYDROCHLORIDE)Adults and adolescents. Initial: 2.5 to10 mg/day in divided doses every 6 to 8 hr.When symptoms are controlled, dosagereduced to 1 to 5 mg daily. Maximum:20 mg/dose with caution.Children. 250 to 750 mcg once daily to q.i.d.I.M. INJECTION (FLUPHENAZINE HYDROCHLORIDE)Adults and adolescents. Initial: 1.25 mg,increased as clinical condition tolerates upto 2.5 to 10 mg daily in divided doses every6 to 8 hr. Maximum: 10 mg daily.DOSAGE ADJUSTMENT For elderly or debilitatedpatients, dosage reduced to 1 to2.5 mg daily in divided doses every 6 to 8 hr.I.M. OR SUBCUTANEOUS INJECTION (FLUPHENAZINEDECANOATE OR ENANTHATE)Adults. Initial: 12.5 to 25 mg every 1 to4 wk, as needed (decanoate). For doses over50 mg, next dose increased cautiously by12.5 mg. Or 25 mg every 2 wk, with doseand dosing interval adjusted based onpatient response (enanthate). Maximum:100 mg/dose.

Adolescents and children age 12. Initial:6.25 to 18.75 mg/wk (decanoate), increasedto 12.5 to 25 mg every 1 to 3 wk, accordingto condition.Children ages 5 to 12. 3.125 to 12.5 mgevery 1 to 3 wk (decanoate), according tocondition.Route Onset Peak DurationP.O. In 1 hr Variable 6–8 hrI.M.* In 1 hr Variable 6–8 hrI.M., In 24– Variable 1–6 wk‡SubQ† 72 hrMechanism of ActionMay block postsynaptic dopamine receptorsites in the CNS. This action may depressareas of the brain that control activity andaggression, including the cerebral cortex,hypothalamus, and limbic system.IncompatibilitiesDon’t mix fluphenazine hydrochloride oralsolution with beverages that contain caffeine,such as coffee and cola; tannins, suchas tea; or pectins, such as apple juice.They’re physically incompatible.ContraindicationsBlood dyscrasias, bone marrow depression,cerebral arteriosclerosis, coma, concomitantuse of large amounts of another CNSdepressant, coronary artery disease, hepaticdysfunction, hypersensitivity to phenothiazines,myeloproliferative disorders, severeCNS depression, severe hypertension orhypotension, subcortical brain damageInteractionsDRUGSadsorbent antidiarrheals, aluminum- ormagnesium-containing antacids: Possiblyinhibited absorption of fluphenazineamantadine, anticholinergics: Possibly intensifiedadverse effects of both drugsamphetamines: Possibly decreased therapeuticeffects of both drugsantihypertensives: Possibly severe hypotensionantithyroid drugs: Increased risk of agranulocytosis* For hydrochloride.† For decanoate and enanthate.‡ For decanoate; 2 wk for enanthate.fluphenazine 451beta blockers: Possibly increased blood levelsand risk of adverse effects of both drugsbromocriptine: Decreased bromocriptineeffectsCNS depressants: Possibly prolonged andintensified CNS depressionerythromycin: Possibly inhibited fluphenazinemetabolismguanethidine: Decreased hypotensive effectof guanethidinelevodopa: Possibly decreased antidyskineticeffect of levodopalithium: Possibly neurotoxicity (disorientation,extrapyramidal reactions, unconsciousness)meperidine: Excessive sedation and hypotensionmetrizamide: Increased risk of seizureswhen injected in subarachnoid area duringfluphenazine therapyoral anticoagulants: Possibly decreased anticoagulanteffectspimozide, other drugs that prolong QT interval:Prolonged QT interval and risk ofarrhythmiasthiazide diuretics: Increased risk of hyponatremia,hypotension, and water intoxicationtricyclic antidepressants: Possibly prolongedand intensified sedationACTIVITIESalcohol use: Possibly increased CNS depressionand increased risk of heatstrokeAdverse ReactionsCNS: Ataxia, cerebral edema, dizziness,drowsiness, headache, insomnia, lightheadedness,nervousness, seizures, slurredspeech, syncope, worsening psychoticsymptomsCV: AV conduction disorders, bradycardia,cardiac arrest, hypercholesterolemia, hypertension,orthostatic hypotension, QT-intervalprolongation, shock, ST-segmentdepression, tachycardiaEENT: Blurred vision, dry mouth, glaucoma,increased salivation, laryngeal edema,laryngospasm, miosis, mydriasis, nasal congestion,papillary hypertrophy of thetongue, parotid gland enlargement, photophobia,pigmentary retinopathy, ptosisENDO: Breast engorgement (females),galactorrhea, hyperglycemia, hypoglycemia,mastalgia, syndrome of inappropriate ADHsecretionEF

452flurazepam hydrochlorideGI: Anorexia, constipation, diarrhea, fecalimpaction, ileus, increased appetite, nausea,vomitingGU: Amenorrhea, bladder paralysis,decreased libido, enuresis, menstrual irregularities,polyuria, urinary frequency, urinaryincontinence, urine retentionHEME: Anemia, aplastic anemia,eosinophilia, leukopenia, thrombocytopenia,thrombocytopenic or nonthrombocytopenicpurpuraRESP: Bronchospasm, dyspnea, increasedrespiratory depthSKIN: Contact dermatitis, dry skin, eczema,erythema, jaundice, photosensitivity, pruritus,seborrheaOther: Heatstroke, hyponatremia, lupuslikesymptoms, weight gainNursing Considerations• Fluphenazine shouldn’t be used to treatdementia-related psychosis in elderlypatients because of an increased mortalityrisk.• Use fluphenazine cautiously in patientswith a history of glaucoma or renalimpairment.• For I.M. and subcutaneous injection, useat least a 21G needle.• Monitor temperature; a significant, unexplainedrise can indicate intolerance and aneed to discontinue drug. Notify prescriberimmediately if this occurs.• Watch for signs of hepatic failure, such asjaundice.• Notify prescriber about worsening psychoticsymptoms: agitation, catatonicstate, confusion, depression, hallucinations,lethargy, paranoid reactions.PATIENT TEACHING• If patient takes elixir form of fluphenazine,instruct her to keep it in an amberor opaque bottle because drug is sensitiveto light.• Advise patient not to mix oral solutionwith beverages that contain caffeine (coffee,cola), tannins (tea), or pectins (applejuice).• Caution patient about possible dizzinessor light-headedness.• Teach patient how to prevent heatstroke,orthostatic hypotension, and photosensitivityreactions.• Warn against stopping drug abruptly.flurazepamhydrochlorideApo-Flurazepam (CAN), Dalmane,Novo-Flupam (CAN), Somnol (CAN)Class, Category, and ScheduleChemical class: BenzodiazepineTherapeutic class: Sedative-hypnoticPregnancy category: Not ratedControlled substance schedule: IVIndications and Dosages To treat insomnia characterized bydifficulty falling asleep, frequent nocturnalawakenings, or early-morningawakeningCAPSULESAdults. 15 to 30 mg at bedtime.DOSAGE ADJUSTMENT Initial dose reducedto 15 mg for elderly or debilitated patientsuntil individual response is known.Route Onset Peak DurationP.O. 15–45 min Unknown 7–8 hrMechanism of ActionMay potentiate the effects of gammaaminobutyricacid (GABA) and other inhibitoryneurotransmitters by binding tospecific benzodiazepine receptor sites in thelimbic and cortical areas of the CNS. As aresult, flurazepam increases GABA’sinhibitory effects and blocks cortical andlimbic arousal.ContraindicationsAcute angle-closure glaucoma, breastfeeding,hypersensitivity to other benzodiazepines,itraconazole or ketoconazole therapy,psychosisInteractionsDRUGScimetidine, diltiazem, disulfiram, erythromycin,fluoxetine, fluvoxamine, itraconazole,nefazodone, estrogen-containing oral contraceptives,propoxyphene, ranitidine, verapamil:Possibly increased blood level andimpaired hepatic metabolism of flurazepamclozapine: Possibly cardiac arrest or respiratorydepressionCNS depressants: Possibly potentiated CNS

depressionlevodopa: Possibly decreased therapeuticeffects of levodopaFOODSgrapefruit juice: Possibly increased bloodlevel and impaired hepatic metabolism offlurazepamACTIVITIESalcohol use: Possibly potentiated CNS andrespiratory depressionAdverse ReactionsCNS: Amnesia, anxiety, ataxia, bizarrebehavior (such as sleep driving), confusion,delusions, depression, dizziness, drowsiness,euphoria, headache, hypokinesia, irritability,malaise, nervousness, slurred speech,tremorCV: Chest pain, palpitations, tachycardiaEENT: Blurred vision, dry mouth, increasedsalivation, photophobiaGI: Abdominal pain, constipation, diarrhea,nausea, thirst, vomitingGU: Libido changesSKIN: DiaphoresisOther: Anaphylaxis, angioedema, physicalor psychological dependenceNursing Considerations• Use flurazepam cautiously in patients withsevere mental depression or reduced respiratoryfunction; drug may intensify mentaldepression and lead to respiratory depression.• Expect to use lowest effective dose in elderlyor debilitated patients to minimize therisk of ataxia, confusion, dizziness, andoversedation.• Monitor liver function test results, asappropriate.PATIENT TEACHING• Instruct patient not to exceed prescribeddosage and not to stop drug abruptly.WARNING Warn patient that, although rare,drug may cause swelling of the oral cavityor throat, which could cause airwayobstruction. If swelling occurs, patientshould seek emergency care immediatelyand never take flurazepam again.• Caution patient about possible morningdizziness or drowsiness.• Because flurazepam can reduce alertness,advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Caution patient to avoid alcohol and CNSdepressants during therapy.• Advise patient to notify prescriber if shebecomes or intends to become pregnantduring therapy.• Inform patient that sleep may be disturbedfor the first few nights after stoppingdrug.• Warn patient and caregiver that somepatients have performed bizarre activitiesafter taking drug, such as driving their car,preparing and eating food, making phonecalls, or having sex while not fully awakeand often with no memory of the event.These episodes usually occur in patientswho have taken the drug with alcohol orother CNS depressant or who have exceededthe recommended dose. If such anepisode occurs, the prescriber should benotified and flurazepam therapy discontinuedimmediately.flurbiprofenflurbiprofen 453Ansaid, Froben (CAN), Froben SR (CAN),Novo-Flurprofen (CAN)Class and CategoryChemical class: Propionic acid derivativeTherapeutic class: Antiarthritis, antiinflammatoryPregnancy category: B (first trimester), Notrated (later trimesters)Indications and Dosages To treat acute or chronic rheumatoidarthritis and osteoarthritisE.R. CAPSULESAdults. 200 mg daily in the evening.TABLETSAdults. Initial: 200 to 300 mg daily individed doses b.i.d. to q.i.d. Maximum:300 mg daily (100 mg/dose).Mechanism of ActionBlocks the activity of cyclooxygenase, theenzyme necessary for prostaglandin synthesis.Prostaglandins, important mediators inthe inflammatory response, cause localvasodilation with swelling and pain. Theyalso play a role in pain transmission fromthe periphery to the spinal cord. By blockingcyclooxygenase and inhibitingprostaglandins, this NSAID causes inflammatorysymptoms and pain to subside.EF

454flurbiprofenContraindicationsAngioedema, asthma, bronchospasm, nasalpolyps, rhinitis, or urticaria induced byaspirin, iodides, or NSAIDs; hypersensitivityto NSAIDsInteractionsDRUGSacetaminophen: Increased risk of renalimpairment with long-term use of bothdrugsantacids: Decreased flurbiprofen effectivenessanticoagulants, cefamandole, cefoperazone,cefotetan, heparin, plicamycin, thrombolytics,valproic acid: Increased risk of bleedingantineoplastics: Increased adverse hematologiceffectscyclosporine: Increased risk of nephrotoxicitydiuretics, triamterene: Decreased effectivenessof these drugsglucocorticoids, other NSAIDs, potassiumsupplements: Increased adverse GI effectsinsulin, oral antidiabetic drugs: Increasedrisk of hypoglycemialithium: Increased risk of lithium toxicitymethotrexate: Increased risk of methotrexatetoxicitysalicylates: Increased risk of GI bleedingACTIVITIESalcohol use, smoking: Increased risk of GIbleedingAdverse ReactionsCNS: Anxiety, cerebral hemorrhage, depression,dizziness, drowsiness, forgetfulness,headache, insomnia, malaise, nervousness,stroke, tremor, weaknessCV: Arrhythmias, heart failure, hypertension,hypotension, palpitations, peripheraledema, tachycardiaEENT: Amblyopia, blurred vision, rhinitis,stomatitis, tinnitus, vision changesGI: Abdominal cramps or distress, anorexia,constipation, diarrhea, diverticulitis, dysphagia,esophagitis, flatulence, gastritis, gastroenteritis,gastroesophageal reflux disease,GI bleeding or ulceration, hemorrhoids,hiatal hernia, hepatitis, increased appetite,indigestion, jaundice, liver failure, melena,nausea, perforation of stomach or intestines,stomatitis, vomitingGU: Hematuria, interstitial nephritis, renalfailure, UTIHEME: Agranulocytosis, aplastic anemia,eosinophilia, leukopenia, neutropenia, pancytopenia,thrombocytopeniaSKIN: Erythema multiforme, exfoliativedermatitis, flushing, rash, Stevens-Johnsonsyndrome, toxic epidermal necrolysisOther: Anaphylaxis, angioedema, hyponatremiaNursing Considerations• Use flurbiprofen with extreme caution inpatients who have a history of ulcer diseaseor GI bleeding because NSAIDs suchas flurbiprofen increase the risk of GIbleeding and ulceration. Expect to useflurbiprofen for the shortest time possiblein these patients.• Be aware that serious GI tract ulceration,bleeding, and perforation may occur withoutwarning signs or symptoms. Elderlypatients are at greater risk. To minimizethe risk, give flurbiprofen with food. If GIdistress occurs, withhold drug and notifyprescriber immediately.• Use flurbiprofen cautiously in patientswith hypertension, and monitor bloodpressure closely throughout therapy. Drugmay cause hypertension or worsen it.WARNING Monitor patient closely forthrombotic events, including MI andstroke, because NSAIDs increase the risk.• Monitor patient—especially if she’s elderlyor receiving long-term flurbiprofen therapy—forless common but serious adverseGI reactions, including anorexia, constipation,diverticulitis, dysphagia, esophagitis,gastritis, gastroenteritis, gastroesophagealreflux disease, hemorrhoids, hiatal hernia,melena, stomatitis, and vomiting.• Monitor liver function test results because,rarely, elevations may progress to severehepatic reactions, including fatal hepatitis,liver necrosis, and hepatic failure.• Monitor BUN and serum creatinine levelsin elderly patients, patients taking diureticsor ACE inhibitors, and patients withheart failure, impaired renal function, orhepatic dysfunction; flurbiprofen maycause renal failure.• Monitor CBC for decreased hemoglobinand hematocrit because drug may worsenanemia.WARNING If patient has bone marrow suppressionor is receiving an antineoplasticdrug, monitor laboratory results (includingWBC count), and watch for evidenceof infection because anti-inflammatory

and antipyretic actions of flurbiprofenmay mask signs and symptoms, such asfever and pain.• Assess patient’s skin regularly for signs ofrash or other hypersensitivity reactionbecause flurbiprofen is an NSAID andmay cause serious skin reactions withoutwarning, even in patients with no historyof NSAID sensitivity. At first sign of reaction,stop drug and notify prescriber.PATIENT TEACHING• Encourage patient to take flurbiprofenwith food or milk to avoid GI distress.• Caution patient about possible blurredvision, dizziness, and drowsiness.• Advise patient to avoid aspirin, alcohol,and smoking during flurbiprofen therapy.• Urge patient to notify prescriber immediatelyif she has blood in urine, easy bruising,itching, rash, swelling, or yellow eyesor skin.• Caution pregnant patient not to takeNSAIDs such as flurbiprofen during thelast trimester because they may cause prematureclosure of the ductus arteriosus.• Explain that flurbiprofen may increase therisk of serious adverse cardiovascular reactions;urge patient to seek immediatemedical attention if signs or symptomsarise, such as chest pain, shortness ofbreath, weakness, and slurring of speech.• Explain that flurbiprofen may increase therisk of serious adverse GI reactions; stressthe importance of seeking immediatemedical attention for such signs andsymptoms as epigastric or abdominalpain, indigestion, black or tarry stools, orvomiting blood or material that looks likecoffee grounds.• Alert patient to rare but serious skin reactions.Urge her to seek immediate medicalattention for rash, blisters, itching, fever,or other indications of hypersensitivity.fluticasonepropionateFlonase, Floventfluticasone furoateVeramystfluticasone 455Class and CategoryChemical class: Trifluorinated corticosteroidTherapeutic class: Antiasthmatic, antiinflammatoryPregnancy category: CIndications and Dosages To prevent asthma attacks, alone or withoral corticosteroidsINHALATION AEROSOLAdults and children age 12 and over usingbronchodilator therapy. Initial: 88 mcginhaled b.i.d. Maximum: 440 mcg inhaledb.i.d.Adults and children age 12 and overswitching from another inhaled corticosteroid.Initial: 88 to 220 mcg inhaled b.i.d.Maximum: 440 mcg inhaled b.i.d.Adults and children age 12 and over usingoral corticosteroid therapy. Initial andmaximum: 880 mcg inhaled b.i.d.Children ages 4 to 11 regardless of previoustherapy. 88 mcg b.i.d. Maximum:88 mcg b.i.d. To prevent seasonal or perennial allergicrhinitisNASAL SUSPENSION (FLONASE)Adults and children age 12 and over.Initial: 100 mcg (2 sprays) in each nostrildaily or 50 mcg (1 spray) in each nostrilb.i.d, as needed. Maintenance: 50 mcg(1 spray) in each nostril daily, as toleratedand needed. Maximum: 200 mcg daily(4 sprays).Children ages 4 to 11. 50 or 100 mcg (1 or2 sprays) in each nostril daily in the morning,as needed. Maximum: 200 mcg daily(4 sprays). To treat seasonal or perennial allergicrhinitisNASAL SUSPENSION (FLONASE)Adults and children age 12 and over.Initial: 100 mcg (2 sprays) in each nostrildaily or 50 mcg (1 spray) in each nostrilb.i.d, as needed. Maintenance: 50 mcg(1 spray) in each nostril daily, as toleratedand needed. Maximum: 200 mcg daily(4 sprays).Children ages 4 to 11. 50 or 100 mcg (1 or2 sprays) in each nostril daily in the morning,as needed. Maximum: 200 mcg daily(4 sprays).NASAL SUSPENSION (VERAMYST)Adults and children age 12 and over.EF

456fluticasoneInitial: 110 mcg (2 sprays) in each nostrilonce daily, decreasedto 55 mcg (1 spray) ineach nostril once daily when symptoms arecontrolled. Maintenance: 55 mcg (1 spray)in each nostril once daily.Children ages 2 to 11. Initial: 55 mcg(1 spray) in each nostril once daily,increased to 110 mcg (2 sprays) in eachnostril once daily, as needed. Maintenance:55 mcg (1 spray) in each nostril once daily.Route Onset Peak DurationInhala- In 24 hr 1–2 wk SeveraltiondaysNasal 12 hr– 4–7 1–2 wk3 days daysMechanism of ActionInhibits cells involved in the inflammatoryresponse of asthma, such as mast cells,eosinophils, basophils, lymphocytes,macrophages, and neutrophils. Fluticasonealso inhibits production or secretion ofchemical mediators, such as histamine,eicosanoids, leukotrienes, and cytokines.ContraindicationsHypersensitivity to fluticasone or its components,primary treatment of status asthmaticusor other acute asthma episodes thatrequire intensive measures, untreated nasalmucosal infection (nasal suspension)InteractionsDRUGSketoconazole, ritonavir and other strongcytochrome P-450 3A4 inhibitors (long-termuse): Possibly increased fluticasone leveland decreased serum cortisol levelAdverse ReactionsCNS: Aggressiveness, agitation, depression,difficulty speaking, dizziness, fatigue, fever,headache, insomnia, malaise, restlessnessEENT: Allergic rhinitis, cataracts, conjunctivitis,dry mouth and throat, eye irritation,glaucoma, hoarseness, laryngitis, loss ofvoice, nasal congestion or discharge, nasalsinus pain, oropharyngeal candidiasis, otitismedia, pharyngitis, sinusitis, throat irritation,tonsillitisENDO: Adrenal insufficiency, cushingoidsymptoms, hyperglycemia, slower growth inchildrenGI: Abdominal pain, diarrhea, indigestion,nausea, vomitingGU: DysmenorrheaHEME: Churg-Strauss syndrome, easybruising, eosinophiliaMS: Arthralgia, myalgia, osteoporosisRESP: Asthma exacerbation, bronchitis,bronchospasm, chest congestion and tightness,cough, dyspnea, pneumonia, upperrespiratory tract infection, wheezingSKIN: Dermatitis, ecchymosis, pruritus,rash, urticariaOther: Anaphylaxis, angioedema, flulikesymptoms, weight gainNursing Considerations• Use fluticasone cautiously in patients withocular herpes simplex, pulmonary tuberculosis,or untreated systemic bacterial,fungal, parasitic, or viral infection.• Although anaphylaxis is rare, monitorpatient closely at start of therapy, especiallyif patient has severe allergy to milk. Ifhypersensitivity reaction occurs, notifyprescriber, expect drug to be discontinued,and provide supportive care, as prescribed.• If patient takes a systemic corticosteroid,expect to taper dosage by no more than2.5 mg daily at weekly intervals, starting1 week after fluticasone therapy begins.WARNING If patient is switched from systemiccorticosteroid to fluticasone, assessfor adrenal insufficiency (fatigue, hypotension,lassitude, nausea, vomiting, weakness)early in therapy and when patienthas infection, stress, trauma, surgery, orother electrolyte-depleting conditions orprocedures. Notify prescriber immediatelyif signs or symptoms develop.• As prescribed, administer a fast-actinginhaled bronchodilator if bronchospasmoccurs immediately after fluticasone use.Expect to stop fluticasone and start anotherdrug therapy.• Expect to titrate fluticasone to lowest effectivedosage after asthma has stabilized.PATIENT TEACHING• Urge patient to use fluticasone regularly, asprescribed, not for acute bronchospasm.• Teach patient how to administer drugaccording to the form prescribed (nasalspray or oral inhaler).• Instruct patient to shake canister and useinhaler according to package instructions.On first use, advise her to spray 4 times

into the air (away from her eyes and shakinginhaler between each test spray) andlook for a fine mist. If inhaler hasn’t beenused for more than 7 days or it’s dropped,it will need to be primed again by shakingwell and then releasing 1 test spray intothe air (away from her face).• If 2 inhalations are prescribed, tell patientto wait at least 1 minute between them.• Instruct patient to gargle and rinse hermouth after each dose to help prevent drymouth and throat, relieve throat irritation,and prevent oropharyngeal yeast infection.• If patient uses more than 1 inhaler,instruct her to use fluticasone last, at least5 minutes after previous inhaler.• Instruct patient to clean inhaler accordingto manufacturer guidelines at least once aweek after her evening dose.• Inform patient that, when counter reads020, she should obtain a refill, if needed.When counter reaches 000, she should discardthe inhaler.• Instruct patient using nasal spray to shakecontainer well before each use.• Explain that symptoms may improvewithin 2 days but that full improvementmay not occur for 1 to 2 weeks or longer.• Caution patient not to increase dosage butto contact prescriber after 1 week if symptomscontinue or worsen.• Urge patient to tell prescriber immediatelyif asthma attacks don’t respond to bronchodilatorsduring fluticasone therapy.• If patient is switching from an oral corticosteroidto fluticasone, urge her to carrymedical identification indicating the needfor supplemental systemic corticosteroidsduring stress or severe asthma attack.• Caution patient to avoid people who haveinfections because fluticasone suppressesthe immune system, increasing the risk ofinfection. Instruct patient to notify prescriberabout exposure to chickenpox,measles, or other infections because additionaltreatment may be needed.fluvastatin sodiumLescol, Lescol XLClass and CategoryChemical class: Heptenoic acid derivativefluvastatin sodium 457Therapeutic class: AntihyperlipidemicPregnancy category: XIndications and Dosages As adjunct to lower cholesterol level inprimary hypercholesterolemia, todecrease progression of coronary atherosclerosis,to reduce risk in patients withcoronary artery disease undergoing coronaryrevascularizationCAPSULESAdults. 20 to 40 mg daily in the evening or40 mg b.i.d. Maximum: 40 mg b.i.d.E.R. TABLETSAdults. 80 mg in the evening. Maximum:80 mg daily. As adjunct to lower cholesterol level inchildren with heterozygous familialhypercholesterolemiaCAPSULESGirls ages 10 to 16 who are at least 1 yearpast menarche. Initial: 20 mg once daily,increased every 6 wk, as needed. Maximum:40 mg b.i.d.DOSAGE ADJUSTMENT For pediatric patients,if maximum dose of 40 mg b.i.d. is reachedwith immediate-release capsules, child maybe switched to extended-release tablets,80 mg once daily.Route Onset Peak DurationP.O. In 1–2 wk In 4–6 wk UnknownP.O. In 2 wk In 4 wk Unknown(E.R.)Mechanism of ActionInterferes with the hepatic enzyme hydroxymethylglutaryl-coenzymeA reductase,reducing formation of mevalonic acid (acholesterol precursor) and interrupting thepathway by which cholesterol is synthesized.When cholesterol level declines inhepatic cells, LDLs are consumed, whichreduces circulating total cholesterol andserum triglycerides.ContraindicationsAcute hepatic disease, breast-feeding,hypersensitivity to fluvastatin or its components,pregnancy, unexplained persistentlyelevated liver enzyme levelsInteractionsDRUGSbile acid sequestrants: Possibly decreasedEF

458fluvoxamine maleatefluvastatin bioavailabilitycimetidine, omeprazole, ranitidine: Significantlyincreased blood fluvastatin levelcolchicine, cyclosporine, erythromycin, gemfibrozil,niacin: Increased risk of severemyopathy and rhabdomyolysiscyclosporine, erythromycin, gemfibrozil,niacin: Increased risk of acute renal failurefluconazole: Increased fluconazole levelitraconazole, ketoconazole: Increased risk ofmyopathyoral contraceptives: Risk of bleedingrifampin: Significantly decreased blood fluvastatinlevel, increased plasma clearanceACTIVITIESalcohol use: Increased bioavailability andblood level of fluvastatinAdverse ReactionsCNS: Dizziness, fatigue, headache, insomnia,weaknessEENT: Pharyngitis, rhinitis, sinusitisGI: Abdominal cramps and pain, constipation,diarrhea, flatulence, indigestion, nausea,vomitingGU: UTIMS: Arthritis, back pain, myalgia, myositis,rhabdomyolysisRESP: Bronchitis, cough, upper respiratorytract infectionSKIN: Pruritus, rashNursing ConsiderationsWARNING Expect to stop drug if CK levelrises sharply or myopathy is suspected.PATIENT TEACHING• Urge patient to comply with monthly laboratorytests early in treatment.• Tell patient to follow prescribed low-fatdiet.• Encourage patient to notify prescriberpromptly about muscle pain or unexplainedweakness.fluvoxaminemaleateLuvox, Luvox CRClass and CategoryChemical class: Aralkylketone derivativeTherapeutic class: AntiobsessionalPregnancy category: CIndications and Dosages To treat obsessive-compulsive disorderTABLETSAdults. Initial: 50 mg at bedtime, increasedby 50 mg every 4 to 7 days, if needed.Maximum: 300 mg daily.Children ages 8 to 17. Initial: 25 mg at bedtime,increased by 25 mg every 4 to 7 days,if needed. Maximum: 200 mg daily.DOSAGE ADJUSTMENT Doses divided foradults taking more than 100 mg daily andfor children taking more than 50 mg daily;given in 2 equal doses b.i.d. or in 2 unequaldoses with the larger dose at bedtime.CAPSULESAdults. Initial: 100 mg at bedtime,increased by 50 mg weekly, if needed.Maximum: 300 mg daily.DOSAGE ADJUSTMENT For elderly patients orthose with hepatic impairment, dosageincreases with extended-release form aremade more slowly. To treat social anxiety disorderCAPSULESAdults. Initial: 100 mg at bedtime,increased by 50 mg weekly, if needed.Maximum: 300 mg daily.DOSAGE ADJUSTMENT For elderly patients orthose with hepatic impairment, dosageincreases with extended-release form aremade more slowly.Route Onset Peak DurationP.O. 3–10 wk Unknown UnknownMechanism of ActionMay potentiate serotonin’s action by blockingits reuptake at neuronal membranes. Anelevated serotonin level may elevate moodand decrease depression and anxiety, whichoften accompany obsessive-compulsive disorder.ContraindicationsAlosetron, astemizole, cisapride, pimozide,terfenadine, thioridazine, or tizanidinetherapy, hypersensitivity to fluvoxaminemaleate or its components, use within 14days of MAO inhibitorInteractionsDRUGSalosetron: Increased plasma alosetron levelalprazolam: Increased plasma alprazolamlevel

antihistamines: Increased risk of impairedmental and motor skillsaspirin, NSAIDs, warfarin: Risk of bleedingastemizole, cisapride, pimozide, terfenadine:Possibly fatal QT prolongationbenzodiazepines: Decreased benzodiazepineclearance, possibly impaired memory andmotor skillsbuspirone: Decreased buspirone effects,increased blood fluvoxamine level, and paradoxicalworsening of obsessive-compulsivedisordercarbamazepine: Increased risk ofcarbamazepine toxicityclozapine: Increased blood clozapine leveldiltiazem: Increased risk of bradycardiahaloperidol: Increased blood haloperidollevel, possibly delayed recall and reducedmemory and attention spanlithium: Possibly increased serotonin reuptakeaction of fluvoxamineMAO inhibitors: Possibly serious or fatalreactions (such as agitation, autonomicinstability, coma, delirium, fluctuating vitalsigns, hyperthermia, myoclonus, and rigidity)methadone: Possibly significantly increasedblood methadone level, increased risk ofmethadone toxicitymetoprolol, propranolol: Increased bloodlevels of these drugs, possibly reduced diastolicblood pressure and heart rate inducedby these drugsserotonergics (such as amphetamines andother psychostimulants, antidepressants, anddopamine agonists): Increased risk of serotoninsyndromesympathomimetics: Possibly increasedeffects of sympathomimetics and increasedrisk of serotonin syndrometacrine: Increased blood level and therapeuticand adverse effects of tacrinetheophylline: Decreased theophylline clearance,increased risk of theophylline toxicitytizanidine: Increased risk of serious adverseeffects, such as hypotension and profoundsedationtricyclic antidepressants: Increased bloodlevels of antidepressantswarfarin: Increased blood warfarin level,prolonged PTFOODScaffeine: Possibly decreased hepatic clearanceof caffeineNursing Considerations• Use fluvoxamine cautiously in patientswith cardiovascular disease, impairedhepatic or renal function, mania, seizures,or suicidal tendencies.WARNING Fluvoxamine shouldn’t be givenwithin 14 days of an MAO inhibitor.WARNING Monitor patient for possibleserotonin syndrome, characterized by agitation,chills, confusion, diaphoresis, diarrhea,fever, hyperactive reflexes, poor coordination,restlessness, shaking, talking oracting with uncontrolled excitement,tremor, and twitching, especially if patientis receiving another drug that raises serotoninlevel (such as dopamine agonist,MAO inhibitor, tryptophan, amphetamine,or other antidepressant or psychostimulant).In its most severe form, serotoninsyndrome can resemble neurolepticmalignant syndrome, which includes ahigh fever, muscle rigidity, autonomicinstability, and possible fluctuations invital signs and mental status.• Watch patient closely (especially children,adolescents, and young adults), for suicidaltendencies, particularly when therapystarts and dosage changes, because depresfluvoxaminemaleate 459ACTIVITIESsmoking: Increased fluvoxamine metabolismAdverse ReactionsCNS: Agitation, anxiety, apathy, chills, confusion,depression, dizziness, drowsiness,fatigue, headache, hypomania, insomnia,malaise, mania, nervousness, neurolepticmalignant syndrome, sedation, serotoninsyndrome, suicidal ideation, tremor, vertigo,yawningCV: Palpitations, tachycardiaEENT: Altered taste, blurred vision, drymouthGI: Anorexia, constipation, diarrhea, flatulence,indigestion, nausea, upper GI bleeding,vomitingGU: Decreased libido, ejaculation disorders,impotence, urinary frequency, urine retentionHEME: Bleeding eventsMS: Muscle twitchingRESP: Dyspnea, upper respiratory tractinfectionSKIN: Diaphoresis, rashOther: Flulike symptoms, weight gainEF

460InteractionsDRUGSanalgesics, carbamazepine, estrogens (includingoral contraceptives), phenobarbital, primfolicacidsion may worsen temporarily during thesetimes and lead to suicidal ideation.• Monitor patient for bleeding, especially ifpatient also takes aspirin, an NSAID, or ananticoagulant. Bleeding can range fromecchymoses, hemtomas, epitaxis, andpetechiae to life-threatening hemorrhage.• Discontinue fluvoxamine therapy gradually,as ordered, to prevent unpleasantadverse reactions.PATIENT TEACHING• Caution patient not to drink alcohol duringfluvoxamine therapy.• Urge patient to avoid potentially hazardousactivities until drug’s CNS effectsare known.WARNING Inform patient that fluvoxamineincreases the risk of a rare but seriousproblem: serotonin syndrome. Encourageher to notify prescriber immediately ifsymptoms develop.• Caution patient not to stop taking drugabruptly. Explain that gradual taperinghelps avoid withdrawal symptoms.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes andparticularly if patient is a child, teenager,or young adult.• Warn patient that fluvoxamine increasesbleeding risk if taken with aspirin, anNSAID, or an anticoagulant and thatbleeding events could range from mild tosevere. Tell patient to seek emergency carefor serious or prlonged bleeding.• Advise pregnant patient to consult withprescriber before her third trimester aboutongoing fluvoxamine therapy because ofan increased risk to her unborn child duringthe third trimester.folic acid(vitamin B 9 )Apo-Folic (CAN), Folvite,Novo-Folacid (CAN)Class and CategoryChemical class: Water-soluble B-complexvitaminTherapeutic class: Nutritional supplementPregnancy category: AIndications and Dosages To prevent deficiency based on U.S. andCanadian recommended daily allowancesTABLETSAdult men and boys age 11 and over.150 to 400 mcg (150 to 220 mcg Canadian)daily.Adult women and girls age 11 and over.150 to 400 mcg (145 to 190 mcg Canadian)daily.Pregnant women. 400 to 800 mcg (445 to475 mcg Canadian) daily.Breast-feeding women. 260 to 800 mcg(245 to 275 mcg Canadian) daily.Children ages 7 to 10. 100 to 400 mcg(125 to 180 mcg Canadian) daily.Children ages 4 to 6. 75 to 400 mcg (90 mcgCanadian) daily.Children from birth to age 3. 25 mcg(50 to 80 mcg Canadian) daily.I.V INFUSIONAdults and children age 11 and over.Dosage individualized based on patientneed and given as part of total parenteralnutrition solution. To treat folic acid deficiencyTABLETSAdults and children age 11 and over.Dosage individualized based on severity ofdeficiency, as prescribed.I.V. INFUSION, I.M. OR SUBCUTANEOUS INJECTIONAdults and children age 11 and over.0.25 to 1 mg daily until hematologicresponse occurs.Mechanism of ActionActs as a catalyst for normal production ofred blood cells, helping to prevent megaloblasticanemia, and helps maintain normalhomocysteine levels. After being convertedto tetrahydrofolic acid in the intestines,folic acid promotes synthesis of severalenzymes, including purine and thymidylates;metabolism of amino acids, includingglycine and methionine; and metabolism ofhistidine, all of which are essential for normalcell structure and growth.ContraindicationsHypersensitivity to folic acid or its components

idone: Possibly increased folic acid requirementsantacids (aluminum- or magnesium-containing),cholestyramine, sulfasalazine:Possibly decreased folic acid absorptionhydantoin anticonvulsants: Possiblydecreased effectiveness of these drugs, possiblyincreased folic acid requirementsmethotrexate, pyrimethamine, triamterene,trimethoprim: Possibly decreased effectivenessof folic acidAdverse ReactionsOther: Allergic reaction (bronchospasm,erythema, fever, malaise, rash, pruritus)Nursing ConsiderationsWARNING Don’t give injection form containingbenzyl alcohol to neonates orimmature infants because a fatal toxic syndromemay occur with CNS, respiratory,circulatory, and renal impairment andmetabolic acidosis.• To prevent decreased absorption, give folicacid supplements at least 1 hour before or4 hours after cholestyramine or sulfasalazineand don’t give antacids within 1 hourbefore or 2 hours after giving folic acid.• Know that folic acid will correct hematologicdisorders in pernicious anemia, butneurologic problems will progressivelyworsen.PATIENT TEACHING• Advise against taking folic acid supplementsas a substitute for proper dietaryintake. Explain that good sources of folicacid include green vegetables, potatoes,cereals, and organ meats. Recommend eatingraw green vegetables because heat usedduring cooking destroys up to 90% of folicacid found in food.• Explain to patients with pernicious anemiathat folic acid won’t affect the neurologicsymptoms associated with the disease.fondaparinuxsodiumArixtraClass and CategoryChemical class: Synthetic pentasaccharidefondaparinux sodium 461factor Xa inhibitorTherapeutic class: AntithrombolyticPregnancy category: BIndications and Dosages To provide prophylaxis against deep veinthrombosis, which may lead to pulmonaryembolism in patients undergoinghip fracture surgery, hip replacementsurgery, knee replacement surgery, orabdominal surgery in patients at risk forthromboembolic complicationsSUBCUTANEOUS INJECTIONAdults. Initial: After hemostasis has beenestablished, 2.5 mg subcutaneously 6 to8 hr after surgery, followed by 2.5 mg subcutaneouslydaily for 5 to 9 days.Maximum: 2.5 mg subcutaneously daily for11 days for hip or knee replacement andabdominal surgery and 24 days for hip fracturesurgery. To treat acute deep vein thrombosis(with warfarin); to treat acute pulmonaryembolism (with warfarin) in ahospital settingSUBCUTANEOUS INJECTIONAdults. Initial: 5 mg if body weight is lessthan 50 kg (110 lb), 7.5 mg if body weightis 50 to 100 kg (110 to 220 lb), and 10 mg ifbody weight exceeds 100 kg daily for at least5 days and until INR is between 2.0 and3.0 (usually in 5 to 9 days)Mechanism of ActionSelectively binds to antithrombin III, whichenhances the inactivation of clotting factorXa by antithrombin III. Inactivation of factorXa interrupts the blood coagulationpathway, which then inhibits thrombin formation.Without thrombin, fibrinogen can’tconvert to fibrin and clots can’t form.IncompatibilitiesDon’t mix fondaparinux sodium with otherinjections or infusions.ContraindicationsActive major bleeding; bacterial endocarditis;body weight less than 50 kg (110 lb) ifpatient is having hip repair or replacementor knee replacement surgery; fondaparinux-inducedthrombocytopenia associatedwith a positive in vitro test for antiplateletantibodies; hypersensitivity to fondaparinux;prophylactic fondaparinux therapy inpatients weighing less than 50 kg (110 lb)EF

462fondaparinux sodiumundergoing hip repair or replacement, kneereplacement, or abdominal surgery; severerenal impairment (creatinine clearance lessthan 30 ml/min/1.73 m 2 )InteractionsDRUGSabciximab, thrombolytics, other drugs thatenhance risk of bleeding: Increased risk ofhemorrhage and spinal or epidural hematomaAdverse ReactionsCNS: Confusion, dizziness, fever, headache,insomniaCV: Edema, elevated serum aminotransferaselevel, hypotensionGI: Constipation, diarrhea, elevated liverfunction test results, indigestion, nausea,vomitingGU: Urine retention, UTIHEME: Anemia, bleeding, elevated APTT,hematoma, postoperative hemorrhage,thrombocytopenia, thrombocytopenia withthrombosisSKIN: Bullous eruption, increased wounddrainage, rash, purpuraOther: Generalized pain; hypokalemia;injection site bleeding, pruritus, and rashNursing Considerations• Fondaparinux shouldn’t be given as prophylaxisfor patients who have had a hipfracture, who are having hip or kneereplacement or abdominal surgery, or whoweigh less than 50 kg (110 lb) because ofincreased risk of bleeding.• Use fondaparinux cautiously in elderlypatients, especially those weighing lessthan 50 kg (110 lb) and are receiving thedrug for pulmomary embolism or deepvein thrombosis, because the risk of druginducedbleeding increases with age.• Don’t give initial dose of fondaparinuxless than 6 hours after surgery.• Inspect fondaparinux for particles or discolorationbefore administration. Be awarethat needle guard on prefilled syringe containsdry natural latex rubber and shouldnm’tbe handled by those sensitive to latex.• Alternate injection sites using left andright anterolateral or left and right posterolateralabdominal wall. Don’t expel airbubble from prefilled syringe before injectionto prevent expelling drug fromsyringe. Don’t give drug by I.M. injection.WARNING If patient is receiving fondaparinuxwith epidural or spinal anesthesiaor spinal puncture, watch closely fordevelopment of spinal hematoma, whichmay cause long-term or permanent paralysis.If you see evidence of neurologicimpairment, such as changes in sensory ormotor function, notify prescriber immediatelybecause urgent care is needed tominimize hematoma’s effect. Risk of spinalor epidural hematoma during fondaparinuxtherapy is increased by indwellingepidural catheters, concurrent use of otherdrugs that affect hemostatis, a history oftraumatic or repeated epidural or spinalpunctures, or a history of spinal deformityor spinal surgery.• Closely monitor patient for bleeding (suchas ecchymosis, epistaxis, hematemesis,hematuria, and melena), especially thoseat risk for decreased drug elimination(such as elderly patients and patients withmild to moderate renal impairment) andthose at increased risk for bleeding (suchas patients with congenital or acquiredbleeding disorders; active ulcerative andangiodysplastic GI disease; hemorrhagicstroke; uncontrolled arterial hypertension;recent brain, spinal, or ophthalmologicsurgery; diabetic retinopathy; or a historyof heparin-induced thrombocytopenia;and those being treated concomitantlywith platelet inhibitors).• Perform periodic CBC, including plateletcount, as ordered. Expect prescriber to discontinuedrug if platelet count falls below100,000/mm 3 . Be aware that routine coagulationtests, such as PT and INR, are notused to monitor fondaparinux therapy; ananti-Xa assay may be used instead. Also,test stools for occult blood, as ordered.• Monitor patient with thrombocytopeniafor evidence of thrombosis that mayappear similar to heparin-induced thrombocytopeniaeven when no exposure toheparin has taken place. If patient’splatelet count falls below 100,000/mm 3 ,fondaparinux should be discontinued.• Monitor renal function test results, asordered. Expect to discontinue drug ifsevere renal impairment or labile renalfunction occurs during fondaparinuxtherapy because the risk of hemorrhageincreases as renal function decreases.

• Store drug at a controlled room temperature.PATIENT TEACHING• Inform patient that fondaparinux can’t betaken orally.• Instruct patient to seek immediate help ifshe experiences signs of thromboembolism,such as neurologic changes andsevere shortness of breath.• Inform patient about the increased risk ofbleeding. Instruct her or family memberto watch for and report abdominal orlower back pain, black stools, bleedinggums, bloody urine, or severe headaches.• Teach patient or family member how toadminister fondaparinux by subcutaneousinjection at home, if needed. Instruct hernot to expel air bubble from a prefilledsyringe to avoid expelling some of thedrug. Tell her to insert the entire needleinto a skinfold held between thumb andforefinger, and remind her to alternateadministration sites.• To minimize bruising, caution the patientnot to rub the injection site after givingthe drug.• Review safe handling and disposal ofsyringes and needles.• Advise patient to have follow-up appointmentsand prescribed laboratory tests.formoterol fumaratedihydrateForadil Aerolizer, OxezeTurbuhaler (CAN), PerforomistClass and CategoryChemical class: Racemic acid saltTherapeutic class: BronchodilatorPregnancy category: CIndications and Dosages To prevent asthma-induced bronchospasmPOWDER FOR ORAL INHALATIONAdults and children age 5 and over. 12 mcgevery 12 hr through inhaler device.Maximum: 24 mcg daily. To prevent exercise-induced bronchospasmPOWDER FOR ORAL INHALATIONAdults and adolescents age 12 and over.formoterol fumarate dihydrate 46312 mcg at least 15 min before exercise every12 hr p.r.n. Maximum: 24 mcg daily. To provide long-term treatment ofbronchospasm in patients with chronicbronchitis and emphysemaPOWDER FOR ORAL INHALATIONAdults. 12 mcg every 12 hr through inhalerdevice. Maximum: 24 mcg daily.SOLUTION FOR ORAL INHALATIONAdults. 20 mcg b.i.d. by nebulization.Maximum: 40 mcg daily.Route Onset Peak DurationOral 1–3 min Unknown 12 hrinhalationMechanism of ActionSelectively attaches to beta 2 receptors onbronchial membranes, stimulating theintracellular enzyme adenyl cyclase to convertadenosine triphosphate to cAMP. Theresulting increase in the intracellular cAMPlevel relaxes bronchial smooth-muscle cells,stabilizes mast cells, and inhibits histaminerelease.ContraindicationsAcute asthma, hypersensitivity to formoterolfumarate or its componentsInteractionsDRUGSadrenergics: Possibly increased sympatheticeffects of formoterolbeta blockers: Decreased effects of formoterol,possibly severe bronchospasmcorticosteroids, non–potassium-sparingdiuretics, xanthine derivatives: Possiblyincreased hypokalemic effect of formoteroldisopyramide, MAO inhibitors, phenothiazines,procainamide, quinidine, tricyclic antidepressants:Possibly prolonged QTc interval,increasing risk of ventricular arrhythmiasAdverse ReactionsCNS: Anxiety, dizziness, fatigue, fever,headache, insomnia, malaise, tremorCV: Angina, arrhythmias, chest pain, hypertension,hypotension, palpitations, tachycardiaEENT: Dry mouth; laryngeal spasm, irritation,or swelling; hoarseness; pharyngitis;rhinitis and tonsillitis (in children); sinusitisEF

464fosfomycin tromethamineENDO: HyperglycemiaGI: Abdominal pain, gastroenteritis, indigestion(in children); nauseaMS: Back pain, leg cramps, muscle spasmsRESP: Asthma exacerbation, bronchitis,bronchospasm (paradoxical or hypersensitivity-induced),cough, dyspnea, increasedsputum production, upper respiratory tractinfectionSKIN: Dermatitis, pruritus, rashOther: Anaphylaxis, angioedema,hypokalemia, metabolic acidosis, viralinfection (in children)Nursing Considerations• Administer formoterol capsules or solutiononly by oral inhalation.• Store capsules and solution in their originalpackaging, and open immediatelybefore use.• To use delivery system for powder form,place capsule in well of inhaler device.Press and release buttons on side of deviceto pierce capsule. Have patient inhale rapidlyand deeply through mouthpiece; drugis dispersed into airways as patient inhales.• Give inhalation solution only by standardjet nebulizer and air compressor.WARNING Monitor patient for worsening ordeteriorating asthma because drug isn’trapid-acting and shouldn’t be used as asubstitute for corticosteroid therapy.• Watch closely for paradoxical bronchospasm;if this occurs, discontinue formoterolimmediately and notify prescriber.• Monitor patients with a history of cardiovasculardisorders, especially coronaryinsufficiency, arrhythmias, or hypertension.Notify prescriber of any significantincreases in pulse rate or blood pressure orworsening of chronic conditions becauseformoterol may produce cardiovascularreactions, including angina, arrhythmias,hypertension or hypotension, palpitations,and tachycardia. Drug may need to be discontinuedif such reactions occur.PATIENT TEACHING• Advise patient, especially if she has significantcardiac history, to inform prescriberof any other drugs she takes before beginningformoterol therapy to prevent harmfuldrug interactions.• Instruct patient to use manufacturer’splastic device for inhaling powder form offormoterol, to always use new inhaler thatcomes with each refill, and not to use aspacer. Tell her never to swallow capsules.• Teach patient how to properly store powdereddrug and inhaler. Instruct her toavoid exposing capsules to moisture andto always handle them with dry handsbecause powder inside capsules must bedry to be inhaled. Also advise her to keepinhaler in a dry place and not to wash it.• Teach patient proper use of powdered formoteroldelivery system. Instruct her toremove capsule from blister pack justbefore use, to place capsule in well ofinhaler device, to press and release buttonson side of device to pierce capsule, andthen to inhale rapidly and deeply throughmouthpiece. Emphasize that she shouldonly inhale, not exhale, into device.• For solution form, teach patient how touse, clean, and store nebulizer equipment.Tell her to leave the vial in its original foilpack until just before use.• Instruct patient who currently uses oral orinhaled corticosteroids to continue usingthem, as prescribed, even if she feels betterafter starting formoterol.• Caution patient not to increase formoteroldosage or frequency without consultingprescriber because she may need a rapidactingbronchodilator.• Urge patient to notify prescriber if hersymptoms worsen, if formoterol becomesless effective, or if she needs more inhalationsof short-acting beta 2 -agonist thanusual. This may indicate that her asthma isworsening.• Instruct patient to notify prescriber immediatelyif she experiences palpitations,chest pain, rapid heart rate, tremor, ornervousness while taking formoterolbecause dosage may need to be adjusted.fosfomycintromethamineMonurolClass and CategoryChemical class: Phosphonic acid derivativeTherapeutic class: AntibioticPregnancy category: B

Indications and Dosages To treat uncomplicated UTI (acute cystitis)caused by Enterococcus faecalis orEscherichia coliGRANULES FOR ORAL SOLUTIONWomen age 18 and over. 3 g as a singledose mixed with water.Route Onset Peak DurationP.O. 2–3 days 48 hr UnknownMechanism of ActionDisrupts the formation of bacterial cellwalls by blocking cell wall precursors.Specifically, fosfomycin inactivates enolpyruvyltransferase, which irreversiblyblocks the condensation of uridine diphosphate-N-acetylglucosaminewith phosphoenolpyruvate,a preliminary step in bacterialcell wall synthesis. Fosfomycin alsodecreases adherence of bacteria to epithelialcells of the urinary tract.ContraindicationsHypersensitivity to fosfomycin or its componentsInteractionsDRUGSmetoclopramide: Decreased blood level andurinary excretion of fosfomycinAdverse ReactionsCNS: Asthenia, dizziness, fever, headache,insomnia, nervousness, paresthesia, somnolenceEENT: Dry mouth, pharyngitis, rhinitisGI: Abdominal pain, anorexia, constipation,diarrhea, flatulence, indigestion, nausea,pseudomembranous colitis, vomitingGU: Dysmenorrhea, dysuria, hematuria,menstrual irregularities, vaginitisMS: Back painSKIN: Pruritus, rashOther: Flulike symptoms, lymphadenopathyNursing Considerations• Use fosfomycin cautiously in patients withimpaired renal function because drugclearance may be decreased.• Expect to obtain urine specimens for cultureand sensitivity tests before and afterfosfomycin therapy.• To reconstitute granules, pour contents ofsingle-dose packet into 90 to 120 ml (3 tofosinopril sodium 4654 oz) of water (not hot water) and stir.Administer immediately after dissolving.WARNING Expect adverse reactions toincrease if more than one dose is used totreat a single episode of acute cystitis.• Monitor patient for diarrhea during andfor at least 2 months after drug therapy;diarrhea may signal pseudomembranouscolitis caused by Clostridium difficile. Ifdiarrhea occurs, notify prescriber andexpect to withhold fosfomycin and treatwith fluids, electrolytes, protein, and anantibiotic effective against C. difficile.PATIENT TEACHING• Explain how to reconstitute fosfomycin,and instruct patient to take drug immediatelyafter it dissolves. Tell her not to takedry granules or mix them with hot water.• To treat each episode of acute cystitis,advise patient to use only a single dose, asprescribed, to avoid increasing the risk ofadverse reactions.• Urge patient to notify prescriber if symptomsdon’t improve in 2 to 3 days.• Instruct patient to return to prescriber forfurther urine testing after taking fosfomycin.• Urge patient to tell prescriber about diarrheathat’s severe or lasts longer than 3days. Explain that watery or bloody stoolscan occur 2 or more months after therapyand can be serious, requiring prompttreatment.fosinopril sodiumMonoprilClass and CategoryChemical class: Phosphinic acid derivativeTherapeutic class: Antihypertensive,vasodilatorPregnancy category: C (first trimester),D (later trimesters)Indications and Dosages To manage blood pressure, alone or withother antihypertensivesTABLETSAdults. Initial: 10 mg daily. Maintenance:20 to 40 mg daily. Maximum: 80 mg daily. To treat heart failureTABLETSAdults. 10 mg daily.EF

466Nursing Considerations• Monitor serum potassium level before andduring fosinopril therapy, as appropriate.• Observe patient being treated for heartfailure for at least 2 hours after givingdrug to detect hypotension or orthostatichypotension. If either develops, notify prescriberand monitor patient until bloodpressure stabilizes. Keep in mind thatorthostatic hypotension is unlikely todevelop in patients with a systolic bloodpressure over 100 mm Hg who receive a10-mg dose.• If patient also receives an antacid, separateadministration times by at least 2 hours.• If patient also receives a diuretic or anotherantihypertensive, expect to reduce itsdosage over 2 to 3 days before starting fosinopril.If blood pressure isn’t controlledwith fosinopril alone, other antihypertenfosinoprilsodiumDOSAGE ADJUSTMENT Initial dosage reducedto 5 mg daily, if needed, for patients withacute heart failure, moderate to severe renalfailure, or recent aggressive diuresis. Dosagemay be increased over several weeks tomaximum of 40 mg daily.Route Onset Peak DurationP.O. 1 hr 2–6 hr 24 hrMechanism of ActionMay reduce blood pressure by affectingrenin-angiotensin-aldosterone system. Byinhibiting angiotensin-converting enzyme,fosinopril:• prevents conversion of angiotensin I toangiotensin II, a potent vasoconstrictorthat also stimulates the adrenal cortex tosecrete aldosterone• may inhibit renal and vascular productionof angiotensin II• decreases serum angiotensin II level andincreases serum renin activity, whichdecreases aldosterone secretion, slightlyincreasing the serum potassium level andfluid loss• decreases vascular tone and blood pressure• inhibits aldosterone release, which reducessodium and water reabsorption andincreases their excretion, further reducingblood pressure.ContraindicationsHypersensitivity to fosinopril, other ACEinhibitors, or their componentsInteractionsDRUGSallopurinol, bone marrow depressants, procainaminde,systemic corticosteroids:Increased risk of potentially fatal neutropeniaor agranulocytosisantacids: Impaired fosinopril absorptioncyclosporine, potassium-sparing diuretics,potassium supplements: Increased risk ofhyperkalemiadiuretics, other antihypertensives: Possiblyadditive hypotensionlithium: Increased blood lithium level andrisk of lithium toxicityNSAIDs: Possibly decreased antihypertensiveeffect of fosinoprilsodium aurothiomalate: Nitritoid reactions,including facial flushing, nausea, vomiting,and hypotensionFOODSsalt substitutes: Increased risk of hyperkalemiaACTIVITIESalcohol use: Possibly additive hypotensionAdverse ReactionsCNS: Confusion, depression, dizziness,drowsiness, fatigue, fever, headache, insomnia,mood changes, sleep disturbance, syncope,tremor, vertigo, weaknessCV: Angina, arrhythmias (including AVconduction disorders, bradycardia, andtachycardia), claudication, hypotension, MI,orthostatic hypotension, palpitationsEENT: Dry mouth, epistaxis, eye irritation,hoarseness, rhinitis, sinus problems, tasteperversion, tinnitus, vision changesGI: Abdominal distention and pain, anorexia,constipation, diarrhea, flatulence, hepaticfailure, hepatitis, hepatomegaly, nausea,pancreatitis, vomitingGU: Decreased libido, flank pain, renalinsufficiency, sexual dysfunction, urinaryfrequencyMS: Arthralgia, gout, myalgiaRESP: Asthma; bronchitis; bronchospasm;dry, persistent, tickling cough; dyspnea; tracheobronchitis;upper respiratory tractinfectionSKIN: Diaphoresis, jaundice, photosensitivity,pruritus, rash, urticariaOther: Anaphylaxis, angioedema, hyperkalemia,weight gain

sive therapy may resume, as prescribed. Ifso, observe for excessive hypotension.WARNING If angioedema affects the face,glottis, larynx, limbs, lips, mucous membranes,or tongue, notify prescriber immediately.Expect to discontinue fosinopriland start appropriate therapy at once. Ifairway obstruction threatens, promptlygive 0.3 to 0.5 ml of epinephrine solution1:1,000 subcutaneously, as prescribed.PATIENT TEACHING• Instruct patient to take fosinopril at sametime each day to improve compliance andmaintain drug’s therapeutic effect.• Emphasize the importance of taking fosinoprilas prescribed, even if patient feelswell. Caution her not to stop taking drugwithout consulting prescriber.• Explain that drug helps control—butdoesn’t cure—hypertension and thatpatient may need lifelong therapy.WARNING Urge patient to seek immediatemedical attention for difficulty breathingor swallowing, hoarseness, or swelling ofthe face, lips, tongue, or throat.• Instruct patient to notify prescriber aboutpersistent, severe nausea, vomiting, anddiarrhea; resulting dehydration may leadto hypotension.• Advise patient not to take other drugs oruse salt substitutes without consulting prescriber.• Encourage patient to keep scheduledappointments with prescriber to monitorblood pressure, blood test results, andeffects of therapy.• Caution patient about possible dizziness.• To minimize effects of orthostatichypotension, advise patient to rise slowlyfrom a lying or sitting position and todangle legs over bed for several minutesbefore standing.• Reinforce prescriber’s recommendationsfor lifestyle changes, such as smoking cessation,stress reduction, dietary improvements,alcohol avoidance, and regularexercise.• If patient is a woman of childbearing age,urge her to use contraception during therapybecause drug may harm fetus.• Advise patient to use caution during exerciseand hot weather because of theincreased risk of dehydration from excessivesweating.fosphenytoinsodiumCerebyxfosphenytoin sodium 467Class and CategoryChemical class: Hydantoin derivativeTherapeutic class: AnticonvulsantPregnancy category: DIndications and Dosages To treat status epilepticusI.V. INFUSION, I.M. INJECTIONAdults and adolescents. Initial: 15 to 20 mgof phenytoin equivalent (PE)/kg I.V. at100 to 150 PE/min. Maintenance: 4 to 6 mgPE/kg daily I.V. or I.M. in divided dosesb.i.d. to q.i.d. Maximum: 30 mg PE/kg astotal loading dose.Children. Initial: 15 to 20 mg PE/kg I.V.given at up to 3 mg PE/kg/min.Maintenance: 4 to 6 mg PE/kg daily I.V. orI.M. in divided doses b.i.d. to q.i.d. To prevent or treat seizures during andafter neurosurgeryI.V. INFUSION, I.M. INJECTIONAdults and adolescents. Initial: 10 to 20 mgPE/kg I.V., not to exceed 150 mg PE/min.Maintenance: 4 to 6 mg PE/kg daily I.V. orI.M. in divided doses b.i.d. to q.i.d.Maximum: 30 mg PE/kg as total loadingdose.Mechanism of ActionIs converted from fosphenytoin (a prodrug)to phenytoin, which limits the spread ofseizure activity and the start of new seizures.Phenytoin does so by regulating voltage-dependentsodium and calcium channelsin neurons, inhibiting calcium movementacross neuronal membranes, andenhancing the sodium-potassium-adenosinetriphosphatase activity in neurons andglial cells. These actions may stem fromphenytoin’s ability to slow the recovery rateof inactivated sodium channels.ContraindicationsHypersensitivity to fosphenytoin, phenytoin,other hydantoins, or their componentsInteractionsDRUGSacetaminophen (long-term use): IncreasedEF

468fosphenytoin sodiumrisk of hepatotoxicityacyclovir: Decreased blood phenytoin level,loss of seizure controlalfentanil: Increased clearance anddecreased effectiveness of alfentanilamiodarone, fluoxetine: Possibly increasedblood phenytoin level and risk of toxicityantacids: Possibly decreased phenytoineffectivenessantineoplastics: Increased phenytoin metabolismbeta blockers: Increased myocardial depressionbupropion, clozapine, loxapine, MAO inhibitors,maprotiline, phenothiazines, pimozide,thioxanthenes: Possibly lowered seizurethreshold and decreased therapeutic effectsof phenytoin, possibly intensified CNSdepressant effects of these drugscalcium: Possibly impaired phenytoinabsorptioncalcium channel blockers: Possibly increasedblood phenytoin levelcarbamazepine: Decreased blood carbamazepinelevel, possibly increased bloodphenytoin level and risk of toxicitychloramphenicol, cimetidine, disulfiram, isoniazid,methylphenidate, metronidazole,phenylbutazone, ranitidine, salicylates, sulfonamides,trimethoprim: Possibly impairedmetabolism of these drugs, increased risk ofphenytoin toxicityCNS depressants: Possibly increased CNSdepressioncorticosteroids, cyclosporine, digoxin, disopyramide,doxycycline, furosemide, levodopa,mexiletine, quinidine: Decreased therapeuticeffects of these drugsdiazoxide: Possibly decreased therapeuticeffects of both drugsdopamine: Possibly sudden hypotension orcardiac arrest after I.V. fosphenytoinadministrationestrogen- and progestin-containing contraceptives:Possibly breakthrough bleedingand decreased contraceptive effectivenessestrogens, progestins: Decreased therapeuticeffects, increased blood phenytoin levelfelbamate: Possibly impaired metabolismand increased blood level of phenytoinfluconazole, itraconazole, ketoconazole,miconazole: Increased blood phenytoin levelfolic acid: Increased phenytoin metabolism,decreased seizure controlhaloperidol: Possibly lowered seizure thresholdand decreased therapeutic effects ofphenytoin; possibly decreased blood haloperidollevelinsulin, oral antidiabetic drugs: Possiblyincreased blood glucose level and decreasedtherapeutic effects of these drugslamotrigine: Possibly decreased therapeuticeffects of lamotriginelidocaine: Possibly decreased blood lidocainelevel, increased myocardial depressionlithium: Increased risk of lithium toxicitymethadone: Possibly increased methadonemetabolism, leading to withdrawal symptomsmolindone: Possibly lowered seizure threshold,impaired absorption, and decreasedtherapeutic effects of phenytoinomeprazole: Possibly increased bloodphenytoin leveloral anticoagulants: Possibly impairedmetabolism of these drugs and increasedrisk of phenytoin toxicity; possiblyincreased anticoagulant effects initially andthen decreased effects with prolonged therapyrifampin: Possibly decreased therapeuticeffects of phenytoinstreptozocin: Possibly decreased therapeuticeffects of streptozocinsucralfate: Possibly decreased phenytoinabsorptiontricyclic antidepressants: Possibly loweredseizure threshold and decreased therapeuticeffects of phenytoin; possibly decreasedblood antidepressant levelvalproic acid: Decreased blood phenytoinlevel, increased blood valproic acid levelvitamin D analogues: Decreased vitamin Danalogue activityxanthines: Possibly inhibited phenytoinabsorption and increased clearance of xanthineszaleplon: Increased clearance and decreasedeffectiveness of zaleplonACTIVITIESalcohol use: Possibly decreased phenytoineffectivenessAdverse ReactionsCNS: Agitation, amnesia, asthenia, ataxia,cerebral edema, chills, coma, confusion,delusions, depression, dizziness, emotionallability, encephalitis, encephalopathy,extrapyramidal reactions, fever, headache,

hemiplegia, hostility, hypoesthesia, lack ofcoordination, malaise, meningitis, nervousness,neurosis, paralysis, personality disorder,positive Babinski’s sign, seizures, somnolence,speech disorders, stroke, stupor,subdural hematoma, syncope, transientparesthesia, tremor, vertigoCV: Atrial flutter, bradycardia, bundlebranchblock, cardiac arrest, cardiomegaly,edema, heart failure, hypertension,hypotension, orthostatic hypotension, palpitations,PVCs, shock, tachycardia, thrombophlebitisEENT: Amblyopia, conjunctivitis, diplopia,dry mouth, earache, epistaxis, eye pain, gingivalhyperplasia, hearing loss, hyperacusis,increased salivation, loss of taste, mydriasis,nystagmus, pharyngitis, photophobia,rhinitis, sinusitis, taste perversion, tinnitus,tongue swelling, visual field defectsENDO: Diabetes insipidus, hyperglycemia,ketosisGI: Anorexia, constipation, diarrhea, dysphagia,elevated liver function test results,flatulence, gastritis, GI bleeding, hepaticnecrosis, hepatitis, ileus, indigestion, nausea,vomitingGU: Albuminuria, dysuria, incontinence,oliguria, polyuria, renal failure, urine retention,vaginal candidiasisHEME: Anemia, easy bruising, leukopenia,thrombocytopeniaMS: Arthralgia, back pain, leg cramps, muscletwitching, myalgia, myasthenia, myoclonus,myopathyRESP: Apnea, asthma, atelectasis, bronchitis,dyspnea, hemoptysis, hyperventilation,hypoxia, increased cough, increased sputumproduction, pneumonia, pneumothoraxSKIN: Contact dermatitis, diaphoresis,maculopapular or pustular rash, photosensitivity,skin discoloration, skin nodule,Stevens-Johnson syndrome, transient pruritus,urticariaOther: Cachexia, cryptococcosis, dehydration,facial edema, flulike symptoms, hyperkalemia,hypokalemia, hypophosphatemia,infection, injection site reaction, lymphadenopathy,sepsisNursing Considerations• Express the dosage, concentration, andinfusion rate of fosphenytoin in PE units.Misreading an order or a label could resultin massive overdose.• Refrigerate unopened fosphenytoin at 2°to 8° C (36° to 46° F), but don’t freeze.• Dilute drug in D 5 W or normal saline solutionto 1.5 to 25 mg PE/ml.• Inspect parenteral solution before administration.Discard solution that containsparticles or is discolored.• Be aware that drug shouldn’t be given I.M.for status epilepticus because I.V. routeallows faster onset and peak.• Keep in mind that I.V. fosphenytoinadministration doesn’t require use of a filter,as with phenytoin administration.• Don’t give fosphenytoin solution fasterthan 150 mg PE/minute because of therisk of hypotension. For a 50-kg (110-lb)patient, infusion typically takes 5 to7 minutes. Fosphenytoin can be givenmore rapidly than I.V. phenytoin.• Follow loading dose with maintenancedosage of oral or parenteral phenytoin orparenteral fosphenytoin, as prescribed.• As prescribed, give I.V. benzodiazepine(such as lorazepam or diazepam) with fosphenytoin;otherwise, drug’s fullantiepileptic effect won’t be immediate.• Monitor ECG, blood pressure, and respiratoryfunction for 10 to 20 minutes afterinfusion ends.• Expect to obtain blood fosphenytoin(phenytoin) level 2 hours after I.V. infusionor 4 hours after I.M. injection.Therapeutic level generally ranges from10 to 20 mcg/ml; steady-state may takeseveral days to several weeks to reach.• Be aware that I.V. or I.M. fosphenytoinmay be substituted for oral phenytoinsodium at same total daily dose and frequency.If prescribed, give daily amount intwo or more divided doses to maintainseizure control.• When switching between phenytoin andfosphenytoin, remember that small differencesin phenytoin bioavailability can leadto significant changes in blood phenytoinlevel and an increased risk of toxicity.• If drug causes transient, infusion-relatedparesthesia and pruritus, decrease or discontinueinfusion, as ordered.• Monitor CBC for thrombocytopenia orleukopenia—signs of hematologic toxicity.Also monitor serum albumin level andresults of renal and liver function tests.• Anticipate increased frequency and severifosphenytoinsodium 469EF

470frovatriptan succinatety of adverse reactions after I.V. administrationin patients with hepatic or renalimpairment or hypoalbuminemia.• Discontinue drug, as ordered, if signs ofhypersensitivity develop: acute hepatotoxicity(hepatic necrosis and hepatitis), fever,lymphadenopathy, and skin reactions duringfirst 2 months of therapy.• Monitor phenytoin level to detect earlysigns of toxicity, such as diplopia, nausea,severe confusion, slurred speech, andvomiting. Expect to reduce or stop drug.WARNING Monitor patient for seizures; attoxic levels, phenytoin is excitatory.WARNING If patient has bradycardia orheart block rhythm, notify prescriber andexpect to withhold drug; severe cardiovascularreactions and death have occurred.• Expect to provide vitamin D supplementif patient has inadequate dietary intakeand is receiving long-term anticonvulsanttreatment.• Document type, onset, and characteristicsof seizures and response to treatment.PATIENT TEACHING• Inform patient that fosphenytoin typicallyis used for short-term treatment.• Instruct patient to notify prescriber immediatelyabout bothersome symptoms, especiallyrash and swollen glands.• Because gingival hyperplasia may developduring long-term therapy, emphasize needfor good oral hygiene and gum massage.• Urge patient to consume adequateamounts of vitamin D.frovatriptansuccinateFrovaClass and CategoryChemical class: Selective 5-hydroxytryptamine1 (5-HT 1 ) receptor agonist, triptanTherapeutic class: Antimigraine agentPregnancy category: CIndications and Dosages To treat acute migraine with or withoutauraTABLETSAdults. 2.5 mg, repeated in 2 hr if needed.Maximum: 7.5 mg daily.Mechanism of ActionBinds to 5-HT 1B and 5-HT 1D receptors onextracerebral and intracranial arteries toinhibit excessive dilation of these vessels.This action may decrease carotid arterialblood flow, thus relieving acute migraines.Frovatriptan may also relieve pain byinhibiting the release of proinflammatoryneuropeptides and reducing transmissionof trigeminal nerve impulses from sensorynerve endings during a migraine attack.ContraindicationsHypersensitivity to frovatriptan or its components,basilar or hemiplegic migraines,cerebrovascular or peripheral vascular disease,ischemic or vasospastic coronaryartery disease (CAD), uncontrolled hypertension,use within 24 hours of otherserotonin-receptor agonists or ergotaminecontainingor ergot-type drugsInteractionsDRUGSdihydroergotamine mesylate, other ergotamine-containingdrugs: Possibly prolongedvasospastic reactionoral contraceptives, propranolol: Possiblyincreased blood frovatriptan levelselective serotonin reuptake inhibitors, suchas citalopram, escitalopram, fluoxetine, fluvoxamine,paroxetine, sertraline; serotoninnorepinephrine reuptake inhibitors, such asduloxetine, venlafaxine: Increased risk oflife-threatening serotonin syndromeAdverse ReactionsCNS: Anxiety, dizziness, dysesthesia,fatigue, headache, hypoesthesia, insomnia,paresthesia, seizures, serotonin syndromeCV: Arrhythmias (such as bradycardia andtachycardia), chest pain, coronary arteryvasospasm, ECG changes, MI, myocardialischemia (transient), palpitations, ventricularfibrillation, ventricular tachycardiaEENT: Abnormal vision, dry mouth, indigestion,rhinitis, sinusitis, tinnitusGI: Abdominal pain, diarrhea, indigestion,vomitingMS: Skeletal painSKIN: Diaphoresis, flushingOther: Generalized painNursing Considerations• Use frovatriptan cautiously in patients

with peripheral vascular disease becausedrug may cause vasospastic reactions,leading to vascular and colonic ischemiawith abdominal pain and bloody diarrhea.Assess patient’s peripheral circulation andbowel sounds during frovatriptan therapy.• Don’t give frovatriptan within 24 hours ofanother 5-HT 1 receptor agonist, such assumatriptan or rizatriptan, or of an ergotamine-containingor ergot-type drug, suchas dihydroergotamine or methysergide.• Administer tablet with fluids.• Assess patient for headache before administeringsecond dose. Don’t administermore than three 2.5-mg tablets a day.WARNING Be aware that some patients havehad serious adverse cardiac reactions—including fatal ones—after using 5-HT 1receptor agonists. However, these reactionsare extremely rare; most were reported inpatients with risk factors for CAD.• Assess patient’s cardiovascular status andinstitute continuous ECG monitoring, asordered, immediately after drug administrationin patients with cardiovascular riskfactors because they’re at risk for asymptomaticcardiac ischemia.• Assess patient for arrhythmias, chest pain,and other signs of heart disease in patientswith risk factors for CAD. Expect to periodicallyassess cardiovascular status ofpatients on long-term therapy.• Be aware that the safety of treating morethan four migraine attacks in 30 days (onaverage) has not been established.• Regularly monitor blood pressure ofhypertensive patients during therapybecause frovatriptan may produce a transientincrease in blood pressure.WARNING Monitor patient for possibleserotonin syndrome, characterized by agitation,chills, confusion, diaphoresis, diarrhea,fever, hyperactive reflexes, poor coordination,restlessness, shaking, talking oracting with uncontrolled excitement,tremor, and twitching, especially if patientis receiving another drug that raises serotoninlevel (such as selective serotoninreuptake inhibitors or serotonin norepinephrinereuptake inhibitors). In its mostsevere form, serotonin syndrome canresemble neuroleptic malignant syndrome,which includes a high fever, muscle rigidity,and autonomic instability with possiblefluctuations in vital signs and mental statuschanges.PATIENT TEACHING• Instruct patient to read and follow manufacturer’sinstructions for using frovatriptanto ensure maximum therapeuticresults.• Remind patient not to exceed prescribeddaily dosage.• Encourage patient to lie down in a dark,quiet room after taking drug to helprelieve migraine.• Instruct patient to seek emergency care forchest, jaw, or neck tightness after drug usebecause drug may cause coronary arteryvasospasm.• Urge patient to report palpitations.• Caution patient about possible adverseCNS effects, and advise her to avoid hazardousactivities until drug’s CNS effectsare known.• Stress need to report any unusual or severesymptoms immediately.furazolidoneFuroxonefurazolidone 471Class and CategoryChemical class: MAO inhibitor, nitrofuranderivativeTherapeutic class: Antibiotic, antiprotozoalPregnancy category: CIndications and Dosages To treat bacterial diarrhea and choleraORAL SUSPENSION, TABLETSAdults and adolescents. 100 mg every 6 hrfor 5 to 7 days.Infants and children age 1 month andover. 1.25 mg/kg every 6 hr for 5 to 7 days.Maximum: 8.8 mg/kg daily. To treat giardiasisORAL SUSPENSION, TABLETSAdults and adolescents. 100 mg every 6 hrfor 7 to 10 days.Infants and children age 1 month andover. 1.25 to 2 mg/kg every 6 hr for 7 to10 days. Maximum: 8.8 mg/kg daily.Mechanism of ActionMay interfere with several bacterial enzymesystems through DNA strand damage.Furazolidone also prevents the inactivationEF

472furosemideof tyramine by GI and hepatic MAObecause it is similar in structure and actionsto MAO inhibitors.ContraindicationsAge less than 1 month; hypersensitivity tofurazolidone, other nitrofurans, or theircomponentsInteractionsDRUGSlevodopa: Increased therapeutic and adverseeffects (particularly hypertension) of levodopameperidine: Possibly agitation, apnea, coma,diaphoresis, fever, and seizuresother MAO inhibitors, sedatives, sympathomimetics,tranquilizers, tricyclic antidepressants:Possibly sudden and severe hypertensivecrisisselective serotonin reuptake inhibitors:Increased risk of serotonin syndromeFOODSfoods and beverages with high content oftyramine or other vasopressor amines:Possibly sudden and severe hypertensivecrisisACTIVITIESalcohol use: Possibly disulfiram-like reactionAdverse ReactionsCNS: Headache, malaiseENDO: HypoglycemiaGI: Abdominal pain, diarrhea, nausea,vomitingGU: Darkened urineHEME: Hemolytic anemia, leukopeniaOther: Allergic reaction (arthralgia, dyspnea,fever, hypotension, urticaria, vesicularmorbilliform rash)Nursing Considerations• Ask patient if she has a history of blooddisorders—especially glucose-6-phosphatedehydrogenase (G6PD) deficiency—beforegiving furazolidone.• As ordered, check G6PD level before givingfurazolidone to whites of Mediterraneanand Near Eastern origin, Asians,or blacks; G6PD deficiency may worsendrug’s hemolytic effect.• If no response occurs within 7 days, expectto discontinue drug because organism isresistant. Provide therapy with otherantibiotics, as prescribed.• If giardiasis symptoms persist, expect toobtain three stool specimens for analysisseveral days apart, starting 3 to 4 weeksafter treatment ends.PATIENT TEACHING• Instruct patient to take drug at evenlyspaced intervals around the clock.• Advise patient to take drug with food if GIdistress occurs.• Direct patient to take a missed dose assoon as she remembers, unless it’s nearlytime for the next scheduled dose. Cautionagainst double-dosing.• Instruct patient to take furazolidone forthe full time prescribed, even if she feelsbetter before finishing the prescription,because stopping too soon could result inreinfection.• Advise patient to store furazolidonebetween 59° and 86° F (15° and 30° C),protected from moisture and light.• Inform patient that drug may cause dizzinessand usually turns urine brown.• Instruct patient to avoid alcohol duringtherapy and for 4 days afterward.• Give patient a list of products to avoidduring furazolidone therapy and for atleast 2 weeks afterward, such as foods andbeverages that contain tyramine and othervasopressor amines (for example, ripecheese, beer, red and white wine, andsmoked or pickled meat, poultry, or fish),OTC appetite suppressants, cough andcold medicines, and other drugs, unlessprescribed.• Instruct patient to notify prescriber if sheexperiences difficult breathing, fever,flushing, itching, muscle aches, or rash.furosemideApo-Furosemide (CAN), Furoside (CAN),Lasix, Lasix Special (CAN), Myrosemide,Novosemide (CAN), Uritol (CAN)Class and CategoryChemical class: SulfonamideTherapeutic class: Antihypertensive, diureticPregnancy category: CIndications and Dosages To reduce edema caused by cirrhosis,heart failure, and renal disease, includingnephrotic syndrome

ORAL SOLUTION, TABLETSAdults. 20 to 80 mg as a single dose,increased by 20 to 40 mg every 6 to 8 hruntil desired response occurs. Maximum:600 mg daily.Children. 2 mg/kg as a single dose,increased by 1 to 2 mg/kg every 6 to 8 hruntil desired response occurs. Maximum:6 mg/kg/dose.I.V. INFUSION, I.V. OR I.M. INJECTIONAdults. 20 to 40 mg as a single dose,increased by 20 mg every 2 hr until desiredresponse occurs.Children. 1 mg/kg as a single dose,increased by 1 mg/kg every 2 hr untildesired response occurs. Maximum:6 mg/kg/dose.DOSAGE ADJUSTMENT Initial single doselimited to 20 mg for elderly patients. To manage mild to moderate hypertension,as adjunct to treat acute pulmonaryedema and hypertensive crisisORAL SOLUTION, TABLETSAdults. Initial: 40 mg b.i.d., adjusted untildesired response occurs. Maximum: 600 mgdaily.I.V. INFUSION OR INJECTIONAdults with normal renal function. 40 to80 mg as a single dose over several minutes.Adults with acute renal failure or pulmonaryedema. 100 to 200 mg as a singledose over several minutes.DOSAGE ADJUSTMENT For patients withacute pulmonary edema without hypertensivecrisis, dosage reduced to 40 mg followedby 80 mg 1 hr later if therapeuticresponse doesn’t occur.Route Onset Peak DurationP.O. 20–60 min 1–2 hr 6–8 hrI.V. 5 min In 30 min 2 hrI.M. 30 min Unknown 2 hrMechanism of ActionInhibits sodium and water reabsorption inthe loop of Henle and increases urine formation.As the body’s plasma volumedecreases, aldosterone production increases,which promotes sodium reabsorption andthe loss of potassium and hydrogen ions.Furosemide also increases the excretion ofcalcium, magnesium, bicarbonate, ammonium,and phosphate. By reducing intracellularand extracellular fluid volume, thefurosemide 473drug reduces blood pressure and decreasescardiac output. Over time, cardiac outputreturns to normal.IncompatibilitiesDon’t mix furosemide (a milky, bufferedalkaline solution) with highly acidic solutions.ContraindicationsAnuria unresponsive to furosemide; hypersensitivityto furosemide, sulfonamides, ortheir componentsInteractionsDRUGSACE inhibitors: Possibly first-dose hypotensionaminoglycosides, cisplatin: Increased risk ofototoxicityamiodarone: Increased risk of arrhythmiasfrom hypokalemiachloral hydrate: Possibly diaphoresis, hotflashes, and hypertensiondigoxin: Increased risk of digitalis toxicityrelated to hypokalemiainsulin, oral antidiabetic drugs: Increasedblood glucose levellithium: Increased risk of lithium toxicityNSAIDs: Possibly decreased diuresisphenytoin, probenecid: Possibly decreasedtherapeutic effects of furosemidepropranolol: Possibly increased blood propranolollevelthiazide diuretics: Possibly profound diuresisand electrolyte imbalancesACTIVITIESalcohol use: Possibly increased hypotensiveand diuretic effects of furosemideAdverse ReactionsCNS: Dizziness, fever, headache, paresthesia,restlessness, vertigo, weaknessCV: Orthostatic hypotension, shock,thromboembolism, thrombophlebitisEENT: Blurred vision, oral irritation, ototoxicity,stomatitis, tinnitus, transient hearingloss (rapid I.V. injection), yellow visionENDO: HyperglycemiaGI: Abdominal cramps, anorexia, constipation,diarrhea, gastric irritation, hepatocellularinsufficiency, indigestion, jaundice,nausea, pancreatitis, vomitingGU: Bladder spasms, glycosuriaHEME: Agranulocytosis (rare), anemia,aplastic anemia (rare), azotemia, hemolyticEF

474furosemideanemia, leukopenia, thrombocytopeniaMS: Muscle spasmsSKIN: Bullous pemphigoid, erythema multiforme,exfoliative dermatitis, photosensitivity,pruritus, purpura, rash, urticariaOther: Allergic reaction (interstitial nephritis,necrotizing vasculitis, systemic vasculitis),dehydration, hyperuricemia, hypochloremia,hypokalemia, hyponatremia,hypovolemiaNursing ConsiderationsWARNING Use furosemide cautiously inpatients with advanced hepatic cirrhosis,especially those who also have a history ofelectrolyte imbalance or hepaticencephalopathy; drug may lead to lethalhepatic coma.• Obtain patient’s weight before and periodicallyduring furosemide therapy to monitorfluid loss.• For once-a-day dosing, give drug in themorning so patient’s sleep won’t be interruptedby increased need to urinate.• Prepare drug for infusion with normalsaline solution, lactated Ringer’s solution,or D 5 W.• Administer drug slowly I.V. over 1 to2 minutes to prevent ototoxicity.• Expect patient to have periodic hearingtests during prolonged or high-dose I.V.therapy.• Monitor blood pressure and hepatic andrenal function as well as BUN, blood glucose,and serum creatinine, electrolyte,and uric acid levels, as appropriate.• Be aware that elderly patients are moresusceptible to hypotensive and electrolytealteringeffects and thus are at greater riskfor shock and thromboembolism.• If patient is at high risk for hypokalemia,give potassium supplements along withfurosemide, as prescribed.• Expect to discontinue furosemide at maximumdosage if oliguria persists for morethan 24 hours.• Be aware that furosemide may worsen leftventricular hypertrophy and adverselyaffect glucose tolerance and lipid metabolism.• Notify prescriber if patient experienceshearing loss, vertigo, or ringing, buzzing,or sense of fullness in her ears. Drug mayneed to be discontinued.PATIENT TEACHING• Instruct patient to take furosemide at thesame time each day to maintain therapeuticeffects. Urge her to take it as prescribed,even if she feels well.• Instruct patient to take the last dose of furosemideseveral hours before bedtime toavoid sleep interruption from diuresis. Ifpatient receives once-daily dosing, adviseher to take the dose in the morning toavoid sleep disturbance caused by nocturia.• Advise patient to change position slowly tominimize effects of orthostatic hypotensionand to take furosemide with food ormilk to reduce GI distress.• Caution patient about drinking alcoholicbeverages, standing for prolonged periods,and exercising in hot weather becausethese actions increase the hypotensiveeffect of furosemide.• Emphasize the importance of weight anddiet control, especially limiting sodiumintake.• Unless contraindicated, urge patient to eatmore high-potassium foods and to take apotassium supplement, if prescribed, toprevent hypokalemia.• Instruct patient to keep follow-upappointments with prescriber to monitorprogress. Urge her to notify prescriberabout persistent, severe nausea, vomiting,and diarrhea because they may causedehydration.• Inform diabetic patient that furosemidemay increase blood glucose level, andadvise her to check her blood glucose levelfrequently.

G H IgabapentinNeurontinClass and CategoryChemical class: Cyclohexane-acetic acidderivativeTherapeutic class: AnticonvulsantPregnancy category: CIndications and Dosages To manage postherpetic neuralgiaCAPSULES, ORAL SOLUTION, TABLETSAdults. Initial: 300 mg on day 1, increasedto 300 mg b.i.d. on day 2, increased to300 mg t.i.d. on day 3, and increased graduallythereafter according to pain response,up to 600 mg t.i.d. Maximum: 1,800 mgdaily. As adjunct to treat partial seizuresCAPSULES, ORAL SOLUTION, TABLETSAdults and adolescents. Initial: 300 mgt.i.d., increased gradually according to clinicalresponse. Maintenance: 900 to 1,800 mgdaily. Maximum: 3,600 mg daily.DOSAGE ADJUSTMENT If creatinine clearanceis 30 to 60 ml/min/1.73 m 2 , dosage reducedto 300 mg b.i.d.; if it’s 15 to 29 ml/min/1.73 m 2 , to 300 mg daily; and if it’s lessthan 15 ml/min/1.73 m 2 , to 300 mg everyother day.Mechanism of ActionIs structurally like gamma-aminobutyricacid (GABA), the main inhibitory neurotransmitterin the brain. Although gabapentin’sexact mechanism of action isunknown, GABA inhibits the rapid firing ofneurons associated with seizures.ContraindicationsHypersensitivity to gabapentin or its componentsInteractionsDRUGSaluminum- and magnesium-containingantacids: Decreased gabapentin bioavailabilityCNS depressants: Increased CNS depressiongabapentin 475ACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Agitation, altered proprioception,amnesia, anxiety, apathy, aphasia, asthenia,ataxia, cerebellar dysfunction, chills, CNStumors, decreased or absent reflexes, delusions,depersonalization, depression, disappearanceof aura, dizziness, dream disturbances,dysesthesia, dystonia, emotionallability, euphoria, facial paralysis, fatigue,fever, hallucinations, headache, hemiplegia,hostility, hyperkinesia, hyperreflexia,hypoesthesia, hypotonia, intracranial hemorrhage,lack of coordination, malaise,migraine headache, nervousness, occipitalneuralgia, paranoia, paresis, paresthesia,positive Babinski’s sign, psychosis, sedation,seizures, somnolence, stupor, subduralhematoma, suicidal ideation, syncope,tremor, vertigoCV: Angina, hypertension, hypotension,murmur, palpitations, peripheral edema,peripheral vascular insufficiency, tachycardia,vasodilationEENT: Abnormal vision, amblyopia, blepharospasm,cataracts, conjunctivitis, diplopia,dry eyes and mouth, earache, epistaxis,eye hemorrhage, eye pain, gingivalbleeding, gingivitis, glossitis, hearing loss,hoarseness, increased salivation, inner earinfection, loss of taste, nystagmus, pharyngitis,photophobia, ptosis (bilateral or unilateral),rhinitis, sensation of fullness inears, stomatitis, taste perversion, tinnitus,tooth discoloration, visual field defectsGI: Abdominal pain, anorexia, constipation,diarrhea, fecal incontinence, flatulence, gastroenteritis,hemorrhoids, hepatitis,hepatomegaly, increased appetite, indigestion,melena, nausea, thirst, vomitingGU: Acute renal failure, decreased libido,impotenceHEME: Anemia, coagulation defect,decreased WBC count, leukopenia, thrombocytopeniaMS: Arthralgia, arthritis, back pain, bonefractures, dysarthria, joint stiffness or swelling,muscle twitching, myalgia, positiveRomberg test, tendinitisRESP: Apnea, cough, dyspnea, pneumonia,pseudocroupSKIN: Abrasion, acne, alopecia, cyst, dia-GHI

476galantamine hydrobromidephoresis, dry skin, eczema, hirsutism, pruritus,purpura, rash, seborrhea, urticariaOther: Dehydration, facial edema, lymphadenopathy,viral infection, weight gain orlossNursing Considerations• As needed, open gabapentin capsules andmix contents with water, fruit juice, applesauce,or pudding before administration.• Administer initial dose at bedtime to minimizeadverse reactions, especially ataxia,dizziness, fatigue, and somnolence.• Give drug at least 2 hours after an antacid.• Don’t exceed 12 hours between doses on a3-times-a-day schedule.• Be aware that routine monitoring of bloodgabapentin level isn’t needed.WARNING To discontinue drug or switch toan a different anticonvulsant, expect tochange gradually over at least 1 week, asprescribed, to avoid loss of seizure control.• Monitor renal function test results, andexpect to adjust dosage, if needed.• Monitor patient closely for evidence ofsuicidal thinking or behavior, especiallywhen therapy starts or dosage changes.PATIENT TEACHING• If patient has trouble swallowing gabapentincapsules, advise him to open them andsprinkle contents in juice or on soft foodimmediately before use.• Instruct patient not to take drug within2 hours after taking an antacid.• Urge patient to take a missed dose as soonas he remembers. If the next dose is in lessthan 2 hours, tell him to wait 1 to 2 hoursbefore taking it and then resume his regularschedule. Caution against doubling thedose.• Caution patient not to stop drug abruptly.• Inform patient about possible ataxia,dizziness, drowsiness, and nystagmus.Advise him to avoid hazardous activitiesuntil drug’s CNS effects are known.• To prevent complications from adverseoral reactions (such as gingivitis), encouragepatient to use good oral hygiene andto seek routine dental care.• Explain that adverse effects usually aremild to moderate and decline with time.• Urge patient to keep follow-up appointmentswith prescriber to check progress.• Urge caregivers to watch closely for evidenceof suicidal tendencies, especiallywhen therapy starts or dosage changes,and to report concerns immediately.• Urge woman who becomes pregnant whiletaking gabapentin to enroll in the NorthAmerican antiepileptic drug pregnancyregistry by calling 1-888-233-2334.Explain that this registry is collectinginformation about the safety of antiepilepticdrugs during pregnancy.galantaminehydrobromideRazadyne, Razadyne ERClass and CategoryChemical class: Tertiary alkaloidTherapeutic class: Antidementia agentPregnancy category: BIndications and Dosages To treat mild to moderate Alzheimer’stypedementiaORAL SOLUTION, TABLETSAdults. Initial: 4 mg b.i.d. Dosage increasedby 8 mg daily every 4 wk, if tolerated.Maximum: 12 mg b.i.d.DOSAGE ADJUSTMENT For patients withmoderately impaired hepatic or renal function,maximum dosage shouldn’t exceed16 mg daily.E.R. CAPSULESAdults. Initial: 8 mg daily. Dosage increasedby 8 mg daily every 4 wk if tolerated.Maximum: 24 mg daily.Route Onset Peak DurationP.O. Unknown 1 hr UnknownMechanism of ActionReduces acetylcholine metabolism by competitivelyand reversibly inhibiting the brainenzyme acetylcholinesterase. Acetylcholineproducingneurons degenerate in the brainsof patients with Alzheimer’s disease.Inhibition of acetylcholinesterase increasesthe amount of acetylcholine, which is neededfor nerve impulse transmission.ContraindicationsHypersensitivity to galantamine hydrobromideor its components, severe hepatic orrenal impairment (creatinine clearance less

than 9 ml/min/1.73 m 2 )InteractionsDRUGSamitriptyline, fluoxetine, fluvoxamine, quinidine:Possibly decreased galantamine clearanceanticholinergics: Possibly interference withcholinesterase activitycholinergic agonists, cholinesterase inhibitors,neuromuscular blockers: Possibly exaggeratedeffects of these drugs and galantaminecimetidine: Possibly increased galantaminebioavailabilityketoconazole, paroxetine: Increased galantaminebioavailabilityAdverse ReactionsCNS: Aggression, asthenia, depression,dizziness, fatigue, fever, headache, insomnia,malaise, somnolence, stroke, suicidalideation, syncope, tremorCV: AV block, bradycardia, chest pain, MI,myocardial ischemiaEENT: RhinitisGI: Abdominal pain, anorexia, diarrhea,flatulence, GI bleeding, indigestion, nausea,vomitingGU: Hematuria, incontinence, renal failureor insufficiency, UTIHEME: AnemiaOther: Dehydration, hypokalemia, weightlossNursing Considerations• Give galantamine twice daily with morningand evening meals, and ensure adequatefluid intake to prevent GI symptoms.• If therapy is interrupted for several days,expect to restart drug at lowest dose becausebenefits are lost when it is discontinued.• Monitor patient’s CV status closely becausecholinesterase inhibitors like galantaminemay have a depressive effect on sinoatrialand AV nodes and may lead to bradycardiaand AV block.• Monitor patient for progressive deteriorationof mental status because drug is lesseffective as Alzheimer's disease progressesand intact cholinergic neurons decrease.PATIENT TEACHING• Instruct patient to take or caregiver to giveregular-strength drug with morning andevening meals. Extended-release capsulesshould be given once in the morning,ContraindicationsConcurrent therapy with repaglinide, gallbladderdisease, hepatic or severe renal dysgemfibrozil477preferably with food.• Tell patient or caregiver to notify prescriberimmediately if therapy stops forseveral days. Prescriber may restart at lowestdose.• Instruct patient to maintain adequate fluidintake throughout galantamine therapy.• Advise patient not to drive or performactivities requiring alertness, especially duringfirst weeks of treatment, because drugmay cause dizziness and drowsiness.• Inform patient and family members thatdrug isn’t a cure for Alzheimer’s disease.gemfibrozilApo-Gemfibrozil (CAN), Gen-Fibro(CAN), Lopid, Novo-Gemfibrozil (CAN),Nu-Gemfibrozil (CAN)Class and CategoryChemical class: Fibric acid derivative,phenoxypentanoic acidTherapeutic class: AntihyperlipidemicPregnancy category: CIndications and Dosages As adjunct (with diet) to treat hyperlipidemiatypes IIb, IV, and VCAPSULES, TABLETSAdults. 600 mg before meals b.i.d.Route Onset Peak DurationP.O. 2–5 days 4 wk UnknownMechanism of ActionMay decrease hepatic triglyceride productionby reducing VLDL synthesis, inhibitingperipheral lipolysis, and decreasing hepaticextraction of free fatty acids. Gemfibrozilalso may inhibit synthesis and increaseclearance of apolipoprotein B, a carriermolecule for VLDL. In addition, it mayaccelerate turnover and removal of totalcholesterol from the liver while increasingcholesterol excretion in the feces. As aresult, triglyceride, total cholesterol, andVLDL levels decrease; the HDL levelincreases; and the LDL level is unaffected.GHI

478gemifloxacin mesylatefunction, hypersensitivity to gemfibrozil orits componentsInteractionsDRUGSchenodiol, ursodiol: Decreased effectivenessof gemfibrozilHMG-CoA reductase inhibitors: Increasedrisk of rhabdomyolysis and acute renalfailureoral anticoagulants: Increased anticoagulationrepaglinide: Increased serum repaglinidelevel and risk of severe hypoglycemiaAdverse ReactionsCNS: Chills, fatigue, headache, hypoesthesia,paresthesia, seizures, somnolence,syncope, vertigoCV: VasculitisEENT: Blurred vision, cataracts, hoarseness,retinal edema, taste perversionGI: Abdominal or epigastric pain,cholelithiasis, colitis, diarrhea, flatulence,heartburn, hepatoma, nausea, pancreatitis,vomitingGU: Decreased male fertility, dysuria,impotenceHEME: Anemia, bone marrow hypoplasia,eosinophilia, leukopenia, thrombocytopeniaMS: Arthralgia, back pain, myalgia, myasthenia,myopathy, myositis, rhabdomyolysis,synovitisRESP: CoughSKIN: Eczema, jaundice, pruritus, rashOther: Anaphylaxis, angioedema, increasedrisk of bacterial and viral infections, lupuslikesymptoms, weight lossNursing Considerations• Monitor serum triglyceride and cholesterollevels, as appropriate.• Periodically review CBC and liver functiontest results during therapy, as ordered.• If serum triglyceride and cholesterol levelsdon’t improve within 3 months, expect toswitch to a different drug, as prescribed.PATIENT TEACHING• Instruct patient to take gemfibrozil30 minutes before breakfast and 30 minutesbefore dinner.• Advise patient to take a missed dose assoon as he remembers, unless it’s nearlytime for the next dose. Caution againstdoubling the dose.• Stress importance of a low-fat diet, regularexercise, alcohol avoidance, and smokingcessation, as appropriate.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to notify prescriber if heexperiences chills; cough; fever; hoarseness;lower back, side, or muscle pain;painful or difficult urination; severeabdominal pain with nausea and vomiting;tiredness; or weakness.• If patient also takes an oral anticoagulant,urge him to report unusual bleeding orbruising; anticoagulant dosage may needto be reduced.• Advise patient to keep scheduled appointmentswith prescriber to check progress.gemifloxacinmesylateFactiveClass and CategoryChemical class: FluoroquinoloneTherapeutic class: AntibioticPregnancy category: CIndications and Dosages To treat acute bacterial exacerbation ofchronic bronchitis caused byStreptococcus pneumoniae,Haemophilus influenzae, H. parainfluenzae,or Moraxella catarrhalisTABLETSAdults. 320 mg daily for 5 days. To treat mild to moderate communityacquiredpneumonia caused by S. pneumoniae,H. influenzae, M. catarrhalis,Mycoplasma pneumoniae, Chlamydiapneumoniae, or Klebsiella pneumoniaeTABLETSAdults. 320 mg daily for 7 days.DOSAGE ADJUSTMENT Dosage should bedecreased to 160 mg daily in patients withcreatinine clearance of 40 ml/min/1.73 m 2or less.Route Onset Peak DurationP.O. 0.5–2 hr Unknown UnknownMechanism of ActionInhibits actions of the enzymes DNA gyraseand topoisomerase IV, which are required

for bacterial growth, thereby causing bacterialcells to die.ContraindicationsHypersensitivity to gemifloxacin, its components,or other fluroroquinolonesInteractionsDRUGSaluminum and magnesium antacids, didanosineas chewable or buffered tablets or pediatricpowder for oral solution, ferrous sulfate,sucralfate, zinc or other metal cations:Reduced blood gemifloxacin levelantipsychotics; class IA antiarrhythmics, suchas procainamide and quinidine; class IIIantiarrhythmics, such as amiodarone andsotalol; erythromycin; tricyclic antidepressants:Possibly prolonged QT intervalprobenecid: Increased blood gemifloxacinlevelwarfarin: Possibly enhanced warfarin anticoagulanteffectsAdverse ReactionsCNS: Dizziness, fever, headache, syncope,transient ischemic attackCV: Peripheral edema, prolonged QT interval,supraventricular tachycardia, vasculitisEENT: Taste perversionGI: Abdominal pain, acute hepatic necrosisor failure, diarrhea, elevated liver functiontest results, hepatitis, jaundice, nausea,pseudomembranous colitis, vomitingGU: Acute renal insufficiency or failure,interstitial nephritisHEME: Agranulocytosis, aplastic orhemolytic anemia, elevated platelet count,elevated INR, hemorrhage, leukopenia,pancytopenia, thrombocytopeniaMS: Arthralgia, myalgia, tendinitis, tendonruptureRESP: Allergic pneumonitisSKIN: Erythema multiforme, exfoliation,facial swelling, photosensitivity, rash,Stevens-Johnson syndrome, toxic epidermalnecrolysis, urticariaOther: Anaphylaxis, angioedema, serumsicknessNursing Considerations• Review patient’s medical history beforegiving gemifloxacin, which shouldn’t beused in patient with a history of prolongedQT interval, patient with uncorrectedelectrolyte disorders, or patientgemifloxacin mesylate 479receiving class IA or III antiarrhythmicsbecause of increased risk of prolonged QTinterval. Monitor elderly patients closelybecause they may be more susceptible toprolonged QT interval.• Use cautiously in patients with CNS disorders,such as epilepsy, or in those prone toseizures because other fluroquinoloneshave caused seizures, increased intracranialpressure, and toxic psychosis. Monitorpatient closely; if CNS alterations occur,notify prescriber immediately and expectdrug to be discontinued.• Monitor patient closely for hypersensitivityreaction, which may occur as soon asfirst dose. If patient has such evidence asangioedema, bronchospasm, dyspnea,itching, rash, jaundice, shortness of breath,and urticaria, notify prescriber immediatelyand expect drug to be discontinued.• Monitor patients prone to tendinitis, suchas the elderly, athletes, and those takingcorticosteroids, for reports of tendon pain,inflammation, or rupture. If present, notifyprescriber. Expect gemifloxacin to bediscontinued, patient placed on bedrestwith no exercise of affected limb, anddiagnostic tests ordered to confirm rupture.• Notify prescriber about severe or prolongeddiarrhea; it may indicate pseudomembranouscolitis caused by Clostridiumdifficile. If diarrhea occurs, notify prescriberand expect to withhold gemifloxacinand treat with fluids, electrolytes,protein, and an antibiotic effective againstC. difficile.• Monitor patients, especially women underage 40 and postmenopausal womenreceiving hormone replacement therapy,for rash. It may appear days after therapystars and resolve in 7 days. Notify prescriberimmediately if rash occurs becauseit can be severe in about 10% of patients.• If patient takes warfarin, monitor coagulationstatus, as ordered, because addinggemifloxacin may increase risk of bleeding.PATIENT TEACHING• Tell patient to swallow tablet whole andtake with a full glass of liquid.• Warn patient not to increase dose becausedoing so may cause life-threatening cardiacarrhythmias.• Instruct patient to complete entire courseof therapy, even if symptoms decreaseGHI

480IncompatibilitiesDon’t administer gentamicin through sameI.V. line as other drugs, especially betalactamantibiotics (penicillins and cephalosporins),because substantial mutual inactivationmay occur. Give drugs through sepagentamicinsulfatebefore prescription is finished.• Caution patient to avoid sun exposure asmuch as possible while taking gemifloxacin.Patient who can’t avoid sunexposure should apply sunscreen and weara hat, sunglasses, and long sleeves to coveras much skin as possible.• Instruct patient to maintain adequatehydration throughout therapy to keepurine from becoming too concentrated.Tell patient to increase fluid intake if urinedarkens or amount voided decreases.• Caution patient to avoid hazardous activitiesuntil CNS effects of drug are known.• Instruct patient to seek medical attentionand notify prescriber immediately if hehas tendon pain, tenderness, or rupture;evidence of hypersensitivity reaction, suchas rash, urticaria, difficulty breathing, orfacial swelling; or palpitations or faintingspells. The drug may need to be stopped.• Urge patient to tell prescriber about diarrheathat’s severe or lasts longer than3 days. Explain that watery or bloodystools can occur 2 or more months aftertherapy and can be serious, requiringprompt treatment.• Tell patient to consult prescriber beforestarting any new medications, includingOTC products, because gemifloxacin mayinteract adversely.• Inform patient that magnesium and/oraluminum antacids; products containingiron; multivitamins containing zinc orother metal cations; and didanosine(Videx) chewable or buffered tablets andpediatric powder for oral solution (if prescribed)shouldn’t be taken within 3 hoursbefore or 2 hours after gemifloxacin andthat gemifloxacin should be taken at least2 hours before sucralfate (if prescribed).• Instruct patient to alert prescriber aboutsevere diarrhea, even up to 2 months aftergemifloxacin therapy has ended.gentamicin sulfateCidomycin (CAN), Garamycin, G-Mycin,JenamicinClass and CategoryChemical class: Aminoglycoside derivedfrom Micromonospora purpureaTherapeutic class: AntibioticPregnancy category: DIndications and Dosages To treat serious bacterial infectionscaused by aerobic gram-negative organismsand some gram-positive organisms,including Citrobacter species,Enterobacter species, Escherichia coli,Klebsiella species, Proteus species,Pseudomonas aeruginosa, Serratiaspecies, Staphylococcus aureus, andmany strains of Streptococcus speciesI.V. INFUSION, I.M. INJECTIONAdults and adolescents. 1 to 1.7 mg/kgevery 8 hr for 7 to 10 days.Children. 2 to 2.5 mg/kg every 8 hr for 7 to10 days.Infants. 2.5 mg/kg every 8 to 16 hr for 7 to10 days.Premature or full-term neonates up to age1 week. 2.5 mg/kg every 12 to 24 hr for 7 to10 days.INTRATHECAL (INTRALUMBAR ORINTRAVENTRICULAR) INJECTIONAdults and adolescents. 4 to 8 mg daily.Infants and children age 3 months andover. 1 to 2 mg daily. To treat uncomplicated UTII.V. INFUSION, I.M. INJECTIONAdults and adolescents weighing morethan 60 kg (132 lb). 160 mg once daily or80 mg every 12 hr.Adults and adolescents weighing less than60 kg. 3 mg/kg once daily or 1.5 mg/kgevery 12 hr.DOSAGE ADJUSTMENT Supplemental dose of1 to 1.7 mg/kg (2 to 2.5 mg/kg for children)given by I.M. injection or I.V. infusion afterhemodialysis, based on infection severity.Mechanism of ActionBinds to negatively charged sites on theouter cell membrane of bacteria, therebydisrupting the membrane’s integrity.Gentamicin also binds to bacterial ribosomalsubunits and inhibits protein synthesis.Both actions lead to cell death.

ate sites.ContraindicationsHypersensitivity or serious toxic reaction toother aminoglycosides, hypersensitivity togentamicin or its componentsInteractionsDRUGSaminoglycosides (concurrent use of two ormore): Decreased bacterial uptake of eachdrug, increased risk of ototoxicity andnephrotoxicitycephalosporins, enflurane, methoxyflurane,vancomycin: Increased risk of nephrotoxicityloop diuretics: Increased risk of ototoxicityand nephrotoxicityneuromuscular blockers: Prolonged respiratorydepression, increased neuromuscularblockadepenicillins: Inactivation of gentamicin bycertain penicillins, increased risk of nephrotoxicityAdverse ReactionsCNS: Acute organic mental syndrome, confusion,depression, fever, headache,increased protein in cerebrospinal fluid,lethargy, myasthenia gravis–like syndrome,neurotoxicity (dizziness, hearing loss, tinnitus,vertigo), peripheral neuropathy orencephalopathy (muscle twitching, numbness,seizures, skin tingling), pseudotumorcerebriCV: Hypertension, hypotension, palpitationsEENT: Blurred vision, increased salivation,laryngeal edema, ototoxicity, stomatitis,vision changesGI: Anorexia, nausea, splenomegaly, transienthepatomegaly, vomitingGU: NephrotoxicityHEME: Anemia, eosinophilia, granulocytopenia,increased or decreased reticulocytecount, leukopenia, thrombocytopeniaMS: Arthralgia, leg crampsRESP: Pulmonary fibrosis, respiratorydepressionSKIN: Alopecia, generalized burning sensation,pruritus, purpura, rash, urticariaOther: Anaphylaxis, injection site pain,superinfection, weight lossNursing Considerations• Before gentamicin therapy begins, expectto obtain a body fluid or tissue specimenfor culture and sensitivity testing, asordered, or check test results, if available.• Drug is best absorbed when given by I.V.route. Blood level is unpredictable after I.M.administration.• For I.V. use, dilute each dose with 50 to200 ml normal saline solution or D 5 W toyield no more than 1 mg/ml. Administerslowly over 30 to 60 minutes.• Don’t give gentamicin through same I.V.line as other drugs without first consultingpharmacist.• Expect to adjust dosage based on peak andtrough blood drug levels drawn after thirdmaintenance dose, as prescribed.• Don’t give gentamicin by subcutaneousroute because it may be painful.• When assisting with intrathecal injection,use only 2 mg/ml of preservative-freepreparation. Drug may be injected directlyor delivered by implanted reservoir.• Don’t give drug to pregnant patientbecause it can cause hearing loss in fetus.WARNING When giving pediatric injectableform of drug, be alert for allergic reactions—includinganaphylaxis and possiblylife-threatening asthmatic episodes—because drug contains sodium bisulfite.• Assess patient for evidence of other infectionsbecause gentamicin may cause overgrowthof nonsusceptible organisms.• Be aware that premature infants, neonates,and elderly patients have an increased riskof nephrotoxicity.PATIENT TEACHING• Stress importance of completing fullcourse of gentamicin therapy.• Instruct patient to immediately reportadverse reactions, such as hearing loss, toavoid permanent effects.glimepirideAmarylClass and CategoryChemical class: SulfonylureaTherapeutic class: AntidiabeticPregnancy category: Cglimepiride 481Indications and Dosages To control blood glucose level in type 2diabetes mellitusTABLETSAdults. 1 to 2 mg daily with first meal ofGHI

482glimepiridethe day. Maintenance: 1 to 4 mg daily,increased by 1 to 2 mg every 1 to 2 wk asneeded for blood glucose control.Maximum: 8 mg daily.DOSAGE ADJUSTMENT Initial dosage reducedto 1 mg daily if needed for patients withrenal impairment. As adjunct (with insulin) to controlblood glucose levelTABLETSAdults. 8 mg daily with low-dose insulin.Route Onset Peak DurationP.O. 2–3 hr Unknown Over 24 hrMechanism of ActionStimulates insulin release from beta cells inpancreas. Glimepiride also increasesperipheral tissue sensitivity to insulin,either by enhancing insulin binding to cellularreceptors or by increasing the numberof insulin receptors.ContraindicationsDiabetes complicated by pregnancy; diabeticcoma; hypersensitivity to glimepiride, sulfonylureas,or their components; ketoacidosis;sole therapy for type 1 diabetes mellitusInteractionsDRUGSACE inhibitors, anabolic steroids, androgens,azole antifungals, bromocriptine, chloramphenicol,clarithromycin, disopyramide, fibricacid derivatives, fluoxetine, guanethidine,H 2 -receptor antagonists, insulin, magnesiumsalts, MAO inhibitors, methyldopa, NSAIDs,octreotide, oral anticoagulants, oxyphenbutazone,phenylbutazone, probenecid, quinidine,quinolones, salicylates, sulfonamides, tetracycline,theophylline, tricyclic antidepressants,urinary acidifiers: Increased risk of hypoglycemiaasparaginase, calcium channel blockers,cholestyramine, clonidine, corticosteroids,danazol, diazoxide, estrogen, glucagon,hydantoins, isoniazid, lithium, morphine,nicotinic acid, oral contraceptives, phenothiazines,rifabutin, rifampin, sympathomimetics,thiazide diuretics, thyroid drugs, urinaryalkalinizers: Increased risk of hyperglycemiabeta blockers: Possibly hyperglycemia ormasking of hypoglycemia signsdigoxin: Increased risk of digitalis toxicitypentamidine: Initially hypoglycemia andthen hyperglycemia if beta cell damageoccursACTIVITIESalcohol use: Altered blood glucose control(usually hypoglycemia)Adverse ReactionsCNS: Abnormal gait, anxiety, asthenia,chills, depression, dizziness, fatigue,headache, hypertonia, hypoesthesia, insomnia,malaise, migraine headache, nervousness,paresthesia, somnolence, syncope,tremor, vertigoCV: Arrhythmias, edema, hypertension,vasculitisEENT: Blurred vision, conjunctivitis, eyepain, pharyngitis, retinal hemorrhage,rhinitis, taste perversion, tinnitusENDO: HypoglycemiaGI: Anorexia, constipation, diarrhea, elevatedliver function test results, epigastric discomfortor fullness, flatulence, heartburn,hunger, nausea, proctocolitis, trace blood instool, vomitingGU: Darkened urine, decreased libido,dysuria, polyuriaHEME: Agranulocytosis, aplastic anemia,eosinophilia, hemolytic anemia, hepaticporphyria, leukopenia, pancytopeniaMS: Arthralgia, leg cramps, myalgiaRESP: DyspneaSKIN: Allergic skin reactions, diaphoresis,eczema, erythema multiforme, exfoliativedermatitis, flushing, jaundice, lichenoidreactions, maculopapular or morbilliformrash, photosensitivity, pruritus, urticariaOther: Disulfiram-like reactionNursing Considerations• Monitor fasting blood glucose level todetermine response to glimepiride. Expectto check glycosylated hemoglobin levelevery 3 to 6 months to evaluate long-termblood glucose control.• Arrange for dietary consultation and diabeticteaching, if appropriate. Ask dietitianto discuss amount of alcohol patient canconsume without risking hypoglycemia.• Expect to switch patient to insulin therapy,as prescribed, during physical stress, suchas infection, surgery, and trauma.WARNING Expect a higher risk of hypoglycemiawhen giving glimepiride to a malnourishedor debilitated patient or onewith renal, hepatic, pituitary, or adrenal

insufficiency. Also be aware that hypoglycemiamay be more difficult to recognizein patients with autonomic neuropathy,the elderly, and patients taking betablockers or other sympatholytic agents.Monitor blood glucose level closely.• Monitor patient with a history of allergiesto other sulfonamide derivatives closelybecause he may be allergic to glimepiride.If allergic reactions persist or worsen (dyspnea,drop in blood pressure, or shock),expect drug to be discontinued.PATIENT TEACHING• Instruct patient to take glimepiride justbefore first meal of the day. Caution himnot to skip the meal after taking drug.• Urge patient not to skip doses or increasedosage without consulting prescriber.• Urge patient to report signs of hypoglycemia,such as anxiety, confusion, dizziness,excessive sweating, headache, and nausea.• Encourage patient to carry candy or othersimple sugars to treat mild hypoglycemia.• Advise patient to consult prescriber beforetaking any OTC drug.• Urge patient to carry identification indicatingthat he has diabetes.• Teach patient how to monitor his bloodglucose level.• Teach patient about exercise, diet, signs ofhyperglycemia and hypoglycemia, hygiene,foot care, and ways to avoid infection.• Instruct patient to notify prescriber aboutdarkened urine, difficulty controlling hisblood glucose level, easy bruising, fever,rash, sore throat, or unusual bleeding.• If photosensitivity is a problem, instructpatient to avoid direct sunlight and towear sunscreen.glipizideGlucotrol, Glucotrol XLClass and CategoryChemical class: SulfonylureaTherapeutic class: AntidiabeticPregnancy category: CIndications and Dosages To control blood glucose level in type 2diabetes mellitusE.R. TABLETSAdults. Initial: 5 mg daily with breakfast.glipizide 483Dosage increased by 5 mg daily every 3 mo,if needed. Maintenance: 5 to 10 mg daily.Maximum: 20 mg daily.TABLETSAdults. Initial: 5 mg 30 min before firstmeal of day. Dosage adjusted by 2.5 to 5 mgevery 2 to 3 days. For daily dose of 15 mgor less, give as a single dose. For dose above15 mg daily, give in 2 divided doses.Maximum: 40 mg daily. As adjunct to or replacement for insulintherapy in type 2 diabetes mellitusCAPSULES, TABLETSAdults who need more than 20 unitsinsulin daily. 5 mg daily, while decreasinginsulin dosage by one-half. Further insulinreductions are based on clinical response.DOSAGE ADJUSTMENT Initial dosage reducedto 2.5 mg daily if needed for patients overage 65 and those with hepatic disease.Route Onset Peak DurationP.O. 10–30 30 min– 12–24 hrmin 2 hrP.O. (E.R.) Unknown Unknown 18–24 hrMechanism of ActionStimulates insulin release from beta cells inpancreas. Glipizide also increases peripheraltissue sensitivity to insulin, either byincreasing insulin binding to cellular receptorsor by increasing number of insulinreceptors.ContraindicationsDiabetes complicated by pregnancy; diabeticcoma; hypersensitivity to glipizide, sulfonylureas,or their components; ketoacidosis;sole therapy for type 1 diabetes mellitusInteractionsDRUGSACE inhibitors, anabolic steroids, androgens,azole antifungals, bromocriptine, chloramphenicol,disopyramide, fibric acid derivatives,guanethidine, H 2 -receptor antagonists,insulin, magnesium salts, MAO inhibitors,methyldopa, octreotide, oral anticoagulants,oxyphenbutazone, phenylbutazone, probenecid,quinidine, salicylates, sulfonamides,tetracycline, theophylline, tricyclic antidepressants,urinary acidifiers: Increased risk ofhypoglycemiaasparaginase, calcium channel blockers,cholestyramine, clonidine, corticosteroids,GHI

484glipizidedanazol, diazoxide, estrogen, glucagon,hydantoins, isoniazid, lithium, morphine,nicotinic acid, oral contraceptives, phenothiazines,rifabutin, rifampin, sympathomimetics,thiazide diuretics, thyroid drugs, urinaryalkalinizers: Increased risk of hyperglycemiabeta blockers: Possibly hyperglycemia ormasking of hypoglycemia signsdigitalis glycosides: Increased risk of digitalistoxicitypentamidine: Initially hypoglycemia andthen hyperglycemia if beta cell damageoccursFOODSall foods: Possibly delayed absorption oftablets if taken within 30 minutes of mealACTIVITIESalcohol use: Altered blood glucose control(usually hypoglycemia)Adverse ReactionsCNS: Abnormal gait, anxiety, asthenia,chills, depression, dizziness, fatigue, headache,hypertonia, hypoesthesia, insomnia,malaise, migraine headache, nervousness,paresthesia, somnolence, syncope, tremor,vertigoCV: Arrhythmias, edema, hypertension,vasculitisEENT: Blurred vision, conjunctivitis, eyepain, pharyngitis, retinal hemorrhage,rhinitis, taste perversion, tinnitusENDO: HypoglycemiaGI: Abdominal pain, anorexia, constipation,diarrhea, elevated liver function test results,epigastric discomfort or fullness, flatulence,heartburn, hunger, nausea, proctocolitis,trace blood in stool, vomitingGU: Darkened urine, decreased libido,dysuria, polyuriaHEME: Agranulocytosis, aplastic anemia,eosinophilia, hemolytic anemia, hepaticporphyria, leukopenia, pancytopeniaMS: Arthralgia, leg cramps, myalgiaRESP: DyspneaSKIN: Allergic skin reactions, diaphoresis,eczema, erythema multiforme, exfoliativedermatitis, flushing, jaundice, lichenoidreactions, maculopapular or morbilliformrash, photosensitivity, urticariaOther: Disulfiram-like reactionNursing Considerations• Use cautiously in patients with glucose 6-phosphate dehydrogenase deficiencybecause hemolytic anemia may develop.Monitor patient’s CBC closely.• To improve blood glucose control, givedrug in divided doses instead of once daily.• Check blood glucose level at least threetimes daily for a patient switching frominsulin to glipizide. Patients who takemore than 40 units of insulin daily mayneed hospitalization during transition.• If patient gradually loses responsiveness toglipizide, expect to give a second antidiabeticto maintain blood glucose control.• Monitor fasting blood glucose level todetermine response to drug. Expect tocheck glycosylated hemoglobin every 3 to6 months or as ordered to evaluate longtermblood glucose control.• Expect to switch patient to insulin therapy,as prescribed, during physical stress, suchas infection, surgery, or trauma.WARNING Risk of hypoglycemia is higherwhen giving glipizide to a malnourishedor debilitated patient or one with renal,hepatic, pituitary, or adrenal insufficiency.PATIENT TEACHING• Tell patient to take glipizide 30 minutesbefore the first meal of the day. Cautionhim not to skip the meal after taking thedrug.• Advise patient not to skip doses orincrease the dosage without consultingprescriber.• Urge patient to report evidence ofhypoglycemia, such as anxiety, confusion,dizziness, excessive sweating, headache,and nausea.• Encourage patient to carry candy or othersimple sugars to treat mild hypoglycemia.• Caution patient to consult prescriberbefore taking any OTC drugs.• Urge patient to carry identification indicatingthat he has diabetes.• Teach patient how to monitor his bloodglucose level.• Teach patient about exercise, diet, signs ofhyperglycemia and hypoglycemia, hygiene,foot care, and ways to avoid infection.• Instruct patient to notify prescriber if heexperiences darkened urine, easy bruising,fever, hypoglycemia or hyperglycemia,rash, sore throat, and unusual bleeding.• If photosensitivity is a problem, instructpatient to avoid direct sunlight and towear sunscreen.

glucagonGlucaGen, Glucagon Diagnostic Kit,Glucagon Emergency KitClass and CategoryChemical class: Synthetic hormoneTherapeutic class: Antihypoglycemic,diagnostic aid adjunctPregnancy category: BIndications and Dosages To provide emergency treatment ofsevere hypoglycemiaI.V., I.M., OR SUBCUTANEOUS INJECTIONAdults and children weighing more than20 kg (44 lb) or, with GlucaGen, more than25 kg (55 lb). 1 mg, repeated in 15 min ifneeded.Children weighing 20 kg or less or, withGlucaGen, 25 kg or less. 0.5 mg, or 0.02 to0.03 mg/kg, repeated in 15 min, if needed. To provide diagnostic assistance byinhibiting bowel peristalsis in radiologicexamination of GI tractI.V. INJECTIONAdults. 0.25 to 2 mg before procedure. Dose,route, and timing vary with segment of GItract examined and length of procedure.Route Onset Peak DurationI.V. 5–20 Unknown 90 min*‡min*†I.M. 15–26 Unknown 90 min*||min*§SubQ 30–45 Unknown 90 min*min** For antihypoglycemic action.† 45 sec to 1 min for smooth-muscle relaxation.‡ 9 to 25 min for smooth-muscle relaxation.§ 4 to 10 min for smooth-muscle relaxation.|| 12 to 32 min for smooth-muscle relaxation.glucagon 485Mechanism of ActionIncreases production of adenylate cyclase,which catalyzes conversion of adenosinetriphosphate to cAMP, a process that inturn activates phosphorylase. Phosphorylasepromotes breakdown of glycogen toglucose (glycogenolysis) in the liver. As aresult, blood glucose level increases and GIsmooth muscles relax.IncompatibilitiesDon’t mix glucagon with sodium chlorideor solutions that have a pH of 3.0 to 9.5;use with dextrose solutions instead.ContraindicationsHypersensitivity to glucagon or its components,pheochromocytomaInteractionsDRUGSoral anticoagulants: Possibly increased anticoagulanteffectsAdverse ReactionsCV: Hypertension, hypotension (withhypersensitivity reaction), tachycardiaGI: Nausea, vomitingRESP: Bronchospasm, respiratory distressSKIN: UrticariaNursing Considerations• Rouse patient as quickly as possiblebecause prolonged hypoglycemia cancause cerebral damage.• For I.V. use, reconstitute 1-mg vial ofglucagon with 1 ml of diluent or 10-mgvial with 10 ml of diluent. Don’t give morethan 1 mg/ml. For large doses, dilute withsterile water for injection.• Before injecting glucagon, place unconsciouspatient on his side to prevent aspirationof vomitus when he regains consciousness.• Administer by slow I.V. injection todecrease risk of adverse reactions, such astachycardia and vomiting.• If patient doesn’t respond to glucagon,expect to give I.V. dextrose.• When patient is conscious or diagnosticprocedure is completed, give oral carbohydratesto restore hepatic glycogen storesand prevent secondary hypoglycemia.• Keep in mind that glucagon isn’t effectivein patients with depleted hepatic glycogenstores caused by such conditions as adrenalinsufficiency, chronic hypoglycemia,and starvation.PATIENT TEACHING• Instruct patient to monitor blood glucoselevel, especially with signs of hypoglycemia.GHI

486glyburide• Teach patient and family members how torecognize signs of hypoglycemia and whento notify prescriber.• Advise patient to carry candy or othersimple sugars to treat early hypoglycemia.• Emphasize importance of a consistentdiet, regular exercise, and proper use ofinsulin or oral antidiabetic drug.• Make sure unstable diabetic patients andfamily members know how to giveglucagon subcutaneously in case of hypoglycemia.Instruct family members to keeppatient on his side and give him a carbohydratewhen he awakens. Advise againstgiving fluids by mouth until patient isfully conscious.• Instruct patient and family members tocall for emergency medical assistance afterglucagon treatment, especially if patientcan’t ingest oral glucose or if he’s takingthe sulfonylurea chlorpropamide, in casesecondary hypoglycemia occurs.glyburide(glibenclamide)Albert Glyburide (CAN), Apo-Glyburide(CAN), DiaBeta, Euglucon (CAN), Gen-Glybe (CAN), Glynase PresTab, Medi-Glybe (CAN), Micronase, Novo-Glyburide (CAN), Nu-Glyburide (CAN)Class and CategoryChemical class: SulfonylureaTherapeutic class: AntidiabeticPregnancy category: C (B for GlynasePresTab and Micronase)Indications and Dosages To control blood glucose level in type 2diabetes mellitusMICRONIZED TABLETSAdults. Initial: 1.5 to 3 mg daily with firstmeal of day, increased by up to 1.5 mg atweekly intervals, if needed. Maintenance:0.75 to 12 mg as a single dose or in divideddoses with meals.NONMICRONIZED TABLETSAdults. Initial: 2.5 to 5 mg daily with firstmeal of the day, increased by up to 2.5 mgat weekly intervals, if needed. Maintenance:1.25 to 20 mg daily as a single dose or individed doses with meals.DOSAGE ADJUSTMENT For conversion frominsulin to glyburide for adults who usemore than 40 units of insulin daily, initialdosage adjusted to 5 mg nonmicronized or3 mg micronized glyburide as a single dosewith 50% of usual insulin dose; glyburidedosage increased gradually, as needed. Foradults who use less than 40 units insulindaily, usual glyburide dosage is used wheninsulin is discontinued.For elderly patients, initial dosage possiblyreduced to 1.25 mg nonmicronized glyburidedaily, gradually increased by 2.5 mg/wk, as needed; or 0.75 to 3 mg micronizeddaily, gradually increased by 1.5 mg/wk, asneeded.Route Onset Peak DurationP.O.* 1 hr 2.3–3.5 hr 12–24 hrP.O.† 15–60 min 1–3 hr 24 hrMechanism of ActionStimulates insulin release from beta cells inthe pancreas. Glyburide also increasesperipheral tissue sensitivity to insulin eitherby enhancing insulin binding to cellularreceptors or by increasing the number ofinsulin receptors.ContraindicationsConcurrent therapy with bosentan, diabetescomplicated by pregnancy; diabetic ketoacidosis;hypersensitivity to glyburide,sulfonylureas, or their components; ketoacidosis;type 1 diabetes mellitusInteractionsDRUGSACE inhibitors, anabolic steroids, androgens,azole antifungals, bromocriptine, chloramphenicol,clarithromycin, disopyramide, fibricacid derivatives, fluoxetine, guanethidine,H 2 -receptor antagonists, insulin, magnesiumsalts, MAO inhibitors, methyldopa, NSAIDs,octreotide, oral anticoagulants, oxyphenbutazone,phenylbutazone, probenecid, quinidine,quinolones, salicylates, sulfonamides, tetracycline,theophylline, tricyclic antidepressants,urinary acidifiers: Increased risk of hypoglycemiaasparaginase, calcium channel blockers,cholestyramine, clonidine, corticosteroids,* Micronized.† Nonmicronized.

danazol, diazoxide, estrogen, glucagon,hydantoins, isoniazid, lithium, morphine,nicotinic acid, oral contraceptives, phenothiazines,rifabutin, rifampin, sympathomimetics,thiazide diuretics, thyroid drugs, urinaryalkalinizers: Increased risk of hyperglycemiabeta blockers: Possibly hyperglycemia ormasking of hypoglycemia signsbosentan: Increased risk of elevated liverenzymescyclosporine: Increased cyclosporine plasmalevel and toxicitydigitalis glycosides: Increased risk of digitalistoxicitymiconazole (oral): Possibly severe hypoglycemiaoral anticoagulants: Possibly potentiated orweakened anticoagulant effectspentamidine: Initial hypoglycemia and thenhyperglycemia if beta cell damage occursrifampin: Decreased glyburide effectivenessFOODShigh-fat foods: Reduced bioavailability ofnonmicronized glyburideACTIVITIESalcohol use: Altered blood glucose control(usually hypoglycemia)Adverse ReactionsCNS: Abnormal gait, anxiety, asthenia,chills, depression, dizziness, fatigue, headache,hypertonia, hypoesthesia, insomnia,malaise, migraine headache, nervousness,paresthesia, somnolence, syncope, tremor,vertigoCV: Arrhythmias, edema, hypertension,vasculitisEENT: Blurred vision, conjunctivitis, eyepain, pharyngitis, retinal hemorrhage,rhinitis, taste perversion, tinnitusENDO: HypoglycemiaGI: Anorexia, constipation, cholestaticjaundice, diarrhea, elevated liver functiontest results, epigastric discomfort or fullness,flatulence, heartburn, hepatic failure,hepatitis, hunger, nausea, proctocolitis,trace blood in stool, vomitingGU: Decreased libido, dysuria, polyuriaHEME: Agranulocytosis, aplastic anemia,eosinophilia, hemolytic anemia, hepaticporphyria, leukopenia, pancytopeniaMS: Arthralgia, leg cramps, myalgiaRESP: DyspneaSKIN: Allergic skin reactions, diaphoresis,eczema, erythema multiforme, exfoliativeglyburide 487dermatitis, flushing, jaundice, lichenoidreactions, maculopapular or morbilliformrash, photosensitivity, urticariaOther: Disulfiram-like reactionNursing Considerations• Use cautiously in patients with glucose 6-phosphate dehydrogenase deficiencybecause hemolytic anemia may develop.Monitor patient’s CBC closely.• Give glyburide as single dose before firstmeal of the day. If patient takes more than10 mg daily or if severe GI distress occurs,give in 2 divided doses before meals.• Monitor fasting blood glucose level todetermine patient’s response to glyburide.Expect to check glycosylated hemoglobinevery 3 to 6 months or as ordered to evaluatelong-term blood glucose control.• When patient switches from insulin to glyburide,check blood glucose level threetimes daily before meals.• Be aware that micronized tablets aren’tequal to nonmicronized tablets; they containsmaller particles, which affects drugbioavailability.WARNING Expect a higher risk of hypoglycemiawhen giving drug to a malnourishedor debilitated patient or one withrenal, hepatic, pituitary, or adrenal insufficiency.Also be aware that hypoglycemiamay be more difficult to recognize inpatients with autonomic neuropathy, theelderly, and patients who are taking betablockers or other sympatholytic agents.Monitor blood glucose level closely.• Monitor patient with history of allergies toother sulfonamide derivatives closelybecause he may be allergic to glyburide. Ifallergic reactions persist or worsen (dyspnea,drop in blood pressure, or shock),expect drug to be discontinued.• Administer insulin as needed and prescribedduring periods of increased stress,such as infection, surgery, and trauma.• Arrange for diabetic teaching and consultationbetween patient and dietitian, ifappropriate.PATIENT TEACHING• Instruct patient to take glyburide justbefore first meal of he day. Caution himnot to skip the meal after taking drug.• Advise patient not to take nonmicronizedglyburide with a high-fat meal because itmay reduce glyburide bioavailability.GHI

488ContraindicationsAngle-closure glaucoma, asthma, hemorglycopyrrolate• Caution patient to avoid skipping doses,discontinuing glyburide, or taking OTCdrugs without first consulting prescriber.• Teach patient how to monitor his bloodglucose level and when to notify prescriberabout changes.• Urge patient to report signs of hypoglycemia:anxiety, confusion, dizziness, excessivesweating, headache, and nausea.• Suggest that patient carry candy or othersimple sugars to treat mild hypoglycemia.• Urge patient to avoid alcohol because itincreases the risk of hypoglycemia.• Advise patient to carry identification indicatingthat he has diabetes.• Teach patient about exercise, diet, signs ofhyperglycemia and hypoglycemia, hygiene,foot care, and ways to avoid infection.• Instruct patient to notify prescriber if heexperiences easy bruising, fever, hypoglycemiaor hyperglycemia, rash, sore throat,and unusual bleeding.• If photosensitivity is a problem, instructpatient to avoid direct sunlight and towear sunscreen.glycopyrrolateRobinul, Robinul ForteClass and CategoryChemical class: Quaternary ammoniumcompoundTherapeutic class: Antiarrhythmic, anticholinergic,cholinergic adjunctPregnancy category: BIndications and Dosages To treat peptic ulcer diseaseTABLETSAdults and adolescents. 1 to 2 mg b.i.d. ort.i.d. Maximum: 8 mg daily.I.V. OR I.M. INJECTIONAdults and adolescents. 0.1 to 0.2 mg every4 hr, p.r.n. Maximum: 4 doses daily. To reduce gastric acid and respiratorysecretions before anesthesiaI.M. INJECTIONAdults and adolescents. 0.0044 mg/kg 30 to60 min before anesthesia or when preanesthesiasedative or opioid is given.Children over age 2. 0.0044 to 0.0088 mg/kg 30 to 60 min before anesthesia or whenpreanesthesia sedative or opioid is given. To counteract intraoperative andanesthesia-induced arrhythmiasI.V. INJECTIONAdults and adolescents. 0.1 mg, repeatedevery 2 to 3 min, if needed.Children over age 2. 0.0044 mg/kg. Doserepeated every 2 to 3 min, if needed.Maximum: 0.1 mg as a single dose. As cholinergic adjunct in curariformblockI.V. INJECTIONAdults and children over age 2. 0.2 mg glycopyrrolatefor each 1 mg neostigmine or5 mg pyridostigmine when given together.Route Onset Peak DurationP.O. 60 min Unknown 8–12 hrI.V. 1 min Unknown 2–3 hr*I.M., 15–30 30–45 2–3 hr*SubQ min minMechanism of ActionInhibits acetylcholine’s action on postganglionicmuscarinic receptors throughoutthe body. Depending on the receptors’ location,glycopyrrolate produces variouseffects, such as:• reducing the volume and acidity of gastricsecretions• controlling excessive bronchial, pharyngeal,and tracheal secretions and dilatingthe bronchi• inhibiting vagal stimulation of the heart• relaxing smooth muscle in the GI and GUtracts.IncompatibilitiesDon’t mix glycopyrrolate with alkalinedrugs or solutions that have a pH over 6.0because drug stability may be affected. ApH over 6.0 may occur if glycopyrrolate ismixed with dexamethasone sodium phosphateor LR solution. Gas or precipitatemay form if glycopyrrolate is mixed insame syringe as chloramphenicol,diazepam, dimenhydrinate, methohexitalsodium, pentobarbital sodium, secobarbitalsodium, sodium bicarbonate, or thiopentalsodium.* For vagal blocking effect; up to 7 hr forreduction of saliva.

hage with unstable cardiovascular status,hepatic disease, hypersensitivity to anticholinergics,ileus, intestinal atony, myastheniagravis, obstructive GI or urinary disorders,severe ulcerative colitis, toxic megacolonInteractionsDRUGSanticholinergics, antiparkinsonian drugs,phenothiazines, tricyclic antidepressants:Possibly increased anticholinergic effectsantidiarrheals (adsorbent): Decreased glycopyrrolateabsorption, leading todecreased therapeutic effectivenessantimyasthenics: Possibly reduced intestinalmotilityatenolol: Possibly potentiated atenololeffectscalcium- or magnesium-containing antacids,carbonic anhydrase inhibitors, citrates, sodiumbicarbonate: Possibly reduced excretionof glycopyrrolate and increased therapeuticand adverse effectscyclopropane: Possibly ventricular arrhythmiasdigoxin: Possibly potentiated digoxin effectshaloperidol, phenothiazines: Possiblydecreased effectiveness of these drugsketoconazole: Possibly decreased ketoconazoleabsorptionmetoclopramide: Possibly antagonizedeffects of metoclopramideopioids: Possibly severe constipation andurine retention, risk of ileuspotassium chloride: Possibly increased severityof potassium chloride–induced gastriclesionsglycopyrrolate 489Adverse ReactionsCNS: Confusion, dizziness, drowsiness,headache, insomnia, nervousness, weaknessCV: Bradycardia (low doses), heart block,palpitations, prolonged QT interval, tachycardia(high doses)EENT: Blurred vision, cycloplegia, dilatedpupils, dry mouth, increased intraocularpressure, loss of taste, mydriasis, nasal congestion,photophobia, taste perversionGI: Abdominal distention, constipation,dysphagia, nausea, vomitingGU: Impotence, urinary hesitancy, urineretentionRESP: DyspneaSKIN: Decreased sweating (heat exhaustion),dry skin, flushing, pruritus, urticariaOther: AnaphylaxisNursing Considerations• Use glycopyrrolate cautiously in patientswith autonomic neuropathy, hepatic disease,mild to moderate ulcerative colitis,prostatic hypertrophy, or hiatal herniabecause drug’s anticholinergic effect canworsen these conditions; gastric ulcerbecause drug may delay gastric emptying;and renal disease because drug excretionmay be altered.• Give tablets 30 to 60 minutes before meals.• As needed and prescribed, give 2-mg doseat bedtime to ensure overnight control ofsymptoms.• For I.V. use, administer by direct injectionwithout diluting. Or inject into tubing offlowing I.V. solution unless it contains analkaline drug or sodium bicarbonate.• Closure system contains dry natural rubberthat may cause hypersensitivity reactionif handled by or used to inject someonewith latex sensitivity.• Use continuous cardiac monitoring, asordered, to assess patient for arrhythmiasduring drug administration.WARNING Check all doses carefully becauseeven a slight overdose can lead to toxicity.• To prevent overheating caused bydecreased sweating, adjust the room temperatureand make sure patient is wellhydrated.PATIENT TEACHING• Advise patient to take glycopyrrolate tablets30 to 60 minutes before meals.• Instruct patient to consult prescriberbefore taking any OTC drugs.• Caution patient about possible drowsinessand dizziness and need to avoid hazardousactivities until drug’s effects are known.• Suggest that patient use sugarless hardcandy, ice, or saliva substitute to relievedry mouth.• Instruct patient to avoid exertion and hotenvironments because he’s prone to heatexhaustion while taking glycopyrrolate.• Urge patient to drink at least 8 glasses ofwater daily, unless contraindicated.• Tell patient to notify prescriber aboutabdominal distention, trouble breathing orurinating, eye pain, irregular heartbeat,sensitivity to light, or severe constipation.GHI

490golimumab• Advise patient to wear sunglasses in brightlight.• Inform male patient that reversible impotencemay occur during therapy.• If urinary hesitancy occurs, advise patientto void before taking each dose.golimumabSimponiClass and CategoryChemical class: Human IgG 1 monoclonalantibodyTherapeutic class: Biologic diseasemodifyinganti-rheumatic drug (DMARD)Pregnancy category: BIndications and Dosages To treat moderate to severe activerheumatoid arthritis in combinationwith methotrexate; to treat active psoriaticarthritis or ankylosing spondylitiswith or without methotrexate or othernonbiologic DMARDsSUBCUTANEOUS INJECTIONAdults. 50 mg monthly.Route Onset Peak DurationSubQ Unknown 2–6 days UnknownMechanism of ActionBinds to a cytokine protein, tumor necrosisfactor alpha (TNFa), to block interactionwith its receptors, which prevents biologicalactivity of TNFa. Elevated TNFa levels inthe blood, synovium, and joints may playan important role in pathophysiology ofsuch inflammatory diseases as rheumatoidarthritis, psoriatic arthritis, and ankylosingspondylitis. Reduced TNFa activity in thesedisorders improves signs and symptoms.ContraindicationsHypersensitivity to golimumab or its componentsInteractionsDRUGSabatacept, anakinra, rituximab: Possiblyincreased risk of serious infectioncytochrome P-450 substrates such ascyclosporine, theophylline, warfarin: Effectsor blood levels of these drugs may changewhen golimumab therapy starts or stopslive vaccines: Increased risk of adverse vaccineeffectsAdverse ReactionsCNS: Dizziness, fever, paresthesiaCV: HypertensionEENT: Nasopharyngitis, oral herpes,pharyngitis, rhinitis, sinusitisGI: Elevated liver enzyme levelsRESP: Bronchitis, pneumonia, tuberculosis,upper respiratory tract infectionSKIN: Cellulitis, new or worsening psoriasisOther: Abscess, antibody formation, infections(including invasive fungal infectionsand reactivation of hepatitis B infection inchronic carriers), influenza, injection siteerythema, lupus-like syndrome, malignanciessuch as lymphoma or leukemia, sepsisNursing Considerations• Make sure patient has a tuberculin skintest before therapy starts. If skin test ispositive, treatment of latent tuberculosismust start before golimumab therapystarts, as prescribed. Also expect antituberculosistherapy to be started ifpatient has a history of latent or activetuberculosis, if adequate therapy can’t beconfirmed, or if patient has a negative testfor latent tuberculosis but also has riskfactors for tuberculosis.WARNING If patient has evidence of anactive infection when drug is prescribed,golimumab therapy shouldn’t start untilinfection has been treated. Monitor allpatients for infection during therapy, especiallythose receiving immunosuppressants.If a serious infection, an opportunisticinfection, or sepsis develops,expect prescriber to stop drug and startappropriate antimicrobial therapy.• Patients with a history of cancer, exceptthose successfully treated for nonmelanomaskin cancer, should be thoroughlyevaluated before golimumab therapystarts because treatment may posemore risks than benefits. Patients withrheumatoid arthritis may have a higherrisk than the general population for developingleukemia while taking a TNF blockersuch as golimumab.• Use golimumab cautiously in patients withrecurrent infection or increased risk ofinfection, patients who live in regions

where tuberculosis and histoplasmosis areendemic, and patients with a history ofhepatitis B infection because drug increasesrisk of infection.• Use golimumab cautiously in patients withcongestive heart failure, demyelinating disorderssuch as multiple sclerosis, andhematologic cytopenias because these disordershave occurred with use of otherTNF blockers.• Be aware that needle cover of syringe containsdry rubber. Don’t handle if you’reallergic to latex.• Take golimumab out of the refrigerator30 minutes before giving injection to allowtime for drug to warm up to room temperature.Never warm drug in any otherway. Rotate injection sites.PATIENT TEACHING• Explain that first injection of golimumabmust be administered with a health careprofessional present.• Teach patient or caregiver how to givegolimumab as a subcutaneous injection athome, if applicable. Tell him to let prefilledsyringe or autoinjector sit at roomtemperature outside carton for 30 minutesbefore injecting. Tell him not to warmdrug in any other way and not to removeneedle cover or cap while letting golimumabwarm up.• Teach patient using autoinjector not topull the device away from his skin until hehears a first “click” and then a second“click” indicating the injection is finished.It may take up to 15 seconds before secondclick is heard and, if device is pulledaway from the skin before the secondclick, a full dose may not have been given.• Emphasize need to inject full amount inprefilled syringe to obtain correct 50-mgdose. Instruct patient to discard any drugleft in prefilled syringe or autoinjector.• If patient is allergic to latex, explain thatneedle cover contains natural dry rubber.• Instruct patient or caregiver to use a punctureresistant container to dispose of needlesand syringes at home.• Inform patient that drug must be refrigerated(not frozen).• Urge patient to check expiration dates andnot to use outdated drug.• Teach patient to rotate injection sites andnever to give injection into an area wheregranisetron hydrochloride 491skin is tender, bruised, red, or hard.• Explain that tuberculosis may occur duringgolimumab therapy. Instruct him toreport persistent cough, wasting or weightloss, and low-grade fever to prescriber.• Teach patient to recognize evidence ofinfection and bleeding disorders and totell prescriber if they occur; drug mayneed to be stopped. Advise patient toavoid people with infections and to haveall prescribed laboratory tests performed.• Inform patient that golimumab therapyincreases the risk of certain kinds of cancer,especially lymphomas and leukemias.Emphasize the importance of having follow-upvisits and reporting unusual orsudden onset of signs or symptoms.• Caution against receiving live-virus vaccineswhile taking golimumab; doing somay adversely affect the immune system.• Tell patient to report lupus-like signs andsymptoms that, although rare, may occurduring therapy, such as chest pain thatdoesn’t go away, shortness of breath, jointpain, or a rash on cheeks or arms that’ssensitive to the sun. Explain that drug mayneed to be discontinued if these occur.• Advise patient to tell all health careproviders about golimumab therapy andto tell prescriber about any OTC drugs,herbal remedies, and vitamin and mineralsupplements being taken.granisetronhydrochlorideKytril, SancusoClass and CategoryChemical class: CarbazoleTherapeutic class: AntiemeticPregnancy category: BIndications and Dosages To prevent nausea and vomiting causedby chemotherapyORAL SOLUTION, TABLETSAdults and adolescents. 1 mg up to 1 hrbefore chemotherapy, repeated 12 hr later.Or, 2 mg up to 1 hr before chemotherapy.I.V. INFUSIONAdults and adolescents. 10 mcg/kg dilutedand infused over 5 min, starting 30 minGHI

492guaifenesinbefore chemotherapy; or 10 mcg/kg undilutedand infused over 30 sec, starting30 min before chemotherapy.TRANSDERMALAdults. 3.1 mg/24 hr patch applied to upperouter arm 24 to 48 hr before chemotherapyand worn up to 7 days. Patch removed nosooner than 24 hr after chemotherapy iscompleted. To prevent nausea and vomiting causedby radiation therapyORAL SOLUTION, TABLETSAdults and adolescents. 2 mg daily given1 hr before radiation therapy. To prevent or treat postoperative nauseaand vomitingI.V. INJECTIONAdults and adolescents. 1 mg given over30 sec before induction of anesthesia orimmediately before reversal anesthesia forprevention. 1 mg administered over 30 secafter surgery for treatment.Mechanism of ActionHas a high affinity for serotonin receptorsalong vagal nerve endings in intestines.Because of this affinity, granisetron preventsnausea and vomiting that usuallyresult when serotonin is released by damagedenterochromaffin cells.IncompatibilitiesDon’t mix granisetron in same solution asother drugs.ContraindicationsHypersensitivity to granisetron or its componentsInteractionsDRUGSdrugs that prolong the QT interval: Increasedrisk of QT-interval prolongationAdverse ReactionsCNS: Asthenia, chills, CNS stimulation,drowsiness, fever, headache, insomnia, somnolenceCV: Hypertension, prolonged QT intervalEENT: Taste perversionGI: Abdominal pain, anorexia, constipation,diarrhea, elevated liver function test results,nausea, vomitingHEME: Anemia, leukopenia, thrombocytopeniaSKIN: Alopecia, reactions at patch applicationsite (pruritus, rash, redness)Nursing Considerations• Use cautiously in patients with arrhythmiasor cardiac conduction disordersbecause granisetron may prolong QTinterval. Patients especially at risk includethose with cardiac disease or electrolyteabnormalities and those receiving cardiotoxicchemotherapy or therapy withanother drug that prolongs QT interval.• For use with chemotherapy, dilute I.V.preparation of granisetron with normalsaline solution or D 5 W to total volume of20 to 50 ml. Mixture may be stored up to24 hours. Use only on days when chemotherapyis given.• Apply transdermal patch to patient’supper outer arm 24 to 48 hours beforechemotherapy, and don’t remove it until atleast 24 hours after chemotherapy is completed.PATIENT TEACHING• Inform patient that granisetron is givenorally or I.V. before chemotherapy to helpprevent nausea.• Instruct patient to take granisetron tabletwithout food to avoid reducing drugbioavailability.• Advise patient to report constipation,fever, severe diarrhea, or severe headache.Also caution about possible drowsiness.• Advise patient wearing granisetron patchto cover it with clothing if there’s a risk ofexposure to sunlight. Tell patient to continuecovering application site with clothingfor 10 days after removal of patch.guaifenesinAnti-Tuss, Balminil Expectorant (CAN),Benylin-E (CAN), Breonesin, CalmylinExpectorant (CAN), Gee-Gee, Genatuss,GG-CEN, Glycotuss, Glytuss, Guaituss,Halotussin, Hytuss, Hytuss 2X,Mucinex, Organidin NR, Resyl (CAN),Robitussin, Scot-tussin Expectorant,Uni-tussinClass and CategoryChemical class: Glyceryl guaiacolateTherapeutic class: ExpectorantPregnancy category: C

Indications and Dosages To relieve cough, especially when secretionsare thickCAPSULES, ORAL SOLUTION, SYRUP, TABLETSAdults and adolescents. 200 to 400 mgevery 4 hr. Maximum: 2,400 mg daily.CAPSULES, ORAL SOLUTION, SYRUPChildren ages 6 to 12. 100 to 200 mg every4hr.Maximum: 1,200 mg daily. To promote productive coughE.R. TABLETS (MUCINEX)Adults and adolescents. 600 to 1,200 mgevery 12 hr. Maximum: 2,400 mg daily.Route Onset Peak DurationP.O. 30 min Unknown 4–6 hrMechanism of ActionIncreases fluid and mucus removal from theupper respiratory tract by increasing thevolume of secretions and reducing theiradhesiveness and surface tension.ContraindicationsHypersensitivity to guaifenesinAdverse ReactionsCNS: Dizziness, headacheGI: Nausea and vomiting (with large doses)SKIN: Rash, urticariaNursing Considerations• As prescribed and as appropriate, give liquidforms of guaifenesin to children.• Watch for evidence of more serious condition,such as cough that lasts longer than1 week, fever, persistent headache, and rash.PATIENT TEACHING• Instruct patient to take each dose with afull glass of water.• Advise patient not to break, crush, or chewE.R. tablets but to swallow them whole.• Tell patient to increase fluid intake (unlesscontraindicated) to help thin secretions.• Advise patient not to take drug longerthan 1 week and to notify prescriber aboutfever, persistent headache, or rash.guanadrel sulfateHylorelClass and CategoryChemical class: Guanidine derivativeguanadrel sulfate 493Therapeutic class: AntihypertensivePregnancy category: BIndications and Dosages To manage hypertensionTABLETSAdults. 5 mg b.i.d., increased to 20 to75 mg daily in divided doses t.i.d. or q.i.d.,if needed.DOSAGE ADJUSTMENT Initial dosage reducedto 5 mg daily if needed for patients withrenal impairment or creatinine clearance of30 to 60 ml/min/1.73 m 2 . Then adjustedafter at least 7 days. Initial dosage reducedto 5 mg every other day if needed forpatients with creatinine clearance less than30 ml/min/1.73 m 2 . Then dosage adjustedafter at least 2 wk.Route Onset Peak DurationP.O. 30 min–2 hr 4–6 hr 4–14 hrMechanism of ActionExerts antihypertensive effect at peripheralsympathetic nerve endings. Through anuptake mechanism, guanadrel is stored inadrenergic neurons, where it displacesnorepinephrine from its storage sites. Thisaction blocks normal release of norepinephrinein response to nerve impulses,which depletes norepinephrine stores insynapses and relaxes vessel walls, thusreducing peripheral resistance and bloodpressure.ContraindicationsHeart failure not caused by hypertension,hypersensitivity to guanadrel or its components,MAO inhibitor use within 1 week ofguanadrel use, pheochromocytomaInteractionsDRUGSalpha blockers, beta blockers, rauwolfia alkaloids:Possibly orthostatic hypotension orbradycardiaamphetamines, appetite suppressants,cyclobenzaprine, haloperidol, loxapine,maprotiline, methylphenidate, phenothiazines,thioxanthenes, tricyclic antidepressants:Decreased antihypertensive effect ofguanadrelanticholinergics: Possibly decreased inhibitionof gastric acid secretionbarbiturates, opioids: Possibly increasedGHI

494guanethidine monosulfatehypotensive effectMAO inhibitors: Possibly severe blood pressureincreaseNSAIDs: Possibly sodium and water retentionand decreased antihypertensive effectof guanadrelsympathomimetics: Possibly reduced antihypertensiveeffect of guanadrel, leading tohypertension; possibly potentiated effects ofsympathomimeticsvasodilators: Increased orthostatic hypotensionACTIVITIESalcohol use: Increased hypotensive effectAdverse ReactionsCNS: Confusion, drowsiness, fatigue, headache,light-headedness, paresthesia, sleepdisturbanceCV: Chest pain, orthostatic hypotension,palpitations, peripheral edemaEENT: Blurred vision, dry mouth andthroat, glossitisGI: Abdominal cramps or pain, anorexia,constipation, diarrhea, indigestion, nausea,vomitingGU: Difficult ejaculation, hematuria, impotence,nocturia, urinary frequency orurgencyMS: Arthralgia, back or neck pain, jointinflammation, leg cramps, muscle weakness,myalgiaRESP: Cough, dyspneaOther: Excessive weight gain or lossNursing Considerations• Use guanadrel cautiously in patients withasthma because drug may aggravate thiscondition. Monitor patient for acute dyspnea,wheezing, and other evidence of asthmaattack. Notify prescriber immediatelyif they develop.WARNING Assess patient for evidence ofoverdose, such as blurred vision, dizziness,and syncope.• Be aware that elderly patients have agreater risk of dizziness and syncope.• Assess for signs of fluid retention andheart failure, including crackles, a new S 3heart sound, and sudden weight gain.PATIENT TEACHING• Explain that guanadrel won’t cure highblood pressure but will help control it.• Instruct patient to take drug at the sametime each day to improve compliance andblood pressure control.• Caution patient about possible dizziness,light-headedness, and fainting, especiallywhen getting up from a lying or sittingposition. Advise him to rise slowly, especiallyin the morning, and to sit with hisfeet dangling for 1 to 2 minutes beforestanding up.• Instruct patient to sit or lie down immediatelyif he feels dizzy.• To prevent fainting, advise patient to avoidalcohol, standing for long periods, pursuingexcessive exercise, and being overlyexposed to hot weather.• Instruct patient to check with prescriberbefore taking OTC drugs during therapy.• Advise patient to follow a low-sodium dietto help reduce blood pressure and preventfluid retention.guanethidinemonosulfateApo-Guanethidine (CAN), IsmelinClass and CategoryChemical class: Guanidine derivativeTherapeutic class: AntihypertensivePregnancy category: CIndications and Dosages To manage moderate to severe hypertensionand renal hypertensionTABLETSAdults. Initial: 10 to 12.5 mg daily, increasedas needed by 10 to 12.5 mg every wk.Maintenance: 25 to 50 mg daily. Somepatients may need up to 300 mg daily.Children. 0.2 mg/kg daily, increased p.r.n.by 0.2 mg/kg every 7 to 10 days. Maximum:3 mg/kg every 24 hr.DOSAGE ADJUSTMENT Initial dosageincreased to 25 to 50 mg daily for hospitalizedadults because they can be monitoredmore closely. Then dosage increased by25 to 50 mg every other day, p.r.n.Route Onset Peak DurationP.O. Unknown 8 hr UnknownMechanism of ActionExerts antihypertensive effect at peripheral

sympathetic nerve endings. Through anuptake mechanism, guanethidine is storedin adrenergic neurons, where it displacesnorepinephrine from its storage sites. Thisaction blocks normal release of norepinephrinein response to nerve impulses,which depletes norepinephrine stores insynapses and relaxes vessel walls, reducingperipheral resistance and blood pressure.ContraindicationsHeart failure not caused by hypertension,hypersensitivity to guanethidine or its components,MAO inhibitor use within 1 weekof guanethidine use, pheochromocytomaInteractionsDRUGSalpha blockers, beta blockers, rauwolfia alkaloids:Possibly orthostatic hypotension orbradycardiaamphetamines, appetite suppressants,cyclobenzaprine, haloperidol, loxapine,maprotiline, methylphenidate, phenothiazines,thioxanthenes, tricyclic antidepressants:Decreased antihypertensive effect ofguanethidineanticholinergics: Possibly decreased inhibitionof gastric acid secretionbarbiturates, opioids: Increased hypotensiveeffectinsulin, oral antidiabetic drugs: Possiblyincreased antidiabetic effect of these drugsMAO inhibitors: Possibly severe blood pressureincreaseNSAIDs: Possibly sodium and water retentionand decreased antihypertensive effectof guanethidinesympathomimetics: Possibly reduced antihypertensiveeffect of guanethidine, leading tohypertension; possibly potentiated effects ofsympathomimeticsvasodilators: Increased orthostatic hypotensionACTIVITIESalcohol use: Increased hypotensive effectAdverse ReactionsCNS: Depression, dizziness, fatigue, headache,lassitude, paresthesia, syncopeCV: Angina, bradycardia, orthostatic hypotension,palpitations, peripheral edemaEENT: Blurred vision, dry mouth, glossitis,nasal congestion, parotid gland tenderness,ptosisNursing Considerations• As prescribed, stop MAO inhibitor therapyat least 1 week before starting guanethidine.• Because guanethidine has cumulativeeffects, give a small initial dose andincrease gradually, as prescribed. Whenblood pressure is controlled, expect toreduce dosage to lowest effective level.• Watch for orthostatic hypotension, whichoccurs most often when patient rises inthe morning and is exacerbated by hotweather, exercise, and alcohol. Assesssupine and standing blood pressures, especiallyafter dosage adjustments.• Measure daily weight to help detect fluidretention. Also observe for edema andother signs of heart failure. A thiazidediuretic may be prescribed to decreasesodium and fluid retention.• Notify prescriber if severe diarrhea occurs.Drug may need to be discontinued.• Monitor febrile patient for increasedhypotension and adverse reactions becausefever decreases drug requirements.• As ordered, stop giving guanethidine2 weeks before surgery to reduce risk ofcardiac arrest during anesthesia.PATIENT TEACHING• Teach patient how to recognize orthostatichypotension, and advise changing positionslowly. Explain that symptoms are worsein the morning and worsened by exercise,hot weather, alcohol, and hot showers.• Instruct patient to report fainting, frequentdizziness, and severe diarrhea.• Caution patient to avoid alcohol because itmay increase risk of orthostatic hypotension.• Instruct patient to weigh himself daily atthe same time, on the same scale, andwearing the same amount of clothing.Advise him to report signs of fluid retention,such as reduced urine volume, sudguanethidinemonosulfate 495GI: Anorexia, constipation, diarrhea(severe), indigestion, nausea, vomitingGU: Ejaculation disorders, elevated BUNlevel, impotence, nocturia, priapism, urinaryfrequencyHEME: Anemia, leukopenia, thrombocytopeniaMS: Leg cramps, muscle twitching, myalgiaRESP: Asthma exacerbation, dyspneaSKIN: Alopecia, dermatitisOther: Weight gainGHI

496guanfacine hydrochlorideden weight increase, and limb swelling.• Urge patient to consult prescriber beforetaking OTC drugs during guanethidinetherapy.• If a diabetic patient takes insulin or a sulfonylurea,instruct him to monitor hisblood glucose level more frequently tocheck for hypoglycemia.• Advise patient to follow a low-sodium dietto help reduce blood pressure and preventfluid retention.guanfacinehydrochlorideIntuniv, TenexClass and CategoryChemical class: Dichlorobenzine derivativeTherapeutic class: AntihypertensivePregnancy category: BIndications and Dosages To manage hypertension, alone or withother antihypertensivesTABLETSAdults. 1 mg daily at bedtime, increased ifneeded to 2 mg after 3 to 4 wk. Increased to3 mg if needed after another 3 to 4 wk.Maintenance: 2 or 3 mg daily.DOSAGE ADJUSTMENT Twice-daily administrationused if blood pressure tends to riseat the end of 24-hr period. To treat attention deficit hyperactivitydisorder (ADHD)E.R. TABLETSAdults and children age 6 and over. Initial:1 mg once daily, increased, as needed, by1 mg/wk. Maintenance: 1 to 4 mg oncedaily. Maximum: 4 mg once daily.Route Onset Peak DurationP.O. Unknown* 8–12 hr† 24 hrMechanism of ActionDecreases sympathetic nerve impulse outflowfrom the vasomotor center of thebrain to the heart and blood vessels by* For single dose; in 1 wk for multipledoses.† For single dose; 1 to 3 mo for multipledoses.stimulating central alpha 2 -adrenergic receptors.This action reduces peripheral vascularresistance, renovascular resistance, heartrate, and blood pressure. Prolonged guanfacineuse may reduce total peripheral vascularresistance, slightly reducing heart rate.Guanfacine also stimulates growth hormonesecretion, reduces circulating plasmacatecholamine levels, and reduces left ventricularhypertrophy.ContraindicationsHypersensitivity to guanfacineInteractionsDRUGSCNS depressants: Possibly increased CNSdepressionketoconazole and other strong CYP3A4/5inhibitors: Increased plasma guanfacinelevel and increased risk of bradycardia,hypotension, and sedationNSAIDs, sympathomimetics, tricyclic antidepressants:Possibly decreased antihypertensiveeffect of guanfacineother antihypertensives: Possibly increasedantihypertensive effect, resulting inhypotensionrifampin and other CYP3A4 inducers:Decreased plasma guanfacine level andeffectivenessvalproic acid: Increased plasma valproic acidlevelACTIVITIESalcohol use: Possibly increased CNS depressionAdverse ReactionsCNS: Anxiety, asthenia, confusion, depression,dizziness, drowsiness, fatigue,headache, irritability, lethargy, nervousness,sedation, seizures, somnolence, syncope,weaknessCV: Atrioventricular block, bradycardia,chest pain, hypertension, orthostatichypotension, sinus arrhythmiaEENT: Conjunctivitis, dry mouthGI: Abdominal pain, constipation, dyspepsia,elevated liver enzyme levels, nausea,vomitingGU: Decreased libido, enuresis, impotence,urinary frequencyRESP: AsthmaSKIN: Dermatitis, diaphoresis, pallor, pruritus,purpura, rashOther: Increased weight

Nursing Considerations• Use guanfacine cautiously in patients withcerebrovascular disease, chronic renal orhepatic failure, recent MI, or severe coronaryinsufficiency.• Give drug at bedtime to minimize daytimesedation.WARNING Expect to stop hypertensiontreatment by decreasing dosage graduallyover 2 to 4 days. Typically, if patient hasn’ttaken drug for 2 or more days, he mayhave withdrawal symptoms, includingabdominal cramps, anxiety, chest pain,diaphoresis, headache, increased salivation,insomnia, irregular heart rate andrhythm, nausea, nervousness, restlessness,tremor, and vomiting.For patients being treated for ADHD,expect to taper dosage gradually over 3 to7 days by no more than 1 mg every 3 to7 days to prevent rebound hypertension.• If you suspect that patient has drugrelateddepression, notify prescriber immediatelyand expect to discontinue drug.PATIENT TEACHING• Instruct patient to take guanfacine at bedtimeto reduce daytime drowsiness.• Tell patient not to break, crush, or chewextended-release tablets before swallowing.• Caution patient about possible drowsiness,and advise him to avoid hazardous activitiesuntil drug’s CNS effects are known.• Urge patient to avoid consuming alcoholand other CNS depressants while takingguanfacine.• Advise patient to report rash.• Inform male patient that guanfacine maycause impotence. Suggest that he discussimpotence with prescriber, if it occurs.• Caution patient not to stop taking drugabruptly because doing so can cause adangerous rise in blood pressure alongwith anxiety and nervousness.halazepamPaxipamClass, Category, and ScheduleChemical class: BenzodiazepineTherapeutic class: AntianxietyPregnancy category: DControlled substance schedule: IVhalazepam 497Indications and Dosages To manage anxietyTABLETSAdults. 20 to 40 mg t.i.d. or q.i.d. Optimal:80 to 160 mg daily.DOSAGE ADJUSTMENT Dosage reduced to20 mg once or twice daily if needed fordebilitated patients.Route Onset Peak DurationP.O. Slow Unknown 6–8 hrMechanism of ActionMay potentiate the effects of gammaaminobutyricacid (GABA) and otherinhibitory neurotransmitters by binding tospecific benzodiazepine receptor sites inlimbic and cortical areas of the CNS. Bybinding to these receptor sites, halazepamincreases inhibitory effects of GABA andblocks cortical and limbic arousal.ContraindicationsAcute angle-closure glaucoma, hypersensitivityto halazepam or its components, itraconazoleor ketoconazole therapy, psychosisInteractionsDRUGSantacids: Possibly altered rate of halazepamabsorptionbarbiturates, CNS depressants, opioids:Increased CNS depression, possibly sedationand impaired motor functioncimetidine, diltiazem, disulfiram, erythromycin,fluoxetine, fluvoxamine, isoniazid, itraconazole,ketoconazole, metoprolol, nefazodone,oral contraceptives, propoxyphene,propranolol, ranitidine, valproic acid, verapamil:Decreased halazepam clearance,increased blood level, and increased risk ofadverse effectsclozapine: Possibly respiratory depressiondigoxin: Increased blood digoxin level andrisk of digitalis toxicitylevodopa: Decreased antidyskinetic effectneuromuscular blockers: Increased orblocked neuromuscular blockadetheophyllines: Decreased sedative effect ofhalazepamACTIVITIESalcohol use: Increased CNS depression, possiblysedation and impaired motor functionsmoking: Decreased halazepam effectivenessGHI

498haloperidolAdverse ReactionsCNS: Agitation, anxiety, ataxia, confusion,depression, dizziness, drowsiness, euphoria,headache, irritability, nervousness, slurredspeech, tremor, weaknessCV: Angina, palpitations, sinus tachycardiaEENT: Diplopia, dry mouth, tinnitusGI: Abdominal cramps or pain, constipation,diarrhea, increased salivation, nausea,vomitingGU: Decreased libido, dysuriaMS: ArthralgiaSKIN: Pruritus, rashNursing Considerations• Use halazepam cautiously in patients withimpaired hepatic or renal function, seizuredisorders, or suicidal tendencies.• Be aware that risk of halazepam addictionand abuse is relatively high.• Monitor renal and liver function testresults, as appropriate, during long-termtreatment.• Expect to withdraw drug gradually over2 weeks to avoid withdrawal symptoms,which include anxiety, confusion, insomnia,psychosis, and seizures.PATIENT TEACHING• Instruct patient to take halazepam exactlyas prescribed and not to stop abruptlybecause withdrawal symptoms may occur.• Caution patient to avoid alcohol and otherCNS depressants during therapy. Advisepatient to avoid OTC drugs, such as coughand cold remedies, because they may containCNS depressants.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to report depression, difficultyvoiding, double vision, persistentdrowsiness, and rash.• Explain that drug’s full effects may notoccur for 6 weeks.haloperidolApo-Haloperidol (CAN), Haldol, Novo-Peridol (CAN), Peridol (CAN)haloperidoldecanoateHaldol Decanoate, Haldol LA (CAN)haloperidol lactateHaldol ConcentrateClass and CategoryChemical class: Butyrophenone derivativeTherapeutic class: Antidyskinetic,antipsychoticPregnancy category: C (haloperidoldecanoate), not rated (haloperidol,haloperidol lactate)Indications and Dosages To treat psychotic disordersORAL SOLUTION, TABLETSAdults and adolescents. 0.5 to 5 mg b.i.d.or t.i.d. Maximum: Usually 100 mg daily.Children ages 3 to 12. 0.05 mg/kg daily individed doses b.i.d. or t.i.d. Increased by0.5 mg every 5 to 7 days, if needed.Maximum: 0.15 mg/kg daily. To treat nonpsychotic behavior disordersand Tourette’s syndromeORAL SOLUTION, TABLETSAdults and adolescents. 0.5 to 5 mg b.i.d.or t.i.d. Maximum: Usually 100 mg daily.Children ages 3 to 12. 0.05 to 0.075 mg/kgdaily in divided doses b.i.d. or t.i.d.Increased by 0.5 mg every 5 to 7 days, ifneeded. Maximum: 0.075 mg/kg daily.DOSAGE ADJUSTMENT Initial dosage reducedto 0.5 to 2 mg b.i.d. or t.i.d. if needed forelderly or debilitated patients. To treat acute psychotic episodesI.M. INJECTIONAdults and adolescents. Initial: 2 to 5 mg,with subsequent doses up to every 60 min.Or, if symptoms are controlled, dose maybe repeated every 4 to 8 hr. Maximum:Usually 100 mg daily. First oral dose may begiven 12 to 24 hr after last parenteral dose. To provide long-term antipsychotic therapyfor patients who require parenteraltherapyLONG-ACTING I.M. (DECANOATE) INJECTIONAdults. Initial: 10 to 15 times the daily oraldose up to 100 mg. Repeated every 4 wk, ifneeded. Maximum: 300 mg/mo.Mechanism of ActionMay block postsynaptic dopamine receptorsin the limbic system and increase brainturnover of dopamine, producing anantipsychotic effect.

ContraindicationsBlood dyscrasias, bone marrow depression,cerebral arteriosclerosis, coma, concurrentuse of large amounts of other CNS depressants,coronary artery disease, epilepsy,hepatic dysfunction, hypersensitivity tohaloperidol or its components, Parkinson’sdisease, severe hypertension or hypotension,severe CNS depression, subcorticalbrain damageRoute Onset Peak DurationI.M.* Unknown 3–4 days† UnknownInteractionsDRUGSamphetamines: Possibly decreased stimulanteffects of amphetamines and decreasedantipsychotic effect of haloperidolanticholinergics, antidyskinetics, antihistamines:Increased anticholinergic effect andrisk of decreased antipsychotic effect ofhaloperidolanticonvulsants: Possibly decreased effectivenessof anticonvulsants and decreasedblood haloperidol levelbromocriptine: Possibly decreased effectivenessof bromocriptinebupropion: Lowered seizure threshold,increased risk of major motor seizureCNS depressants: Increased CNS depressionand risk of respiratory depression andhypotensiondiazoxide: Possibly hypoglycemiadopamine (high-dose therapy): Possiblydecreased vasoconstrictionephedrine: Possibly decreased vasopressoreffect of ephedrineepinephrine: Possibly severe hypotensionand tachycardiafluoxetine: Increased risk of severe and frequentextrapyramidal effectsguanadrel, guanethidine: Decreasedhypotensive effects of these drugslevodopa, pergolide: Possibly decreased therapeuticeffects of these drugslithium: Increased risk of neurotoxicityMAO inhibitors, maprotiline, tricyclic antidepressants:Increased sedative and anticholinergiceffects of these drugs* For haloperidol decanoate and lactate.† For haloperidol decanoate only; 30 to45 min for haloperidol lactate.haloperidol 499metaraminol: Possibly decreased vasopressoreffect of metaraminolmethoxamine: Decreased vasopressor effect,shortened duration of methoxamine actionmethyldopa: Possibly disorientation, slowedor difficult thought processesphenylephrine: Decreased vasopressorresponse to phenylephrineACTIVITIESalcohol use: Increased CNS depression andrisk of respiratory depression and hypotensionAdverse ReactionsCNS: Agitation, anxiety, confusion, drowsiness,dystonia, euphoria, extrapyramidalreactions that may be irreversible (akathisia,pseudoparkinsonism, tardive dyskinesia),hallucinations, headache, insomnia, neurolepticmalignant syndrome, restlessness,slurred speech, tremor, vertigoCV: Cardiac arrest, hypertension, orthostatichypotension, QT-interval prolongation,ventricular arrythmias, tachycardia, torsadesde pointesEENT: Blurred vision, dry mouth, increasedsalivation (all drug forms); stomatitis (oralsolution)ENDO: Breast engorgement, galactorrheaGI: Constipation, nausea, vomitingGU: Decreased libido, difficult ejaculation,impotence, menstrual irregularities, urineretentionHEME: Agranulocytosis, anemia, leukocytosis,leukopeniaSKIN: Diaphoresis, photosensitivity, rashOther: Heatstroke, weight gainNursing Considerations• Haloperidol shouldn’t be used to treatdementia-related psychosis in the elderlybecause of an increased mortality risk.• Use haloperidol cautiously in patients witha history of prolonged QT interval,patients with uncorrected electrolyte disturbances,and patients receiving Class IAor III antiarrhythmics because of anincreased risk of prolonged QT interval.Monitor elderly patients closely becausethey may have an increased risk of prolongedQT interval.• Dilute oral solution with a beverage, suchas cola or orange, apple, or tomato juice.• Give haloperidol decanoate (long-actingform prepared in sesame oil to produceGHI

500heparinslow, sustained release) by deep I.M. injectioninto gluteal muscle using Z-tracktechnique and 21G needle. Don’t give morethan 3 ml per site. Expect to reach stableplasma level after third or fourth dose.• If injection solution has a slight yellowdiscoloration, be aware that this changedoesn’t affect potency.• Watch for tardive dyskinesia (potentiallyirreversible involuntary movements) inpatients receiving long-term therapy, especiallyelderly women who take large doses.• Monitor CBC, especially if patient has alow WBC count or history of druginducedleukopenia or neutropenia, oftenduring the first few months of therapy. IfWBC count drops, especially if neutrophilcount drops below 1,000/mm 3 , expecthaloperidol to be discontinued. If neutropeniais significant, also monitorpatient for fever or other symptoms ofinfection and provide appropriate treatment,as prescribed.• If extrapyramidal reactions occur duringthe first few days of treatment, reducedosage, as prescribed. If symptoms persist,drug may be discontinued. Dystonia alsomay occur during first few days of treatment,especially in patients receiving higherdoses and in males and younger agegroups.Notify prescriber.• Avoid stopping haloperidol abruptlyunless severe adverse reactions occur.• Monitor for signs of neuroleptic malignantsyndrome, a rare but possibly fataldisorder linked to antipsychotic drugs.Signs include altered mental status,arrhythmias, fever, and muscle rigidity.WARNING Sudden death, QT-interval prolongation,and torsades de pointes,although uncommon, may occur inpatients receiving haloperidol despite thelack of such predisposing factors as electrolyteimbalance, concurrent therapy withdrugs known to prolong the QT interval,underlying cardiac abnormalities,hypothyroidism, and familial long-QTsyndrome.PATIENT TEACHING• Advise patient to take haloperidol exactly asprescribed and not to stop abruptly becausewithdrawal symptoms may occur.• To prevent oral mucosal irritation, instructpatient to dilute liquid form with juice orcola before taking it.• Caution patient to avoid skin contact withoral solution because it may cause a rash.• Advise patient to take tablets with food ora full glass of milk or water to reduce GIdistress.• Instruct patient to consume adequate fluidsand to take precautions against heatstroke.• Urge patient not to drink alcohol duringtherapy.• If sedation occurs, caution patient to avoiddriving and other hazardous activities.• Instruct patient to report repetitive movements,tremor, and vision changes.heparin calciumCalcilean (CAN), Calciparineheparin sodiumHepalean (CAN), Heparin Leo (CAN),Heparin Lock Flush, LiquaeminClass and CategoryChemical class: GlycosaminoglycanTherapeutic class: AnticoagulantPregnancy category: CIndications and Dosages To prevent and treat deep vein thrombosisand pulmonary embolism, to treatperipheral arterial embolism, and toprevent thromboembolism before andafter cardioversion of chronic atrial fibrillationI.V. INFUSION OR INJECTIONAdults. Loading: 35 to 70 units/kg or5,000 units by injection. Then 20,000 to40,000 units infused over 24 hr.Children. Loading: 50 units/kg by injection.Then 100 units/kg infused every 4 hr or20,000 units/m 2 infused over 24 hr.I.V. INJECTIONAdults. Initial: 10,000 units. Maintenance:5,000 to 10,000 units every 4 to 6 hr.Children. Initial: 50 units/kg. Maintenance:100 units/kg/dose every 4 hr.I.V. OR SUBCUTANEOUS INJECTIONAdults. Loading: 5,000 units I.V. Then10,000 to 20,000 units subcutaneously.Maintenance: 8,000 to 10,000 units subcutaneouslyevery 8 hr or 15,000 to 20,000 unitssubcutaneously every 12 hr.

To diagnose and treat disseminatedintravascular coagulation (DIC)I.V. INFUSION OR INJECTIONAdults. 50 to 100 units/kg every 4 hr. Drugmay be discontinued if no improvementoccurs in 4 to 8 hr.Children. 25 to 50 units/kg every 4 hr.Drug may be discontinued if no improvementoccurs in 4 to 8 hr. To prevent postoperative thromboembolismSUBCUTANEOUS INJECTIONAdults. 5,000 units 2 hr before surgery andthen 5,000 units every 8 to 12 hr for 7 daysor until patient is fully ambulatory. To prevent clots in patients undergoingopen-heart and vascular surgeryI.V. INFUSION OR INJECTIONAdults. 300 units/kg for procedures thatlast less than 60 min; 400 units/kg for proceduresthat last longer than 60 min.Minimum: 150 units/kg.Children. 300 units/kg for procedures thatlast less than 60 min. Then dosage basedon coagulation test results. Minimum:150 units/kg. To maintain heparin lock patencyI.V. INJECTIONAdults. 10 to 100 units/ml heparin flushsolution (enough to fill device) after eachuse of device.DOSAGE ADJUSTMENT Increased dosage maybe needed if patient needs aggressive anticoagulationto treat or prevent life-threateningthromboses, if heparin will be givenI.V., and if heparin has been manufacturedunder the new standard implemented inOctober, 2009. (The letter “N” appears inthe lot number or after the expiration dateon heparin products made under the newstandard. An exception is Hospira, whichidentifies its new-standard products using alot number starting with “82” or higher.)Route Onset Peak DurationI.V. Immediate Minutes UnknownSubQ 20–60 min Unknown UnknownMechanism of ActionBinds with antithrombin III, enhancingantithrombin III’s inactivation of the coagulationenzymes thrombin (factor IIa) andfactors Xa and XIa. At low doses, heparininhibits factor Xa and prevents conversionheparin 501of prothrombin to thrombin. Thrombin isneeded for conversion of fibrinogen to fibrin;without fibrin, clots can’t form. At highdoses, heparin inactivates thrombin, preventingfibrin formation and existing clotextension.IncompatibilitiesDon’t mix heparin with any other drugunless you have an order to do so and havechecked with pharmacist. Heparin isincompatible with many drugs and solutions,especially ones that contain a phosphatebuffer, sodium bicarbonate, or sodiumoxalate.ContraindicationsHypersensitivity to heparin or its components;neonates; severe thrombocytopenia;uncontrolled bleeding, except in DICInteractionsDRUGSantihistamines, digoxin, nicotine, tetracyclines:Decreased anticoagulant effect ofheparinaspirin, NSAIDs, platelet aggregationinhibitors, sulfinpyrazone: Increased plateletinhibition and risk of bleedingcefamandole, cefoperazone, cefotetan, methimazole,plicamycin, propylthiouracil, valproicacid: Possibly hypoprothrombinemia andincreased risk of bleedingchloroquine, hydroxychloroquine: Possiblythrombocytopenia and increased risk ofhemorrhageethacrynic acid, glucocorticoids, salicylates:Increased risk of bleeding and GI ulcerationand hemorrhagenitroglycerin (I.V.): Possibly decreased anticoagulanteffect of heparinprobenecid: Possibly increased anticoagulanteffect of heparinthrombolytics: Increased risk of hemorrhageACTIVITIESsmoking: Decreased anticoagulant effectAdverse ReactionsCNS: Chills, dizziness, fever, headache,peripheral neuropathyCV: Chest pain, thrombosisEENT: Epistaxis, gingival bleeding, rhinitisGI: Abdominal distention and pain, hematemesis,melena, nausea, vomitingGU: Hematuria, hypermenorrheaHEME: Easy bruising, excessive bleedingGHI

502can apply gentle pressure to the site afterwithdrawing needle.• Alternate injection sites, and watch forsigns of bleeding and hematoma.• To prepare heparin for continuous infusion,invert container at least six times toprevent drug from pooling. Anticipateslight discoloration of prepared solution;this doesn’t indicate a change in potency.• During continuous I.V. therapy, expect toobtain APTT after 8 hours of therapy. Usethe arm opposite the infusion site.• For intermittent I.V. therapy, expect toadjust dose based on coagulation testresults performed 30 minutes earlier.Therapeutic range is typically 1.5 to2.5 times the control.• Bleeding is major adverse effect of heparintherapy. Take safety precautions to preventbleeding, such as having patient use a softbristledtoothbrush and an electric razor.Bleeding may occur at any site and alsomay indicate an underlying problem, suchas GI or urinary tract bleeding. Other sitesof bleeding that could be fatal and requireimmediate attention includes adrenal,ovarian, and retroperitoneal hemorrhage.• Monitor blood test results, and observe forsigns of bleeding, such as ecchymosis,epistaxis, hematemesis, hematuria, melena,and petechiae. Thrombocytopenia of anydegree should be monitored closely. Ifplatelet count drops below 100,000/mm 3or recurrent thrombosis develops, notifyprescriber and expect heparin to be discontinued.• Make sure all health care providers knowthat patient is receiving heparin.• Keep protamine sulfate on hand to use asan antidote for heparin. Be aware thateach milligram of protamine sulfate neutralizes100 units of heparin.• Be aware that prescriber may order oralanticoagulants before discontinuingheparin to avoid increased coagulationcaused by heparin withdrawal. Heparinmay be discontinued when full therapeuticeffect of oral anticoagulant is achieved.• Know that women over age 60 have highestrisk of hemorrhage during therapy.• Watch closely if patient is receivingheparin therapy and nitroglycerin I.V.because PTT may decrease and thenrebound after nitroglycerin is discontinheparinfrom wounds, thrombocytopeniaMS: Back pain, myalgia, osteoporosisRESP: Dyspnea, wheezingSKIN: Alopecia, cyanosis, petechiae, pruritus,urticariaOther: Anaphylaxis; injection sitehematoma, irritation, pain, redness, andulcerationNursing Considerations• Use heparin cautiously in alcoholics; menstruatingwomen; patients over age 60,especially women; and patients with mildhepatic or renal disease or a history ofallergies, asthma, or GI ulcer.WARNING Be aware that the new standardfor manufacturing heparin in the U.S. hasdecreased its I.V. potency by about 10%.When using this route, determine if theheparin has been manufactured under thenew standard by looking for the letter “N”in the lot number or after the expirationdate (or, if made by Hospira, the number“82” or higher at the start of the lot number).If giving such heparin, be aware thatmore drug may be required than in thepast to achieve desired level of anticoagulationin some patients. The change inpotency also may require more frequent orintensive APTT or ACT monitoring.Change in potency doesn’t appear problematicusing subcutaneous route.WARNING Give heparin only by subcutaneousor I.V. route; I.M. use causeshematoma, irritation, and pain.• Avoid injecting any drugs by I.M. routeduring heparin therapy, to decrease risk ofbleeding and hematoma.WARNING Don’t use heparin sodium injectionas a catheter-lock flush because fatalerrors have occurred in children when1-ml heparin sodium injection vials wereconfused with 1-ml catheter-lock flushvials. Always examine vial labels closely toensure correct product is being used.• Administer subcutaneous heparin intoanterior abdominal wall, above the iliaccrest, and 5 cm (2) or more away fromthe umbilicus. To minimize subcutaneoustissue trauma, lift adipose tissue awayfrom deep tissues; don’t aspirate for bloodbefore injecting drug; don’t move needlewhile injecting drug; and don’t massageinjection site before or after injection. You

hyaluronan (high-molecular-weight); hydralazine hydrochloride 503ued. Monitor PTT closely, and be preparedto adjust heparin dose, as prescribed.WARNING Delayed-onset, heparin-inducedthrombocytopenia may occur severalweeks after heparin is discontinued andmay progress to heparin-induced thrombocytopeniathrombosis, causing venousand arterial thromboses.• Various heparin products contain the preservativebenzyl alcohol, which isn’t recommendedfor children under age 1month because it may cause gasping syndrome,which may be fatal.PATIENT TEACHING• Explain that heparin can’t be taken orally.• Inform patient about increased risk ofbleeding; urge her to avoid injuries and touse a soft-bristled toothbrush and an electricrazor.• Urge patient to report any abnormal signor symptom to prescriber, even weeks afterheparin has been discontinued, because ofthe potential for delayed adverse reactions.• Advise patient to avoid drugs that interactwith heparin, such as aspirin and ibuprofen.• Instruct patient and family to watch forand report abdominal or lower back pain,black stools, bleeding gums, bloody urine,excessive menstrual bleeding, nosebleeds,and severe headaches.• Explain that temporary hair loss may occur.• Advise patient to wear or carry appropriatemedical identification.hyaluronan (highmolecular-weight)Euflexxa, OrthoviscClass and CategoryChemical class: Natural complexglycosaminoglycan sugarTherapeutic class: AnalgesicPregnancy category: Not ratedIndications and Dosages To relieve osteoarthritic knee pain inpatients who respond inadequately toconservative nonpharmacologic therapyand to simple analgesicsINTRA-ARTICULAR INJECTION (ORTHOVISC)Adults. 30 mg/wk for 3 to 4 wk.INTRA-ARTICULAR INJECTION (EUFLEXXA)Adults. 20 mg/wk for 3 wk.Mechanism of ActionRelieves pain associated with osteoarthritisby lubricating the joint and absorbingshock when the joint moves. Hyaluronan isa viscoelastic substance normally found injoint tissues and in the fluid that fills joints;it is instilled directly into the joint.ContraindicationsHypersensitivity to hyaluronan avian,avian-derived products (such as eggs, feathers,or poultry) or any of their components;knee infections; skin diseases affecting theknee areaAdverse ReactionsCNS: HeadacheMS: Acute arthritis, arthralgia, back pain,bursitisOther: Injection site bruising, edema, erythema,pain, pruritus, or rashNursing Considerations• Prepare patient for removal of joint effusion,if present, before hyaluronan injection.• Assist the trained health care professionalwho gives intra-articular injections, asneeded, making sure that strict aseptictechnique is followed during procedure.• Be aware that prefilled syringe is for singleuse and that contents of syringe should beused immediately after opening.PATIENT TEACHING• Inform patient that transient knee pain,swelling, or other localized reactions, suchas itchiness or bruising, may occur afterhyaluronan injection.• Instruct patient to avoid strenuous orweight-bearing activities lasting longerthan 1 hour for 48 hours after injection.• Inform patient that she may feel achy afterinjection but that this discomfort is typicallymild and brief.• Advise patient that pain may not berelieved until after third injection.hydralazinehydrochlorideApo-Hydralazine (CAN), Apresoline(CAN), Novo-Hylazin (CAN)GHI

504hydralazine hydrochlorideClass and CategoryChemical class: Phthalazine derivativeTherapeutic class: Antihypertensive,vasodilatorPregnancy category: CIndications and Dosages To manage essential hypertension, aloneor with other antihypertensivesTABLETSAdults. Initial: 40 mg daily in divided dosesb.i.d. or q.i.d. for first 2 to 4 days and thenincreased to 100 mg daily in divided dosesb.i.d. or q.i.d. for remainder of first wk.Maximum: Usually 200 mg daily, but sometimes300 to 400 mg daily.Children. 0.75 mg/kg daily in divided dosesb.i.d. or q.i.d. Increased gradually over 3 to4wk.Maximum: 7.5 mg/kg or 200 mg daily. To manage severe essential hypertensionwhen drug can’t be taken orally or whenneed to reduce blood pressure is urgentI.V. OR I.M. INJECTIONAdults. 5 to 40 mg, repeated as needed.Children. 1.7 to 3.5 mg/kg daily in divideddoses every 4 to 6 hr, as needed.Route Onset Peak DurationP.O. 20–30 min 1–2 hr 2–4 hrI.V. 5–20 min 10–80 min 2–6 hrI.M. 10–30 min 1 hr 2–6 hrMechanism of ActionMay act in a manner that resembles organicnitrates and sodium nitroprusside, exceptthat hydralazine is selective for arteries. It:• exerts a direct vasodilating effect on vascularsmooth muscle• interferes with calcium movement in vascularsmooth muscle by altering cellularcalcium metabolism• dilates arteries, not veins, which minimizesorthostatic hypotension and increases cardiacoutput and cerebral blood flow• causes reflex autonomic response thatincreases heart rate, cardiac output, andleft ventricular ejection fraction• has a positive inotropic effect on the heart.IncompatibilitiesDon’t mix hydralazine in I.V. infusion solutions.ContraindicationsCoronary artery disease, hypersensitivity tohydralazine or its components, mitral valvediseaseInteractionsDRUGSbeta blockers: Increased effects of bothdrugsdiazoxide, MAO inhibitors, other antihypertensives:Risk of severe hypotensionepinephrine: Possibly decreased vasopressoreffect of epinephrineNSAIDs: Decreased hydralazine effectssympathomimetics: Possibly decreased antihypertensiveeffect of hydralazineFOODSall foods: Possibly increased bioavailabilityof hydralazineAdverse ReactionsCNS: Chills, fever, headache, peripheralneuritisCV: Angina, edema, orthostatic hypotension,palpitations, tachycardiaEENT: Lacrimation, nasal congestionGI: Anorexia, constipation, diarrhea, nausea,vomitingRESP: DyspneaSKIN: Blisters, flushing, pruritus, rash,urticariaOther: Lupus-like symptoms, especiallywith high doses; lymphadenopathyNursing Considerations• Monitor CBC, lupus erythematosus cellpreparation, and ANA titer before therapyand periodically as appropriate duringlong-term treatment.• Anticipate that drug may change color insolution. Consult pharmacist if colorchanges.• Be aware that hydralazine may changecolor when exposed to a metal filter.• Give tablets with food to increase bioavailability.• Monitor blood pressure and pulse rateregularly and weigh patient daily duringtherapy.• Check blood pressure with patient in lying,sitting, and standing positions, and watchfor signs of orthostatic hypotension.Expect orthostatic hypotension to be mostcommon in the morning, during hotweather, and with exercise.WARNING Expect to discontinue drugimmediately if patient has lupus-like

symptoms, such as arthralgia, fever, myalgia,pharyngitis, and splenomegaly.• Expect prescriber to withdraw hydralazinegradually to avoid a rapid increase in bloodpressure.• Expect to treat peripheral neuritis withpyridoxine.PATIENT TEACHING• Instruct patient to take hydralazine tabletswith food.• Advise patient to change position slowly,especially in the morning. Caution thathot showers may increase hypotension.• Instruct patient to immediately notify prescriberabout fever, muscle and jointaches, and sore throat.• Urge patient to report numbness and tinglingin limbs, which may require treatmentwith another drug.• Caution patient against stopping drugabruptly because doing so may causesevere hypertension.hydrochlorothiazideEsidrix, Hydro-chlor, Hydro-D,HydroDIURIL, Microzide, Neo-Codema(CAN), Novo-Hydrazide (CAN), Oretic,Urozide (CAN)Class and CategoryChemical class: BenzothiadiazideTherapeutic class: Antihypertensive, diureticPregnancy category: BIndications and Dosages To manage hypertensionCAPSULESAdults. 12.5 mg daily.ORAL SOLUTION, TABLETSAdults. 25 to 100 mg daily as a single doseor in divided doses b.i.d.Children age 6 months and over. 1 to2 mg/kg daily as a single dose or in divideddoses b.i.d.Infants under age 6 months. Up to 3 mg/kgdaily. As adjunct to treat edema caused by cirrhosis,corticosteroids, estrogen, heartfailure, or renal disordersORAL SOLUTION, TABLETSAdults. 25 to 100 mg b.i.d., once daily, orevery other day for 3 to 5 days/wk.Children age 6 months and over. 1 tohydrochlorothiazide 5052 mg/kg daily as a single dose or in divideddoses b.i.d.Infants under age 6 months. Up to 3mg/kg daily.Route Onset Peak DurationP.O. 2 hr 4 hr 6–12 hrContraindicationsAnuria; hypersensitivity to hydrochlorothiazide,other thiazides, sulfonamide derivatives,or their components; renal failureInteractionsDRUGSACTH, amphotericin B, corticosteroids:Increased electrolyte depletion, especiallypotassiumamantadine: Possibly increased blood leveland risk of toxicity of amantadineamiodarone: Increased risk of arrhythmiasfrom hypokalemiaantihypertensives: Increased antihypertensiveeffectsbarbiturates, opioids: Possibly orthostatichypotensioncalcium: Possibly increased serum calciumlevelcholestyramine, colestipol: Reduced GIabsorption of hydrochlorothiazidediazoxide: Increased antihypertensive andhyperglycemic effects of hydrochlorothiazidediflunisal: Possibly increased blood hydrochlorothiazideleveldigoxin: Increased risk of digitalis toxicityfrom hypokalemiadopamine: Possibly increased diuretic effectsof both drugsinsulin, oral antidiabetic drugs: Possiblyincreased blood glucose levellithium: Decreased lithium clearance,increased risk of lithium toxicityneuromuscular blockers: Possibly enhancedneuromuscular blockade from hypokalemianondeplarizing skeletal muscle relaxants:Possibly increased response to muscle relaxantsNSAIDs: Decreased diuretic effect of hydrochlorothiazide,increased risk of renal failureoral anticoagulants: Possibly decreased anticoagulanteffectssympathomimetics: Possibly decreased antihypertensiveeffect of hydrochlorothiazideGHI

506hydrochlorothiazideMechanism of ActionA thiazide diuretic, hydrochlorothiazidepromotes movement ofsodium (Na + ), chloride (Cl – ), andwater (H 2 O) from blood in peritubularcapillaries into nephron’sdistal convoluted tubule, asshown. Initially, it may decreaseextracellular fluid volume, plasmavolume, and cardiac output,which helps explain blood pressurereduction. It also may reduceblood pressure by direct arterialdilation. After several weeks,extracellular fluid volume, plasmavolume, and cardiac output returnto normal, and peripheral vascularresistance remains decreased.NephronPeritubularcapillaryCl-Distal convoluted tubuleH 2 ONa+vitamin D: Increased risk of hypercalcemiaACTIVITIESalcohol use: Possibly orthostatic hypotensionAdverse ReactionsCNS: Dizziness, fever, headache, insomnia,paresthesia, vertigo, weaknessCV: Hypotension, orthostatic hypotension,vasculitisEENT: Blurred vision, dry mouthENDO: HyperglycemiaGI: Abdominal cramps, anorexia, constipation,diarrhea, indigestion, jaundice, nausea,pancreatitis, vomitingGU: Decreased libido, impotence, interstitialnephritis, nocturia, polyuria, renal failureHEME: Agranulocytosis, aplastic anemia,hemolytic anemia, leukopenia, neutropenia,thrombocytopeniaMS: Muscle spasms and weaknessSKIN: Alopecia, cutaneous vasculitis, erythemamultiforme, exfoliative dermatitis,photosensitivity, purpura, rash, Stevens-Johnson syndrome, toxic epidermal necrolysis,urticariaOther: Anaphylaxis, dehydration, hypercalcemia,hyperuricemia, hypochloremia,hypokalemia, hyponatremia, hypovolemia,metabolic alkalosis, weight lossNursing Considerations• Give hydrochlorothiazide in the morningand early evening to avoid nocturia.• Monitor fluid intake and output, dailyweight, blood pressure, and serum levelsof electrolytes, especially potassium.• Assess for evidence of hypokalemia, suchas muscle spasms and weakness.• Monitor BUN and serum creatinine levels.• Check blood glucose level often, asordered, in diabetic patients, and expect toincrease antidiabetic dosage, as needed.• If patient has gouty arthritis, expectincreased risk of gout attacks during therapy.PATIENT TEACHING• Advise patient to take hydrochlorothiazidemorning and early evening to avoid awakeningduring the night to urinate.• Instruct patient to take drug with food ormilk if adverse GI reactions occur.• Tell patient to weigh herself at the sametime each day wearing the same amountof clothing and to notify prescriber if shegains more than 2 lb (0.9 kg) per day or5 lb (2.3 kg) per week.• Instruct patient to eat a diet high in potassium-richfood, including citrus fruits,bananas, tomatoes, and dates.• Advise patient to change position slowlyto minimize effects of orthostatichypotension.• Urge patient to report decreased urination,muscle cramps and weakness, andunusual bleeding or bruising.

hydrocortisone(cortisol)Cortef, Cortenema, HydrocortonehydrocortisoneacetateCortifoam, Hydrocortone AcetatehydrocortisonecypionateCortefhydrocortisonesodium phosphateHydrocortone Phosphatehydrocortisonesodium succinateA-hydroCort, Solu-CortefClass and CategoryChemical class: GlucocorticoidTherapeutic class: Adrenocorticoid replacement,anti-inflammatoryPregnancy category: Not rated; C (Cortifoam)Indications and Dosages To treat severe inflammation or acuteadrenal insufficiencyORAL SUSPENSION, TABLETS (HYDROCORTISONE,HYDROCORTISONE CYPIONATE)Adults. 20 to 240 mg daily as a single doseor in divided doses.I.V. INFUSION OR I.V., I.M., OR SUBCUTANEOUSINJECTION (HYDROCORTISONE SODIUM PHOS-PHATE); I.M. INJECTION (HYDROCORTISONE)Adults. 15 to 240 mg daily as a single doseor in divided doses. Usual: One-half to onethirdthe oral dose.DOSAGE ADJUSTMENT Dosage increased tomore than 240 mg daily if needed to treatacute disease.I.V. INFUSION; I.V. OR I.M. INJECTION(HYDROCORTISONE SODIUM SUCCINATE)Adults. 100 to 500 mg every 2, 4, or 6 hr. To treat joint and tissue inflammationINTRA-ARTICULAR INJECTION (HYDROCORTISONEACETATE)hydrocortisone 507Adults. 25 to 37.5 mg injected into largejoints or bursae as a single dose, or 10 to25 mg into small joints as a single dose.INTRALESIONAL INJECTION (HYDROCORTISONEACETATE)Adults. 5 to 12.5 mg injected into tendonsheaths as a single dose, or 12.5 to 25 mginjected into ganglia as a single dose.SOFT-TISSUE INJECTION (HYDROCORTISONEACETATE)Adults. 25 to 50 mg as a single dose.Sometimes a dose of up to 75 mg is needed. As adjunct to treat ulcerative proctitis ofthe distal portion of the rectum inpatients who can’t retain hydrocortisoneor other corticosteroid enemasRECTAL AEROSOL (HYDROCORTISONE ACETATE)Adult men. Initial: 1 applicatorful once ortwice daily for 2 to 3 wk; then every otherday thereafter. Maintenance: Highly individualized. To treat ulcerative colitisENEMA (HYDROCORTISONE)Adults. 100 mg every night for 2 to 3 wk oruntil condition improves.Route Onset Peak DurationP.O.† Unknown 1 hr 1.25–P.O.||1.5 daysUnknown 1–2 hr UnknownI.V. ‡§ Rapid Unknown UnknownI.M.† Unknown 4–8 hr UnknownI.M.‡ Rapid 1 hr UnknownI.M.§ Rapid 1 hr VariableOther* Unknown 24–48 hr 3 days–4 wkMechanism of ActionBinds to intracellular glucocorticoid receptorsand suppresses inflammatory andimmune responses by:• inhibiting neutrophil and monocyte accumulationat inflammation site and suppressingtheir phagocytic and bactericidalactivity• stabilizing lysosomal membranes† Hydrocortisone‡ Phosphate§ Succinate|| Cypionate* Acetate; intra-articular, intralesional, andsoft-tissue injection.GHI

508hydrocortisone• suppressing antigen response of macrophagesand helper T cells• inhibiting synthesis of cellular mediatorsof inflammatory response, such ascytokines, interleukins, and prostaglandins.ContraindicationsHypersensitivity to hydrocortisone or itscomponents, idiopathic thrombocytopenicpurpura (I.M.), intestinal conditions prohibitingintrarectal steroids (P.R.), recentlive-virus vaccination, systemic fungalinfectionInteractionsDRUGSacetaminophen: Increased risk of hepatotoxicityamphotericin B, carbonic anhydraseinhibitors: Possibly severe hypokalemiaanabolic steroids, androgens: Increased riskof edema and severe acneanticholinergics: Possibly increased intraocularpressureanticoagulants, thrombolytics: Increased riskof GI ulceration and hemorrhage, possiblydecreased therapeutic effects of these drugsasparaginase: Increased risk of hyperglycemiaand toxicityaspirin, NSAIDs: Increased risk of GI distressand bleedingcholestyramine: Possibly increased hydrocortisoneclearancecyclosporine: Possibly increased action ofboth drugs; increased risk of seizuresdigoxin: Possibly hypokalemia-inducedarrhythmias and digitalis toxicityephedrine, phenobarbital, phenytoin, rifampin:Decreased blood hydrocortisone levelestrogens, oral contraceptives: Increased therapeuticand toxic effects of hydrocortisoneinsulin, oral antidiabetic drugs: Possiblyincreased blood glucose levelisoniazid: Possibly decreased therapeuticeffects of isoniazidmacrolide antibiotics: Possibly decreasedhydrocortisone clearancemexiletine: Decreased blood mexiletine levelneuromuscular blockers: Possibly increasedneuromuscular blockade, causing respiratorydepression or apneapotassium-depleting drugs, such as thiazidediuretics: Possibly severe hypokalemiapotassium supplements: Possibly decreasedeffects of these supplementssomatrem, somatropin: Possibly decreasedtherapeutic effects of these drugsstreptozocin: Increased risk of hyperglycemiavaccines: Decreased antibody response andincreased risk of neurologic complicationsACTIVITIESalcohol use: Increased risk of GI distress andbleedingAdverse ReactionsCNS: Ataxia, behavioral changes, depression,dizziness, euphoria, fatigue, headache,increased intracranial pressure with papilledema,insomnia, malaise, mood changes,paresthesia, seizures, steroid psychosis, syncope,vertigoCV: Arrhythmias (from hypokalemia), fatembolism, heart failure, hypertension,hypotension, thromboembolism, thrombophlebitisEENT: Exophthalmos, glaucoma, increasedintraocular pressure, nystagmus, posteriorsubcapsular cataractsENDO: Adrenal insufficiency during stress,cushingoid symptoms (buffalo hump, centralobesity, moon face, supraclavicular fatpad enlargement), diabetes mellitus, growthsuppression in children, hyperglycemia,negative nitrogen balance from proteincatabolismGI: Abdominal distention; hiccups;increased appetite; nausea; pancreatitis;peptic ulcer; rectal abnormalities, such asbleeding, blistering, burning, itching, orpain (rectal form); ulcerative esophagitis;vomitingGU: Amenorrhea, glycosuria, menstrualirregularities, perineal burning or tinglingHEME: Easy bruising, leukocytosisMS: Arthralgia; aseptic necrosis of femoraland humeral heads; compression fractures;muscle atrophy, twitching, or weakness;myalgia; osteoporosis; spontaneous fractures;steroid myopathy; tendon ruptureSKIN: Acne; altered skin pigmentation;diaphoresis; erythema; hirsutism; necrotizingvasculitis; petechiae; purpura; rash; scarring;sterile abscess; striae; subcutaneous fatatrophy; thin, fragile skin; urticariaOther: Anaphylaxis, hypocalcemia, hypokalemia,hypokalemic alkalosis, impairedwound healing, masking of signs of infection,metabolic alkalosis, suppressed skintest reaction, weight gain

hydromorphone hydrochloride 509Nursing Considerations• Systemic hydrocortisone shouldn’t begiven to immunocompromised patients,such as those with fungal and other infections,including amebiasis, hepatitis B,tuberculosis, vaccinia, and varicella.• Give daily dose of hydrocortisone inmorning to mimic normal peak in adrenocorticalsecretion of corticosteroids.• When possible, give oral dose with food ormilk to avoid GI distress.• Don’t give acetate injectable suspension byI.V. route.• Give hydrocortisone sodium succinate as adirect I.V. injection over 30 seconds to severalminutes, or as an intermittent or acontinuous infusion. For infusion, diluteto 1 mg/ml or less with D 5 W, normalsaline solution, or dextrose 5% in normalsaline solution.• Inject I.M. form deep into gluteal muscle,and rotate injection sites to prevent muscleatrophy. Subcutaneous injection maycause atrophy and sterile abscess.• Shake foam container vigorously for 5 to10 seconds before each use. Gently withdrawapplicator plunger past the fill-lineon the applicator barrel while container isupright on a level surface. Administer rectalfoam only with provided applicator.After each use, wash applicator, containercap, and underlying tip with warm water.• High-dose therapy shouldn’t be given forlonger than 48 hours. Be alert for depressionand psychotic episodes.• Monitor weight, blood pressure, and electrolytelevels regularly during therapy.• Expect hydrocortisone to worsen infectionsor mask signs and symptoms.• Monitor blood glucose level in diabeticpatients, and increase insulin or oralantidiabetic drug dosage, as prescribed.• Know that elderly patients are at high riskfor osteoporosis during long-term therapy.• Anticipate the possibility of acute adrenalinsufficiency with stress, such as emotionalupset, fever, surgery, or trauma. Increasehydrocortisone dosage, as prescribed.WARNING Avoid withdrawing drug suddenlyafter long-term therapy because adrenalcrisis can result. Expect to reduce dosagegradually and monitor response.PATIENT TEACHING• Advise patient to take daily dose of hydrocortisoneat 9 a.m.• Instruct patient to take tablets or oral suspensionwith milk or food.• Teach patient how to use foam or enemaform, if prescribed.• Caution patient not to stop drug abruptlywithout first consulting prescriber.• Instruct patient to report early evidence ofadrenal insufficiency: anorexia, difficultybreathing, dizziness, fainting, fatigue, jointpain, muscle weakness, and nausea.• Inform patient that he may bruise easily.• Advise patient on long-term therapy tohave periodic eye examinations.• If patient receives long-term therapy, urgeher to carry or wear medical identification.• Caution patient to avoid people withinfections because drug can suppressimmune system, increasing risk of infection.If patient comes into contact withchickenpox or measles, instruct him to callprescriber because he may need prophylacticcare.hydromorphonehydrochloride(dihydromorphinone)Dilaudid, Dilaudid-5, Dilaudid-HP,Hydrostat IR, Palladone, PMS-Hydromorphone (CAN), PMS-Hydromorphone Syrup (CAN)Class, Category, and ScheduleChemical class: Phenanthrene derivative,semisynthetic opioid derivativeTherapeutic class: AnalgesicPregnancy category: CControlled substance schedule: IIIndications and Dosages To relieve moderate to severe painORAL SOLUTIONAdults. 2.5 to 10 mg every 3 to 6 hr, p.r.n.TABLETSAdults. 2 mg every 3 to 6 hr, p.r.n.Increased to 4 mg or more every 4 to 6 hr, ifindicated.E.R. CAPSULESAdults. Highly individualized and dependenton patient’s previous total daily 24-houropioid use. Once dosage is determined,GHI

510hydromorphone hydrochloridedrug is given daily.I.V. INJECTIONAdults. 1 mg every 3 hr, p.r.n.I.M. OR SUBCUTANEOUS INJECTIONAdults. 1 or 2 mg every 3 to 6 hr, p.r.n.Increased to 3 or 4 mg every 4 to 6 hr, ifneeded for severe pain.SUPPOSITORIESAdults. 3 mg every 4 to 8 hr, p.r.n.Route Onset Peak DurationP.O. 30 min 1.5–2 hr 4 hrI.V. 10–15 15–30 min 2–3 hrminI.M. 15 min 30–60 min 4–5 hrSubQ 15 min 30–90 min 4 hrP.R. 30 min Unknown 4 hrMechanism of ActionMay bind with opioid receptors in thespinal cord and higher levels in the CNS. Inthis way, hydromorphone is believed tostimulate mu and kappa receptors, thusaltering the perception of and emotionalresponse to pain.ContraindicationsAcute asthma; hypersensitivity to hydromorphone,other narcotics, or their components;increased intracranial pressure;severe respiratory depression; upper respiratorytract obstructionInteractionsDRUGSanticholinergics: Increased risk of ileus,severe constipation, or urine retentionantihypertensives, diuretics, guanadrel, guanethidine,mecamylamine: Increased risk oforthostatic hypotensionbarbiturate anesthetics: Increased sedativeeffect of hydromorphonebelladonna alkaloids, difenoxin and atropine,diphenoxylate and atropine, kaolin pectin,loperamide, paregoric: Increased risk of CNSdepression and severe constipationbuprenorphine, butorphanol, dezocine,nalbuphine, pentazocine: Possibly potentiatedor suppressed symptoms of spontaneousopioid withdrawalCNS depressants, other opioid analgesics:Additive CNS depression and hypotensionhydroxyzine: Increased analgesia, CNSdepression, and hypotensionmetoclopramide: Decreased effect of metoclopramideon GI motilitynaloxone: Possibly withdrawal symptoms inphysically dependent patientsnaltrexone: Possibly prolonged respiratorydepression or cardiac arrestneuromuscular blockers: Additive CNSdepressionACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Anxiety, confusion, dizziness, drowsiness,euphoria, hallucinations, headache,nervousness, restlessness, sedation, somnolence,tremor, weaknessCV: Hypertension, orthostatic hypotension,palpitations, tachycardiaEENT: Blurred vision, diplopia, dry mouth,laryngeal edema, laryngospasm, nystagmus,tinnitusGI: Abdominal cramps, anorexia, biliarytract spasm, constipation, hepatotoxicity,nausea, vomitingGU: Dysuria, urine retentionRESP: Dyspnea, respiratory depression,wheezingSKIN: Diaphoresis, flushingOther: Injection site pain, redness, andswelling; physical and psychological dependenceNursing Considerations• To improve analgesic action, give hydromorphonebefore pain becomes intense.• Give I.V. form by direct injection over atleast 2 minutes. For infusion, mix drugwith D 5 W, normal saline solution, orRinger’s solution.• Monitor patient for respiratory depressionwhen using I.V. route. Keep resuscitationequipment and naloxone nearby.• Rotate I.M. and subcutaneous injectionsites.• Monitor effectiveness of hydromorphonein relieving pain; consult prescriber asneeded.• Assess patient for constipation.• Monitor patient for evidence of physicaldependence or abuse.• Anticipate that drug may mask or worsengallbladder pain.• Be aware that all other around-the-clockopioid analgesics should be stopped whenE.R. capsules are prescribed. Expect to give

immediate-release nonopioid analgesicsfor exacerbation of pain and for preventingpain during certain activities.PATIENT TEACHING• Instruct patient to take drug exactly asprescribed and before pain is severe.• Advise patient to take drug with food toavoid GI distress.• Tell patient not to break open or chew E.R.capsules but to swallow them whole.• Instruct patient to refrigerate suppositories.• Caution patient to avoid alcohol and OTCdrugs during therapy, unless prescriberapproves.• Instruct patient to report constipation,difficulty breathing, severe nausea, orvomiting.• Inform patient that drug may causedrowsiness and sedation. Advise her toavoid hazardous activities until drug’sCNS effects are known.• Tell patient to change position slowly tominimize orthostatic hypotension.• To avoid withdrawal, instruct physicallydependent patient not to stop takinghydromorphone abruptly.hydroxychloroquinesulfatePlaquenilClass and CategoryChemical class: 4-aminoquinoline compoundTherapeutic class: Antiprotozoal, antirheumatic,lupus erythematosus suppressantPregnancy category: CIndications and Dosages To prevent malariaTABLETSAdults. 400 mg the same day of each weekstarting 2 wk before entering endemic areaand continuing until departure fromendemic area. If this isn’t possible, initially800 mg in two divided doses 6 hr apart, followed1 wk later with 400 mg and then400 mg on same day of each week thereafteruntil departure from endemic area.Infants and children. 5 mg/kg the same dayMechanism of ActionMay mildly suppress the immune system,inhibiting production of rheumatoid factorand acute phase reactants. Hydroxychloroquinealso accumulates in WBCs, stabilizinglysosomal membranes and inhibitingenzymes such as collagenase and proteasesthat cause cartilage breakdown. Theseactions may decrease symptoms of rheumahydroxychloroquinesulfate 511of each week, starting 2 wk before enteringendemic area and continuing until departurefrom endemic area. If this isn’t possible,initially 10 mg/kg in two divided doses6 hr apart, followed 1 wk later with 5 mg/kgand then 5 mg/kg on same day of eachweek thereafter until departure fromendemic area. Maximum: Adult dosage. To treat acute attacks of malaria causedby Plasmodium vivax, P. malariae, P.ovale, and susceptible strains of P. falciparumTABLETSAdults. Initial: 800 mg, followed by 400 mgin 6 to 8 hr and 400 mg on next 2 consecutivedays. Or, 800 mg given as a single doseor an initial dose of 10 mg base/kg (maximum,620 mg base [800 mg]), followed by5 mg base/kg (maximum, 310 mg base[400 mg]) 6 hr after first dose, 5 mg base/kg18 hr after second dose, and 5 mg base/kg24 hr after third dose.Infants and children. Initial: 10 mg base/kg(maximum, 620 mg base [800 mg]), followedby 5 mg base/kg (maximum, 310 mgbase [400 mg]) 6 hr after first dose, 5 mgbase/kg 18 hr after second dose, and 5 mgbase/kg 24 hr after third dose. To treat chronic discoid and systemiclupus erythematosusTABLETSAdults. Initial: 400 mg once or twice dailyfor several weeks or months. Maintenance:200 to 400 mg daily. To treat acute or chronic rheumatoidarthritisTABLETSAdults. Initial: 400 to 600 mg daily for 4 to12 wk. Maintenance: 200 mg to 400 mgdaily.DOSAGE ADJUSTMENT For patients withrheumatoid arthritis who develop troublesomeadverse reactions, initial dosagedecreased for 5 to 10 days and then graduallyincreased to optimum response level.GHI

512hydroxychloroquine sulfatetoid arthritis and lupus erythematosus.Hydroxychloroquine also binds to andalters DNA of malaria parasite to prevent itfrom reproducing. It also may increase thepH of acid vesicles, which interferes withvesicle function and may inhibit parasiticphospholipid metabolism in erythrocytes,thereby halting plasmodial activity.ContraindicationsHypersensitivity to 4-aminoquinoline compounds(including hydroxychloroquine),long-term therapy in children, retinal orvisual changes related to 4-aminoquinolinecompoundsInteractionsDRUGSaurothioglucose: Increased risk of blooddyscrasiasdigoxin: Increased digoxin concentrationsAdverse ReactionsCNS: Abnormal nerve conduction, ataxia,dizziness, emotional lability, headache, irritability,lassitude, nervousness, neuromuscularsensory abnormalities, nightmares,psychosis, seizures, vertigoCV: Cardiomyopathy (prolonged high doses)EENT: Abnormal pigmentation (bullseyeappearance) or colored vision, blurredvision, central scotoma with decreased visualacuity, corneal deposits, decreasedcorneal sensitivity, diplopia, irreversibleretinal damage (in lupus erythematosus orrheumatoid arthritis), halo vision, lassitude,macular edema or atrophy, nerve-relatedhearing loss, nystagmus, pericentral or paracentralscotoma, photophobia, retinal funduschanges, tinnitus, visual abnormalitiesENDO: HypoglycemiaGI: Abdominal cramps, anorexia, diarrhea,elevated liver function test results, fulminanthepatic failure, nausea, vomitingHEME: Agranulocytosis, aplastic anemia,hemolysis (in patients with glucose-6-phosphatedehydrogenase [G6PD] deficiency),leukopenia, thrombocytopeniaMS: Atrophy of proximal skeletal musclegroups, depressed tendon reflexes, muscleweaknessRESP: BronchospasmSKIN: Acute generalized exanthematouspustulosis, alopecia, altered mucosal andskin pigmentation, bleaching of hair, dermatitis(including exfoliative dermatitis),non–light-sensitive psoriasis, pruritus, psoriasisexacerbation, rash, Stevens-Johnsonsyndrome, urticariaOther: Angioedema, porphyria, weight lossNursing Considerations• Use hydroxychloroquine cautiously inpatients with G6PD deficiency, patientswith hepatic disease or alcoholism, andpatients taking hepatotoxic drugs.• Monitor children closely for adverse reactionsbecause they’re especially sensitive to4-aminoquinoline compounds.• Observe patients with psoriasis closelybecause hydroxychloroquine may lead tosevere psoriasis attack. Also monitorpatients with porphyria closely becausehydroxychloroquine may worsen it. Expectto use hydroxychloroquine in patientswith psoriasis or porphyria only after risksand benefits have been considered.• During prolonged therapy, obtain periodicblood cell counts, as ordered, to detectadverse hematologic effects. Expect to stopdrug if severe adverse effects occur.• Monitor patient’s vision when givinghydroxychloroquine for lupus erythematosusor rheumatoid arthritis because irreversibleretinal damage may occur in somepatients during long-term or high-dosetherapy. Ask regularly about vision abnormalities,such as light flashes or streaks,that may indicate retinopathy. Expectpatient to have an initial ophthalmologicexamination, followed by examinationsevery 3 months. Report changes to prescriberimmediately, and expect drug to bestopped. Retinal changes may progresseven after therapy stops.• Monitor patient on long-term therapy formuscle weakness and abnormal knee andankle reflexes. If present, notify prescriberand expect drug to be stopped.• Expect drug to be stopped if patient withrheumatoid arthritis shows no improvement,such as reduced joint swelling orincreased mobility, in 6 months.• If serious adverse reactions occur, notifyprescriber immediately. Expect drug to bestopped. Also expect to give ammoniumchloride (8 g daily in divided doses foradults) 3 or 4 days weekly for severalmonths because acidification of urine

increases renal excretion of drug.PATIENT TEACHING• Instruct patient to take drug with meals ormilk to minimize stomach upset.• Tell patient to take hydroxychloroquineexactly as prescribed because taking toomuch may cause serious adverse reactionsand taking too little or skipping dosesdecreases effectiveness.• Caution patient to notify prescriber abouttroublesome adverse reactions.Hydroxychloroquine dosage may need tobe adjusted or drug stopped.• Caution patient who takes drug forrheumatoid arthritis or lupus erythematosusabout possible visual reactions and theneed for periodic eye examinations. Tellpatient to notify prescriber about abnormalvisual changes, including blurredvision, halos around lights, and light flashesor streaks; explain that drug will needto be stopped.• Tell patient receiving prolonged therapyabout the need for periodic blood tests todetect adverse effects.• Advise patient to notify prescriber if muscleweakness develops.hydroxyzinehydrochlorideApo-Hydroxyzine (CAN), Atarax,Multipax (CAN), Novo-Hydroxyzin(CAN)hydroxyzinepamoateVistarilClass and CategoryChemical class: Piperazine derivativeTherapeutic class: Antianxiety, antiemetic,antihistamine, sedative-hypnoticPregnancy category: CIndications and Dosages To relieve anxiety and induce sedationand hypnosisCAPSULES, ORAL SUSPENSION, SYRUP, TABLETSAdults and adolescents. 50 to 100 mg as asingle dose.Children. 600 mcg/kg as a single dose.hydroxyzine 513I.M. INJECTIONAdults and adolescents. 50 to 100 mg every4 to 6 hr, p.r.n. (antianxiety); 50 mg as asingle dose (sedative-hypnotic). To treat pruritusCAPSULES, ORAL SUSPENSION, SYRUP, TABLETSAdults and adolescents. 25 to 100 mg t.i.d.or q.i.d., p.r.n.Children. 500 mcg/kg every 6 hr, p.r.n. To provide antiemetic effectsCAPSULES, ORAL SUSPENSION, SYRUP, TABLETSAdults and adolescents. 25 to 100 mg t.i.d.or q.i.d., p.r.n.Children. 500 mcg/kg every 6 hr, p.r.n.I.M. INJECTIONAdults and adolescents. 25 to 100 mg, p.r.n.Children. 1.1 mg/kg as a single dose. As adjunct to permit reduction in preoperativeand postoperative opioid dosageI.M. INJECTIONAdults and adolescents. 25 to 100 mg givenwith prescribed opioid.Children. 1.1 mg/kg given with prescribedopioid.DOSAGE ADJUSTMENT For elderly patients,treatment is started at lowest possibledosage.Route Onset Peak DurationP.O. 15–60 min Unknown 4–6 hrI.M. 20–30 min Unknown 4–6 hrMechanism of ActionCompetes with histamine for histamine 1receptor sites on surfaces of effector cells.This suppresses results of histaminic activity,including edema, flare, and pruritus.Hydroxyzine’s antiemetic effect may stemfrom central anticholinergic actions.Sedative actions occur at subcortical level ofCNS and are dose-related.ContraindicationsBreast-feeding; early pregnancy; hypersensitivityto cetirizine, hydroxyzine, or theircomponentsInteractionsDRUGSCNS depressants: Increased CNS depressionACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Drowsiness, hallucinations, headache,GHI

514InteractionsDRUGSanticholinergics: Possibly increased antihyoscyaminesulfateinvoluntary motor activity, seizures, tremorEENT: Dry mouthSKIN: Pruritus, rash, urticariaOther: Allergic reaction, injection site painNursing Considerations• Don’t give hydroxyzine by subcutaneousor I.V. route because tissue necrosis mayoccur.• Inject I.M. form deep into large muscle,using Z-track method.• Observe for oversedation if patient takesanother CNS depressant.PATIENT TEACHING• Urge patient to avoid alcohol.• Caution patient about drowsiness; tell herto avoid hazardous activities until drug’sCNS effects are known.• Instruct woman to tell prescriber if she isor could be pregnant because drug is contraindicatedin early pregnancy.hyoscyamine sulfateAnaspaz, A-Spas S/L, Cystospaz,Cystospaz-M, Donnamar, ED-SPAZ,Gastrosed, Levbid, Levsin, Levsin/SL,Levsinex Timecaps, Symax SL,Symax SRClass and CategoryChemical class: Belladonna alkaloid, tertiaryamineTherapeutic class: Antimuscarinic, antispasmodicPregnancy category: CIndications and Dosages To treat peptic ulcers and GI tract disorderscaused by spasmELIXIR, ORAL SOLUTIONAdults and adolescents. 0.125 to 0.25 mgevery 4 to 6 hr.Children. Dosage individualized by weight.E.R. CAPSULESAdults and adolescents. 0.375 mg every12 hr.E.R. TABLETSAdults and adolescents. 0.375 to 0.75 mgevery 12 hr. Maximum: 1.5 mg daily.TABLETSAdults and adolescents. 0.125 to 0.5 mgt.i.d. or q.i.d.Children. Dosage individualized by weight.I.V., I.M., OR SUBCUTANEOUS INJECTIONAdults and adolescents. 0.25 to 0.5 mgevery 4 to 6 hr.Children. Dosage individualized by weight. To control salivation and excessive secretionsduring surgical proceduresI.V. INJECTIONAdults and adolescents. 0.5 mg 30 to60 min before procedure.Route Onset Peak DurationP.O.* 20–30 30–60 4 hrP.O. (E.R.)†min min20–30 40–90 12 hrmin minI.V., I.M., 2–3 15–30 4 hrSubQ min minMechanism of ActionCompetitively inhibits acetylcholine at autonomicpostganglionic cholinergic receptors.Because the most sensitive receptors are insalivary, bronchial, and sweat glands, hyoscyamineacts mainly to reduce salivary,bronchial, and sweat gland secretions. Italso causes GI smooth muscle to contractand decreases gastric secretion and GImotility. It also causes bladder detrusormuscle to contract, reduces nasal andoropharyngeal secretions, and decreases airwayresistance from relaxation of smoothmuscle in the bronchi and bronchioles.ContraindicationsAcute hemorrhage and hemodynamicinstability; angle-closure glaucoma; hepaticdisease; hypersensitivity to hyoscyamine,other anticholinergics, or their components;ileus; intestinal atony; myastheniagravis; myocardial ischemia; obstructive GIdisease; obstructive uropathy; renal disease;severe ulcerative colitis; tachycardia; toxicmegacolon* For tablets only; for elixir and oral solution,onset is 5 to 20 min, and peak andduration are unknown.† For E.R. tablets only; for E.R. capsules,onset and peak are unknown, and durationis 12 hr.

cholinergic effectsantidiarrheals (adsorbent): Possiblydecreased hyoscyamine effectscalcium- and magnesium-containing antacids,carbonic anhydrase inhibitors, citrates,sodium bicarbonate, urinary alkalinizers:Possibly potentiated therapeutic andadverse effects of hyoscyaminehaloperidol: Possibly decreased haloperidoleffectsketoconazole: Possibly reduced ketoconazoleabsorptionmetoclopramide: Possibly antagonized therapeuticeffects of metoclopramideopioid analgesics: Increased risk of severeconstipation and ileusAdverse ReactionsCNS: Drowsiness, insomniaEENT: Blurred vision; dry mouth, nose,and throat; photophobiaENDO: Decreased lactationGI: ConstipationGU: Impotence, urine retentionSKIN: Decreased sweatingOther: Heatstroke, injection site rednessand urticariaNursing Considerations• Use hyoscyamine cautiously in patientswho have arrhythmias, autonomic neuropathy,coronary artery disease, heart failure,hiatal hernia with reflux esophagitis,hypertension, hyperthyroidism, renal failure,or tachycardia.• Give drug 30 to 60 minutes before mealsand at bedtime. Give bedtime dose at least2 hours after last meal of day.• Anticipate that tablets may not disintegrateand may appear in stool.WARNING Anticipate an increased risk ofdrug-induced heatstroke in hot or humidweather because hyoscyamine decreasessweating.WARNING Be aware that lower doses mayparadoxically decrease heart rate.Higher doses affect nicotinic receptorsin autonomic ganglia, causing delirium,disorientation, hallucinations, and restlessness.• Monitor urine output, and be alert forurine retention.PATIENT TEACHING• Instruct patient to void before takingeach dose and to notify prescriber if sheibuprofen 515has trouble urinating during therapy.• Advise patient to take drug 30 to 60 minutesbefore meals and at bedtime. Bedtimedose should be taken at least 2 hours afterlast meal of the day.• Explain that drug may cause drowsiness.Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• If patient reports dry mouth, suggest usingsugarless hard candy or gum.• Inform male patient that drug may causeimpotence. If it occurs, suggest that he discussit with prescriber.• Advise patient to avoid exposure to hightemperatures and to increase fluid intake,unless contraindicated.ibuprofenActiprofen Caplets (CAN), Advil,Apo-Ibuprofen (CAN), Bayer SelectIbuprofen Pain Relief Formula Caplets,Caldolor, Children’s Advil, Children’sMotrin, Dolgesic, Excedrin IB, Genpril,Haltran, Ibifon 600 Caplets, Ibuprin,Ibuprohm Caplets, Ibu-Tab, Medipren,Midol IB, Motrin, Motrin-IB, Novo-Profen (CAN), Nu-Ibuprofen (CAN),Nuprin, Pamprin-IB, Q-Profen, Rufen,TrendarClass and CategoryChemical class: Propionic acid derivativeTherapeutic class: Analgesic, antiinflammatory,antipyreticPregnancy category: C (before 30 weeks gestation);D (starting at 30 weeks gestation)Indications and Dosages To relieve pain in rheumatoid arthritisand osteoarthritisCAPSULES, CHEWABLE TABLETS, ORAL SUSPENSION,TABLETSAdults. 300 mg q.i.d., or 400, 600, or 800 mgt.i.d. or q.i.d. Range: 1.2 to 3.2 g daily. To relieve mild to moderate painCAPSULES, CHEWABLE TABLETS, ORAL SUSPENSION,TABLETSAdults. 400 mg every 4 to 6 hr, p.r.n.I.V. INFUSIONAdults. 400 to 800 mg infused over at least30 minutes, every 6 hours, as needed. To relieve acute migraine painGHI

516ibuprofenCAPSULES, CHEWABLE TABLETS, ORAL SUSPENSION,TABLETSAdults. 200 to 400 mg at onset of migrainepain. Maximum: 400 mg daily. To relieve pain in primary dysmenorrheaCAPSULES, CHEWABLE TABLETS, ORAL SUSPENSION,TABLETSAdults. 400 mg every 4 hr, p.r.n. To relieve pain in juvenile arthritisCAPSULES, CHEWABLE TABLETS, ORAL SUSPENSION,TABLETSChildren. 30 to 70 mg/kg daily in divideddoses t.i.d. or q.i.d.; 20 mg/kg daily for milddisease. To relieve minor aches, pains, and dysmenorrheaand to reduce feverCAPSULES, CHEWABLE TABLETS, ORAL SUSPENSION,TABLETSAdults. 200 to 400 mg every 4 to 6 hr.Maximum: 1.2 g daily. To relieve moderate to severe pain as anadjunct to opioid analgesicsI.V. INFUSIONAdults. 400 mg to 800 mg infused over atleast 30 minutes, every 6 hours, as needed. To reduce feverCAPSULES, CHEWABLE TABLETS, ORAL SUSPENSION,TABLETSChildren ages 6 months to 12 years. 5 to10 mg/kg every 4 to 6 hr. Maximum: 40 mg/kg daily.I.V. INFUSIONAdults. 400 mg infused over at least30 minutes, followed by 400 mg infusedover at least 30 minutes, every 4 to 6 hours.Or, 100 to 200 mg infused over at least30 minutes, every 4 hours, as needed.Route Onset Peak DurationP.O.* 30 min Unknown 4–6 hrP.O.† Up to 7 days 1–2 wk UnknownP.O.‡ In 1 hr 2–4 hr 6–8 hrMechanism of ActionBlocks activity of cyclooxygenase, theenzyme needed to synthesize prostaglandins,which mediate inflammatory responseand cause local vasodilation, swelling, andpain. By inhibiting prostaglandins, this* For analgesic effects.† For anti-inflammatory effects.‡ For antipyretic effects.NSAID reduces inflammatory symptomsand relieves pain. Ibuprofen’s antipyreticaction probably stems from its effect on thehypothalamus, which increases peripheralblood flow, causing vasodilation andencouraging heat dissipation.ContraindicationsAngioedema, asthma, bronchospasm, nasalpolyps, rhinitis, or urticaria caused byhypersensitivity to aspirin, ibuprofen,iodides, or other NSAIDs; perioperativepain with coronary artery bypass graft surgeryInteractionsDRUGSacetaminophen: Possibly increased renaleffects with long-term use of both drugsantihypertensives: Decreased effectiveness ofthese drugsaspirin: Possibly decreased cardioprotectiveand stroke-preventive effects of aspirinaspirin, other NSAIDs: Increased risk ofbleeding and adverse GI effectsbone marrow depressants: Possibly increasedleukopenic and thrombocytopenic effects ofbone marrow depressantscefamandole, cefoperazone, cefotetan:Increased risk of hypoprothrombinemiaand bleedingcolchicine, platelet aggregation inhibitors:Increased risk of GI bleeding, hemorrhage,and ulcerscorticosteroids, potassium supplements:Increased risk of adverse GI effectscyclosporine: Increased risk of nephrotoxicityfrom both drugs, increased blood cyclosporineleveldigoxin: Increased blood digoxin level andrisk of digitalis toxicitydiuretics (loop, potassium-sparing, and thiazide):Decreased diuretic and antihypertensiveeffectsgold compounds, nephrotoxic drugs:Increased risk of adverse renal effectsheparin, oral anticoagulants, thrombolytics:Increased anticoagulant effects, increasedrisk of hemorrhageinsulin, oral antidiabetics: Possibly increasedhypoglycemic effects of these drugslithium: Increased blood lithium levelmethotrexate: Decreased methotrexateclearance and increased risk of toxicityplicamycin, valproic acid: Increased risk of

hypoprothrombinemia and GI bleeding,hemorrhage, and ulcersprobenecid: Possibly increased blood level,effectiveness, and risk of toxicity of ibuprofenACTIVITIESalcohol use: Increased risk of adverse GIeffectsAdverse ReactionsCNS: Aseptic meningitis, dizziness, headache,nervousness, seizures, strokeCV: Fluid retention, heart failure, hypertension,MI, peripheral edema, tachycardiaEENT: Amblyopia, epistaxis, stomatitis, tinnitusGI: Abdominal cramps, distention, or pain;anorexia; constipation; diarrhea; diverticulitis;dyspepsia; dysphagia; elevated liverfunction test results; epigastric discomfort;esophagitis; flatulence; gastritis; gastroenteritis;gastroesophageal reflux disease; GIbleeding, hemorrhage, perforation, orulceration; heartburn; hemorrhoids; hepaticfailure; hepatitis; hiatal hernia; indigestion;melena; nausea; stomatitis; vomitingGU: Cystitis, hematuria, renal failure(acute)HEME: Agranulocytosis, anemia, aplasticanemia, eosinophilia, hemolytic anemia,leukopenia, neutropenia, pancytopenia, prolongedbleeding time, thrombocytopeniaRESP: Bronchospasm, dyspnea, wheezingSKIN: Blisters, erythema multiforme, photosensitivity,pruritus, rash, Stevens-Johnson syndrome, toxic epidermal necrolysis,urticariaOther: Anaphylaxis, angioedema, flulikesymptoms, hypokalemia, weight gainibuprofen 517Nursing Considerations• Use ibuprofen with extreme caution inpatients with a history of ulcer disease orGI bleeding because NSAIDs such asibuprofen increase risk of GI bleeding andulceration. Expect to use ibuprofen forshortest time possible in these patients.• Risk of serious cardiovascular thromboticevents such as a MI or stroke increases thelonger ibuprofen is used. Expect to givedrug for shortest time possible.• For I.V. use, dilute Caldolor brand ofibuprofen to final concentration of 4 mg/ml or less using 0.9% sodium chlorideinjection, 5% dextrose injection, or lactatedRinger’s solution. For an 800-mg dose,dilute 8 ml Caldolor in at least 200 mldiluent; for a 400-mg dose, dilute 4 mlCaldolor in at least 100 ml diluent.Diluted solutions may be kept at roomtemperature up to 24 hours. When infusingibuprofen intravenously, infusion timemust be at least 30 minutes.• Serious GI tract ulceration, bleeding, andperforation may occur without warningsymptoms. Elderly patients are at greaterrisk. To minimize risk, give oral drug withfood. If GI distress occurs, withhold drugand notify prescriber immediately.• Use ibuprofen cautiously in patients withhypertension, and monitor blood pressureclosely throughout therapy. Drug maycause hypertension or worsen it.WARNING Monitor patient closely forthrombotic events, including MI andstroke, because NSAIDs increase the risk.• Monitor patient—especially if he’s elderlyor receiving long-term oral ibuprofen therapy—forless common but serious adverseGI reactions, including anorexia, constipation,diverticulitis, dysphagia, esophagitis,gastritis, gastroenteritis, gastroesophagealreflux disease, hemorrhoids, hiatal hernia,melena, stomatitis, and vomiting.• Monitor liver function test results because,in rare cases, elevations may progress tosevere hepatic reactions, including fatalhepatitis, liver necrosis, and hepatic failure.• Monitor BUN and serum creatinine levelsin elderly patients, patients taking diureticsor ACE inhibitors, and patients withheart failure, impaired renal function, orhepatic dysfunction; drug may cause renalfailure.• Monitor CBC for decreased hemoglobinand hematocrit. Drug may worsen anemia.WARNING If patient has bone marrow suppressionor is receiving an antineoplasticdrug, monitor laboratory results (includingWBC count), and watch for evidenceof infection. Ibuprofen’s anti-inflammatoryand antipyretic actions may mask signsand symptoms, such as fever and pain.• Assess patient’s skin regularly for signs ofrash or other hypersensitivity reactionbecause ibuprofen is an NSAID and maycause serious skin reactions without warning,even in patients with no history ofNSAID sensivitity. At first sign of reaction,GHI

518ibutilide fumaratestop drug and notify prescriber.• Although analgesic effect occurs at lowdoses, expect to give at least 400 mg fourtimes daily for anti-inflammatory effect.• Expect higher doses for rheumatoidarthritis than for osteoarthritis.• Be aware that ibuprofen oral suspensionmay contain sucrose, which may affectblood glucose level in diabetic patients.PATIENT TEACHING• Instruct patient to take tablets with a fullglass of water, and caution him not to liedown for 15 to 30 minutes to preventesophageal irritation.• Advise patient to take drug with food orafter meals to reduce GI distress.• Urge patient no more drug or for longertime than prescribed because stomachbleeding may occur and risk of MI orstroke may increase.• Instruct patient to consult prescriber if heneeds to take drug for more than 3 daysfor fever or 10 days for pain; if stomachproblems (heartburn, upset, pain) recur; ifhe has a history of ulcers, bleeding problems,hypertension, or heart or renal disease;if he takes a diuretic; or if he’s overage 65.• Inform patient with phenylketonuria thatMotrin chewable tablets contain aspartame.• Inform patient that full therapeutic effectfor arthritis may take 2 weeks or longer.• Urge patient to avoid taking two differentNSAIDs at the same time, unless directed,and to alert prescriber before takingibuprofen if he has ever had an allergicreaction to any other analgesic or feverreducingdrug or has a history of asthma.• Urge patient to avoid alcohol, aspirin, andcorticosteroids while taking ibuprofen,unless prescribed. If patient takes aspirinas prevention of MI or stroke, explain thatibuprofen may interfere with this effect.• Suggest that patient wear sunscreen andprotective clothing when outdoors.• Advise patient to report flulike symptoms,rash, signs of GI bleeding, swelling, visionchanges, and weight gain.• Urge parents to tell prescriber promptly ifchild receiving drug develops a severe orpersistent sore throat, high fever, headache,persistent diarrhea, nausea, or vomitingor hasn’t been drinking fluids.• Advise parents to consult prescriber beforegiving OTC ibuprofen to a child if thechild has asthma, ulcers, bleeding problems,high blood pressure, heart or kidneydisease, a need for diuretic therapy, seriousadverse effects from previous use of feverreducers or pain relievers, or persistentstomach problems, such as heartburn,upset stomach, or stomach pain.• Caution pregnant patient not to takeNSAIDs such as ibuprofen during lasttrimester because they may cause prematureclosure of the ductus arteriosus.• Explain that ibuprofen may increase riskof serious adverse cardiovascular reactions;urge patient to seek immediatemedical attention if signs or symptomsarise, such as chest pain, shortness ofbreath, weakness, and slurring of speech.• Explain that ibuprofen may increase riskof serious adverse GI reactions; stressimportance of seeking immediate medicalattention for such signs and symptoms asepigastric or abdominal pain, indigestion,black or tarry stools, or vomiting blood ormaterial that looks like coffee grounds.• Alert patient to rare but serious skin reactions.Urge him to seek immediate medicalattention for rash, blisters, itching, fever,or other indications of hypersensitivity.ibutilide fumarateCorvertClass and CategoryChemical: Methanesulfonanilide derivativeTherapeutic: Class III antiarrhythmicPregnancy category: CIndications and Dosages To rapidly convert recent-onset atrialflutter or fibrillation to sinus rhythmI.V. INFUSIONAdults weighing 60 kg (132 lb) or more.1 mg over 10 min. Dose repeated 10 minafter first dose is finished if arrhythmia persists.Adults weighing less than 60 kg. 0.01 mg/kg over 10 min. Dose is repeated 10 minafter first dose is completed if arrhythmiapersists.DOSAGE ADJUSTMENT Infusion stopped ifarrhythmia is terminated or if sustained or

nonsustained ventricular tachycardia orprolonged QT or QTc interval develops.Mechanism of ActionMay promote sodium movement throughslow inward sodium channels in myocardialcell membranes. Ibutilide also may inhibitpotassium channels in myocardial cellmembranes involved in cardiac repolarization.These actions prolong cardiac actionpotential by delaying repolarization andincreasing atrial and ventricular refractoriness.As a result, sinus rate slows and AVconduction is delayed.ContraindicationsHypersensitivity to ibutilide or componentsInteractionsDRUGSamiodarone, astemizole, disopyramide, maprotiline,phenothiazines, procainamide,quinidine, sotalol, tricyclic antidepressants:Possibly prolonged QT interval, leading toincreased risk of proarrhythmiasAdverse ReactionsCNS: Headache, syncopeCV: AV block, bradycardia, bundle-branchblock, heart failure, hypertension, hypotension,idioventricular rhythm, orthostatichypotension, palpitations, prolonged QTinterval, sinus and supraventricular tachycardia,supraventricular arrhythmias, ventriculararrhythmias, ventricular tachycardia(sustained and nonsustained)GI: NauseaGU: Renal failureNursing Considerations• Before giving ibutilide, check serum electrolytelevels and expect to correct abnormalities,as prescribed. Be especially alertfor hypokalemia and hypomagnesemia,which can lead to arrhythmias.• Give drug undiluted or dilute in 50 mlnormal saline solution or D 5 W. Add contentsof 10-ml vial (0.1 mg/ml) to 50 mlsolution to obtain 0.017 mg/ml. Usepolyvinyl chloride plastic bags or polyolefinbags for admixtures. Give drugwithin 24 hours (48 hours if refrigerated).• Infuse drug slowly over 10 minutes.• As ordered, monitor patient’s cardiacrhythm continuously during infusion andfor at least 4 hours afterward—longer ifarrhythmias appear or if patient hasabnormal hepatic function. Observepatient for ventricular ectopy.• Make sure defibrillator and drugs to treatsustained ventricular tachycardia are availableduring therapy and when monitoringpatient after therapy.PATIENT TEACHING• Inform patient that ibutilide will be givenby I.V. infusion and that his heart rhythmwill be monitored continuously.• Ask patient to report chest pain, faintness,numbness, tingling, palpitations, andshortness of breath.• Advise patient to keep follow-up appointmentsto monitor heart rhythm.iloperidoneFanaptiloperidone 519Class and CategoryChemical class: Piperidinyl-benzisoxazolederivativeTherapeutic class: Second-generationantipsychotic; atypical antipsychoticPregnancy category: CIndications and Dosages To treat schizophreniaTABLETSAdults. Initial: 1 mg twice daily, adjusted totarget dosage range as follows: 2 mg twicedaily on day 2, 4 mg twice daily on day 3,and 6 mg twice daily on day 4. Dosage maybe further increased, if needed, as follows:8 mg twice daily on day 5, 10 mg twicedaily on day 6, and 12 mg twice daily onday 7. Maximum: 12 mg b.i.d. twice daily.DOSAGE ADJUSTMENT For patients takingstrong CYP2D6 or CYP3A4 inhibitors,dosage reduced by half.Route Onset Peak DurationP.O. 1–2 wk 2–4 hr UnknownMechanism of ActionSelectively blocks serotonin type 2 (5-HT 2 )and dopamine type 2 (D 2 ) receptors inCNS, thereby suppressing psychotic symptoms.ContraindicationsHypersensitivity to iloperidone or its componentsGHI

520iloperidoneInteractionsDRUGSantibiotics such as fluoroquinolones ormacrolides, class I A antiarrhythmics such asprocainamide or quinidine, class III antiarrhythmicssuch as amiodarone or sotalol,other antipsychotic drugs such as chlorpromiazineor thioridazine, or any other drug thataffects the QT interval such as methadone orpentamidine: Possibly prolonged QT intervalantihyertensive drugs: Increased antihypertensiveeffectsCYP3A4 inhibitors such as ketoconazole,CYP2D6 inhibitors such as fluoxetine orparoxetine: Increased plasma iloperidoneleveldextromethorphan: Increased blood dextromethorphanlevelAdverse ReactionsCNS: Aggression, delusion, dizziness,extrapyramidal effects, fatigue, lethargy,seizures, somnolence, suicidal ideation,restlessness, tremorCV: CHF, orthostatic hypotension, palpitations,QT-interval prolongation, tachycardiaEENT: Blurred vision, conjunctivitis, drymouth, nasal congestion, nasopharyngitis,upper respiratory tract infectionENDO: Diabetic ketoacidosis, elevated prolactinlevels, hyperglycemia, hyperosmolarcomaGI: Abdominal discomfort, diarrhea, nauseaGU: Ejaculation failure, erectile dysfunction,priapism, urinary incontinenceHEME: LeukopeniaMS: Arthralgia, musculoskeletal stiffness,spasms, myalgiaRESP: DyspneaSKIN: RashOther: Weight gainNursing Considerations• Iloperidone shouldn’t be used in patientswith a history of cardiovascular diseasesuch as QT-interval prolongation, recentMI, uncompensated heart failure, or cardiacarrhythmias. It also shouldn’t be usedin patients taking other drugs known toprolong the QT interval and in patientswith hepatic impairment.WARNING Iloperidone shouldn’t be used totreat patients with dementia-related psychosis,especially elderly patients, becauseof an increased risk of death.• Use cautiously in patients who have a historyof seizures or who have conditionsthat lower the seizure threshold, such asAlzheimer’s dementia. Also use cautiouslyin patients at risk for aspiration pneumonia.• Expect to start dosage adjustment schedulein patients who have been off iloperidonetherapy for more than 3 days.• Obtain baseline serum potassium andmagnesium levels in patients at risk forelectrolyte imbalances, and then monitorperiodically throughout therapy, asordered, because electrolyte imbalancesincrease risk of prolonged QT interval orarrhythmia. If patient reports dizziness,palpitations, or syncope, notify prescriberand expect further evaluation to be done.WARNING Neuroleptic malignant syndromehas occurred in patients taking otherantipsychotic drugs. Monitor patient forhyperpyrexia, muscle rigidity, altered mentalstatus, and autonomic instability. Ifpresent, notify prescriber immediately,expect drug to be discontinued, and startintensive treatment, as prescribed. Watchfor recurrence if patient resumes antipsychotictherapy.• Monitor patient for tardive dyskinesia,which has occurred with other antipsychoticdrugs. If patient develops involuntary,dyskinetic movements, notify prescriberand expect to discontinue drug.• Monitor blood glucose level, especially inpatients with diabetes mellitus, becauseiloperidone may alter blood glucoseenough to induce life-threatening ketoacidosisor hyperosmolar coma.• Monitor patient’s CBC periodically, asordered, especially during first few monthsof therapy, because iloperidone may causeneutropenia. Also, be aware that otherantipyschotic drugs have caused sometimesfatal leukopenia and agranulocytosis.If patient’s WBC count decreases,expect drug to be discontinued.• Monitor patient closely for abnormal tendenciesthat may suggest suicidal thinking,especially when iloperidone therapy startsor dosage is changed.PATIENT TEACHING• Inform patient that when iloperidonetherapy starts, dosage must be adjusted forup to a week to reach target level. Also

explain that adjustment process will needto be repeated if she skips drug for morethan 3 days.• Advise patient or caregiver o notify prescriberabout unusual, severe, or persistentadverse reactions because drug may needto be discontinued.• Urge patient or caregiver to report evidenceof abnormal thinking, especiallywhen therapy starts or dosage changes.• Tell diabetic patient to monitor blood glucoselevels closely and to report persistentelevations immediately to prescriber.• Caution patient to avoid hazardous activitiesuntil CNS effects of drug are known.Patient should also avoid alcohol.• Instruct patient to avoid activities thatmight raise body temperature, such asdoing strenuous exercise, being exposed toextreme heat, taking other drugs withanticholinergic activity, or being subjectedto dehydration.• Stress the need to comply with follow-upappointments and laboratory tests.• Tell patient to rise slowly from lying to sittingposition and from sitting position tostanding to avoid dizziness or lightheadednessduring therapy.iloprostVentavisClass and CategoryChemical class: Synthetic analogue ofprostacyclin PGI 2Therapeutic class: Pulmonary arterial antihypertensivePregnancy category: CIndications and Dosages To improve symptoms and exercise toleranceand prevent further deteriorationfrom pulmonary arterial hypertensionin patients with New York HeartAssociation (NYHA) Class III or IVsymptomsINHALATION SOLUTIONAdults. Initial: 2.5 mcg as one-time dose. Iftolerated well for 2 hr, dosage increased to5 mcg. Maintenance: 5 mcg six to ninetimes daily during waking hours with atleast 2 hr between each dose. Maximum:45 mcg daily.Nursing Considerations• Use iloprost cautiously in patients withhepatic or renal impairment.• Give iloprost only with the Prodose AADSystem, a pulmonary drug delivery device.Avoid letting solution contact skin or eyes.WARNING Don’t give drug if patient’s systolicblood pressure is less than 85 mm Hg.• Notify prescriber if patient develops exertionalsyncope because dosage may needto be adjusted.WARNING Stop iloprost immediately ifpatient develops evidence of pulmonaryedema, such as shortness of breath, anxiety,restlessness, and abnormal breathsounds. Notify prescriber, and providesupportive care, as prescribed.• Monitor patient’s vital signs while startingtherapy because drug may cause syncope.• Assess patient’s compliance with treatmentregimen. If patient has repeatedly lengthiloprost521Mechanism of ActionDilates systemic and pulmonary arterialvascular beds, which lowers blood pressurein pulmonary arterial system.ContraindicationsHypersensitivity to iloprost or its componentsInteractionsDRUGSanticoagulants: Increased risk of bleedingantihypertensives, vasodilators: Increasedhypotensive effectAdverse ReactionsCNS: Apathy, dizziness, headache, insomnia,restlessness, syncopeCV: Chest pain, congestive heart failure,hypotension, palpitations, peripheraledema, supraventricular tachycardia,thrombosis, vasodilationEENT: Epistaxis, gingival bleeding, tonguepainENDO: HyperglycemiaGI: Abdominal cramps, diarrhea, nausea,vomitingGU: Renal failureMS: Back pain, muscle cramps or spasmsRESP: Bronchospasm, dyspnea, hemoptysis,increased cough, pneumonia, wheezingSKIN: FlushingOther: Flulike symptoms, increased alkalinephosphatase levelGHI

522imipramineened treatment times, resulting in incompletedosing, notify prescriber. A differentstrength may be ordered that decreasesinhalation time, which may help increasecompliance.PATIENT TEACHING• Instruct patient to use iloprost inhalationtherapy exactly as prescribed. Tell patientthat at least 2 hours must elapse betweendoses but that benefits of iloprost may notlast 2 hours, so he should adjust times ofadministration to cover planned activities.• Teach patient how to administer iloprostusing Prodose AAD System. Tell patient tohave a backup system available in case ofequipment malfunction.• Advise patient to stand up slowly becausedrug may cause dizziness or faintness. Ifthese symptoms persist or worsen, tellpatient to notify prescriber because adosage adjustment may be required.imipraminehydrochlorideApo-Imipramine (CAN), Impril (CAN),Norfranil, Novopramine (CAN),Tipramine, TofranilimipraminepamoateTofranil-PMClass and CategoryChemical class: Dibenzazepine derivativeTherapeutic class: AntidepressantPregnancy category: Not ratedIndications and Dosages To treat depressionCAPSULESAdults. Initial: 75 mg daily at bedtime,gradually increased as needed and tolerated.Maximum: 300 mg daily (hospitalizedpatients), 200 mg/day (outpatients).TABLETSAdults. Initial: 25 to 50 mg t.i.d. or q.i.d.,gradually increased as needed and tolerated.Maximum: 300 mg daily (hospitalizedpatients), 200 mg daily (outpatients).DOSAGE ADJUSTMENT Initial dosage reducedto 25 mg at bedtime for depressed elderlypatients; then adjusted as needed and toleratedup to 100 mg daily in divided doses.Adolescents. Initial: 25 to 50 mg daily individed doses, adjusted as needed and tolerated.Maximum: 100 mg daily.Children ages 6 to 12. 10 to 30 mg daily individed doses b.i.d. As adjunct to treat childhood enuresisTABLETSChildren age 6 and over. 25 mg 1 hr beforebedtime. Increased to 50 mg if no responseoccurs within 1 wk and child is under age12; increased to 75 mg if child is age 12 orover. Maximum: 2.5 mg/kg daily.Route Onset Peak DurationP.O. 2–3 wk* Unknown UnknownMechanism of ActionMay interfere with reuptake of serotonin(and possibly other neurotransmitters) atpresynaptic neurons, thus enhancing serotonin’seffects at postsynaptic receptors.Mood elevation may result from restorationof normal levels of neurotransmitters atnerve synapses. This tricyclic antidepressantalso blocks acetylcholine receptors, whichmay explain how it relieves enuresis.ContraindicationsAcute recovery period after MI; hypersensitivityto imipramine, other tricyclic antidepressants,or their components; use within2 weeks of MAO inhibitor therapyInteractionsDRUGSamantadine, anticholinergics, antidyskinetics,antihistamines: Risk of increased anticholinergiceffects, including confusion,hallucinations, and nightmaresanticonvulsants: Increased risk of CNSdepression, increased risk of seizures,decreased effectiveness of imipramineantithyroid drugs: Possibly agranulocytosisbarbiturates, carbamazepine: Possiblydecreased imipramine level and effectscimetidine, fluoxetine: Possibly increasedblood imipramine levelclonidine, guanadrel, guanethidine: Possiblydecreased antihypertensive effects of thesedrugs, increased CNS depression (clonidine)* For antidepressant effect.

CNS depressants: Increased CNS depression,respiratory depression, and hypotensiondisulfiram, ethchlorvynol: Risk of delirium,increased CNS depression (ethchlorvynol)estramustine, estrogen-containing oral contraceptives,estrogens: Risk of increased bioavailabilityof imipramine, increaseddepressionMAO inhibitors: Increased risk of hypertensivecrisis, severe seizures, and deathoral anticoagulants: Possibly increased anticoagulantactivitypimozide, probucol: Risk of arrhythmiassympathomimetics (including ophthalmicepinephrine and vasoconstrictive local anesthetics):Increased risk of arrhythmias,hyperpyrexia, hypertension, tachycardiathyroid hormones: Risk of increased therapeuticand adverse effects of both drugsACTIVITIESalcohol use: Increased CNS depression,increased alcohol effectssun exposure: Increased risk of photosensitivityAdverse ReactionsCNS: Anxiety, ataxia, chills, confusion,delirium, dizziness, drowsiness, excitation,extrapyramidal reactions, fever, hallucinations,headache, insomnia, nervousness,nightmares, parkinsonism, seizures, stroke,suicidal ideation, tremorCV: Arrhythmias, orthostatic hypotension,palpitationsEENT: Blurred vision, dry mouth, increasedintraocular pressure, pharyngitis, taste perversion,tinnitus, tongue swellingENDO: Gynecomastia, syndrome of inappropriateADH secretionGI: Constipation, diarrhea, heartburn, ileus,increased appetite, nausea, vomitingGU: Impotence, libido changes, testicularswelling, urine retentionHEME: Agranulocytosis, bone marrowdepressionRESP: WheezingSKIN: Alopecia, diaphoresis, jaundice, photosensitivity,pruritus, rash, urticariaOther: Allergic reaction, facial edema,weight gaincholinergic effects may cause urine retentionand increased intraocular pressure.WARNING Don’t give MAO inhibitors within2 weeks of imipramine. Patient mayexperience hypertensive crisis, seizures,and death.• Frequently assess for adverse reactionsduring first 2 hours of therapy.• Check supine and standing blood pressurefor orthostatic hypotension before andduring imipramine therapy and beforedosage increases.• Anticipate increased risk of arrhythmias inpatients with a history of cardiac disease.• When drug is used for depression, expectmood elevation to take 2 to 3 weeks.Watch patient closely for suicidal tendencies,especially children and adolescentsand especially when therapy starts ordosage changes, because depression mayworsen temporarily at these times.• Avoid abrupt withdrawal of drug inpatients on long-term therapy. Such withdrawalmay cause headache, malaise, nausea,sleep disturbance, and vomiting.• Taper drug gradually, as ordered, a fewdays before surgery to avoid risk of hypertensionduring surgery.• Obtain CBC, as ordered, if patient experiencessigns and symptoms of infection,such as fever or pharyngitis.• Limit amount of drug given to potentiallysuicidal patient.PATIENT TEACHING• Advise patient to take imipramine exactlyas prescribed. Warn that stopping drugabruptly may cause headache, malaise,nausea, trouble sleeping, and vomiting.• Caution parents to monitor child or adolescentclosely for suicidal tendencies,especially when therapy starts or dosagechanges.• Urge patient to report chills, trouble urinating,dizziness, excess sedation, fever,palpitations, signs of allergic reaction, andsore throat.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Urge patient to avoid alcohol duringimipramine therapy because it increasesCNS depression and alcohol effects.• Suggest that patient eat small, frequentmeals to help relieve nausea.• Instruct patient to avoid prolonged expoimipramine523Nursing Considerations• Use imipramine cautiously in patientswith a history of urine retention or angleclosureglaucoma because drug’s anti-GHI

524immune globulinsure to sunlight because of the risk ofphotosensitivity.• Inform male patient about possible impotenceand increased or decreased libido.• If patient reports dry mouth, suggest sugarlesscandy or gum to relieve it. Tell himto check with prescriber if dry mouth persistsafter 2 weeks.immune globulinintramuscular(human)(gamma globulin, IG)BayGam, WinRho SDFimmune globulinintravenous(human)(IGIV, immune serumglobulin, ISG, IVIG)Gamimune N 5% S/D, Gamimune N10% S/D, Gammagard Liquid,Gammagard S/D, Gammagard S/D 0.5 g,Gammar-P IV, Gamunex 10%, IveegamEN, Octagam 5%, Polygam S/D,Rhophylac, Sandoglobulin,Venoglobulin-I, Venoglobulin-S 5%,Venoglobulin-S 10%, WinRho SDFClass and CategoryChemical class: Polyvalent antibodyTherapeutic class: Antibacterial,anti–Kawasaki disease agent, antipolyneuropathyagent, antiviral, immunizingagent, platelet count stimulatorPregnancy category: CIndications and Dosages To treat primary immunodeficiencyI.M. INJECTION (BAYGAM)Adults. 0.66 ml/kg (at least 200 mg/kg)every 3 to 4 wk; initial dose may be doubled.I.V. INFUSION (GAMIMUNE N 5% S/D OR10% S/D)Adults. 100 to 200 mg/kg every mo. Ifresponse is inadequate, dose may beincreased to as much as 400 mg/kg or dosingfrequency may be increased.I.V. INFUSION (GAMMAGARD S/D, POLYGAM S/D)Adults. 200 to 400 mg/kg initially, then atleast 100 mg/kg every mo thereafter. Ifresponse is inadequate, dose or frequencymay be adjusted.I.V. INFUSION (GAMMAR-P IV)Adults. 200 to 400 mg/kg every 3 to 4 wk.Adolescents and children. 200 mg/kg every3to 4wk.I.V. INFUSION (GAMUNEX 10%)Adults. 300 to 600 mg/kg every 3 or 4 wk.I.V. INFUSION (IVEEGAM EN)Adults. 200 mg/kg every mo.I.V. INFUSION (OCTAGAM 5%)Adults. Initial: 30 mg/kg/hr for first30 minutes; increased, if tolerated, to60 mg/kg/hr for second 30 minutes and, iftolerated, to 120 mg/kg/hr for another30 minutes; followed by maintenance infusionof up to 200 mg/kg/hr.I.V. INFUSION (SANDOGLOBULIN)Adults and children. 200 mg/kg every mo.If response is inadequate, dose may beincreased to 300 mg/kg or dosing frequencymay be increased.I.V. INFUSION (VENOGLOBULIN-I)Adults and children. 200 mg/kg every mo.If response is inadequate, dose may beincreased to 300 to 400 mg/kg every mo ordosing frequency may be increased.I.V. INFUSION (VENOGLOBULIN-S 5% OR 10%)Adults and children. 200 mg/kg every mo.If response is inadequate, dose may beincreased to as much as 400 mg/kg or dosingfrequency may be increased. To treat primary immunodeficiency disordersassociated with defects inhumoral immunityI.V. INFUSION (GAMMAGARD LIQUID)Adults and children. 300 to 600 mg/kgdaily every 3 to 4 wk. To treat idiopathic thrombocytopenicpurpura (ITP)I.V. INFUSION (GAMIMUNE N 5% S/D)Adults and children. 400 mg/kg daily for5 days. Or, 1,000 mg/kg for 1 or 2 days forpatients not at risk for increased fluid volume.I.V. INFUSION (GAMIMUNE N 10% S/D)Adults and children. 1,000 mg/kg for 1 or2 days for patients not at risk for increasedfluid volume.I.V. INFUSION (GAMUNEX 10%)Adults. 1 g/kg daily for 2 consecutive days(second dose may be withheld if adequate

immune globulin 525increase in platelet count occurs 24 hoursafter first dose). Or, 0.4 g/kg daily for 5 consecutivedays.DOSAGE ADJUSTMENT In acute ITP of childhood,I.V. Sandoglobulin therapy may bediscontinued after second day of 5-daycourse if initial platelet count response isadequate (30,000 to 50,000/mm 3 ). Inchronic ITP, an additional I.V. infusion of400 mg/kg (of either Sandoglobulin orGamimune) may be prescribed if plateletcount falls below 30,000/mm 3 or if patientdevelops significant bleeding. If responseremains inadequate, an additional I.V. infusionof 800 to 1,000 mg/kg may be given.I.V. INFUSION (GAMMAGARD S/D)Adults. 1 g/kg. If response is inadequate, upto three separate doses may be administeredon alternate days.I.V. INFUSION (RHOPHYLAC)Adults. 50 mcg/kg at 2 ml/15 to 60 seconds.I.V. INFUSION (SANDOGLOBULIN)Adults and adolescents. 400 mg/kg dailyfor 2 to 5 consecutive days.I.V. INFUSION (VENOGLOBULIN-I)Adults and children. Induction: Cumulativedose up to 2 g/kg over 2 to 7 consecutivedays. Maintenance (adults): 2 g/kg as a singledose every 2 wk as needed to maintainplatelet count above 30,000/mm 3 or preventbleeding episodes. Maintenance (children):1 g/kg as a single dose every 2 wk asneeded to maintain platelet count above30,000/mm 3 or prevent bleeding episodes.I.V. INFUSION (VENOGLOBULIN-S 5% OR 10%)Adults and children. Cumulative dose upto 2,000 mg/kg over 5 consecutive days.DOSAGE ADJUSTMENT An additional I.V.infusion of 1,000 mg/kg may be administeredto maintain a platelet count of30,000/mm 3 in children or 20,000/mm 3 inadults or to prevent bleeding episodes. To treat acute or chronic pediatric ITP;to treat chronic adult-onset ITP; to treatprediatric- and adult-onset ITP secondaryto HIV infectionI.V. INJECTION (WINRHO SDF)Adults and children. Initial: 250 internationalunits/kg given as a single injectionover 3 to 5 min. Or, 125 internationalunits/kg given as a single injection over 3 to5 min and repeated once on a separate day.Maintenance: Frequency and dosage highlyindividualized based on patient’s hemoglobinand platelet levels.DOSAGE ADJUSTMENT For patients withhemoglobin level less than 10 g/dl, dosereduced to 125 to 200 internationalunits/kg. As adjunct to treat Kawasaki diseaseI.V. INFUSION (GAMMAGARD S/D)Adults and adolescents. 1 g/kg as a singledose; or, 400 mg/kg daily for 4 consecutivedays.I.V. INFUSION (IVEEGAM EN, VENOGLOBULIN-S 5%OR 10%)Adults and adolescents. 2 g/kg as a singledose; or, Iveegam EN may be given at400 mg/kg daily for 4 days. To decrease the risk of graft-versus-hostdisease, interstitial pneumonia, septicemia,and other infections during first100 days after bone marrow transplantationI.V. INFUSION (GAMIMUNE N 5% S/D OR 10% S/D)Adults over age 20. 500 mg/kg on 7th and2nd days before transplant (or at time whenconditioning therapy for transplantationbegins), and then weekly through 90th dayafter transplant. As adjunct to treat bacterial infectionssecondary to B-cell chronic lymphocyticleukemiaI.V. INFUSION (GAMMAGARD S/D, POLYGAM S/D)Adults and adolescents. 400 mg/kg every3to 4wk. To prevent bacterial infection in childrenwith HIV who are immunosuppressedI.V. INFUSION (GAMIMUNE N 5% S/D OR10% S/D)Children. 400 mg/kg daily every 28 days. To prevent hepatitis AI.M. INJECTION (BAYGAM)Adults with household or institutionalcontacts. 0.02 ml/kg (0.01 ml/lb).Adults traveling to areas where hepatitis Ais common. 0.02 ml/kg if staying less than3 mo, 0.06 ml/kg (repeated every 4 to 6 mo)if staying 3 mo or longer. To prevent or lessen severity of measles(rubeola) in susceptible personsI.M. INJECTION (BAYGAM)Adults. 0.2 ml/kg (0.11 ml/lb) for personsexposed fewer than 6 days previously. To provide passive immunization againstvaricella in immunosuppressed patientsI.M. INJECTION (BAYGAM)Adults. 0.6 to 1.2 ml/kg if varicella-zosterimmune globulin (human) is unavailable.GHI

526Mechanism of ActionReleases antibody-specific globulins to producean antibody-antigen reaction thatresults in bacterial lysis and facilitates bacterialphagocytosis. In treatment of ITP,immune globulin blocks iron receptors onmacrophages to increase immunoglobulinaction. Immune globulin also increasescytokine production and improves B-cellimmune function by regulating T-cell andmacrophage activity. Newly formed antigenimmuneglobulin To reduce the risk of infection and fetaldamage in women who have beenexposed to rubella in early pregnancyI.M. INJECTION (BAYGAM)Adults. 0.55 ml/kg. To suppress Rh isoimmunizationI.M. INJECTION, I.V. INFUSION (RHOPHYLAC)Adult pregnant women. 1,500 internationalunits as a single dose at 28 to 30 wk gestationfollowed by 1,500 international unitswithin 72 hr after delivery of an Rh-positivenewborn.I.M. INJECTION (WINRHO SDF)Adult pregnant women. 1,500 internationalunits as a single dose at 28 wk gestationfollowed by 600 international units within72 hr after delivery of an Rh-positive newborn.I.V. INJECTION (WINRHO SDF)Adult pregnant women. 1,500 internationalunits as a single dose infused over 3 to5 min at 28 wk gestation followed by600 international units over 3 to 5 minwithin 72 hr after delivery of an Rh-positivenewborn.DOSAGE ADJUSTMENT For patients morethan 34 wk gestation and having an abortion,amniocentesis, or other manipulativeprocedure, 600 international units givenwithin 72 hr but preferably immediatelyafter procedure. For patients 34 wk gestationor less and having amniocentesis orchorionic villus sampling, 1,500 internationalunits given immediately after procedureand repeated every 12 wk for durationof pregnancy. For patients with threatenedabortion at any stage of pregnancy,1,500 international units given immediately. To treat incompatible blood transfusionsI.M. INJECTION, I.V. INFUSION (RHOPHYLAC)Adults exposed to Rh-positive RBCs.100 international units/2 ml transfusedblood or 1 ml erythrocyte concentratewithin 72 hr of exposure.I.M. INJECTION (WINRHO SDF)Adults exposed to Rh-positive wholeblood. 6,000 international units every 12 hruntil total dose (60 international units/mlof blood) is given.Adults exposed to Rh-positive RBCs.6,000 international units every 12 hr untiltotal dose (120 international units/ml ofcells) is given.I.V. INJECTION (WINRHO SDF)Adults exposed to Rh-positive wholeblood. 3,000 international units infusedover 3 to 5 min every 8 hr until total dose(45 international units/ml of blood) isgiven.Adults exposed to Rh-positive RBCs.3,000 international units infused over 3 to5 min every 8 hr until total dose (90 internationalunits/ml of cells) is given. To treat massive fetomaternal hemorrhageI.M. INJECTION, I.V. INFUSION (RHOPHYLAC)Adults exposed to Rh-positive RBCs.1,500 international units plus 100 internationalunits for every 1 ml of fetal RBCsexceeding 15 ml if transplacental bleeding isquantified or an additional 1,500 internationalunits if transplacental bleeding can’tbe quantified within 72 hours of hemorrhage.I.M. INJECTION (WINRHO SDF)Adults exposed to Rh-positive wholeblood. 6,000 international units every 12 hruntil total dose (60 international units/mlof blood) is given.Adults exposed to Rh-positive RBCs.6,000 international units every 12 hr untiltotal dose (120 international units/ml ofcells) is given.I.V. INJECTION (WINRHO SDF)Adults exposed to Rh-positive wholeblood. 3,000 international units infusedover 3 to 5 min every 8 hr until total dose(45 international units/ml of blood) isgiven.Adults exposed to Rh-positive RBCs.3,000 international units infused over 3 to5 min every 8 hr until total dose (90 internationalunits/ml of cells) is given.Route Onset Peak DurationI.V. Unknown Unknown 21–28 days

antibody complexes produce split complementcomponents that cause bacterial lysis.In Kawasaki disease and bacterial infectionswith B-cell chronic lymphocyticleukemia, immune globulin neutralizes bacterialand viral toxins that harm immuneand inflammatory responses.IncompatibilitiesDon’t mix immune globulin with any otherdrugs, including other immune globulins,or with any I.V. solutions other than D 5 Wor manufacturer’s supplied diluent becauseeffects of doing so are unknown.ContraindicationsHypersensitivity to immune globulin(human) or its components, IgA deficiencyin patients with known antibody to IgAInteractionsDRUGSlive-virus vaccines: Possibly decreasedresponse to vaccineAdverse ReactionsCNS: Headache, malaiseCV: TachycardiaGI: Nausea, vomitingMS: Arthralgia, back pain, myalgiaRESP: DyspneaNursing Considerations• Before giving immune globulin, monitorpatient’s fluid volume and BUN andserum creatinine levels, as ordered, todetermine risk for acute renal failure.Those at increased risk include patientswith renal insufficiency, diabetes mellitus,volume depletion, sepsis, or paraproteinemia;those taking nephrotoxic drugs; andthose over age 65. Expect drug to be discontinuedif renal function deteriorates.• When preparing immune globulin, verifythat appropriate form is being used—either immune globulin intramuscular forI.M. injection or immune globulin intravenousfor I.V. infusion.• To reconstitute drug (except GammagardLiquid, which doesn’t need reconstitution),follow manufacturer’s guidelinesand use only diluent recommended bymanufacturer. Don’t shake solution; excessiveshaking causes foaming. If drug ordiluent is cold, drug may take up to20 minutes to dissolve.• If drug is reconstituted outside of sterilelaminar airflow conditions, administer itimmediately and discard unused portions.• Consult manufacturer’s guidelines todetermine appropriate flow rate for startinginfusion. Expect to increase flow rateafter 15 to 30 minutes, as specified.• When giving drug by I.M. injection, injectit only into deltoid muscle of upper armor anterolateral aspect of upper thigh. Ifgiving a dose larger than 5 ml, divide itand administer at separate sites.WARNING Watch for an acute inflammatoryreaction in patients who have neverreceived immune globulin therapy before,in those whose last treatment was morethan 8 weeks before, and in those whoseinitial infusion rate exceeded 1 ml/minute.Within 30 minutes to 1 hour after beginningof infusion, assess for chills, fever,facial flushing, feeling of tightness inchest, dizziness, nausea, vomiting,diaphoresis, and hypotension. Notify prescriberimmediately if such symptomsoccur, and be prepared to stop infusionuntil symptoms have subsided.WARNING After immune globulin administration,monitor patient closely for asepticmeningitis. Notify prescriber if patientdevelops drowsiness, fever, nausea, vomiting,nuchal rigidity, photophobia, painfuleye movements, or severe headache.• Be aware that immune globulin intravenousis made from human plasma andtherefore may contain infectious agents,such as viruses. Risk of transmitting avirus by infusion has been reduced byscreening blood donors, testing donatedblood, and inactivating or removing certainviruses from the product.• For patient receiving WinRho SDF to treatITP, assess clinical response by monitoringpatient’s platelet count, RBC count, hemoglobinlevel, and reticulocyte level.• For patient receiving WinRho SDF forexposure to incompatible blood transfusionsor massive fetal hemorrhage, givedrug within 72 hours of incident.PATIENT TEACHING• Instruct patient to immediately report anysymptoms he experiences after receivingimmune globulin.• Inform patient to postpone live-virus vaccinationsfor up to 11 months after receivimmuneglobulin 527GHI

528inamrinone; indapamideing immune globulin because drug maydelay or inhibit response to vaccine.inamrinone(amrinone)InocorClass and CategoryChemical class: Bipyridine derivativeTherapeutic class: Cardiac inotropePregnancy category: CIndications and Dosages To treat heart failure in patients whohaven’t responded sufficiently to digoxin,diuretics, or vasodilatorsI.V. INFUSIONAdults. Initial: 0.75 mg/kg by bolus over2 to 3 min and repeated after 30 min, ifneeded. Maintenance: 5 to 10 mcg/ kg/minby infusion. Maximum: 10 mg/kg daily.Route Onset Peak DurationI.V. 2–5 min In 10 min 30 min–2 hrMechanism of ActionInhibits phosphodiesterase enzymes thatnormally degrade myocardial cAMP. Thisaction increases intracellular levels ofcAMP, which regulates intracellular andextracellular calcium balance. Increasedintracellular cAMP level enhances influx ofcalcium into cell, thereby increasing force ofmyocardial contractions. Inamrinone alsoacts directly on peripheral vascular smoothmusclecells, causing relaxation and dilation,which reduces preload and afterload.IncompatibilitiesDon’t administer inamrinone through sameI.V. line as furosemide because precipitatemay form. Don’t dilute inamrinone in solutionthat contains dextrose because a chemicalinteraction occurs over 24 hours.ContraindicationsHypersensitivity to inamrinone, bisulfites,or their components; severe aortic or pulmonaryvalvular diseaseInteractionsDRUGSdisopyramide: Possibly severe hypotensionAdverse ReactionsCNS: FeverCV: Chest pain, hypotension, pericarditis,supraventricular tachycardia, ventriculararrhythmiasGI: Abdominal pain, anorexia, elevated liverfunction test results, hepatotoxicity, nausea,vomitingHEME: Elevated erythrocyte sedimentationrate, thrombocytopenia (especially withhigh-dose or prolonged treatment)MS: MyositisRESP: Hypoxemia, pleuritisSKIN: JaundiceOther: Infusion site burningNursing ConsiderationsWARNING Be aware that inamrinone mayincrease risk of ventricular arrhythmias inpatients with atrial flutter or fibrillation.To minimize risk, expect to pretreat suchpatients with digoxin.• Give drug undiluted or diluted in normalor half-normal (0.45) saline solution to aconcentration of 1 to 3 mg/ml, as prescribed.Use diluted solution within24 hours.WARNING Monitor vital signs regularly. Ifblood pressure falls significantly, slow orstop infusion and notify prescriber.• Monitor weight, cardiac index, centralvenous pressure, pulmonary artery wedgepressure, and fluid intake and output asappropriate to assess drug’s effectiveness.WARNING Assess often for signs of thrombocytopenia,such as bruising or bleedingand altered platelet count. If signs appear,expect to decrease inamrinone dose or discontinuedrug.PATIENT TEACHING• Instruct patient to notify you or anothernurse if he becomes dizzy, which mayindicate hypotension.indapamideApo-Indapamide (CAN), Gen-Indapamide (CAN), Lozide (CAN), Lozol,Novo-Indapamide (CAN), Nu-Indapamide (CAN)Class and CategoryChemical class: Sulfonamide

Therapeutic class: Antihypertensive, diureticPregnancy category: BIndications and Dosages To treat edema caused by heart failureTABLETSAdults. 2.5 mg daily in the morning,increased to 5 mg daily after 1 wk, if indicated. To manage hypertensionTABLETSAdults. 2.5 mg daily, increased to 5 mg after4 wk, if needed.Route Onset Peak DurationP.O.* 1–2 hr Unknown 36 hrP.O.† 1–2 wk 8–12 wk Up to 8 wkMechanism of ActionActs mainly on distal convoluted tubules,where it enhances excretion of sodium,chloride, and water by inhibiting sodiumion movement across renal tubules. Theresulting decrease in plasma and extracellularfluid volume decreases peripheral vascularresistance and reduces blood pressure.This thiazide diuretic also may cause arterialvasodilation by blocking calcium channelsin smooth-muscle cells.ContraindicationsAnuria; hypersensitivity to thiazide or relateddiuretics or to sulfonamide-derived drugsInteractionsDRUGSamiodarone: Increased risk of arrhythmiasif hypokalemia developscholestyramine, colestipol: Decreased indapamideabsorptiondiazoxide: Increased risk of hyperglycemiadigoxin: Increased risk of digitalis toxicity ifhypokalemia developshypotension-producing drugs: Increasedantihypertensive or diuretic effectslithium: Increased risk of lithium toxicityneuromuscular blockers: Possibly increasedneuromuscular blockade, risk of respiratorydepressionoral anticoagulants: Possibly decreased anticoagulanteffects* For edema.† For hypertension (with multiple doses).indapamide 529Adverse ReactionsCNS: Anxiety, dizziness, drowsiness, fatigue,fever, headache, mood changes, nervousness,sleep disturbance, vertigo, weaknessCV: Arrhythmias, hypercholesterolemia,orthostatic hypotension, palpitationsEENT: Dry mouthENDO: Hyperglycemia, hypoglycemiaGI: Anorexia, constipation, diarrhea, hepatitis,nausea, pancreatitis, thirst, vomitingGU: Impotence, nocturiaMS: Gout, muscle spasmsSKIN: Jaundice, necrotizing vasculitis, photosensitivity,pruritus, rash, urticariaOther: Dilutional hypochloremia andhyponatremia, hypokalemia, metabolicalkalosis, weight lossNursing Considerations• Administer indapamide with food or milkto reduce adverse GI reactions.• Give drug early in the day to avoid nocturia.• Weigh patient daily, and monitor fluidintake and output, blood pressure, andserum electrolyte levels, especially in elderlywomen, because severe hyponatremiaand hypokalemia may occur. Hypokalemiaalso commonly occurs in patients takingdiuretics. Report electrolyte abnormalities,and expect to provide corrective measures,as prescribed.• Monitor BUN and serum creatinine levelsregularly, as appropriate.• If muscle cramps and weakness developfrom hypokalemia, expect prescriber toorder potassium supplement or potassiumsparingdiuretic.• When managing hypertension, expecttherapeutic response to indapamide totake several weeks.PATIENT TEACHING• Advise patient to take indapamide early inthe day to avoid nighttime urination andto take it with food or milk to minimizeGI distress.• Encourage patient to eat high-potassiumfoods, such as oranges and bananas.• Caution patient to change position slowlyto minimize effects of orthostatichypotension.• Instruct patient to weigh himself daily atthe same time and wearing similar clothing.Direct him to report a weight gain ofmore than 2 lb (0.9 kg) per day or 5 lbGHI

530indomethacin(2.3 kg) per week.• Inform patient about possible photosensitivity.• If patient has a dry mouth, suggest sugarlessgum or hard candy to relieve it.indomethacinApo-Indomethacin (CAN), Indocid(CAN), Indocin, Indocin SR, Novo-Methacin (CAN), Nu-Indo (CAN)indomethacinsodium trihydrateApo-Indomethacin (CAN), Indameth,Indocid (CAN), Indocid PDA (CAN),Indocin, Indocin I.V., Novomethacin(CAN)Class and CategoryChemical class: Indoleacetic acid derivativeTherapeutic class: Antigout, antiinflammatory,antirheumaticPregnancy category: Not ratedIndications and Dosages To relieve symptoms of ankylosing spondylitis,osteoarthritis, and rheumatoidarthritisCAPSULES, ORAL SUSPENSIONAdults. 25 to 50 mg b.i.d. to q.i.d., increasedby 25 or 50 mg daily every wk, if needed.Maximum: 200 mg daily. After adequateresponse, dosage reduced as low as possible.E.R. CAPSULES (ANTIRHEUMATIC)Adults. 75 mg daily, increased to 75 mgb.i.d, if needed.SUPPOSITORIESAdults. 50 mg up to q.i.d. To relieve symptoms of acute goutyarthritisCAPSULES, ORAL SUSPENSIONAdults. Initial: 100 mg. Increased up to50 mg t.i.d. Maximum: 200 mg daily. Afterpain is relieved, dosage tapered until drug isdiscontinued.SUPPOSITORIESAdults. 50 mg up to q.i.d. Maximum:200 mg daily. To treat inflammation and relieve acuteshoulder pain from bursitis or tendinitisCAPSULES, ORAL SUSPENSIONAdults. 75 to 150 mg daily in divided dosest.i.d. or q.i.d. for 7 to 14 days.SUPPOSITORIESAdults. 50 mg up to q.i.d. Maximum:200 mg daily.DOSAGE ADJUSTMENT Dosage reduced forelderly patients. To treat hemodynamically significantpatent ductus arteriosus in prematureinfants weighing 500 to 1,750 g (1 to3.9 lb)I.V. INJECTIONInfants over age 7 days. Initial: 200 mcg/kg(0.2 mg/kg) over 5 to 10 sec; 1 or 2 additionaldoses of 250 mcg/kg (0.25 mg/kg)given at 12- to 24-hr intervals, if needed.Neonates ages 2 to 7 days. Initial: 200 mcg/kg (0.2 mg/kg) over 5 to 10 sec; 1 or 2 additionaldoses of 200 mcg/kg (0.2 mg/kg)given at 12- to 24-hr intervals, if needed.Neonates under age 48 hours. Initial:200 mcg/kg (0.2 mg/kg) over 5 to 10 sec;1 or 2 additional doses of 100 mcg/kg(0.1 mg/kg) given at 12- to 24-hr intervals,if needed.Route Onset Peak DurationP.O.* 2–4 hr 2–5 days UnknownP.O.† 30 min Unknown 4–6 hrP.O.‡ In 7 days 1–2 wk UnknownMechanism of ActionBlocks activity of cyclooxygenase, theenzyme needed to synthesize prostaglandins,which mediate inflammatory responseand cause local vasodilation, swelling, andpain. By blocking cyclooxygenase andinhibiting prostaglandins, this NSAIDreduces inflammatory symptoms and helpsrelieve pain.IncompatibilitiesDon’t give indomethacin suspension withalkaline antacids or liquids. Don’t mixreconstituted indomethacin sodium withI.V. infusion solutions.ContraindicationsAllergy or hypersensitivity to aspirin, indomethacin,iodides, other NSAIDs, or theircomponents; history of proctitis or recentrectal bleeding (suppositories)* For antigout effects.† For anti-inflammatory effects.‡ For antirheumatic effects.

InteractionsDRUGSNote: All effects listed are for oral formsand suppositories unless indicated.acetaminophen: Increased risk of adverserenal effects (long-term use of both drugs)aluminum- and magnesium-containing antacids:Possibly decreased blood indomethacinlevelaminoglycosides: Increased risk of aminoglycosidetoxicityantihypertensives: Decreased effectiveness ofthese drugsaspirin, other NSAIDs: Increased risk ofadverse GI effects and non-GI bleedingbone marrow depressants: Possibly increasedleukopenic or thrombocytopenic effects ofthese drugscefamandole, cefoperazone, cefotetan:Increased risk of hypoprothrombinemiaand bleedingcolchicine, platelet aggregation inhibitors:Increased risk of GI bleeding, hemorrhage,and ulcerscorticosteroids, potassium supplements:Increased risk of adverse GI effectscyclosporine: Increased risk of nephrotoxicityfrom both drugs, increased bloodcyclosporine leveldiflunisal: Increased blood indomethacinlevel and risk of GI bleedingdigoxin: Increased blood digoxin level andrisk of digitalis toxicity (all forms)diuretics (thiazide, loop, and potassiumsparing):Decreased diuretic and antihypertensiveeffectsgold compounds, nephrotoxic drugs:Increased risk of adverse renal effectsheparin, oral anticoagulants, thrombolytics:Possibly increased anticoagulant effects andrisk of hemorrhagelithium: Increased blood lithium level andrisk of toxicitymethotrexate: Increased risk of methotrexatetoxicityplicamycin, valproic acid: Increased risk ofhypoprothrombinemia and GI bleeding,hemorrhage, and ulcersprobenecid: Increased blood level and effectivenessof indomethacin, increased risk ofindomethacin toxicityzidovudine: Increased blood zidovudinelevel and risk of toxicity, increased risk ofindomethacin toxicityindomethacin 531ACTIVITIESalcohol use: Increased risk of adverse GIeffectsAdverse ReactionsNote: All reactions are for oral forms andsuppositories unless indicated.CNS: Confusion, depression, dizziness,drowsiness, fatigue, hallucinations, headache,intraventricular hemorrhage (I.V.),peripheral neuropathy, seizures, stroke, syncope,vertigoCV: Arrhythmias, chest pain, edema, fluidretention (all forms), heart failure, hypertension,MI, pulmonary hypertension (I.V.),tachycardiaEENT: Blurred vision, corneal and retinaldamage, epistaxis, hearing loss, tinnitusENDO: Hypoglycemia (I.V.)GI: Abdominal cramps or pain, abdominaldistention (I.V.), anorexia, constipation,diarrhea, diverticulitis, dyspepsia, dysphagia,epigastric discomfort, esophagitis, gastricperforation, gastritis, gastroenteritis,gastroesophageal reflux disease, GI bleedingand ulceration (all forms), hemorrhoids,hepatic dysfunction (I.V.), hepatic failure,hiatal hernia, ileus (I.V.), indigestion, melena,nausea, necrotizing enterocolitis (I.V.),pancreatitis, peptic ulcer, perforation ofstomach or intestine, stomatitis, vomiting(all forms)GU: Acute renal falure, hematuria, interstitialnephritis, nephrotic syndrome, oliguria(I.V.), proteinuria, renal dysfunction (I.V.),vaginal bleedingHEME: Agranulocytosis, anemia, aplasticanemia, bone marrow depression, disseminatedintravascular coagulation, hemolyticanemia, iron deficiency anemia, leukopenia,neutropenia, pancytopenia, thrombocytopenia,unusual bleeding or bruising (allforms)RESP: Asthma, respiratory depressionSKIN: Ecchymosis, erythema multiforme,erythema nodosum, photosensitivity, pruritus,rash, Stevens-Johnson syndrome, toxicepidermal necrolysis, urticariaOther: Anaphylaxis, angioedema, hyperkalemia(I.V.), hyponatremia (I.V.), injectionsite irritationNursing Considerations• Use indomethacin with extreme caution inpatients with history of ulcer disease or GIGHI

532indomethacinbleeding because NSAIDs such asindomethacin increase risk of GI bleedingand ulceration. Expect to use drug forshortest time possible in these patients.• Be aware that serious GI tract ulceration,bleeding, and perforation may occur withoutwarning symptoms. Elderly patientsare at greater risk. To minimize risk, giveoral indomethacin with food, a full glassof water (not suspension), or an antacid toreduce GI distress.• If GI distress occurs, withhold drug andnotify prescriber immediately.• Use indomethacin cautiously in patientswith hypertension, and monitor bloodpressure closely throughout therapy. Drugmay cause hypertension or worsen it.• Shake suspension well before giving it.• For arthritis, give up to 100 mg of dailydose (not E.R. capsules) at bedtime toreduce nighttime pain and morning stiffness.• Make sure suppository stays in rectum atleast 1 hour to improve absorption.• To reconstitute I.V. form, add 1 to 2 ml ofpreservative-free sodium chloride forinjection or preservative-free sterile waterto vial. Solution made with 1 ml diluentcontains 100 mcg (0.1 mg) indomethacin/0.1ml. Solution made with 2 ml diluentcontains 50 mcg (0.05 mg) indomethacin/0.1ml. Use solution immediatelybecause it contains no preservatives.Discard unused portion.• Be aware that scheduled I.V. doses may bewithheld if infant or neonate has anuria ora significant decrease in urine output (lessthan 0.6 ml/kg/hr).• When using I.V. form, avoid extravasationto protect surrounding tissue.• Anticipate a second course (3 more doses)of I.V. indomethacin if patent ductus arteriosusfails to close or reopens. After twocourses, surgery may be performed.WARNING Monitor patient closely forthrombotic events, including MI andstroke, because NSAIDs increase the risk.• Monitor patient—especially if he’s elderlyor receiving long-term indomethacin therapy—forless common but serious adverseGI reactions, including anorexia, constipation,diverticulitis, dysphagia, esophagitis,gastritis, gastroenteritis, gastroesophagealreflux disease, hemorrhoids, hiatal hernia,melena, stomatitis, and vomiting.• Monitor liver function test results because,rarely, elevations may progress to severehepatic reactions, including fatal hepatitis,liver necrosis, and hepatic failure.• Monitor BUN and serum creatinine levelsin elderly patients, those taking diureticsor ACE inhibitors, and those with heartfailure, impaired renal function, or hepaticdysfunction; drug may cause renal failure.• Monitor CBC for decreased hemoglobinand hematocrit. Drug may worsen anemia.WARNING If patient has bone marrow suppressionor is receiving an antineoplasticdrug, monitor laboratory results (includingWBC count), and watch for evidenceof infection because anti-inflammatoryand antipyretic actions of indomethacinmay mask signs and symptoms, such asfever and pain.• Assess patient’s skin regularly for signs ofrash or other hypersensitivity reactionbecause indomethacin is an NSAID andmay cause serious skin reactions withoutwarning, even in patients with no historyof NSAID sensitivity. At first sign of reaction,stop drug and notify prescriber.• Because indomethacin causes sodiumretention, monitor weight and blood pressure,especially if patient has hypertension.• When drug is used to treat gouty arthritis,expect its action to peak in 24 to 36 hoursand significant swelling to gradually disappearover 3 to 5 days.• Be aware that E.R. form shouldn’t be usedto treat gouty arthritis.• Expect to use suppositories for patientswho can’t swallow oral form.• To evaluate drug effectiveness, assess forreduced pain and inflammation andimproved joint mobility.• Expect patient to have intermittent checkupsduring long-term therapy and an ophthalmologicexamination if vision changes.PATIENT TEACHING• Urge patient to take indomethacin capsuleswith full glass of water and to avoidlying down for 15 to 30 minutes afterward.This helps prevent drug from lodging inesophagus and causing irritation. Cautionpatient not to open or crush capsules.• Instruct patient to take drug with food oran antacid to reduce GI distress.• Instruct patient to make sure suppository

stays in rectum at least 1 hour.• Urge patient to avoid alcohol duringindomethacin therapy.• Remind patient that improvement maynot occur for 2 to 4 weeks after startingindomethacin and that he should continuetaking drug, as prescribed.• Inform breast-feeding patient that indomethacinappears in breast milk and maycause seizures in infants. Urge her to useanother feeding method during therapy.• Caution against prolonged sun exposureduring therapy.• Urge patient to notify prescriber immediatelyabout changes in vision or hearing,fever, itching, rash, sore throat, swelling inarms or legs, and weight gain.• Stress importance of having ordered laboratorytests and eye examinations duringlong-term therapy.• Caution pregnant patient not to takeNSAIDs such as indomethacin during lasttrimester because they may cause prematureclosure of the ductus arteriosus.• Explain that indomethacin may increaserisk of serious adverse cardiovascular reactions;urge patient to seek immediatemedical attention if signs or symptomsarise, such as chest pain, shortness ofbreath, weakness, and slurring of speech.• Explain that indomethacin may increaserisk of serious adverse GI reactions; stressneed to seek immediate medical attentionfor such signs and symptoms as epigastricor abdominal pain, indigestion, black ortarry stools, or vomiting blood or materialthat looks like coffee grounds.• Alert patient to rare but serious skin reactions.Urge him to seek immediate medicalattention for rash, blisters, itching, fever,or other indications of hypersensitivity.infliximabRemicadeClass and CategoryChemical class: Monoclonal antibodyTherapeutic class: Anti-inflammatoryPregnancy category: CIndications and Dosages To control moderate to severe Crohn’sdisease long-termI.V. INFUSIONAdults and children. Induction: 5 mg/kgover 2 hr, repeated 2 and 6 wk after firstinfusion. Maintenance: 5 mg/kg over 2 hrevery 8 wk.DOSAGE ADJUSTMENT For adults whorespond and then lose response, dosagemay be increased to 10 mg/kg. To reduce number of draining enterocutaneousand rectovaginal fistulas andto maintain fistula closure in fistulizingCrohn’s diseaseI.V. INFUSIONAdults. Induction: 5 mg/kg over 2 hr,repeated 2 and 6 wk after first infusion.Maintenance: 5 mg/kg over 2 hr every 8 wk.DOSAGE ADJUSTMENT For patients whorespond and then lose response, dosagemay be increased to 10 mg/kg. To reduce signs and symptoms, to induceand maintain remission and mucosalhealing, and to eliminate corticosteroiduse in patients with moderately toseverely active ulcerative colitis whohave had an inadequate response to conventionaltherapyI.V. INFUSIONAdults. 5 mg/kg over 2 hr, repeated 2 and6 wk after infusion. Maintenance: 5 mg/kgover 2 hr every 8 wk. As adjunct to reduce signs and symptoms,inhibit progression of structuraldamage, and improve physical functionin patients with moderate to severeactive rheumatoid arthritisI.V. INFUSIONAdults. 3 mg/kg, with methotrexate, repeated2 and 6 wk after first infusion and thenevery 8 wk thereafter. To treat active ankylosing spondylitisI.V. INFUSIONAdults. 5 mg/kg, repeated 2 and 6 wk afterfirst infusion and then every 6 wk thereafter. To reduce signs and symptoms, inhibitprogression of structural damage, andimprove physical function in patientswith psoriatic arthritisI.V. INFUSIONAdults. 5 mg/kg, with or without methotrexate,repeated 2 and 6 wk after first infusionand then every 8 wk thereafter. To treat chronic severe plaque psoriasisin patients who are candidates for sysinfliximab533GHI

534Nursing Considerations• Infliximab therapy shouldn’t be started ina patient with an active infection, includingserious localized infection.• Use with extreme caution if patient has ahistory of chronic or recurrent infection,known exposure to tuberculosis, anunderlying condition that predisposes toinfection, or residence or travel to areas ofendemic tuberculosis or mycoses, such ashistoplasmosis, coccidioidomycosis, orblastomycosis.• Use cautiously in elderly patients becausethey have a higher risk of infection.• Use cautiously in patients with previous orongoing hematologic abnormalitiesbecause infliximab may cause serious oreven life-threatening adverse hematologiceffects. Montior patient’s CBC regularly, asordered. If adverse effects occur, expectdrug to be discontinued.WARNING Because drug increases risk ofdeveloping tuberculosis or reactivatinglatent tuberculosis, expect prescriber toevaluate patient’s risk and start tuberculosistreatment, as needed, before startinginfliximab.WARNING Infliximab increases risk of seriousor fatal opportunistic infections,including invasive fungal infections as wellas bacterial and viral infections. The mostcommon ones include aspergillosis, candidiasis,coccidioidomycosis, histoplasmosis,listeriosis, and pneumocytosis.WARNING Watch for infection, especially ifpatient receives immunosuppressant therapyor has a chronic infection. Upper resinfliximabtemic therapy but those therapies aremedically less appropriateI.V. INFUSIONAdults. 5 mg/kg, repeated 2 and 6 wk afterfirst infusion and every 8 wk thereafter.Mechanism of ActionBinds with cytokine tumor necrosis factoralpha(TNF-alpha), preventing it frombinding with its receptors. As a result, TNFalphacan’t produce proinflammatorycytokines and endothelial permeability.Infiltration of inflammatory cells intoinflamed intestine and joints declines.IncompatibilitiesDon’t infuse infliximab in same I.V. linewith other drugs or through plasticizedpolyvinyl chloride infusion equipment ordevices.ContraindicationsBreastfeeding; hypersensitivity to infliximab,murine proteins, or their components;moderate or severe New York HeartAssociation (NYHA) Class III or IV heartfailureInteractionsDRUGSanakinra, etanercept: Increased risk of neutropeniaand serious infectionsAdverse ReactionsCNS: Chills, dizziness, fatigue, fever,Guillain-Barré syndrome, headache, meningitis,neuritis, numbness, paresthesia, stroke,syncope, tinglingCV: Arrhythmias, chest pain, hypertension,hypotension, MI, myelitis, neuropathies,pericardial effusion, systemic and cutaneousvasculitis, thrombophlebitisEENT: Oral candidiasis, pharyngitis, rhinitis,sinusitis, visual changesGI: Abdominal hernia; abdominal pain;acute hepatic failure; cholecystitis; cholestasis;diarrhea; dyspepsia; elevated aminotranferases;GI hemorrhage; hepatitis; hepatotoxicity;ileus; intestinal obstruction, perforation,or stenosis; melena; pancreatitis;nausea; splenic infarction; splenomegaly;vomitingGU: Kidney infection, renal failure, ureteralobstruction, UTI, vaginal candidiasis,vaginitisHEME: Anemia, leukopenia, neutropenia,pancytopenia, thrombocytopeniaMS: Ankylosing spondylitis, arthralgia, backpain, limb weakness, myalgia, psoriaticarthritisRESP: Adult respiratory distress syndrome,bronchitis, cough, dyspnea, interstitial lungdisease, pneumonia, tuberculosis, respiratorytract infection, wheezingSKIN: Facial flushing, jaundice, pruritus,psoriasis, rash, urticariaOther: Antibody formation to infliximab;bacterial, fungal, or viral infection; infusionreaction; lupuslike symptoms; lymphadenopathy;malignancies, such as leukemia andlymphomas, including hepatosplenic T-celllymphoma; sepsis

piratory tract infections and UTI are mostcommon, but sepsis and fatal infectionshave occurred.• To reconstitute infliximab, use 21G (orsmaller) needle to add 10 ml sterile waterfor injection to each vial of drug. Swirl tomix; don’t shake. Solution may foam andbe clear or light yellow.• Withdraw volume equal to amount ofreconstituted drug from a 250-ml glassbottle or polypropylene or polyolefin infusionbag of normal saline solution. Thenadd reconstituted infliximab to bottle todilute to 250 ml. Use within 3 hours.• Infuse over at least 2 hours using polyethylene-linedinfusion set and in-line, sterile,nonpyrogenic, low–protein-binding filterwith pores 1.2 microns or less. Don’t reuse.• Be prepared to stop infusion if hypersensitivityor CNS reaction occurs. Keep acetaminophen,antihistamines, corticosteroids,and epinephrine on hand. A reaction mayoccur 2 hours to 12 days after infusion.WARNING Avoid giving drug to patientswith New York Heart Association Class IIIor IV congestive heart failure (CHF)because it may worsen the condition orcause death. If patient does receive infliximab,expect to stop it if CHF worsens.• Because severe hepatic reactions mayoccur, monitor liver function. Expect tostop drug if jaundice develops or liverenzymes are 5 times or more the upperlimit of normal.• Be aware that infliximab is a tumor necrosisfactor (TNF) blocker. Malignancies,especially leukemia and such rare lymphomasas hepatosplenic T-cell lymphomahave been reported in patients, particularlychildren and adolescents, receiving TNFblockers. Patients at increased risk ofleukemia are those with rheumatoidarthritis. Patients at increased risk of lymphomasare those with rheumatoid arthritis,Crohn’s disease, ankylosing spondylitis,psoriatic arthritis, and plaque psoriasis,especially those with long-term or veryactive disease. Monitor them closely.PATIENT TEACHING• Inform patient that infliximab should takeeffect within 1 to 2 weeks.• Urge patient to report evidence of infection,such as painful urination, cough, andsore throat. Infusion reaction (chest pain,chills, dyspnea, facial flushing, fever, itching,headache, rash) may occur for up to12 days.• Explain that infliximab increases the riskof lymphoma; urge prompt medical attentionfor suspicious signs or symptoms.ipecac syrupIpecac Syrupipecac syrup 535Class and CategoryChemical class: Cephaelis acuminata orCephaelis ipecacuanha derivativeTherapeutic class: EmeticPregnancy category: CIndications and Dosages To induce vomiting after drug overdoseand certain types of poisoningSYRUPAdults and children over age 12. 15 to 30 mlfollowed by 240 ml water. Dose repeated ifvomiting doesn’t begin within 20 to 30 min.Children ages 1 to 12. 15 ml preceded orfollowed by 120 to 240 ml water. Doserepeated if vomiting doesn’t begin within20 to 30 min.Infants ages 6 months to 1 year. 5 to 10 mlpreceded or followed by 120 to 240 mlwater.Route Onset Peak DurationP.O. 20–30 min Unknown 20–25 minMechanism of ActionInduces vomiting by irritating gastricmucosa and stimulating medullarychemoreceptor trigger zone in CNS.ContraindicationsLoss of gag reflex, poisoning with strychnineor corrosives (such as alkaloid substances,petroleum distillates, and strongacids), seizures, semiconsciousness orunconsciousness, severe inebriation, shockInteractionsDRUGSactivated charcoal: Lack of emetic effectAdverse ReactionsCNS: Depression, drowsinessEENT: Aspiration of vomitus, coughingGI: Diarrhea, indigestionGHI

536ipratropium bromideNursing Considerations• Give ipecac syrup only to consciouspatients, and follow with adequate water.Give young or frightened children waterbefore or after ipecac.• Expect vomiting to start in 20 to 30 minutes.• If vomiting doesn’t start within 30 minutesof second dose, prepare for gastriclavage.• Don’t give ipecac after ingestion of petroleumdistillates, such as gasoline, or causticsubstances, to avoid further injury toesophagus.• If activated charcoal will be given, expectto do so after patient vomits or 30 minutesafter second ipecac dose because activatedcharcoal adsorbs and inhibits ipecac.• Arrhythmias, atrial fibrillation, bradycardia,fatal myocarditis, hypotension, myalgia,or muscle stiffness or weakness maydevelop if patient takes too much ipecacor doesn’t vomit.PATIENT TEACHING• Inform patient of ipecac’s effects.• Tell adult patient to drink 8 oz (240 ml) ofwater after taking drug and child to drink4 to 8 oz (120 to 240 ml) before or aftertaking drug.• Inform patient or parents of child thatdiarrhea may occur after taking drug.• Urge parents to keep ipecac syrup andphone number of a poison control center.WARNING Advise parents to replace theiripecac extract or tincture with ipecacsyrup. Explain that ipecac fluid extract is14 times more concentrated than ipecacsyrup and can cause serious, possiblytoxic, effects if given incorrectly.ipratropiumbromideApo-Ipravent (CAN), Atrovent,Kendral-Ipratropium (CAN)Class and CategoryChemical class: Quaternary N-methylisopropyl derivative of noratropineTherapeutic class: Anticholinergic, bronchodilatorPregnancy category: BIndications and Dosages To treat bronchitis and COPDINHALATION AEROSOLAdults and adolescents. 2 to 4 inhalations(36 to 72 mcg) t.i.d. or q.i.d. Maximum: Upto 12 inhalations (216 mcg)/24 hr.INHALATION SOLUTION FOR NEBULIZERAdults and adolescents. 250 to 500 mcgdissolved in preservative-free sterile normalsaline solution every 6 to 8 hr. For severeCOPD exacerbations, 500 mcg every 4 to8hr. To treat perennial and allergic rhinitisNASAL SPRAYAdults and children age 6 and over. 2 spraysof 0.03% (21 mcg/spray) per nostril b.i.d.or t.i.d. Maximum: 12 sprays (252 mcg)/24 hr. To treat rhinorrhea caused by thecommon coldNASAL SPRAYAdults and children age 5 and over. 2 spraysof 0.06% (42 mcg/spray) per nostril t.i.d. orq.i.d. for up to 4 days. Maximum: 16 sprays(672 mcg)/24 hr.Route Onset Peak DurationInhalation 5–15 min 1–2 hr 3–8 hrNasal 5 min 1–4 hr 4–8 hrContraindicationsHypersensitivity to atropine, ipratropiumbromide, or their components; hypersensitivityto peanuts, soya lecithin, soybeans, orrelated products (with aerosol inhaler)InteractionsDRUGSanticholinergics: Increased anticholinergiceffectstacrine: Decreased effects of both drugsAdverse ReactionsCNS: Dizziness, insomniaCV: Atrial fibrillation (oral inhalation),bradycardia (nasal spray), edema, hypertension,palpitations, supraventricular tachycardia(oral inhalation), tachycardiaEENT: Acute eye pain, dry mouth or pharyngealarea, laryngospasm, taste perversion(all drug forms); blurred vision, eye irritationand pain, glaucoma or worsening ofexisting glaucoma (if nasal spray comes incontact with eyes); epistaxis, mydriasis,nasal dryness and irritation, pharyngitis,

irbesartan 537Mechanism of ActionAfter acetylcholine is releasedfrom cholinergic fibers, ipratropiumprevents it from attachingto muscarinic receptors onmembranes of smooth-musclecells, as shown at right. By blockingacetycholine’s effects inbronchi and bronchioles, ipratropiumrelaxes smooth musclesand causes bronchodilation.AcetylcholineIpratropiumCholinergic fiberSmooth-musclecell membraneMuscarinic receptorrhinitis, sinusitis, tinnitus (with nasal spray)GI: Bowel obstruction, constipation, diarrhea,ileus, nausea, vomitingGU: Prostatitis, urine retentionMS: ArthritisRESP: Bronchitis, bronchospasm, cough,dyspnea, increased sputum production,wheezingSKIN: Dermatitis, pruritus, rash, urticariaOther: Anaphylaxis, angioedema, flulikesymptomsNursing Considerations• Use ipratropium cautiously in patientswith angle-closure glaucoma, benign prostatichyperplasia, or bladder neckobstruction and in patients with hepaticor renal dysfunction.• As prescribed, mix ipratropium inhalationsolution with preservative-free albuterol,and preservative-free ipratropium inhalationsolution with cromolyn inhalationsolution. Use within 1 hour.• When using a nebulizer, apply a mouthpieceto prevent drug from leaking outaround mask and causing blurred visionor eye pain.PATIENT TEACHING• Caution patient not to use ipratropium totreat acute bronchospasm.• Inform patient that although some peoplefeel relief within 24 hours of drug use,maximum effect may take up to 2 weeks.• Teach patient to use inhaler or nasal spray.Tell him to shake inhaler well at each use.• Advise patient to keep spray out of hiseyes because it may irritate them or blurhis vision. If spray comes in contact witheyes, instruct patient to flush them withcool tap water for several minutes and tocontact prescriber.• Instruct patient to rinse mouth after eachnebulizer or inhaler treatment to helpminimize throat dryness and irritation.• If patient is using 0.06% nasal spray for acommon cold, advise against use forlonger than 4 days.• Teach patient to track canister contents bycounting and recording number of doses.• Advise patient to report decreasedresponse to ipratropium as well as difficultyvoiding, eye pain, nasal dryness, nosebleeds, palpitations, and vision changes.irbesartanAvaproClass and CategoryChemical class: Nonpeptide angiotensin IIantagonistTherapeutic class: AntihypertensivePregnancy category: DIndications and Dosages To manage hypertension, alone or withother antihypertensivesGHI

538irbesartanTABLETSAdults and adolescents. Initial: 150 mgdaily. Maximum: 300 mg daily.DOSAGE ADJUSTMENT Initial dosage reducedto 75 mg daily for patients with hypovolemiaor hyponatremia from such causes ashemodialysis or vigorous diuretic therapy.Children ages 6 to 12. Initial: 75 mg daily.Maximum: 150 mg daily. To treat nephropathy in type 2 diabetesmellitusTABLETSAdults. 300 mg daily.Route Onset Peak DurationP.O. Unknown In 4–6 wk UnknownMechanism of ActionSelectively blocks binding of the potentvasoconstrictor angiotensin (AT) II to AT 1receptor sites in many tissues, includingvascular smooth muscle and adrenal glands.This inhibits the vasoconstrictive andaldosterone-secreting effects of AT II, whichreduces blood pressure.ContraindicationsHypersensitivity to irbesartan or its componentsInteractionsDRUGSdiuretics: Possibly additive hypotensiveeffectsAdverse ReactionsCNS: Anxiety, dizziness, fatigue, headache,nervousnessCV: Chest pain, hypotension, peripheraledema, tachycardiaEENT: Pharyngitis, rhinitisGI: Abdominal pain, diarrhea, heartburn,hepatitis, indigestion, nausea, vomitingGU: UTIMS: Musculoskeletal painRESP: Upper respiratory tract infectionSKIN: RashNursing Considerations• If patient has known or suspected hypovolemia,provide treatment, such as I.V. normalsaline solution, as prescribed, to correctthis condition before beginning irbesartantherapy. Or expect to begin therapy with alower dosage.• Check blood pressure often to evaluatedrug’s effectiveness.• If blood pressure isn’t controlled withirbesartan alone, expect to also give adiuretic, such as hydrochlorothiazide, asprescribed.WARNING If patient receives a diuretic oranother antihypertensive during irbesartantherapy, frequently monitor blood pressurebecause he’s at risk for hypotension.• If patient experiences symptomatic hypotension,expect to stop drug temporarily.Immediately place him in supine positionand prepare to give I.V. normal saline solution,as prescribed. Expect to resume drugtherapy after blood pressure stabilizes.• If patient receives a diuretic, provide adequatehydration, as appropriate, to helpprevent hypovolemia. Also monitorpatient for signs and symptoms of hypovolemia,such as hypotension, dizziness,and fainting.WARNING Monitor patient for increasedBUN and serum creatinine levels if he hasheart failure or impaired renal functionbecause drug may cause acute renal failure.If increases are significant or persistent,notify prescriber immediately.PATIENT TEACHING• Advise patient to take drug at the sametime each day to maintain its therapeuticeffect.• Explain importance of regular exercise,proper diet, and other lifestyle changes incontrolling hypertension.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to consult prescriberbefore taking any new drug.• To reduce risk of dehydration and hypotension,advise patient to drink adequatefluids during hot weather and exercise.• Instruct patient to contact prescriber ifsevere nausea, vomiting, or diarrhea occursand continues because of the risk ofdehydration and hypotension.• Advise female patient to notify prescriberimmediately about known or suspectedpregnancy. Explain that if she becomespregnant, prescriber may replace irbesartanwith another antihypertensive that’ssafe to use during pregnancy.• Urge patient to keep follow-up appointmentswith prescriber to monitorprogress.

iron dextran(contains 50 mg of elemental iron permilliliter)DexFerrum, DexIron (CAN), InFeDClass and CategoryChemical class: Iron salt, mineralTherapeutic class: AntianemicPregnancy category: CIndications and Dosages To treat iron deficiency anemiaI.V. INFUSIONAdults and children weighing more than15 kg (33 lb). Dose (ml) 0.0442 (desiredhemoglobin observed hemoglobin) lean body weight (kg) (0.26 lean bodyweight). Or, consult dosage table in packageinsert. Maximum: 2 ml (100 mg) daily.Children over age 4 months weighing 5 to15 kg (11 to 33 lb). Dose (ml) 0.0442(desired hemoglobin observed hemoglobin) weight (kg) (0.26 weight). Or,consult dosage table in package insert.Maximum: 1 ml (50 mg) daily. To replace iron lost in blood lossI.V. INFUSIONAdults. Replacement iron (mg) ml ofblood loss hematocrit.Mechanism of ActionRestores hemoglobin and replenishes ironstores. Iron, an essential component ofhemoglobin, myoglobin, and severalenzymes (including cytochromes, catalase,and peroxidase), is needed for catecholaminemetabolism and normal neutrophilfunction.In iron dextran therapy, iron binds toavailable protein parts after the drug hasbeen split into iron and dextran by cells ofthe reticuloendothelial system. The boundiron forms hemosiderin or ferritin, physiologicforms of iron, and transferrin, whichreplenish hemoglobin and depleted ironstores. Dextran is metabolized or excreted.IncompatibilitiesDon’t mix iron dextran with blood fortransfusion, other drugs, or parenteralnutrition solutions for I.V. infusion.iron dextran 539ContraindicationsAnemia other than iron deficiency, hypersensitivityto iron dextran or its componentsAdverse ReactionsCNS: Chills, disorientation, dizziness, fever,headache, malaise, paresthesia, seizures,syncope, unconsciousness, weaknessCV: Arrhythmias, bradycardia, chest pain,hypertension, hypotension, shock, tachycardiaEENT: Altered tasteGI: Abdominal pain, diarrhea, nausea,vomitingGU: HematuriaHEME: LeukocytosisMS: Arthralgia, arthritis, backache, myalgia,rhabdomyolysisRESP: Bronchospasm, dyspnea, respiratoryarrest, wheezingSKIN: Cyanosis, diaphoresis, rash, pruritus,purpura, urticariaOther: Anaphylaxis, infusion site phlebitisNursing Considerations• Expect oral iron therapy to stop beforeiron dextran therapy starts. Iron dextran isgiven only when oral therapy isn’t feasible;it also may be given by I.M. injection.• Expect to monitor hemoglobin level,hematocrit, serum ferritin level, and transferrinsaturation, as ordered, before, during,and after iron dextran therapy.WARNING Before starting iron dextran therapy,give a test dose of 0.5 ml iron dextrangradually over 30 seconds, as prescribed,and monitor patient closely for anaphylacticreaction.• Wait 1 to 2 hours before giving remainderof dose. Infuse undiluted iron dextranslowly, at no more than 1 ml/minute(50 mg/minute).WARNING Monitor patient closely for signsand symptoms of anaphylaxis (such assevere hypotension, loss of consciousness,collapse, dyspnea, and seizures) duringand after infusion. Patients with a historyof asthma or allergies are at increased riskfor anaphylaxis, possibly death. Instituteemergency resuscitation measures as needed,including epinephrine administration,as prescribed.WARNING Assess blood pressure often afteriron dextran administration becausehypotension is a common adverse effectthat may be related to infusion rate; avoidrapid infusion.GHI

540Mechanism of ActionActs to replenish iron stores lost duringdialysis because of increased erythropoiesisand insufficient absorption of iron from GItract. Iron is an essential component ofhemoglobin, myoglobin, and severalenzymes, including cytochromes, catalase,and peroxidase, and is needed for catecholaminemetabolism and normal neuironsucrose• Be aware that patient may have adversereactions, including arthralgia, backache,chills, and vomiting, 1 to 2 days after drugtherapy. Symptoms should resolve within3 to 4 days.• Assess patients with a history of rheumatoidarthritis for exacerbation of joint painand swelling.• If patient has cardiovascular disease, watchfor worsening from drug’s adverse effects.• Assess patient for iron overload, characterizedby sedation, decreased activity, paleeyes, and bleeding in GI tract and lungs.• Store iron dextran at 59° to 86° F (15° to30° C ).PATIENT TEACHING• Instruct patient to immediately reportsigns of adverse reaction, such as shortnessof breath, wheezing, or rash, during irondextran therapy.• Advise patient not to take any oral ironwithout first consulting prescriber.• Inform patient that symptoms of irondeficiency may include decreased stamina,learning problems, shortness of breath,and fatigue. Urge patient to plan periodsof activity and rest to avoid excessivefatigue.• Stress need to follow dosage regimen andkeep follow-up medical and laboratoryappointments.iron sucrose(contains 100 mg of elemental iron per5 ml)VenoferClass and CategoryChemical class: Iron salt, mineralTherapeutic class: AntianemicPregnancy category: BIndications and Dosages To treat iron deficiency anemia inhemodialysis patients receiving erythropoietinI.V. INJECTIONAdults. Initial: 100 mg elemental ironinjected undiluted over 2 to 5 min duringdialysis. Usual: 100 mg elemental iron everywk to 3 times/wk to total dose of 1,000 mg.Dosage repeated as needed to maintain targetlevels of hemoglobin and hematocritand acceptable blood iron level. Maximum:100 mg/dose.I.V. INFUSIONAdults. Initial: 100 mg elemental ironinfused diluted over 15 min during dialysis.Usual: 100 mg elemental iron every wk to3 times/wk to a total dose of 1,000 mg.Dosage repeated as needed to maintain targetlevels of hemoglobin and hematocritand acceptable blood iron level. Maximum:100 mg/dose. To treat iron deficiency anemia in peritonealdialysis patients receiving erythropoietinI.V. INFUSIONAdults. Initial: 300 mg elemental ironinfused diluted over 1.5 hr on days 1 and14, followed by 400 mg elemental ironinfused over 2.5 hr on day 28. Dosagerepeated as needed to maintain target levelsof hemoglobin and hematocrit and acceptableblood iron level. Maximum: 1,000 mg/28 days. To treat iron deficiency anemia in nondialysispatients with chronic renal diseaseregardless of whether they’re receivingerythropoietinI.V. INJECTIONAdults. Initial: 200 mg elemental ironinjected undiluted over 2 to 5 min andrepeated 4 more times over a 14-day periodfor a total dose of 1,000 mg. Dosage repeatedas needed to maintain target levels ofhemoglobin and hematocrit and acceptableblood iron level. Maximum: 1,000 mg/14 days.I.V. INFUSIONAdults. 500 mg elemental iron infuseddiluted over 3.5 to 5 hr on days 1 and 14.Dosage repeated as needed to maintain targetlevels of hemoglobin and hematocritand acceptable blood iron level. Maximum:1,000 mg/14 days.

trophil function. Iron sucrose injection alsonormalizes RBC production by bindingwith hemoglobin or being stored as ferritinin reticuloendothelial cells of the liver,spleen, and bone marrow.IncompatibilitiesDon’t mix with other drugs or parenteralnutrition solutions for I.V. infusion.ContraindicationsAnemia other than iron deficiency, hypersensitivityto iron salts or their components,iron overloadInteractionsDRUGSchloramphenicol: Possibly decreased effectivenessof iron sucroseoral iron preparations: Possibly reducedabsorption of oral iron supplementsAdverse ReactionsCNS: Asthenia, dizziness, fatigue, fever,headache, hypoesthesia, malaiseCV: Chest pain, heart failure, hypertension,hypotension, peirpheral edemaEENT: Conjunctivitis, ear pain, nasal congestion,nasopharyngitis, rhinitis, sinusitis,taste perversionENDO: Hyperglycemia, hypoglycemiaGI: Abdominal pain, constipation, diarrhea,elevated liver function test results, nausea,occult-positive feces, peritoneal infection,vomitingGU: UTIMS: Arthralgia, arthritis, back pain, legcramps, muscle pain or weakness, myalgiaRESP: Cough, dyspnea, pneumonia, upperrespiratory tract infectionSKIN: Pruritus, rashOther: Anaphylaxis; fluid overload; gout;hypervolemia; infusion or injection siteburning, pain, or redness; sepsisNursing Considerations• To reconstitute iron sucrose injection forinfusion, dilute 100 mg elemental iron inmaximum of 100 ml normal saline solution(for hemodialysis patients) or 250 ml(for peritoneal dialysis and nondialysispatients) immediately before infusion.Discard any unused diluted solution.• Give drug directly into dialysis line byslow I.V. injection or by infusion.WARNING Monitor patient closely for evidenceof anaphylaxis, such as severehypotension, loss of consciousness, collapse,dyspnea, or seizures, during andafter therapy. Institute emergency resuscitationmeasures as needed.WARNING Assess blood pressure often afterdrug administration because hypotensionis a common adverse reaction that may berelated to infusion rate (avoid rapid infusion)or total cumulative dose.• Monitor hemoglobin, hematocrit, serumferritin, and transferrin saturation, asordered, before, during, and after ironsucrose therapy. Test serum iron level48 hours after last dose. Notify prescriberand expect to stop therapy if blood ironlevels are normal or elevated, to preventiron toxicity.• Watch for evidence of iron overload, suchas sedation, decreased activity, pale eyes,and bleeding in GI tract and lungs.PATIENT TEACHING• Advise patient not to take any oral ironpreparations during iron sucrose therapywithout first consulting prescriber.• Inform patient that symptoms of irondeficiency may include decreased stamina,learning problems, shortness of breath,and fatigue.isocarboxazidMarplanMechanism of ActionIrreversibly binds to MAO, reducing itsactivity and increasing levels of neurotransisocarboxazid541Class and CategoryChemical class: Hydrazine derivativeTherapeutic class: AntidepressantPregnancy category: CIndications and Dosages To treat major depressionTABLETSAdults and adolescents over age 16. Initial:10 mg b.i.d., increased by 10 mg daily every2 to 4 days, as needed and tolerated.Maximum: 60 mg daily.Route Onset Peak DurationP.O. 7–10 days Unknown 10 daysGHI

542isocarboxazidmitters, including serotonin and the catecholamineneurotransmitters dopamine,epinephrine, and norepinephrine. This regulationof CNS neurotransmitters helps toease depression. With long-term use, drugresults in down-regulation (desensitization)of alpha 2 - or beta-adrenergic and serotoninreceptors after 2 to 4 weeks, which also producesan antidepressant effect.ContraindicationsCardiovascular disease; cerebrovascular disease;heart failure; hepatic disease; historyof headaches; hypersensitivity to isocarboxazidor its components; hypertension;pheochromocytoma; severe renal impairment;use of anesthetics, antihypertensives,bupropion, buspirone, carbamazepine, CNSdepressants, cyclobenzaprine, dextromethorphan,meperidine, selective serotoninreuptake inhibitors, sympathomimetics, ortricyclic antidepressants; use within 14 daysof another MAO inhibitorInteractionsDRUGSanticholinergics, antidyskinetics, antihistamines:Increased anticholinergic effect, prolongedCNS depression (with antihistamines)anticonvulsants: Increased CNS depression,possibly altered seizure patternantihypertensives, diuretics: Increased hypotensiveeffectbromocriptine: Possibly interference withbromocriptine effectsbupropion: Increased risk of bupropion toxicitybuspirone, guanadrel, guanethidine:Increased risk of hypertensioncaffeine-containing drugs: Increased risk ofdangerous arrhythmias and severe hypertensioncarbamazepine, cyclobenzaprine, maprotiline,other MAO inhibitors: Increased risk ofhyperpyretic crisis, hypertensive crisis,severe seizures, and death; altered pattern ofseizures (with carbamazepine)CNS depressants: Increased CNS depressiondextromethorphan: Increased risk of excitation,hypertension, and hyperpyrexiadoxapram: Increased vasopressor effects ofeither drugfluoxetine, paroxetine, sertraline, trazodone,tricyclic antidepressants: Increased risk oflife-threatening serotonin syndromehaloperidol, loxapine, molindone, phenothiazines,pimozide, thioxanthenes: Prolongedand intensified anticholinergic, hypotensive,and sedative effectsinsulin, oral antidiabetic drugs: Increasedhypoglycemic effectslevodopa: Increased risk of sudden, moderateto severe hypertensionlocal anesthetics (with epinephrine orlevonordefrin): Possibly severe hypertensionmeperidine, other opioid analgesics:Increased risk of coma, hyperpyrexia,hypotension, immediate excitation, rigidity,seizures, severe hypertension, severe respiratorydepression, shock, sweating, anddeathmethyldopa: Increased risk of hallucinations,headache, hyperexcitability, andsevere hypertensionmethylphenidate: Increased CNS stimulationmetrizamide: Decreased seizure thresholdand increased risk of seizuresoral anticoagulants: Increased anticoagulantactivityphenylephrine (nasal or ophthalmic):Potentiated vasopressor effect of phenylephrinerauwolfia alkaloids: Increased risk of moderateto severe hypertension, CNS depression(when isocarboxazid is added to rauwolfiaalkaloid therapy), CNS excitationand hypertension (when rauwolfia alkaloidis added to isocarboxazid therapy)spinal anesthetics: Increased risk of hypotensionsympathomimetics: Prolonged and intensifiedcardiac stimulant and vasopressoreffectstryptophan: Increased risk of confusion, disorientation,hyperreflexia, hyperthermia,hyperventilation, mania or hypomania, andshiveringFOODSaged cheese; avocados; bananas; fava orbroad beans; cured meat or sausage; overripefruit; pickled or smoked fish, meats or poultry;protein extract; soy sauce; yeast extract;and other foods high in tyramine or otherpressor amines: Increased risk of dangerousarrhythmias and severe hypertensive crisisACTIVITIESalcohol-containing products that also maycontain tyramine, such as beer (including

educed-alcohol and alcohol-free beer), hardliquor, liqueurs, sherry, and wines (red andwhite): Increased risk of developing hypertensivecrisisAdverse ReactionsCNS: Agitation, dizziness, drowsiness, fever,headache, insomnia, intracranial bleeding,overstimulation, restlessness, sedation, suicidalideation, tremor, weaknessCV: Bradycardia, chest pain, edema, hypertensivecrisis, orthostatic hypotension, palpitations,tachycardiaEENT: Blurred vision, dry mouth, mydriasis,photophobia, yellowing of scleraGI: Abdominal pain, anorexia, constipation,diarrhea, elevated liver function test results,increased appetite, nauseaGU: Dark urine, oliguria, sexual dysfunctionHEME: LeukopeniaMS: Muscle spasms, myoclonus, neck stiffnessSKIN: Clammy skin, diaphoresis, jaundice,rashOther: Unusual weight gainNursing Considerations• Monitor patient’s blood pressure duringisocarboxazid therapy to detect hypertensivecrisis and decrease risk of orthostatichypotension.WARNING Notify prescriber immediately ifpatient has evidence of hypertensive crisis(drug’s most serious adverse effect), suchas chest pain, headache, neck stiffness, andpalpitations. Expect to stop drug immediatelyif these occur.• Keep phentolamine readily available totreat hypertensive crisis. Give 5 mg by slowI.V. infusion, as prescribed, to reduceblood pressure without causing excessivehypotension. Use external cooling measures,as prescribed, to manage fever.• To avoid hypertensive crisis, expect to wait10 to 14 days when switching patient fromone MAO inhibitor to another or whenswitching from a dibenzazepine-relateddrug, such as amitriptyline or perphenazine.• Monitor patient with a history of epilepsyfor seizures because isocarboxazid mayalter seizure threshold. Institute seizureprecautions according to facility protocol.• Monitor liver function test results, andassess patient for abdominal pain, darkisocarboxazid 543urine, and jaundice because isocarboxazidmay cause hepatic dysfunction.• Expect to observe some therapeutic effectin 7 to 10 days, but keep in mind that fulleffect may not occur for 4 to 8 weeks.• Be aware that, for maintenance therapy,the smallest possible dose should be used.Once clinical effect has been achieved,expect to decrease the dosage slowly overseveral weeks.• Keep dietary restrictions in place for atleast 2 weeks after stopping isocarboxazidbecause of slow recovery from drug’senzyme-inhibiting effects.• Ideally, expect to stop drug 10 days beforeelective surgery, as prescribed, to avoidhypotension.• Anticipate that coadministration with aselective serotonin reuptake inhibitor maycause confusion, diaphoresis, diarrhea,seizures, and other less severe symptoms.• Monitor depressed patient for suicidal tendencies,especially when therapy starts ordosage changes, because depression mayworsen temporarily. If suicidal tendenciesarise, institute suicide precautions, asappropriate and according to facility policy,and notify prescriber immediately.• Monitor patient for sudden insomnia. If itdevelops, notify prescriber and be preparedto give drug early in the day.PATIENT TEACHING• Inform patient and family members thattherapeutic effects of isocarboxazid maytake several weeks to appear and that heshould continue taking drug as prescribed.• Caution parents to monitor pediatricpatients, including adolescents, closely forsuicidal tendencies, especially when therapystarts or dosage changes.• Caution patient to rise slowly from a lyingor sitting position to minimize effects oforthostatic hypotension.WARNING Instruct patient to avoid the followingfoods, beverages, and drugs duringisocarboxazid therapy and for 2 weeksafterward: alcohol-free and reducedalcoholbeer and wine; appetite suppressants;beer; broad beans; cheese (exceptcottage and cream cheese); chocolate andcaffeine in large quantities; dry sausage(including Genoa salami, hard salami,Lebanon bologna, and pepperoni); hayfever drugs; inhaled asthma drugs; liver;GHI

544isoetharinemeat extract; OTC cold and cough medicines(including those containing dextromethorphan);nasal decongestants (tablets,drops, or spray); pickled herring; productsthat contain tyramine; protein-rich foodsthat may have undergone protein changesby aging, fermenting, pickling, or smoking;sauerkraut; sinus drugs; weight-lossproducts; yeast extracts (including brewer’syeast in large quantities); yogurt; andwine.• Advise patient to notify prescriber immediatelyabout chest pain, dizziness, headache,nausea, neck stiffness, palpitations,rapid heart rate, sweating, and vomiting.• Advise patient to inform all health careproviders (including dentists) that he takesan MAO inhibitor because certain drugsare contraindicated within 2 weeks of it.• Urge patient to avoid hazardous activitiesuntil drug’s adverse effects are known.• Urge patient with diabetes mellitus who’staking insulin or an oral antidiabetic tocheck blood glucose level often duringtherapy because isocarboxazid may affectglucose control.• Caution patient not to stop taking drugabruptly to avoid recurrence of originalsymptoms.isoetharinehydrochlorideArm-a-Med Isoetharine (0.062%,0.125%, 0.167%, 0.2%, 0.25%), Beta-2(1%), Bronkosol (1%), Dey-LuteIsoetharine (0.08%, 0.1%, 0.17%,0.25%)isoetharinemesylateBronkometer (0.61%)Class and CategoryChemical class: CatecholamineTherapeutic class: BronchodilatorPregnancy category: Not ratedIndications and Dosages To prevent and treat reversible bronchospasmfrom chronic bronchitis oremphysemaINHALATION AEROSOLAdults and adolescents. 1 or 2 inhalations(340 or 680 mcg) every 4 hr.INHALATION SOLUTION FOR HAND-BULB NEBULIZERAdults. 3 to 7 inhalations of undiluted0.5% or 1% solution every 4 hr.INHALATION SOLUTION FOR NEBULIZERAdults. 2.5 to 10 mg over 15 to 20 min.Repeated every 4 hr, p.r.n.Route Onset Peak DurationInhalation 5 min 5–15 min 2–3 hrMechanism of ActionAttaches to beta 2 receptors on bronchial cellmembranes, which stimulates the intracellularenzyme adenylate cyclase to convertadenosine triphosphate to cyclic adenosinemonophosphate (cAMP). Increased intracellularlevels of cAMP help relax bronchialsmooth-muscle cells, stabilize mast cells,and inhibit histamine release.ContraindicationsHypersensitivity to isoetharine, sympathomimeticamines, or their componentsInteractionsDRUGSbeta blockers: Decreased effects of bothdrugscyclopropane, halothane: Increased risk ofarrhythmiasephedrine: Increased cardiac stimulationepinephrine: Increased epinephrine effectsguanethidine: Decreased hypotensive effectsisoproterenol: Excessive cardiac stimulationMAO inhibitors: Increased risk of hypertensivecrisis, increased vascular effects ofisoetharinemethyldopa: Increased vasopressor responsenitrates: Possibly decreased effects of bothdrugsoxytocic drugs: Increased risk of hypotensionrauwolfia alkaloids: Increased risk of hypertensiontricyclic antidepressants: Increased risk ofarrhythmiasAdverse ReactionsCNS: Anxiety, dizziness, headache, insomnia,tremor, vertigo, weaknessCV: Angina, arrhythmias, hypertension,palpitations, tachycardia

EENT: Choking sensation, eyelid or lipswelling, laryngospasm, taste perversionGI: Nausea, vomitingRESP: Bronchospasm, cough, paradoxicalincreased airway resistance (with excessiveuse), wheezingSKIN: Dermatitis, flushing, pruritus, urticariaOther: Angioedema, facial edemaNursing Considerations• Dilute 1% isoetharine inhalation solutionwith 1 to 4 ml sterile normal saline solution;0.062% to 0.25% solutions don’tneed to be diluted before use.• Don’t use a solution that’s pink or darkerthan light yellow or one that contains precipitate.• Wait 1 minute after initial inhaler dose toassess whether patient needs a seconddose.• Monitor blood pressure and pulse, andobserve for arrhythmias during therapy.PATIENT TEACHING• Teach patient how to use isoetharineinhaler or nebulizer.• Instruct patient to take drug exactly asdirected and not to exceed dosage.• Instruct patient not to take other drugs,even OTC drugs, unless prescribed.• Teach patient how to determine when canisterneeds to be replaced by counting andrecording number of doses.• Instruct patient to report chest pain, difficultybreathing, failure to respond to usualisoetharine dose, irregular heartbeat, productivecough, or tremor.isoniazid(isonicotinic acidhydrazide, INH)Isotamine (CAN), Laniazid, Nydrazid,PMS-Isoniazid (CAN)Class and CategoryChemical class: Isonicotinic acid derivativeTherapeutic class: Antibiotic, antitubercularPregnancy category: CIndications and Dosages To prevent tuberculosisSYRUP, TABLETS, I.M. INJECTIONisoniazid 545Adults and adolescents. 300 mg daily.Children. 10 mg/kg daily (up to 300 mg). As adjunct to treat active tuberculosisSYRUP, TABLETSAdults and adolescents. 300 mg daily or15 mg/kg (up to 900 mg) 2 or 3 times/wk,based on treatment regimen.Children. 10 to 20 mg/kg (up to 300 mg)daily or 20 to 40 mg/kg (up to 900 mg) 2 or3 times/wk, based on treatment regimen.I.M. INJECTIONAdults and adolescents. 5 mg/kg (up to300 mg) daily or 15 mg/kg (up to 900 mg)2 or 3 times/wk, based on treatment regimen.Children. 10 to 20 mg/kg (up to 300 mg)daily or 20 to 40 mg/kg (up to 900 mg) 2 or3 times/wk, based on treatment regimen.Mechanism of ActionInterferes with lipid and nucleic acid synthesisin actively growing tubercule bacillicells. Isoniazid also disrupts bacterial cellwall synthesis and may interfere withmycolic acid synthesis in mycobacterialcells.ContraindicationsHistory of serious adverse reactions (suchas hepatic injury) from isoniazid, hypersensitivityto isoniazid or its componentsInteractionsDRUGSacetaminophen: Increased risk of hepatotoxicityand possibly nephrotoxicityalfentanil: Decreased alfentanil clearanceand increased duration of effectsaluminum-containing antacids: Decreasedisoniazid absorptionbenzodiazepines: Decreased benzodiazepineclearancecarbamazepine: Increased blood carbamazepinelevel and toxicity, increased risk of isoniazidtoxicitycorticosteroids: Decreased isoniazid effectscycloserine: Increased risk of adverse CNSeffects and CNS toxicitydisulfiram: Changes in behavior and coordinationenflurane: Increased risk of high-outputrenal failurehalothane: Increased risk of hepatotoxicityand hepatic encephalopathyhepatotoxic drugs, rifampin: Increased riskGHI

546isoniazidof hepatotoxicityketoconazole: Possibly decreased blood ketoconazolelevel and resistance to antifungaltreatmentmeperidine: Risk of hypotensive episodes orCNS depressionnephrotoxic drugs: Increased risk of nephrotoxicityoral anticoagulants: Increased anticoagulationphenytoin: Increased blood phenytoin level,increased risk of phenytoin toxicitytheophylline: Increased theophylline levelFOODShistamine-containing foods, such as tuna,skipjack, and other tropical fish: Inhibitedaction of the enzyme diamine oxidase infoods, possibly resulting in headache,sweating, palpitations, flushing, andhypotension.tyramine-containing foods, such as cheeseand fish: Increased response to tyramine infoods, possibly resulting in chills; diaphoresis;headache; light-headedness; and red,itchy, clammy skinACTIVITIESalcohol use: Increased risk of hepatotoxicityand increased isoniazid metabolismAdverse ReactionsCNS: Clumsiness, confusion, dizziness,encephalopathy, fatigue, fever, hallucinations,neurotoxicity, paresthesia, peripheralneuritis, psychosis, seizures, weaknessCV: VasculitisEENT: Optic neuritisENDO: Gynecomastia, hyperglycemiaGI: Abdominal pain, anorexia, elevated liverfunction test results, epigastric distress,hepatitis, nausea, vomitingGU: GlycosuriaHEME: Agranulocytosis, aplastic anemia,eosinophilia, hemolytic anemia, sideroblasticanemia, thrombocytopeniaMS: Arthralgia, joint stiffnessSKIN: Jaundice, pruritus, rashOther: Hypocalcemia, hypophosphatemia,injection site irritation, lupus-like symptoms,lymphadenopathyNursing Considerations• Administer isoniazid cautiously to diabetic,alcoholic, or malnourished patients andthose at risk for peripheral neuritis.• Give drug 1 hour before or 2 hours aftermeals to promote absorption. If GI distressoccurs, give drug with a smallamount of food or an antacid that doesn’tcontain aluminum 1 hour before or2 hours after meal.• Monitor liver enzyme studies, which maybe ordered monthly, because isoniazid cancause severe (possibly fatal) hepatitis.• About 50% of patients metabolize isoniazidslowly, which may lead to increasedtoxic effects. Watch for adverse reactions,such as peripheral neuritis; if they occur,expect to decrease dosage.• Give isoniazid with other antituberculoticdrugs, as prescribed, to prevent developmentof resistant organisms.• Be aware that patients with advanced HIVinfection may experience more severeadverse reactions in greater numbers.PATIENT TEACHING• Instruct patient to take isoniazid exactly asprescribed and not to stop without firstconsulting prescriber. Explain that treatmentmay take months or years.• Direct patient to take drug on an emptystomach 1 hour before or 2 hours aftermeals. If GI distress occurs, instruct himto take drug with food or an antacid thatdoesn’t contain aluminum.• Advise patient to report signs of hepaticdysfunction, including dark urine,decreased appetite, fatigue, and jaundice.• Caution patient not to drink alcohol whiletaking isoniazid because alcohol increasesthe risk of hepatotoxicity.• Give patient a list of tyramine-containingfoods to avoid when taking isoniazid, suchas cheese, fish, salami, red wine, and yeastextracts. Explain that consuming thesefoods during isoniazid therapy may causeunpleasant adverse reactions, such aschills, pounding heartbeat, and sweating.• Tell patient to avoid histamine-containingfoods such as tuna, skipjack, and othertropical fish during therapy to avoid suchadverse reactions as headache, sweating,rapid heartbeat, flushing, and low bloodpressure.• Tell patient that he’ll need periodic laboratorytests and physical examinations.• Urge patient to report fever, nausea,numbness and tingling in arms and legs,rash, vision changes, vomiting, and yellowingskin.

isoproterenol(isoprenaline)IsuprelisoproterenolhydrochlorideIsuprel, Isuprel MistometerisoproterenolsulfateMedihaler-IsoClass and CategoryChemical class: CatecholamineTherapeutic class: Antiarrhythmic, bronchodilatorPregnancy category: B (inhalation), C (I.V.infusion)isoproterenol 547Indications and Dosages To treat bronchospasm in asthma andto prevent and treat bronchospasm inCOPDINHALATION AEROSOL (ISOPROTERENOLHYDROCHLORIDE)Adults and adolescents. 1 oral inhalation(120 to 131 mcg), repeated in 2 to 5 min.Inhalations repeated every 3 to 4 hr, p.r.n.INHALATION AEROSOL (ISOPROTERENOL SULFATE)Adults and adolescents. 1 oral inhalation(80 mcg), repeated in 2 to 5 min.Inhalations repeated every 4 to 6 hr, p.r.n.INHALATION SOLUTION FOR NEBULIZER (ISOPRO-TERENOL)Adults and adolescents. 2.5 mg diluted andadministered over 10 to 20 min. Repeatedevery 4 hr, p.r.n.Children. 0.05 to 0.1 mg/kg (up to 1.25 mg)diluted and administered over 10 to 20 min.Repeated every 4 hr, p.r.n. To manage bronchospasm during anesthesiaI.V. INJECTION (ISOPROTERENOL HYDROCHLORIDE)Adults. 0.01 to 0.02 mg, repeated p.r.n. To treat bradycardia with significanthemodynamic change, such as thirddegreeheart block or prolonged QTintervalsI.V. INFUSION (ISOPROTERENOL HYDROCHLORIDE)Adults. Initial: 2 mcg/min. Titrated accordingto heart rate, as ordered. Maximum:10 mcg/min.Route Onset Peak DurationI.V.* Unknown Unknown 1–2 hrI.V.† In 5 min Unknown 10 minInhala- In 5 min 5–15 min In 3 hrtionMechanism of ActionStimulates beta 1 receptors in the myocardiumand cardiac conduction system,resulting in positive inotropic and chronotropiceffects. Isoproterenol also shortensAV conduction time and refractory periodin patients with AV block. This actionincreases ventricular rate and halts bradycardiaand associated syncope.In addition, isoproterenol attaches tobeta 2 receptors on bronchial cell membranes.This action stimulates the intracellularenzyme adenylate cyclase to convertadenosine triphosphate to cyclic adenosinemonophosphate (cAMP). An increasedintracellular cAMP level relaxes bronchialsmooth-muscle cells, stabilizes mast cells,and inhibits histamine release.ContraindicationsAngina pectoris, heart block or tachycardiafrom digitalis toxicity, ventricular arrhythmiasthat require inotropic therapy (I.V.form); hypersensitivity to isoproterenol orits components, such as sulfite in somepreparations (inhalation form); tachyarrhythmias(I.V. and inhalation forms)InteractionsDRUGSNote: All interactions listed are for I.V. formunless indicated.alpha blockers, other drugs with this action:Possibly decreased peripheral vasoconstrictingand hypertensive effects of isoproterenolanesthetics (hydrocarbon inhalation):Increased risk of atrial and ventriculararrhythmiasastemizole, cisapride, drugs that prolong QTcinterval, terfenadine: Possibly prolongedQTc intervalbeta blockers (ophthalmic): Decreased effects*For treatment of bronchospasm.†For treatment of bradycardia.GHI

548isoproterenolof isoproterenol, increased risk of bronchospasm,wheezing, decreased pulmonaryfunction, and respiratory failurebeta blockers (systemic): Increased risk ofbronchospasm, decreased effects of bothdrugs (including inhaled isoproterenol)digoxin: Increased risk of arrhythmias,hypokalemia, and digitalis toxicitydiuretics, other antihypertensives: Possiblydecreased antihypertensive effectsergot alkaloids: Increased vasoconstrictionand vasopressor effectsMAO inhibitors: Intensified and extendedcardiac stimulation and vasopressor effectsquinidine, other drugs that affect myocardialreaction to sympathomimetics: Increased riskof arrhythmiastheophylline: Increased risk of cardiotoxicity,decreased blood theophylline levelthyroid hormones: Increased effects of bothdrugs, increased risk of coronary insufficiencyin patients with coronary artery diseasetricyclic antidepressants: Increased vasopressorresponse, increased risk of prolongedQTc interval and arrhythmiasAdverse ReactionsCNS: Dizziness, headache, insomnia, nervousness,syncope, tremor, weaknessCV: Angina, arrhythmias, bradycardia,hypertension, hypotension, palpitations,tachycardia, ventricular arrhythmiasEENT: Dry mouth, oropharyngeal edema,taste perversionENDO: HyperglycemiaGI: Heartburn, nausea, vomitingMS: Muscle spasms and twitchingRESP: Bronchitis, bronchospasm, cough,dyspnea, increased sputum production,pulmonary edema, wheezingSKIN: Dermatitis, diaphoresis, erythemamultiforme, flushing, pallor, pruritus, rash,Stevens-Johnson syndrome, urticariaOther: Angioedema, hypokalemiaNursing Considerations• Expect to give lowest possible dose of isoproterenolfor shortest possible time tominimize tolerance.• Don’t administer I.V. isoproterenol if solutionis pink or brown or contains precipitate.• Administer isoproterenol infusion througha large vein, and monitor patient for signsof extravasation.• Monitor blood pressure, cardiac rhythm,central venous pressure, and urine outputwhen giving I.V. drug. Adjust infusion rateto response, as ordered.• Notify prescriber immediately if heart rateincreases significantly or exceeds 110 beats/minute during I.V. infusion.• Know that drug may increase pulse pressureand cause hypotension. Expect toreduce I.V. infusion slowly to decrease riskof hypotension.WARNING Be aware that drug markedlyincreases risk of arrhythmias. If anarrhythmia develops, expect to give acardioselective beta blocker, such asatenolol.• Isoproterenol isn’t used regularly to treatasthma, decreased cardiac output,hypotension, or shock because it increasesthe risk of arrhythmias, hypotension, andischemia.WARNING If drug aggravates a ventilationperfusionproblem, expect blood oxygenlevel to fall even as breathing seems toimprove.PATIENT TEACHING• Instruct patient not to use isoproterenolinhaler more often than prescribedbecause it may cause cardiac and respiratoryproblems.• Teach patient to use the inhaler. Provide aspacer, as needed.• Instruct patient to wait 2 to 5 minutesbefore taking second inhalation.• Advise patient to rinse his mouth afterinhalation to remove drug residue andminimize mouth dryness.• Inform patient that saliva may appearpink after inhalation.• If patient uses a corticosteroid inhaler, tellhim to take isoproterenol first and wait atleast 2 minutes before taking corticosteroid.• Instruct patient to notify prescriber aboutchest pain, dizziness, hyperglycemic symptoms(such as abdominal cramps, lethargy,nausea, and vomiting), insomnia, irregularheartbeat, palpitations, tremor, and weakness.• Advise patient to also report reducedeffectiveness of isoproterenol, increaseduse of inhaler, and increased symptomsafter taking drug.

isosorbide dinitrateApo-ISDN (CAN), Cedocard-SR (CAN),Coradur (CAN), Coronex (CAN),Dilatrate-SR, Isordil Tembids, IsordilTitradose, SorbitrateisosorbidemononitrateIMDUR, ISMO, MonoketClass and CategoryChemical class: Organic nitrateTherapeutic class: Antianginal, vasodilatorPregnancy category: CIndications and Dosages To treat or prevent anginaCHEWABLE TABLETSAdults. 5 mg every 2 to 3 hr, p.r.n. (dinitrate).E.R. CAPSULESAdults. 40 to 80 mg every 8 to 12 hr (dinitrate).E.R. TABLETSAdults. 20 to 80 mg every 8 to 12 hr (dinitrate);30 to 60 mg daily, increased graduallyas tolerated to 120 mg daily (mononitrate).S.L. TABLETSAdults. 2.5 to 5 mg every 2 to 3 hr, p.r.n.(dinitrate).InteractionsDRUGSacetylcholine, norepinephrine: Possiblydecreased effectiveness of these drugsantihypertensives, calcium channel blockers,opioid analgesics, other vasodilators:Increased risk of orthostatic hypotensionaspirin: Increased blood level and pharmaisosorbide549TABLETSAdults. 5 to 40 mg every 6 hr, adjusted asneeded (dinitrate); 20 mg in 2 doses given7 hr apart (mononitrate).Route Onset Peak DurationP.O.* 1 hr † Unknown 5–6 hrP.O. In 3 min Unknown 30 min–(chewable)*2 hrP.O. 30 min Unknown 6–8 hr(E.R.)*P.O. In 3 min Unknown 2 hr(S.L.)*ContraindicationsAngle-closure glaucoma; cerebral hemorrhage;concurrent use of sildenafil; headtrauma; hypersensitivity to isosorbide,other nitrates, or their components; orthostatichypotension; severe anemia*For dinitrate.†For mononitrate, onset also is 1 hr; peakand duration are unknown.GHIMechanism of ActionIsosorbide may interact withnitrate receptors in vascularsmooth-muscle cell membranes.By interacting with receptors’sulfhydryl groups, drug isreduced to nitric oxide. Nitricoxide activates the enzymeguanylate cyclase, increasingintracellular formation of cyclicguanosine monophosphate(cGMP). An increased cGMPlevel may relax vascular smoothmuscle by forcing calcium out ofmuscle cells, causing vasodilation.This improves cardiac output byreducing mainly preload but alsoafterload.Cell exteriorNitratereceptorCell interiorIsosorbideNitricoxideGuanylatecyclaseCalciumSmoothmusclecellmembranecGMP

550isosorbidecologic action of isosorbidesildenafil, tadalafil, vardenafil: Increased riskof hypotension and deathsympathomimetics: Increased risk of hypotension,possibly decreased therapeuticeffects of isosorbideACTIVITIESalcohol use: Increased risk of orthostatichypotensionAdverse ReactionsCNS: Agitation, confusion, dizziness, headache,insomnia, restlessness, syncope, vertigo,weaknessCV: Arrhythmias, orthostatic hypotension,palpitations, peripheral edema, tachycardiaEENT: Blurred vision, diplopia (all forms);sublingual burning (S.L. form)GI: Abdominal pain, diarrhea, indigestion,nausea, vomitingGU: Dysuria, impotence, urinary frequencyHEME: Hemolytic anemiaMS: Arthralgia, muscle twitchingRESP: Bronchitis, pneumonia, upper respiratorytract infectionSKIN: Diaphoresis, flushing, rashNursing Considerations• Use isosorbide cautiously in patients withhypovolemia or mild hypotension.Monitor patient for increased hypotensionand reduced cardiac output.• Give drug 1 hour before or 2 hours aftermeals. Give with meals if patient experiencessevere headaches or adverse GI reactions.• Know that patient may experience dailyheadaches from isosorbide’s vasodilatingeffects. Give acetaminophen, as prescribed,to relieve pain.WARNING Be aware that stopping drugabruptly may cause angina and increasethe risk of MI.• Monitor blood pressure often duringisosorbide therapy, especially in elderlypatients; drug may cause severe hypotension.• Keep isosorbide protected from heat andlight.PATIENT TEACHING• Teach patient and family to recognizesigns and symptoms of angina, includingchest pain, fullness, or pressure, whichcommonly is accompanied by sweatingand nausea. Pain may radiate down theleft arm or into the neck or jaw. Informfemale patients and those with diabetesmellitus or hypertension that they mayexperience only fatigue and shortness ofbreath.• Caution patient not to crush or chewisosorbide E.R. capsules or tablets or S.L.tablets unless specifically ordered to do soby prescriber.• Instruct patient to place S.L. tablet undertongue and not to swallow it, but to let itdissolve. Explain that moisture in mouthpromotes drug absorption and that tinglingor burning in the mouth indicatesdrug effectiveness.• Advise patient to chew chewable tabletswell and to keep them in his mouth for1 to 2 minutes before swallowing toenhance drug absorption.• Instruct patient to take drug before anysituation or activity that might precipitateangina.• Advise patient to carry isosorbide withhim at all times.• Caution patient that abrupt drug discontinuationmay cause angina and increasethe risk of MI.• Instruct patient to notify prescriber aboutblurred vision, fainting, increased anginaattacks, rash, and severe or persistentheadaches.• Teach patient to reduce the effects oforthostatic hypotension by changing positionslowly. Advise him to lie down if hebecomes dizzy.• Inform patient that drug commonly causesheadache, which typically resolves aftera few days of continuous therapy. Suggestthat patient take acetaminophen as neededand as prescribed.• Advise patient to avoid potentially hazardousactivities until drug’s CNS effectsare known.• Urge patient to avoid alcohol consumption.• Instruct patient to store drug in a tightlyclosed container and protect from lightand heat.• Advise male patient with erectile dysfunctionto alert prescriber that he is takingisosorbide because sildenafil, tadalafil, andvardenafil can cause fatal reactions whentaken with isosorbide.

isotretinoinAccutane, ClaravisClass and CategoryChemical class: RetinoidTherapeutic class: Acne inhibitorPregnancy category: XIndications and Dosages To treat severe recalcitrant nodular acneunresponsive to conventional therapyCAPSULESAdults. Initial: 0.5 mg to 1 mg/kg daily in2 divided doses, increased as needed up to2 mg/kg daily given in 2 divided doses.Maximum: 2 mg/kg daily. Course of therapygiven for 15 to 20 wk with second coursegiven, as needed, after a period of 2 mo ormore off therapy.Mechanism of ActionInhibits sebaceous gland function and keratinization,which results in diminishednodular formation associated with recalcitrantnodular acne.ContraindicationsHypersensitivity to isotretinoin or any of itscomponents, hypersensitivity to parabens,pregnancyInteractionsDRUGScorticosteroids (systemic): Possibly increasedrisk of osteoporosishormonal contraceptives including microdosedprogesterone preparations, medroxyprogesteroneinjection, levonorgestrelimplants: Possibly decreased effectiveness ofcontraceptivephenytoin: Possibly increased risk of osteomalaciatetracyclines: Increased risk of benignintracranial hypertensionvitamin A supplements: Increased risk ofadditive toxic effectsAdverse ReactionsCNS: Aggressive or violent behavior,depression, dizziness, drowsiness, emotionalinstability, fatigue, headache, insomnia,lethargy, malaise, nervousness, paresthesias,pseudotumor cerebri, psychosis, seizures,stroke, suicidal ideation, syncope, weaknessCV: Chest pain, decreased high-densityisotretinoin 551lipoprotein level, edema, elevated creatininephosphokinase level, hypercholesteremia,hypertriglyceridemia, palpitation, stroke,tachycardia, vascular thrombotic disease,vasculitisENDO: Abnormal menses, alterations inblood glucose levelsEENT: Bleeding and inflammation of gums,cataracts, color vision disorder, conjunctivitis,corneal opacities, decreased nightvision, dry mouth or nose, dry eyes, epistaxis,eyelid inflammation, hearing impairment,keratitis, optic neuritis, photophobia,tinnitus, visual disturbances, voice alterationGI: Colitis, hepatitis, ileitis, inflammatorybowel disease, liver enzyme elevation, nausea,pancreatitisGU: Glomerulonephritis, hematuria, proteinuria,WBCs in urineHEME: Anemia, agranulocytosis, neutropenia,platelet count elevation, sedimentationrate elevation, thrombocytopeniaMS: Arthralgia, arthritis, back pain (children),bone abnormalities, calcification oftendons and ligaments, premature epiphysealclosure, tendonitisRESP: Bronchospasms, respiratory infectionSKIN: Alopecia, bruising, disseminated herpessimplex, dry lips or skin, eczema, eruptivexanthomas, facial erythema, flushing,fulminant acne, hair abnormalities, hirsutism,hyperpigmentation, hypopigmentation,increased sunburn susceptibility,infections, nail dystrophy, paronychia, peelingof palms and soles, photoallergic orphotosensitizing reactions, pruritus, pyogenicgranuloma, rash, seborrhea, skinfragility, sweating, urticariaOther: Abnormal wound healing, alkalinephosphatase increase, allergic reactions,hyperuricemia, lymphadenopathy, weightlossNursing Considerations• Ensure that women of childbearing agehave had two negative urine or serumpregnancy tests with a sensitivity of atleast 50 mIU/ml, joined the AccutaneSurvey, signed the consent form, andwatched the videotape provided by manufacturerprior to beginning isotretinointherapy.GHI

552isradipineWARNING Notify prescriber if elevatedserum triglyceride levels can’t be controlledor if symptoms of pancreatitisoccur (abdominal pain, nausea, vomiting).Drug may need to be discontinuedbecause fatal hemorrhagic pancreatitis hasoccurred with drug use.• Obtain serum lipid level before therapyand periodically thereafter, as ordered, todetect elevated lipid levels that result fromisotretinoin therapy.• Monitor liver enzyme levels periodically,as ordered, because drug can cause hepatitis.• Assess patient frequently for adverse reactionsand report to prescriber any thatoccur; drug may have serious adverseeffects that require discontinuation.PATIENT TEACHING• Instruct patient to take isotretinoin withfood or milk.• Advise women of childbearing age thattwo forms of contraceptives must be usedsimultaneously (unless absolute abstinenceis the chosen method) 1 month beforetherapy and for 1 month after therapy hasstopped because of potential for fetalharm. Inform women who use oral contraceptivesthat drug may lessen effectivenessof oral contraceptives. Urge patient tonotify prescriber immediately if pregnancyoccurs.• Stress importance of picking up isotretinoinprescription within 7 days of apregnancy test or, for male patients orwomen not of childbearing potential,within 30 days of prescription.• Urge patient to report headache, nausea,vomiting and visual disturbances immediatelyto prescriber because drug will needto be discontinued immediately andpatient referred to a neurologist.• Caution patient and family that isotretinoinmay cause aggressive or violentbehavior, depression, psychosis, and suicidalideation. Instruct patient to notify prescriberimmediately if changes in moodoccur.• Tell patient to report hearing changes ortinnitus, visual difficulties, abdominalpain, rectal bleeding, or severe diarrhea toprescriber because drug may need to bediscontinued.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.Caution that changes in night vision mayoccur suddenly.• Caution patient not to donate blood duringtherapy and for 1 month after therapyhas stopped because blood might be givento a pregnant woman.• Warn patient that transient exacerbationof acne may occur, especially during initialtherapy and to notify prescriber if thisoccurs.• Instruct patient to avoid wax epilation andskin resurfacing procedures during therapyand for at least 6 months thereafterbecause of scarring potential.• Caution patient to avoid exposure todirect sunlight or UV light and to wearsunscreen when outdoors.• Inform patient that contact lens tolerancemay decrease during and after isotretinointherapy.• Alert patient to the potential for mildmusculoskeletal adverse reactions, whichusually clear rapidly after drug is discontinued.Urge patient to notify prescriber ifsymptoms become bothersome or seriousbecause drug may need to be discontinued.• Advise patient not to take vitamin A supplementswhile on isotretinoin therapybecause of potentially additive toxiceffects.• Instruct patient to notify all prescribers ofisotretinoin use because of the risk ofinteractions.• Inform patient of need for frequent laboratorytests and importance of complyingwith scheduled appointments.isradipineDynaCircClass and CategoryChemical class: Dihydropyridine derivativeTherapeutic class: AntihypertensivePregnancy category: CIndications and Dosages To manage essential hypertensionCAPSULESAdults. Initial: 2.5 mg b.i.d., increased by5 mg every 2 to 4 wk, if needed. Maximum:20 mg daily.

Mechanism of ActionInhibits calcium movement into coronaryvascular smooth-muscle cells by blockingthe slow calcium channels in their membranes.By decreasing intracellular calciumlevel, isradipine inhibits smooth-muscle cellcontractions. The result is relaxation ofcoronary and vascular smooth muscle,decreased peripheral vascular resistance,and reduced systolic and diastolic bloodpressure, all of which decrease myocardialoxygen demand.Route Onset Peak DurationP.O. 2–3 hr 2–4 wk UnknownContraindicationsHypersensitivity to isradipine or its componentsInteractionsDRUGSanesthetics (hydrocarbon inhalation), antihypertensives,hydrochlorothiazide, prazocin:Increased risk of hypotensionbeta blockers: Increased adverse effects ofbeta blockerscimetidine: Increased blood level and bioavailabilityof isradipinedigoxin: Transiently increased blood digoxinlevel and risk of digitalis toxicityestrogens: Possibly increased fluid retentionand decreased isradipine effectslithium: Increased risk of neurotoxicityNSAIDs, sympathomimetics: Possiblydecreased therapeutic effects of isradipineprocainamide, quinidine: Increased risk ofprolonged QT intervalFOODSgrapefruit juice: Doubled isradipine bioavailabilityother foods: Prolonged time to achieve peakblood levelAdverse ReactionsCNS: Asthenia, dizziness, fatigue, headache,paresthesia, somnolence, stroke, syncope,transient ischemic attack, weaknessCV: Angina, atrial fibrillation, heart failure,hypotension, MI, orthostatic hypotension,palpitations, peripheral edema, tachycardia,ventricular fibrillationEENT: Gingival hyperplasia, pharyngitis,rhinitisisradipine 553GI: Abdominal cramps, constipation, diarrhea,elevated liver function test results,indigestion, nausea, vomitingHEME: LeukopeniaMS: Back painRESP: CoughSKIN: Flushing, photosensitivity, rash,urticariaOther: AngioedemaNursing Considerations• Monitor blood pressure and heart rateoften during isradipine therapy.• Monitor patient with impaired hepatic orrenal function for an increased bloodisradipine level.• Avoid giving isradipine with food becausedoing so increases time to peak effect byabout 1 hour.• Observe for mild peripheral edema causedby vasodilation of small blood vessels.Know that this type of edema doesn’tresult from fluid retention or heart failure.PATIENT TEACHING• Inform patient that isradipine therapy willbe long-term and will require laboratorytests and follow-up visits to monitor drugeffects.• Instruct patient to take drug exactly asprescribed and to swallow capsules whole,not crushing or chewing them.• Advise patient to take drug on an emptystomach 1 hour before or 2 hours aftermeals.• Instruct patient to take a missed dose assoon as he remembers it unless it’s nearlytime for the next dose. In that case, advisehim to wait and take next scheduled dose,but not to double the dose. If more thanone dose is missed, tell him to contact prescriber.WARNING Urge patient not to stop takingdrug suddenly. Doing so may lead to lifethreateningproblems.• Inform patient that fragments of capsulesmay be visible in stool.• Caution patient not to drink grapefruitjuice during isradipine therapy.• Urge patient to avoid potentially hazardousactivities until isradipine’s CNSeffects are known.• Caution patient to change position slowlyto minimize orthostatic hypotension.• Urge patient to contact prescriber if heGHI

554itraconazoleexperiences chest pain, fainting, irregularheartbeat, rash, or swollen ankles whiletaking isradipine.• Instruct patient to maintain good oralhygiene, perform gum massage, and see adentist every 6 months to prevent gumbleeding and gum disorders.• To help prevent photosensitivity reactions,caution patient to avoid direct sunlightand to wear protective clothing and applysunscreen when outdoors.• Instruct patient to store drug at roomtemperature in a dry place.itraconazoleSporanoxClass and CategoryChemical class: Triazole derivativeTherapeutic class: AntifungalPregnancy category: CIndications and Dosages To treat blastomycosis caused by Blastomycesdermatitidis and histoplasmosiscaused by Histoplasma capsulatumCAPSULESAdults and adolescents. Initial: 200 mgdaily, increased by 100 mg daily, if needed.Maximum: 400 mg daily, with dosagegreater than 200 mg given in divided dosesb.i.d. To treat aspergillosis unresponsive toamphotericin BCAPSULESAdults and adolescents. 200 to 400 mgdaily, with dosage greater than 200 mg dailygiven in divided doses b.i.d. To treat oropharyngeal candidiasisORAL SOLUTIONAdults and adolescents. 100 mg b.i.d. for7 to 14 days. To treat esophageal candidiasisORAL SOLUTIONAdults and adolescents. 100 mg daily for atleast 3 wk and continued for 2 wk aftersymptoms resolve. To treat onychomycosis of toenails onlyor of toenails and fingernailsCAPSULESAdults and adolescents. 200 mg daily for12 wk. To treat onychomycosis of fingernailsonlyCAPSULESAdults and adolescents. 200 mg b.i.d. for7 days; then repeated after 3 wk.Mechanism of ActionInhibits the synthesis of ergosterol, anessential component of fungal cell membranes,by binding with a cytochrome P-450 enzyme needed to convert lanosterol toergosterol. Lack of ergosterol results inincreased cellular permeability and leakageof cell contents. Itraconazole also may leadto fungal cell death by inhibiting fungal respirationunder aerobic conditions.ContraindicationsConcurrent therapy with cisapride, dofetilide,ergot alkaloids, HMG-CoA inhibitors(lovastatin and simvastatin), levomethadyl,nisoldipine, oral midazolam, pimozide,quinidine, or triazolam; evidence of ventriculardysfunction, as in congestive heartfailure (CHF) or a history of it (onychomycosistreatment); hypersensitivity to itraconazoleor its components; planning forpregnancy during onychomycosis treatmentInteractionsDRUGSalfentanil, buspirone, busulfan, carbamazepine,cyclosporine, digoxin, docetaxel, indinavir,methylprednisolone, phenytoin,pimozide, rifabutin, ritonavir, saquinavir,sirolimus, tacrolimus, trimetrexate, vincaalkaloids: Possibly increased blood levels ofthese drugs and serious adverse effectsalprazolam, diazepam, oral midazolam, triazolam:Elevated blood levels and possiblyprolonged sedative effects of these drugsantacids, anticholinergics, H 2 -receptorantagonists, omeprazole, sucralfate: Possiblydecreased itraconazole absorptionatorvastatin, lovastatin, simvastatin:Increased blood levels of these drugs; possiblyrhabdomyolysiscalcium channel blockers: Possibly edemaand increased blood levels of these drugscarbamazepine, isoniazid, nevirapine, phenobarbital,phenytoin, rifabutin, rifampin:Possibly decreased blood itraconazole levelcilostazol; eletriptan; glucocorticosteroids suchas budesonide, dexamethasone, fluticasone,and methylprednisolone; trimetrexate:

Possibly inhibited metabolism of thesedrugscisapride, dofetilide, disopyramide, halofantrine,levomethadyl, pimozide, quinidine:Possibly increased plasma levels of thesedrugs leading to potentially life-threateningcardiovascular complications such as cardiacarrest, prolonged QT interval, torsadesde pointes, ventricular tachycardia, andsudden deathclarithromycin, erythromycin, indinavir,ritonavir: Possibly increased blood itraconazoleleveldidanosine: Possibly decreased therapeuticeffects of itraconazoleergot alkaloids: Possibly increased plasmaergot alkaloid elevation leading to cerebralischemia and ischemia of the extremitiesfentanyl: Possibly increased plasma fentanyllevel causing potentially fatal respiratorydepressionnisoldipine: Increased plasma nisoldipinelevels that do not decrease after drug dosageis reducedoral antidiabetic drugs: Possibly increasedblood levels of these drugs and risk ofhypoglycemiawarfarin: Increased anticoagulant effect ofwarfarinAdverse ReactionsCNS: Dizziness, drowsiness, fatigue, fever,headache, paresthesia, peripheral neuropathy,vertigoCV: CHF, hypertriglyceridemia, hypertension,peripheral edemaEENT: Blurred vision, diplopia, transient orpermanent hearing loss, tinnitisGI: Abdominal pain, anorexia, constipation,diarrhea, elevated liver function test results,flatulence, hepatic failure, hepatitis, hepatotoxicity,hyperbilirubinemia, indigestion,nausea, vomitingGU: Erectile dysfunction, menstrual irregularities,urinary incontinenceHEME: Leukopenia, neutropenia, thrombocytopeniaMS: Arthralgia, myalgiaRESP: Cough, dyspnea, pulmonary edemaSKIN: Alopecia, diaphoresis, erythemamultiforme, exfoliative dermatitis, leukocytoclasticvasculitis, photosensitivity, pruritus,rash, Stevens-Johnson syndrome, toxicepidermal necrolysis, urticariaOther: Anaphylaxis, angioedema,hypokalemia, serum sicknessitraconazole 555Nursing Considerations• Use itraconazole with extreme caution inpatients with risk factors for CHF, such asischemic or valvular heart disease, significantCOPD, and renal failure and otheredematous disorders because of increasedrisk of developing CHF during itraconazoletreatment.• Use itraconazole cautiously in patientswith hypersensitivity to other azole antifungals(because cross-hypersensitivity isunknown) and in patients with renal orhepatic impairment.• Because itraconazole has been linked toserious adverse cardiac and hepatic effects,expect to send appropriate nail specimensfor laboratory testing to confirm onychomycosisbefore beginning therapy.WARNING Keep in mind that itraconazole is apotent inhibitor of the cytochrome P-4503A4 (CYP3A4) isoenzyme system, whichmay increase blood levels of drugs metabolizedby this system. Patients taking suchdrugs as cisapride with itraconazole orother CYP3A4 inhibitors have experiencedlife-threatening cardiovascular complications,such as prolonged QT interval, torsadesde pointes, and ventricular tachycardia,as well as sudden death.• Administer itraconazole capsules (not oralsolution) with a meal to ensure maximalabsorption.• Keep in mind that a patient with AIDSmay have hypochlorhydria, which reducesdrug absorption. For such a patient,expect to administer higher doses of itraconazole.• Monitor liver function test results inpatients with impaired hepatic functionand those who have experienced hepatotoxicitywith other drugs.• If patient develops signs and symptoms ofperipheral neuropathy or CHF, such asfatigue, dyspnea, and peripheral edema,expect to discontinue drug.• Assess patient for rash every 8 hours duringtherapy; notify prescriber if rashoccurs.• If patient also receives warfarin, monitorPT and assess patient for signs and symptomsof bleeding.GHI

556itraconazole• If patient also receives digoxin, monitorblood digoxin level as appropriate todetect toxic level, and assess patient forsigns and symptoms of digitalis toxicity,such as nausea and yellow vision.PATIENT TEACHING• Instruct patient to take itraconazole capsuleswith a meal, but oral solution withoutfood.• If patient also takes an oral antidiabeticdrug, instruct him to check his blood glucoselevel often because of the increasedrisk of hypoglycemia.• Advise patient to avoid taking antacidswith oral itraconazole.• Advise patient to notify prescriber immediatelyof changes in other drugs, such asnew drugs and dosage changes.• Advise patient to notify prescriber immediatelyabout abdominal pain, diarrhea,headache, hearing loss, nausea, peripheralneuropathy, rash, or vomiting.• Instruct patient to notify prescriber if heexperiences signs of liver problems, suchas abdominal pain, dark urine, fatigue, lossof appetite, pale stools, weakness, or yelloweyes or skin.• Caution breast-feeding patient to consultprescriber about continuation of breastfeedingduring itraconazole therapy.

kanamycin sulfate 557J K Lkanamycin sulfateKantrexClass and CategoryChemical class: AminoglycosideTherapeutic class: AntibioticPregnancy category: DIndications and Dosages To treat infections caused by gramnegativeorganisms (including Acinetobacterspecies, Enterobacter aerogenes,Escherichia coli, Haemophilus influenzae,Klebsiella pneumoniae, Neisseriaspecies, Proteus species, Providenciaspecies, Salmonella species, Serratiamarcescens, Shigella species, and Yersiniaspecies) and gram-positive organisms(including Staphylococcus aureusand Staphylococcus epidermidis)I.M. INJECTIONAdults and children. 3.75 mg/kg every 6 hr,5 mg/kg every 8 hr, or 7.5 mg/kg every 12 hrfor 7 to 10 days. Maximum: 1.5 g daily.I.V. INFUSIONAdults and children. 5 mg/kg every 8 hr or7.5 mg/kg every 12 hr for 7 to 10 days.Maximum: 1.5 g daily. As adjunct to suppress intestinalbacterial growthCAPSULESAdults. 1 g/hr for 4 hr and then 1 g every6 hr for 36 to 72 hr. To treat hepatic comaCAPSULESAdults. 8 to 12 g daily in divided doses. To treat respiratory tract infectionINHALATION NEBULIZERAdults. 250 mg b.i.d. to q.i.d. Maximum:1.5 g daily.DOSAGE ADJUSTMENT For elderly patientsand those with renal failure, dosage reducedand blood kanamycin level and renal functiontest results monitored.Mechanism of ActionBinds to negatively charged sites on bacterialouter cell membranes, which disrupts cellmembrane integrity. Kanamycin also bindsto bacterial ribosomal subunits and inhibitsprotein synthesis; these actions lead to celldeath.Route Onset Peak DurationP.O. Slow Unknown UnknownI.V. Rapid Unknown UnknownI.M. Unknown 1–2 hr UnknownIncompatibilitiesDon’t mix kanamycin in same syringe oradminister through same I.V. line as otherantibiotics.ContraindicationsHypersensitivity to kanamycin, otheraminoglycosides, or their components;intestinal obstruction (oral form)InteractionsDRUGScephalosporins, vancomycin: Increased riskof nephrotoxicitydigoxin, loop diuretics: Increased ototoxicand nephrotoxic effects of kanamycingeneral anesthetics, neuromuscular blockers:Increased risk of neuromuscular blockadepenicillins: Inactivation of kanamycin orsynergistic effectsAdverse ReactionsCNS: Ataxia, dizziness, headacheEENT: Hearing lossGI: DiarrheaGU: Elevated BUN and serum creatininelevels, oliguria, proteinuriaMS: Muscle paralysisRESP: ApneaSKIN: Injection site irritation or painNursing Considerations• Obtain body fluid or tissue specimen forculture and sensitivity testing beforekanamycin therapy begins, as indicated.Therapy may begin before test results areavailable.• Administer I.M. injection deep into upperouter quadrant of gluteus maximus.Rotate injection sites.• Be aware that oral kanamycin is minimallyabsorbed from intact GI mucosa but maybe more absorbed from mechanically irrigatedareas of the GI tract.• For I.V. use, dilute 500-mg vial with 100 to200 ml normal saline solution or D 5 W, or1-g vial with 200 to 400 ml normal salineJKL

558ketoprofensolution or D 5 W, and infuse over 30 to60 min. Vial contents may darken duringstorage but potency isn’t affected.• Keep patient well hydrated before andduring therapy.• Monitor blood kanamycin level periodicallyduring therapy, as appropriate.• Prolonged treatment increases risk of ototoxicityand nephrotoxicity. Monitor hearingand renal function if therapy lastslonger than 10 days.PATIENT TEACHING• Explain need to take kanamycin at prescribedintervals around the clock untilpatient completes full course of therapy.• Advise patient to report dizziness, hearingloss, and severe diarrhea or headache.ketoprofenActron, Apo-Keto (CAN), Orudis,Orudis KT, Orudis-SR (CAN), Oruvail,RhodisClass and CategoryChemical class: Propionic acid derivativeTherapeutic class: Analgesic, antiinflammatoryPregnancy category: BIndications and Dosages To treat symptoms of rheumatoidarthritisCAPSULES, TABLETSAdults. Initial: 75 mg t.i.d. or 50 mg q.i.d.Maximum: 300 mg daily.E.R. CAPSULESAdults. Maintenance: 150 to 200 mg daily.Maximum: 300 mg daily. To relieve pain in dysmenorrheaTABLETSAdults. Initial: 25 to 50 mg every 6 to 8 hrp.r.n. Maximum: 300 mg daily.DOSAGE ADJUSTMENT Dosage reduced by33% to 50% for patients with renal impairment.Mechanism of ActionBlocks activity of cyclooxygenase, theenzyme needed for prostaglandin synthesis.Prostaglandins, important mediators ofinflammatory response, cause local vasodilationwith swelling and pain. By blockingcyclooxygenase and inhibitingprostaglandins, this NSAID reduces inflammatorysymptoms and relieves pain.ContraindicationsAngioedema; aspirin-, iodide-, or NSAIDinducedasthma, bronchospasm, nasalpolyps, rhinitis, or urticaria; hypersensitivityto ketoprofen or its componentsInteractionsDRUGSACE inhibitors: Possibly decreased hypotensiveeffect of ACE inhibitorsacetaminophen: Possibly increased adverserenal effects with long-term acetaminophenuseaspirin, other NSAIDs: Increased risk ofbleeding and adverse GI effects, increasedand prolonged blood ketoprofen levelscefamandole, cefoperazone, cefotetan:Increased risk of hypoprothrombinemiaand bleedingcolchicine, platelet aggregation inhibitors:Increased risk of GI bleeding, hemorrhage,and ulcerscorticosteroids, potassium supplements:Increased risk of adverse GI effectscyclosporine: Increased risk of nephrotoxicityfrom both drugs, increased bloodcyclosporine leveldiuretics (loop, potassium-sparing, and thiazide):Decreased diuretic and antihypertensiveeffectsgold compounds, nephrotoxic drugs:Increased risk of adverse renal effectsheparin, oral anticoagulants, thrombolytics:Increased anticoagulant effects, increasedrisk of hemorrhageinsulin, oral antidiabetic drugs: Possiblyincreased hypoglycemic effects of thesedrugslithium: Increased blood lithium level andpossibly toxicitymethotrexate: Decreased methotrexateclearance, increased risk of methotrexatetoxicityplicamycin, valproic acid: Increased risk ofhypoprothrombinemia and GI bleeding,hemorrhage, and ulcersprobenecid: Possibly increased blood level,effectiveness, and risk of toxicity of ketoprofenACTIVITIESalcohol use: Increased risk of adverse GIeffects

Adverse ReactionsCNS: Headache, irritability, nervousness,seizures, strokeCV: Edema, fluid retention, hypertension,MI, tachycardiaEENT: Tinnitus, vision changesGI: Abdominal pain, anorexia, constipation,diarrhea, diverticulitis, dyspepsia, dysphagia,flatulence, gastritis, gastroenteritis, gastroesophagealreflux disease, GI bleedingand ulceration, hepatic failure, hiatal hernia,indigestion, melena, nausea, perforationof stomach or intestine, stomatitis,vomitingGU: Acute renal failure, decreased urineoutputHEME: Agranulocytosis, anemia, easybruising, hemolytic anemia, leukopenia,neutropenia, pancytopenia, thrombocytopeniaRESP: Asthma, respiratory depressionSKIN: Erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis,rashOther: Anaphylaxis, angioedema, rapidweight gainNursing Considerations• Use ketoprofen with extreme caution inpatients with history of ulcer disease or GIbleeding because NSAIDs such as ketoprofenincrease risk of GI bleeding and ulceration.Expect to use ketoprofen for shortesttime possible in these patients.• Be aware that serious GI tract ulceration,bleeding, and perforation may occur withoutwarning symptoms. Elderly patientsare at greater risk. To minimize risk, givedrug with food. If GI distress occurs, withholddrug and notify prescriber immediately.• Use ketoprofen cautiously in patients withhypertension, and monitor blood pressureclosely throughout therapy. Drug maycause hypertension or worsen it.WARNING Monitor patient closely forthrombotic events, including MI andstroke, because NSAIDs increase the risk.• Monitor patient—especially if he’s elderlyor receiving long-term ketoprofen therapy—forless common but serious adverseGI reactions, including anorexia, constipation,diverticulitis, dysphagia, esophagitis,gastritis, gastroenteritis, gastroesophagealketoprofen 559reflux disease, hemorrhoids, hiatal hernia,melena, stomatitis, and vomiting.• Monitor liver function test results because,rarely, elevations may progress to severehepatic reactions, including fatal hepatitis,liver necrosis, and hepatic failure.• Monitor BUN and serum creatinine levelsin elderly patients, patients taking diureticsor ACE inhibitors, and patients withheart failure, impaired renal function, orhepatic dysfunction; drug may cause renalfailure.• Monitor CBC for decreased hemoglobinlevel and hematocrit because drug mayworsen anemia.WARNING If patient has bone marrow suppressionor is receiving an antineoplasticdrug, monitor laboratory results (includingWBC count), and watch for evidenceof infection because anti-inflammatoryand antipyretic actions of ketoprofen maymask signs and symptoms, such as feverand pain.• Assess patient’s skin regularly for signs ofrash or other hypersensitivity reactionbecause ketoprofen is an NSAID and maycause serious skin reactions without warning,even in patients with no history ofNSAID sensivitity. At first sign of reaction,stop drug and notify prescriber.• If patient takes acetaminophen, monitorfluid intake and output, BUN level, andserum creatinine level for evidence ofadverse renal effects.PATIENT TEACHING• Instruct patient to take ketoprofen withfood or after meals to prevent GI upset.Advise him to take drug with a full glass ofwater and to avoid lying down for 15 to30 minutes afterward to prevent drugfrom lodging in esophagus and causingirritation.• Advise patient to swallow drug whole andnot to crush, break, chew, or open capsules.• Instruct patient to avoid aspirin, aspirincontainingproducts, and alcohol whiletaking ketoprofen to decrease risk ofadverse GI effects.• Tell patient not to take more drug thanprescribed because stomach bleeding mayoccur.• If patient takes an anticoagulant, tell himto watch for and immediately reportJKL

560ketorolac tromethaminebleeding problems, such as bloody or tarrystools and bloody vomitus.• If patient takes insulin or an oral antidiabetic,advise him to monitor blood glucoselevel closely. Urge him to carry candyor other simple sugars to treat mild hypoglycemia.If he has frequent or severe episodes,instruct him to consult prescriber.• Inform patient that he may be nervousand irritable while taking ketoprofen.• Instruct patient to notify prescriber immediatelyif he develops a rash, decreasedurine output, dark yellow or brown urine,or signs of fluid retention, includingswelling of extremities and unexplainedrapid weight gain.• Caution pregnant patient not to takeNSAIDs such as ketoprofen during lasttrimester because they may cause prematureclosure of the ductus arteriosus.• Explain that ketoprofen may increase riskof serious adverse cardiovascular reactions;urge patient to seek immediatemedical attention if signs or symptomsarise, such as chest pain, shortness ofbreath, weakness, and slurring of speech.• Explain that ketoprofen may increase riskof serious adverse GI reactions; stressimportance of seeking immediate medicalattention for such signs and symptoms asepigastric or abdominal pain, indigestion,black or tarry stools, or vomiting blood ormaterial that looks like coffee grounds.• Alert patient to rare but serious skin reactions.Urge him to seek immediate medicalattention for rash, blisters, itching, fever,or other indications of hypersensitivity.ketorolactromethamineToradolClass and CategoryChemical class: Acetic acid derivativeTherapeutic class: Analgesic, antiinflammatoryPregnancy category: CIndications and Dosages To treat moderate to severe painTABLETSAdults ages 16 to 64. Initial: 20 mg as singledose, followed by 10 mg every 4 to 6 hrp.r.n., up to 4 times a day. Maximum:40 mg daily for no more than 5 days.DOSAGE ADJUSTMENT For patients weighingless than 50 kg, elderly patients, andpatients with impaired renal function, initialdose reduced to 10 mg.I.M. INJECTIONAdults ages 16 to 64. Initial: 60 mg as singledose, followed by oral ketorolac if needed;or 30 mg every 6 hr p.r.n. Maximum: 120mg daily for no more than 5 days.DOSAGE ADJUSTMENT For patients weighingless than 50 kg, elderly patients, andpatients with impaired renal function, initialdose reduced to 30 mg, followed by oralketorolac if needed; or 15 mg every 6 hrp.r.n., up to maximum of 60 mg daily forno more than 5 days.I.V. INJECTIONAdults ages 16 to 64. Initial: 30 mg as singledose, followed by oral ketorolac if needed;or 30 mg every 6 hr p.r.n. Maximum:120 mg daily for no more than 5 days.DOSAGE ADJUSTMENT For patients weighingless than 50 kg, elderly patients, andpatients with impaired renal function, initialdose reduced to 15 mg, followed by oralketorolac if needed; or 15 mg every 6 hrp.r.n., up to maximum of 60 mg daily forno more than 5 days.Route Onset Peak DurationP.O. 30–60 min 2–3 hr 5–6 hrI.M., I.V. 30–60 min 1–2 hr 4–6 hrMechanism of ActionBlocks cyclooxygenase, an enzyme neededto synthesize prostaglandins. Prostaglandinsmediate inflammatory response and causelocal vasodilation, swelling, and pain. Theyalso promote pain transmission fromperiphery to spinal cord. By blocking cyclooxygenaseand inhibiting prostaglandins,this NSAID reduces inflammation andrelieves pain.ContraindicationsAdvanced renal impairment or risk of renalimpairment due to volume depletion;before or during surgery if hemostasis iscritical; breast-feeding; cerebrovascularbleeding; concurrent use of aspirin or othersalicylates, other NSAIDs, or probenecid;

hemorrhagic diathesis; history of GI bleeding,GI perforation, or peptic ulcer disease;hemophilia or other bleeding problems,including coagulation or platelet functiondisorders; hypersensitivity to ketorolactromethamine, aspirin, other NSAIDs, ortheir components; incomplete hemostasis;labor and delivery; treatment of perioperativepain during coronary artery bypassgraft surgeryInteractionsDRUGSACE inhibitors, angiotensin II receptorantagonists: Increased risk of renal impairment;decreased effectiveness of these drugsacetaminophen, gold compounds: Increasedrisk of adverse renal effectsamphotericin, penicillamine, and othernephrotoxic drugs: Increased risk or severityof adverse renal reactionsantihypertensives, diuretics: Possibly reducedeffects of these drugsaspirin and other salicylates, other NSAIDs:Additive toxicitycefamandole, cefoperazone, cefotetan:Possibly hypoprothrombinemiacorticosteroids, potassium supplements:Increased risk of gastric ulcers or hemorrhagefurosemide: Decreased effects of furosemideheparin, oral anticoagulants, platelet aggregationinhibitors, thrombolytics: Increasedrisk of GI bleeding and I.M. hematoma formationlithium: Possibly increased blood lithiumlevel and increased risk of lithium toxicitymethotrexate: Possibly methotrexate toxicitynondepolarizing muscle relaxants: Increasedrisk of apneapentoxifylline, selective serotonin reuptakeinhibitors: Increased risk of bleedingplicamycin, valproic acid: Possibly hypoprothrombinemiaand increased risk of bleedingprobenecid: Decreased elimination ofketorolac, increased risk of adverse effectsACTIVITIESalcohol use: Increased risk of adverse GIeffectsAdverse ReactionsCNS: Aseptic meningitis, cerebral hemorrhage,coma, dizziness, drowsiness, headache,psychosis, seizures, strokeketorolac tromethamine 561CV: Edema, fluid retention, hypertensionEENT: Laryngeal edema, stomatitisENDO: HyperglycemiaGI: Abdominal pain; acute pancreatitis;bloating; constipation; diarrhea; diverticulitis;flatulence; GI bleeding, perforation, orulceration; hepatitis; hepatic failure; jaundice;indigestion; nausea; perforation ofstomach or intestines; vomiting; worseningof inflammatory bowel diseaseGU: Interstitial nephritis, renal failure,urine retentionHEME: Agranulocytosis, anemia, aplastic orhemolytic anemia, eosinophilia, leukopenia,lymphadenopathy, pancytopenia, thrombocytopeniaRESP: Bronchospasm, pneumonia, respiratorydepressionSKIN: Diaphoresis, erythema multiforme,exfoliative dermatitis, photosensitivity, pruritus,rash, Stevens-Johnson syndrome,toxic epidermal necrolysis, urticariaOther: Anaphylaxis, angioedema, hyperkalemia,hyponatremia, injection site pain,sepsis, unusual weight gainNursing Considerations• Read ketorolac label carefully. Don’t useI.M. form for I.V. route. Know that ketorolacisn’t for intrathecal or epidural use.• Inject I.M. ketorolac slowly, deep into alarge muscle mass. Monitor site for bleeding,bruising, or hematoma.• Give I.V. injection over at least 15 seconds.• Notify prescriber if pain relief is inadequateor if breakthrough pain occursbetween doses because supplemental dosesof an opioid analgesic may be required.WARNING Monitor liver function testresults. If elevated levels persist or worsen,notify prescriber and expect to stop drug,as ordered, to prevent hepatic impairment.WARNING Monitor patients with a historyof peripheral edema, heart failure, orhypertension for adequate fluid balancebecause drug can promote fluid retentionand worsen these conditions. Assesspatient for dyspnea, edema, unexplainedrapid weight gain, and decreased activitytolerance. Notify prescriber if such symptomsdevelop.• Use ketorolac with extreme caution inpatients with history of ulcer disease or GIbleeding because NSAIDs like ketorolacJKL

562ketorolac tromethamineincrease risk of GI bleeding and ulceration.Use ketorolac in these patients forshortest length of time possible.• Serious GI tract ulceration and bleedingand perforation of stomach or intestinecan occur without warning or symptoms.Elderly patients are at greater risk. To minimizerisk, give drug with food. If GI distressoccurs, withhold drug and notify prescriberimmediately.• Monitor patient with history of inflammatorybowel disease, such as ulcerative colitisor Crohn’s disease, because ketorolacmay worsen these conditions.• Use ketorolac cautiously in patients withhypertension, and monitor blood pressureclosely throughout therapy because drugcan lead to onset of hypertension or worsenexisting hypertension.WARNING Monitor patient closely forthrombotic events including MI andstroke because NSAIDs such as ketorolacincrease risk.• Monitor patient—especially if elderly—forless common but serious adverse GI reactions,including anorexia, constipation,diverticulitis, dysphagia, esophagitis, gastritis,gastroenteritis, gastroesophagealreflux disease, hemorrhoids, hiatal hernia,melena, stomatitis, and vomiting.• Monitor liver function test results becauserarely, elevations may progress to severehepatic reactions, including fatal hepatitis,liver necrosis, and hepatic failure.• Monitor BUN and serum creatinine levelsin patients with heart failure, impairedrenal function, or hepatic dysfunction;those who are taking diuretics or ACEinhibitors; and the elderly because drugmay cause renal failure.• Monitor CBC for decreased hemoglobinand hematocrit because drug may worsenanemia.WARNING In patient who has bone marrowsuppression or is receiving antineoplasticdrug therapy, monitor laboratory results(including WBC) and assess for evidenceof infection because ketorolac has antiinflammatoryand antipyretic actions thatmay mask signs and symptoms, such asfever and pain.• Assess patient’s skin routinely for rash orother evidence of hypersensitivity reactionsbecause ketorolac is an NSAID andmay cause serious skin reactions withoutwarning, even in patients with no historyof NSAID hypersensitivity. Stop drug atfirst sign of reaction, and notify prescriber.PATIENT TEACHING• Instruct patient to take ketorolac tabletswith a meal, a snack, or an antacid to preventstomach upset. Advise him to takedrug with a full glass of water and to stayupright for at least 15 minutes afterward.• Advise patient not to take aspirin, othersalicylates, or other NSAIDs while takingketorolac without consulting prescriber.Urge patient to limit use of acetaminophento only a few days during ketorolactherapy and to notify prescriber of use.• Instruct him to immediately report bloodin urine, easy bruising, itching, rash,swelling, or yellow eyes or skin.• Caution pregnant patient that NSAIDslike ketorolac shouldn’t be taken duringlast trimester because drug may cause prematureclosure of the ductus arteriosus.• Explain that ketorolac may increase risk ofserious adverse cardiovascular reactions;urge patient to seek immediate medicalattention if signs or symptoms arise, suchas chest pain, shortness of breath, weakness,and slurring of speech.• Tell patient that ketorolac also mayincrease risk of serious adverse GI reactions;stress importance of seeking immediatemedical attention if signs or symptomsoccur, such as epigastric or abdominalpain, indigestion, black tarry stools,and vomiting blood or coffee groundmaterial.• Alert patient to the possibility of seriousskin reactions, although rare, occurringwith ketorolac therapy. Urge patient toseek immediate medical attention if signsor symptoms occur, such as a rash, blisters,fever, or other signs of hypersensitivity,such as itching.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Urge patient to avoid alcohol while takingketorolac.• Encourage patient to have dental proceduresperformed before starting drug therapybecause of increased risk of bleeding.• Teach patient proper oral hygiene measures,and encourage him to use a soft-bristledtoothbrush while taking ketorolac.

labetalolhydrochlorideNormodyne, TrandateClass and CategoryChemical class: Benzamine derivativeTherapeutic class: AntihypertensivePregnancy category: CIndications and Dosages To manage hypertensionTABLETSAdults. Initial: 100 mg b.i.d., increased by100 mg b.i.d. as needed and tolerated every2 to 3 days. Maintenance: 200 to 400 mgb.i.d. For severe hypertension, 1.2 to 2.4 gdaily in divided doses b.i.d. or t.i.d. To manage severe hypertension andtreat hypertensive emergenciesI.V. INFUSIONAdults. 200 mg diluted in 160 ml of D 5 Wand infused at 2 mg/min until desiredresponse occurs.I.V. INJECTIONAdults. 20 mg given over 2 min; additionaldoses given in increments of 40 to 80 mgevery 10 min as indicated until desiredresponse occurs. Maximum: 300 mg.Route Onset Peak DurationP.O. 20 min– 1–4 hr 8–24 hr2 hrI.V. 2–5 min 5–15 min 2–4 hrMechanism of ActionSelectively blocks alpha 1 and beta 2 receptorsin vascular smooth muscle and beta 1receptors in heart to reduce peripheral vascularresistance and blood pressure. Potentbeta blockade prevents reflex tachycardia,which commonly occurs when alpha blockersreduce resting heart rate, cardiac output,or stroke volume.IncompatibilitiesDon’t dilute labetalol in sodium bicarbonatesolution or give through same I.V. lineas alkaline drugs, such as furosemide; doingso may cause white precipitate to form.ContraindicationsAsthma, cardiogenic shock, heart failure,labetalol hydrochloride 563hypersensitivity to labetalol or its components,second- or third-degree heart block,severe bradycardiaInteractionsDRUGSallergen immunotherapy, allergenic extractsfor skin testing: Increased risk of serious systemicreaction or anaphylaxisbeta blockers, digoxin: Increased risk ofbradycardiacalcium channel blockers, clonidine, diazoxide,guanabenz, reserpine: Possibly hypotensioncimetidine: Possibly increased labetaloleffectsestrogens, NSAIDs: Possibly reduced antihypertensiveeffect of labetalolgeneral anesthetics: Increased risk of hypotensionand myocardial depressioninsulin, oral antidiabetic drugs: Increasedrisk of hyperglycemianitroglycerin: Possibly hypertensionphenoxybenzamine, phentolamine: Possiblyadditive alpha 1 -blocking effectssympathomimetics with alpha- and betaadrenergiceffects (such as pseudoephedrine):Possibly hypertension, excessive bradycardia,or heart blockxanthines (aminophylline and theophylline):Possibly decreased therapeutic effects ofboth drugsFOODSall food: Increased blood labetalol levelACTIVITIESalcohol use: Increased labetalol effectsAdverse ReactionsCNS: Anxiety, confusion, depression, dizziness,drowsiness, fatigue, paresthesia, syncope,vertigo, weakness, yawningCV: Bradycardia, chest pain, edema, heartblock, heart failure, hypotension, orthostatichypotension, ventricular arrhythmiasEENT: Nasal congestion, taste perversionGI: Elevated liver function test results,hepatic necrosis, hepatitis, indigestion, nausea,vomitingGU: Ejaculation failure, impotenceRESP: Dyspnea, wheezingSKIN: Jaundice, pruritus, rash, scalp tinglingNursing Considerations• During I.V. labetalol use, monitor bloodJKL

564lacosamidepressure according to facility policy, usuallyevery 5 minutes for 30 minutes, thenevery 30 minutes for 2 hours, and thenevery hour for 6 hours.• Keep patient in supine position for3 hours after I.V. administration.WARNING Be aware that labetalol maskscommon signs of shock.• Monitor blood glucose level in diabeticpatient because labetalol may concealsymptoms of hypoglycemia.• Be aware that stopping labetalol tabletsabruptly after long-term therapy couldresult in angina, MI, or ventriculararrhythmias. Expect to taper dosage over2 weeks while monitoring response.PATIENT TEACHING• Advise patient to report confusion, difficultybreathing, rash, slow pulse, andswelling in arms or legs.• Caution patient not to stop drug abruptlybecause doing so could cause angina andrebound hypertension.• Suggest that patient minimize effects oforthostatic hypotension by rising slowly,avoiding sudden position changes, andtaking labetalol at bedtime, if approved byprescriber.• Instruct diabetic patient to check bloodglucose level often and to be alert for signsand symptoms of hypoglycemia.• Inform patient that scalp tingling mayoccur early in treatment but is transient.• Urge patient to avoid alcohol duringlabetalol therapy.lacosamideVimpatClass and CategoryChemical class: Functionalized amino acidTherapeutic class: AnticonvulsantPregnancy category: CIndications and Dosages As adjunct to treat partial-onset seizuresin patients with epilepsyTABLETSAdults and adolescents age 17 and over.Initial: 50 mg b.i.d., increased by 100 mg/day at weekly intervals based on responseand tolerance. Maintenance: 200 to 400 mgdaily.I.V. INFUSIONAdults and adolescents age 17 and over.Initial: 50 mg infused over 30 to 60 minb.i.d., increased by 100 mg/day at weeklyintervals. Maintenance: 200 to 400 mg daily.DOSAGE ADJUSTMENT For patients with creatinineclearance of 30 ml/min/1.73 m 2 orless, maximum is 300 mg daily.Mechanism of ActionMay selectively inactivate voltage-gatedsodium channels, which prevents seizureactivity by stabilizing hyperexcitable neuronalmembranes and inhibiting repetitiveneuronal firing in the brain.ContraindicationsHypersensitivity to lacosamide and its componentsInteractionsDRUGSdrugs that may prolong the QT interval:Possibly further QT-interval prolongationAdverse ReactionsCNS: Asthenia, ataxia, attention deficit,cerebellar syndrome, confusion, depression,dizziness, feeling drunk, fever, headache,hypoaesthesia, impaired balance, irritability,memory impairment, mood alteration,paresthesia, somnolence, suicidal ideation,tremor, vertigoCV: Palpitations, prolonged QT intervalEENT: Blurred vision, diplopia, dry mouth,nystagmus, oral hypoaesthesia, tinnitusGI: Constipation, diarrhea, dyspepsia, nausea,vomitingHEME: Anemia, neutropeniaMS: Dysarthria, muscle spasmsSKIN: Pruritus, rashOther: Delayed multi-organ hypersensitivityreaction; injection site pain, irritation,and erythemaNursing Considerations• Use cautiously in patients with conductionproblems (such as AV block, sick sinussyndrome) and no pacemaker in place orin patients with severe cardiac disease(such as myocardial ischemia, heart failure).Lacosamide may affect conduction.• Use cautiously in patients with diabeticneuropathy or cardiovascular diseasebecause drug may predispose them to atrialfibrillation or flutter.

• Watch patient closely for suicidal tendencies,particularly when therapy starts anddosage changes, because depression mayworsen temporarily during these timesand lead to suicidal ideation.• Be aware that lacosamide therapy shouldbe discontinued gradually over at least1 week to minimize seizure frequency.• Monitor patient closely for hypersensitivityreactions to lacosamide, such as rash,pruritus, and more than one organ abnormality,such as elevated liver enzymes andmyocarditis or pancreatitis.PATIENT TEACHING• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Encourage patient to carry medical identificationthat indicates her diagnosis anddrug therapy.lactuloseAcilac (CAN), Cephulac, Cholac,Chronulac, Constilac, Constulose,Duphalac, Enulose, Evalose, Heptalac,Lactulax (CAN), Laxilose (CAN),PMS-Lactulose (CAN), PortalacClass and CategoryChemical: Synthetic disaccharide sugarTherapeutic: Ammonia reducer, laxativePregnancy category: BIndications and Dosages To treat constipationPOWDER, SYRUPAdults. Initial: 10 to 20 g daily, increasedp.r.n. Maximum: 40 g daily. To prevent and treat hepatic encephalopathyPOWDER, SYRUPAdults. Initial: 20 to 30 g t.i.d. or q.i.d. untiltwo or three soft stools occur daily. Usual:60 to 100 g daily in divided doses. For acuteepisodes, 20 to 30 g every 2 hr initially toachieve rapid laxative effect and thenreduced to usual dosage.RETENTION ENEMAAdults. 200 g (300 ml) diluted in 700 mlwater or normal saline solution and givenevery 4 to 6 hr, as needed.Nursing Considerations• When giving lactulose by retention enema,use a rectal tube with a balloon to helppatient retain enema for 30 to 60 minutes.If not retained for at least 30 minutes,repeat dose. Be sure to deflate balloon andremove rectal tube after completingadministration.• Expect to periodically check serum electrolytelevels of elderly or debilitatedpatient who uses oral drug longer than6 months.• Monitor blood ammonia level in patientwith hepatic encephalopathy. Also watchfor dehydration, hypernatremia, andhypokalemia when giving higher lactulosedoses to treat this condition.• Monitor diabetic patient for hyperglylactulose565Mechanism of ActionArrives unchanged in the colon, where itbreaks down into lactic acid and smallamounts of formic and acetic acids, acidifyingfecal contents. Acidification leads toincreased osmotic pressure in the colon,which, in turn, increases stool water contentand softens stool.Also, lactulose makes intestinal contentsmore acidic than blood. This preventsammonia diffusion from intestine intoblood, as occurs in hepatic encephalopathy.The trapped ammonia is converted intoammonia ions and, by lactulose’s catharticeffect, is expelled in feces with othernitrogenous wastes.Route Onset Peak DurationP.O. 24–48 hr Unknown UnknownContraindicationsHypersensitivity to lactulose or its components,low-galactose dietInteractionsDRUGSantacids, antibiotics (especially oral neomycin),other laxatives: Decreased effectivenessof lactuloseAdverse ReactionsGI: Abdominal cramps and distention,diarrhea, flatulenceENDO: HyperglycemiaOther: Hypernatremia, hypokalemia, hypovolemiaJKL

566lamotriginecemia because lactulose contains galactoseand lactose.• Plan to replace fluids if frequent bowelmovements cause hypovolemia.PATIENT TEACHING• Advise patient to take lactulose with foodor dilute with juice to reduce sweet taste.• Direct patient not to use other laxativeswhile taking lactulose.• Instruct patient to report abdominal distentionor severe diarrhea.• Advise diabetic patient to check blood glucoselevel often and to report hyperglycemia.• Instruct patient to increase fluid intake iffrequent bowel movements occur.• Teach patient with chronic constipationthe importance of exercising, increasingfiber in diet, and increasing fluid intake.• Inform patient that because oral lactulosemust reach the colon to work, bowelmovement may not occur for 24 to48 hours after taking drug.lamotrigineLamictalClass and CategoryChemical class: PhenyltriazineTherapeutic class: AnticonvulsantPregnancy category: CIndications and Dosages As adjunct to treat partial seizures; totreat generalized seizures of Lennox-Gastaut syndrome; to treat primarygeneralized tonic-clonic seizuresCHEWABLE TABLETS, TABLETSAdults and children age 12 and over takingvalproate. 25 mg every other day for 2 wk,followed by 25 mg once daily for 2 wk.Increased by 25 to 50 mg every 1 to 2 wk, ifneeded. Maintenance: 100 to 400 mg daily.Children ages 2 to 12 taking valproate.0.15 mg/kg daily as a single dose or individed doses b.i.d. for 2 wk and then0.3 mg/kg daily as single dose or in divideddoses b.i.d. for next 2 wk. Increased by0.3 mg/kg every 1 to 2 wk, if needed, toreach maintenance dosage. Maintenance:1 to 5 mg/kg daily as single dose or individed doses b.i.d. Maximum: 200 mgdaily.Adults and children age 12 and over takingan antiepileptic drug other than carbamazepine,phenytoin, phenobarbital,primidone, or valproate. 25 mg once dailyfor 2 wk, followed by 50 mg once daily for2 wk. Increased by 50 mg every 1 to 2 wk, ifneeded. Maintenance: 225 to 375 mg dailyin 2 divided doses b.i.d. Maximum: 400 mgdaily.Children ages 2 to 12 taking an an ant i-epileptic drug other than carbamazepine,phenytoin, phenobarbital, primidone, orvalproate. 0.3 mg/kg daily in 1 or 2 divideddoses for 2 wk; followed by 0.6 mg/kg dailyin 2 divided doses for 2 wk. Increased by0.6 mg/kg daily every 1 to 2 wk, if needed.Maintenance: 4.5 to 7.5 mg/kg daily in2 divided doses. Maximum: 300 mg dailyAdults and children age 12 and over takingcarbamazepine, phenytoin, phenobarbital,or primidone but not valproate. 50 mgonce daily for 2 wk and then 100 mg dailyin divided doses b.i.d. for 2 wk. Increasedby 100 mg every 1 to 2 wk, if needed.Maintenance: 300 to 500 mg daily in divideddoses b.i.d. Maximum: 700 mg daily individed doses b.i.d.Children ages 2 to 12 taking carbamazepine,phenytoin, phenobarbital, or primidonebut not valproate. 0.6 mg/kg daily individed doses b.i.d. for 2 wk and then 1.2mg/kg daily in divided doses b.i.d. for 2 wk.Increased by 1.2 mg/kg every 1 to 2 wk, ifneeded to reach maintenance dosage.Maintenance: 5 to 15 mg/kg daily in divideddoses b.i.d. Maximum: 400 mg daily. To treat partial seizures after conversionfrom carbamazepine, phenytoin, phenobarbital,primidone, or valproateCHEWABLE TABLETS, TABLETSAdults and adolescents age 16 and overconverting from carbamazepine, phenytoin,phenobarbital, or primidone. 50 mgonce daily for 2 wk, followed by 100 mgonce daily for next 2 wk. Increased by100 mg daily every 1 to 2 wk (while continuingto take carbamazepine, phenytoin,phenobarbital, or primidone), until usualmaintenance dosage—500 mg daily individed doses b.i.d.—is achieved. Then carbamazepine,phenytoin, phenobarbital, orprimidone dosage tapered in 20% decrementsweekly over 4 wk and then discontinued.

Adults and adolescents age 16 and overconverting from valproate. 25 mg everyother day for 2 wk followed by 25 mg oncedaily for 2 wk. Then increased by 25 to50 mg daily every 1 to 2 wk until dosage of200 mg daily is achieved. At this time valproatedosage decreased to 500 mg daily bydecrements no greater than 500 mg dailyevery wk and then maintained at 500 mgdaily for 1 wk. After completion of week,lamotrigine dosage increased to 300 mgdaily and maintained for 1 wk while valproatedosage decreased to 250 mg dailyand maintained for 1 wk. Then lamotriginedosage increased by 100 mg daily every wkto achieve maintenance dose of 500 mgdaily. Once achieved, valproate therapy isdiscontinued. As maintenance therapy for bipolar 1disorder to delay occurrence of moodepisodes (depression, mania, hypomania,mixed episodes)CHEWABLE TABLETS, TABLETSAdults not taking carbamazepine, phenytoin,phenobarbital, primidone, rifampin,or valproate. 25 mg once daily for 2 wk,followed by 50 mg once daily for 2 wk, followedby 100 mg once daily for 1 wk andthen increased to 200 mg once daily asmaintenance dose. Maximum: 200 mgdaily.Adults taking valproate. 25 mg every otherday for 2 wk, followed by 25 mg once dailyfor 2 wk, followed by 50 mg once daily for1 wk, and then increased to 100 mg oncedaily as maintenance dose.Adults taking carbamazepine, phenytoin,phenobarbital, primidone, or rifampin,but not valproate. 50 mg once daily for2 wk followed by 100 mg once daily individed doses for 2 wk, followed by 200 mgonce daily in divided doses for 1 wk andthen increased to 300 mg daily in divideddoses for 1 wk and then increased to400 mg daily in divided doses as maintenancedose.DOSAGE ADJUSTMENT For patient starting orstopping estrogen-containing oral contraceptives,lamotrigine dosage may need to beadjusted on individual basis. For patientwith moderate to severe liver impairmentwithout ascites, dosage reduced by 25%. Forpatient with severe liver impairment withascites, dosage reduced by 50%.lamotrigine 567Mechanism of ActionMay stabilize neuron membranes by blockingtheir sodium channels and inhibitingrelease of excitatory neurotransmitters,such as glutamate and aspartate, throughthese channels. By blocking the release ofneurotransmitters, lamotrigine inhibits thespread of seizure activity in the brain andreduces seizure frequency.Route Onset Peak DurationP.O. Days to Unknown UnknownwksContraindicationsHypersensitivity to lamotrigine or its componentsInteractionsDRUGSacetaminophen (long-term use): Possiblydecreased blood lamotrigine levelcarbamazepine: Decreased blood lamotriginelevel; possibly increased risk of dizziness,diplopia, ataxia, and blurred visionfolate inhibitors, such as co-trimoxazoleand methotrexate: Increased blood lamotrigineleveloral contraceptives: Decreased blood lamotriginelevel during 3 weeks of active hormonaltherapy and increased blood lamotriginelevel during 1 week of inactive hormonaltherapy; possibly reduced effectivenessof oral contraceptivesoxcarbazepine: Possibly increased risk ofheadache, dizziness, nausea, and somnolencephenobarbital, phenytoin, primidone:Decreased blood lamotrigine level, possiblyincreased CNS depressiontopiramate: Increased topiramate levelvalproic acid: Increased lamotrigine level,decreased lamotrigine clearance, decreasedblood valproic acid levelACTIVITIESalcohol use: Possibly increased CNS depressionAdverse ReactionsCNS: Amnesia, anxiety, ataxia, confusion,depression, dizziness, drowsiness, emotionallability, fever, headache, increased seizureactivity, lack of coordination, suicidalideationJKL

568lanreotideCV: Chest painEENT: Blurred vision, diplopia, dry mouth,nystagmusGI: Abdominal pain, anorexia, constipation,diarrhea, hepatic failure, vomitingHEME: Anemia, aplastic anemia, disseminatedintravascular coagulation, eosinophilia,leukopenia, neutropenia, pancytopenia,pure red cell aplasia, thrombocytopeniaSKIN: Petechiae, photosensitivity, pruritus,rash, Stevens-Johnson syndrome, toxic epidermalnecrolysisOther: Acute multiorgan failure, angioedema,flulike symptoms, lymphadenopathyNursing Considerations• Use cautiously in patients with illnessesthat could affect metabolism or eliminationof lamotrigine, such as renal, hepatic,or cardiac functional impairment.WARNING Lamotrigine may cause potentiallylife-threatening rash. Notify prescriberat first sign, and expect to discontinuedrug. Lamotrigine therapy shouldn’tbe restarted after rash subsides.• Monitor patient for adverse reactions,especially suicidal thoughts, at start oftherapy and with each dosage increase.• Monitor patient for seizure activity duringlamotrigine therapy.• Stopping lamotrigine abruptly mayincrease seizure activity. Expect to taperdosage over at least 2 weeks, even fortreatment of bipolar disorder.PATIENT TEACHING• Advise patient to take lamotrigine exactlyas prescribed and not to stop abruptlybecause seizure activity may increase.• Advise patient to notify prescriber immediatelyif rash occurs.• Instruct patient to report increased seizureactivity, vision changes, and vomiting.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to avoid direct sunlight andto wear protective clothing to minimizerisk of photosensitivity.• Instruct patient to wear or carry medicalidentification stating that she takes ananticonvulsant.• Caution patient or caregiver about possibilityof suicidal thoughts, especially whentherapy begins or dosage changes.• Tell female patient to notify prescriber ifshe becomes pregnant, is consideringpregnancy, or starts or stops an oral hormonalcontraceptive or other female hormonalpreparation.• Urge woman who becomes pregnant whiletaking lamotrigine to enroll in the NorthAmerican antiepileptic drug pregnancyregistry by calling 1-888-233-2334.Explain that registry is collecting informationabout safety of antiepileptic drugsduring pregnancy.lanreotideSomatulin DepotClass and CategoryChemical class: Somatostatin analogTherapeutic class: Growth inhibitorPregnancy category: CIndications and Dosages To treat acromegaly in patients with aninadequate response to or who cannot betreated with surgery or radiationSUBCUTANEOUS INJECTIONAdults. Initial: 90 mg every 4 wk for 3 mo;then dosage adjusted according to growthhormone (GH) level. If GH level is less than1 nanogram/ml, dosage reduced to 60 mgevery 4 wk. If GH level is 1 to 2.5 nanograms/ml,dosage is 90 mg every 4 wk. IfGH level is above 2.5 nanograms/ml,dosage increased to 120 mg every 4 wk.DOSAGE ADJUSTMENT For patient withmoderate to severe renal or hepatic failure,initial dose reduced to 60 mg every 4 wk for3 mo; then adjusted according to GH level.Mechanism of ActionReduces growth hormone (GH) and insulingrowth factor-1 levels, allowing for normalizationof these hormones in patients withacromegaly. An octapeptide analog of naturalsomatostatin, lanreotide has a highaffinity for human somatostatin receptors 2and 5. Activity at these receptors may beresponsible for GH inhibition.ContraindicationsHypersensitivity to lanreotide or its componentsInteractionsDRUGSbeta blockers, calcium channel blockers:

Additive depressive effects on heart ratebromocriptine: Possibly increased action ofbromocriptinecyclosporine: Possibly decreased cyclosporineeffectivenessdrugs metabolized by the liver, quinidine, terfenadine:Possibly increased blood levels ofthese drugsinsulin, oral antidiabetic drugs: Possiblydecreased effectiveness of these drugsoral drugs: Possibly decreased absorption ofthese drugsAdverse ReactionsCNS: HeadacheCV: Bradycardia, hypertensionENDO: Hyperglycemia, hypoglycemiaGI: Abdominal pain, cholelithiasis, constipation,diarrhea, flatulence, loose stools,nausea, vomitingHEME: AnemiaMS: ArthralgiaSKIN: Erythema, pruritusOther: Injection site reactions (induration,pain, pruritus, redness, swelling), weightlossNursing Considerations• Check patient’s blood glucose level beforestarting lanreotide therapy and wheneverdosage changes because drug may causehypoglycemia or hyperglycemia.• Inject drug deep into subcutaneous tissueof upper, outer quadrant of buttock. Donot fold the skin. Insert needle perpendicularto the skin, rapidly and to its fulllength. Alternate between left and rightbuttocks.• If patient has underlying cardiovasculardisease, watch for changes in heart rateand blood pressure because drug maycause bradycardia or hypertension.• Monitor patient’s GH and insulin growthfactor-1 levels, as ordered, to assess lanreotide’seffects.PATIENT TEACHING• Inform patient that lanreotide will begiven as a subcutaneous injection every4 weeks and that it may cause discomfortat the site.• Tell patient that periodic blood tests willbe needed to monitor lanreotide’s effectiveness.• Instruct diabetic patient to monitor bloodglucose level closely.lansoprazole 569lansoprazolePrevacid, Prevacid I.V., PrevacidSoluTabdexlansoprazoleKapidexClass and CategoryChemical class: Substituted benzimidazoleTherapeutic class: Antisecretory, antiulcerPregnancy category: BIndications and Dosages To treat duodenal ulcers and maintainhealed duodenal ulcersDELAYED-RELEASE CAPSULES, DELAYED-RELEASESUSPENSION, DELAYED-RELEASE ORALLYDISINTEGRATING TABLETSAdults. 15 to 30 mg daily before morningmeal for 4 wk. Maximum: 30 mg daily. To treat gastric ulcersDELAYED-RELEASE CAPSULES, DELAYED-RELEASESUSPENSION, DELAYED-RELEASE ORALLYDISINTEGRATING TABLETSAdults. 15 to 30 mg daily before morningmeal for up to 8 wk. To treat gastroesophageal reflux diseaseDELAYED-RELEASE CAPSULES, DELAYED-RELEASESUSPENSION, DELAYED-RELEASE ORALLYDISINTEGRATING TABLETSAdults. 15 mg daily before morning mealfor up to 8 wk. To treat non-erosive gastroesophagealreflux diseaseCAPSULES (DEXLANSOPRAZOLE)Adults. 30 mg once daily for 4 wk. To heal all grades of erosive esophagitisCAPSULES (DEXLANSOPRAZOLE)Adults. 60 mg once daily for up to 8 wk. To maintain healed erosive esophagitisCAPSULES (DEXLANSOPRAZOLE)Adults. 30 mg once daily. To treat erosive esophagitisDELAYED-RELEASE CAPSULES, DELAYED-RELEASESUSPENSION, DELAYED-RELEASE ORALLYDISINTEGRATING TABLETSAdults. Initial: 30 mg daily before morningmeal for up to 8 wk. Continued another8 wk if indicated. Maintenance: 15 mg daily. To treat erosive esophagitis short-term(up to 7 days) in patients unable to takeoral medicationI.V. INFUSIONJKL

570Nursing Considerations• Give lansoprazole before meals. Antacidsmay be given as well, if needed.• If patient is prescribed capsules and hastrouble swallowing them, open and sprinklegranules on applesauce, Ensure, pudlansoprazoleAdults. 30 mg daily infused over 30 min forup to 7 days. To treat pathological hypersecretoryconditions, such as Zollinger-EllisonsyndromeDELAYED-RELEASE CAPSULES, DELAYED-RELEASESUSPENSION, DELAYED-RELEASE ORALLYDISINTEGRATING TABLETSAdults. Initial: 60 mg daily before morningmeal, increased as needed according topatient’s condition. Doses exceeding120 mg/day administered in divided doses.Maximum: 180 mg daily. To eradicate Helicobacter pylori andreduce risk of duodenal ulcer recurrenceDELAYED-RELEASE CAPSULES, DELAYED-RELEASESUSPENSION, DELAYED-RELEASE ORALLYDISINTEGRATING TABLETSAdults. 30 mg plus 1 g amoxicillin and500 mg clarithromycin every 12 hr beforemeals for 10 to 14 days. Or, 30 mg plus 1 gamoxicillin t.i.d. before meals for 14 days. To treat symptomatic pediatric gastroesophagealreflux diseaseDELAYED-RELEASE CAPSULES, DELAYED-RELEASESUSPENSION, DELAYED-RELEASE ORALLYDISINTEGRATING TABLETSChildren ages 12 to 17. 15 mg daily for upto 8 wk.Children ages 1 to 11 weighing 30 kg (66lb) or less. 15 mg daily for up to 12 wk.Children ages 1 to 11 weighing more than30 kg. 30 mg daily for up to 12 wk. To treat symptomatic pediatric erosiveesophagitisDELAYED-RELEASE CAPSULES, DELAYED-RELEASESUSPENSION, DELAYED-RELEASE ORALLYDISINTEGRATING TABLETSChildren ages 12 to 17. 30 mg daily for upto 8 wk.Children ages 1 to 11 weighing 30 kg (66lb) or less. 15 mg daily for up to 12 wk.Children ages 1 to 11 weighing more than30 kg. 30 mg daily for up to 12 wk. To treat frequent heartburnE.R. CAPSULES (PREVACID 24-HR)Adults. 1 capsule daily for 14 days. Mayrepeat course every 4 months.Route Onset Peak DurationP.O. 1–3 hr Unknown Over 24 hrMechanism of ActionBinds to and inactivates the hydrogenpotassiumadenosine triphosphate enzymesystem (also called the proton pump) ingastric parietal cells. This action blocks thefinal step of gastric acid production.IncompatibilitiesDon’t give any other drugs with parenterallansoprazole, and dilute only with solutionsrecommended by manufacturer (sterilewater for initial reconstitution and normalsaline solution, lactated Ringer’s solution,or D 5 W for further dilution).ContraindicationsHypersensitivity to lansoprazole or its componentsInteractionsDRUGSampicillin, digoxin, iron salts, ketoconazole,other drugs that depend on low gastric pH forbioavailability: Inhibited absorption ofthese drugsatazanavir: Decreased blood level and possiblyreduced effectiveness of atazanavirsucralfate: Delayed lansoprazole absorptiontheophylline: Slightly decreased blood theophyllinelevelwarfarin: Increased INR and PT with possiblyincreased risk of serious bleedingAdverse ReactionsCNS: Dizziness, headacheGI: Abdominal pain, anorexia, diarrhea,elevated liver enzymes, hepatotoxicity,increased appetite, nausea, pancreatitis,pseudomembranous colitis, vomitingGU: Interstitial nephritis, urine retentionHEME: Agranulocytosis, aplastic anemia,decreased hemoglobin, hemolytic anemia,leukopenia, neutropenia, pancytopenia,thrombocytopenia, thrombotic thrombocytopenicpurpuraMS: Arthralgia, myositisRESP: Upper respiratory tract infectionSKIN: Erythema multiforme, pruritus,rash, Stevens-Johnson syndrome, toxic epidermalnecrolysisOther: Anaphylaxis, hyperkalemia, injectionsite reaction

ding, cottage cheese, yogurt, or strainedpears. Don’t crush granules. Have patientswallow mixture immediately. Or, emptygranules into 2 ounces apple, orange, ortomato juice; mix quickly, and havepatient swallow immediately. Then add 2or more ounces of juice to glass and havepatient drink immediately to ensure fulldose.• For delayed-release orally disintegratingtablets, place tablet on patient’s tongueand let it dissolve, with or without water,until patient can swallow particles.• For patient with nasogastric tube, don’t useoral suspension. Instead use capsules ororally disintegrating tablets. For capsuleform, open capsule, mix granules in 40 mlapple juice only, and inject through tube.Then flush tube with apple juice only. Fordisintegrating tablets, place tablet in syringeand draw up 4 ml (for 15-mg tablet) or 8ml (for 30-mg tablet) of water. Shake gently,and inject through tube within 15 minutes.Then refill syringe with 5 ml of water,shake gently, and inject through tube.• For delayed-release oral suspension, emptypacket contents into a container with2 tablespoons water (no other liquids orfoods), stir well, and have patient drinkimmediately. If any particles remain incontainer, add more water, stir, and havepatient drink again immediately.• Reconstitute parenteral form by injecting5 ml sterile water into 30-mg drug vial.Mix gently until powder dissolves. Usewithin 1 hour. After reconstitution, dilutewith 50 ml normal saline solution, lactatedRinger’s solution, or D 5 W. Give within12 hours if mixed with D 5 W or 24 hours ifmixed with normal saline solution or lactatedRinger’s solution.• Give parenteral drug with a filter followingmanufacturer’s guidelines. Change filterevery 24 hours. Give as I.V. infusion over30 minutes. Flush line with normal salinesolution, lactated Ringer’s solution, orD 5 W before and after giving lansoprazole.• Expect to give lansoprazole with antibioticsbecause decreased gastric acid secretionhelps antibiotics eradicate H. pylori.• If lansoprazole is given with antibiotics,watch for diarrhea from possible pseudomembranouscolitis caused by Clostridiumdifficile. If diarrhea occurs, notify prescriberand expect to withhold drug andtreat with fluids, electrolytes, protein, andan antibiotic effective against C. difficile.PATIENT TEACHING• Urge patient to take drug exactly as prescribed,usually before a meal (preferablybreakfast) to decrease gastric acid output.• If patient has trouble swallowing dexlansoprazolecapsules, tell her to open themand sprinkle granules on 1 tablespoon ofapplesauce and swallow immediately. Ifpatient has trouble swallowing lansoprazolecapsules, tell her to open them andsprinkle granules on applesauce, Ensure,pudding, cottage cheese, yogurt, orstrained pears and to swallow immediatelywithout chewing. Or, she may empty granulesinto 2 ounces of apple, orange, ortomato juice, mix quickly, and swallowimmediately. Tell her to refill glass with2 or more ounces of juice and drinkimmediately to ensure a full dose.• If patient was prescribed delayed-releaseorally disintegrating tablets, tell her to placetablet on tongue, let it dissolve, and thenswallow particles with or without water.• If patient was prescribed delayed-releaseoral suspension, tell her to empty contentsof packet into a container with 2 tablespoonsof water (no other liquids orfoods), stir well, and drink immediately. Ifparticles remain in container, she shouldadd water, stir, and drink immediately.• Inform patient that she may take antacidswith lansoprazole.• Advise patient to report severe headache,or worsening of symptoms immediately toprescriber.• Urge patient to tell prescriber about diarrheathat’s severe or lasts longer than3 days. Remind patient that watery orbloody stools can occur 2 or more monthsafter antibiotic therapy and can be serious,requiring prompt treatment.lanthanumcarbonateFosrenollanthanum carbonate 571Class and CategoryChemical class: Rare earth elementJKL

572leflunomideMechanism of ActionDuring digestion, phosphate is releasedinto the upper GI tract (below left) andabsorbed into the bloodstream, increasingserum phosphate levels. In patientswith end-stage renal disease, however,inefficient phosphate clearance from theblood leads to abnormally elevated levels.Lanthanum dissociates in the upperGI tract, releasing ions that attach tounbound phosphate to form an insolublecomplex (below right). Unabsorbed intothe bloodstream, these altered phosphatemolecules can’t elevate the patient’sserum phosphate level.Duodenum cross sectionDuodenum cross sectionPhosphatemoleculePhosphatemoleculeVilliInsolublephosphateVilliReleasedlanthanumionTherapeutic class: Phosphate binderPregnancy category: CIndications and Dosages To reduce serum phosphate levels inpatients with end-stage renal diseaseTABLETSAdults. Initial: 250 to 500 mg t.i.d. withmeals; increased, as needed, by 750 mgdaily every 2 to 3 wk until acceptable serumphosphate level is reached.ContraindicationsBowel obstruction, hypersensitivity to lanthanumcarbonate or any of its components,hypophosphatemiaAdverse ReactionsCNS: HeadacheCV: HypotensionEENT: RhinitisENDO: HypercalcemiaGI: Abdominal pain, constipation, diarrhea,nausea, vomitingGU: Dialysis graft occlusionRESP: BronchitisNursing Considerations• Use lanthanum carbonate cautiously inpatients with acute peptic ulcer, ulcerativecolitis, Crohn’s disease, or bowel obstructionbecause drug effects are unknown inthese patients.• Monitor the patient’s serum phosphatelevels, as ordered, especially during dosageadjustment, to determine effectiveness oflanthanum carbonate therapy. Serumphosphate levels should fall below6.0 mg/dl.PATIENT TEACHING• Instruct patient to take lanthanum carbonatewith or immediately after meals.• Advise patient to chew each tablet thoroughlybefore swallowing. If patient hastrouble chewing tablets, tell her she maycrush them.• Urge patient to take drug exactly as prescribed,and explain that it may take weeksto reach a desired serum phosphate level.leflunomideAravaClass and CategoryChemical class: MalonitrilamideimmunomodulatorTherapeutic class: AntirheumaticPregnancy category: X

Indications and Dosages To relieve symptoms of active rheumatoidarthritis, improve physical functionand slow disease progressionTABLETSAdults. Loading: 100 mg daily for 3 days.Maintenance: 20 mg daily, reduced to 10 mgdaily if poorly tolerated. Maximum: 20 mg/day.Mechanism of ActionInhibits dihydroorotate dehydrogenase, theenzyme in autoimmune process that leadsto rheumatoid arthritis. With this action,leflunomide relieves inflammation and preventsalteration of the autoimmune process.ContraindicationsHypersensitivity to leflunomide or its components,pregnancyInteractionsDRUGSactivated charcoal, cholestyramine:Decreased blood leflunomide levellive-virus vaccines: Possibly adverse reactionsto vaccines caused by leflunomideinducedimmunosuppressionmethotrexate: Risk of hepatotoxicityNSAIDs: Possibly impaired NSAIDmetabolismrifampin, tolbutamide: Increased bloodleflunomide levelAdverse ReactionsCNS: Anxiety, dizziness, drowsiness, fatigue,fever, headache, paresthesiaCV: Chest pain, hypertension, palpitations,tachycardiaEENT: Blurred vision, conjunctivitis, drymouth, epistaxis, mouth ulcers, pharyngitis,rhinitis, sinusitisGI: Abdominal pain, cholestasis, constipation,diarrhea, elevated liver function testresults, flatulence, gastritis, gastroenteritis,hepatic failure, hepatitis, nausea, vomitingGU: UTIHEME: Agranulocytosis, anemia, pancytopenia,thrombocytopeniaMS: Back pain, synovitis, tendinitisRESP: Asthma, bronchitis, dyspnea, interstitiallung disease, respiratory tract infectionSKIN: Alopecia (transient), erythematousrash, jaundice, pruritus, urticariaOther: Sepsis, weight lossleflunomide 573Nursing Considerations• Leflunomide isn’t recommended forpatients with severe immunodeficiency,bone marrow dysplasia, or severe, uncontrolledinfections because of its immunosuppressanteffect.• Test patient for latent tuberculosis beforestarting leflunomide. If positive, expectstandard medical treatment to be givenbefore leflunomide therapy starts.• Obtain baseline blood pressure beforestarting leflunomide, and monitor periodicallythereafter because drug may causehypertension.• Assess liver enzyme (ALT and AST) levelsat start of therapy, monthly during first6 months, and if stable, every 6 to 8 weeksthereafter, as ordered. Expect to stop drugif hepatic dysfunction develops.• Obtain platelet count, WBC count, andhemoglobin or hematocrit at start of therapyand every 4 to 8 weeks thereafter, asordered.• Notify prescriber if patient develops seriousinfection because drug may need to beinterrupted and cholestyramine or charcoalgiven to eliminate drug rapidly.WARNING Monitor patient’s respiratoryfunction closely because drug may causeinterstitial lung disease that could becomelife-threatening. If patient develops acough and dyspnea, notify prescriber;drug may need to be stopped, and patientmay need cholestyramine or charcoal toeliminate drug rapidly.PATIENT TEACHING• Advise patient that leflunomide doesn’tcure arthritis but may relieve its symptomsand improve physical function.• Inform patient that reversible hair lossmay occur.• Caution woman of childbearing potentialnot to become pregnant while taking drugbecause of the high risk of birth defects.•Instruct patient to report signs of hepatotoxicity,such as mouth ulcers, unusualbleeding or bruising, and yellow skin oreyes.• Tell patient to report signs of respiratorydysfunction, such as cough and dyspnea.• Advise patient to avoid live vaccines duringleflunomide therapy.• Instruct patient to notify prescriber if shedevelops an infection.JKL

574Nursing Considerations• Be aware that patients with heparininducedthrombocytopenia have lowplatelet counts, which can lead to severebleeding and even death. Lepirudin worksto prevent clotting without further reducingplatelet count.• To reconstitute, mix lepirudin with normalsaline solution or sterile water forinjection. Warm solution to room temperaturebefore giving.• For I.V. bolus delivery, reconstitute 50 mgdrug with 1 ml sterile water for injectionor sodium chloride for injection. Thenfurther dilute by withdrawing reconstitutedsolution into 10-ml syringe and addingenough sterile water for injection, sodiumchloride for injection, or D 5 W to producea total volume of 10 ml, or 5 mg of lepirudin/ml.Administer prescribed doseover 15 to 20 seconds.• For I.V. infusion, reconstitute 2 vials ofdrug and transfer to infusion bag thatcontains 250 or 500 ml normal salinesolution or D 5 W. Concentration will be0.4 or 0.2 mg/ml.• Adjust infusion rate as prescribed, accordingto patient’s APTT ratio, which is APTTdivided by a control value. Target APTTratio during treatment is 1.5 to 2.5.• Expect to obtain first APTT 4 hours afterstarting infusion and to obtain follow-upAPTT daily (more often for patients withhepatic or renal impairment).• Stop infusion for 2 hours, as ordered, ifAPTT is above target range. Expect todecrease infusion rate by half when relepirudinlepirudinRefludanClass and CategoryChemical class: Yeast-derived recombinantform of hirudinTherapeutic class: AnticoagulantPregnancy category: BIndications and Dosages To prevent thromboembolic complicationsin patients with heparin-inducedthrombocytopenia and associatedthromboembolic diseaseI.V. INFUSION AND INJECTIONAdults. Initial: 0.4 mg/kg, but no more than44 mg, given by bolus over 15 to 20 sec, followedby continuous infusion of 0.15 mg/kg/hr for 2 to 10 days or longer, as indicated.Maximum: 0.21 mg/kg/hr.DOSAGE ADJUSTMENT For patients withrenal insufficiency, bolus dose decreased to0.2 mg/kg and infusion rate adjusted as follows:for creatinine clearance of 45 to 60 ml/min/1.73 m 2 , 50% of standard infusionrate; for clearance of 30 to 44 ml/min/1.73 m 2 , 30% of standard infusion rate; forclearance of 15 to 29 ml/min/1.73 m 2 , 15%of standard infusion rate; for clearance lessthan 15 ml/min/1.73 m 2 , expect drug to bestopped.Route Onset Peak DurationI.V. Immediate Unknown UnknownMechanism of ActionForms a tight bond with thrombin, neutralizingthis enzyme’s actions, even when theenzyme is trapped within clots. One moleculeof lepirudin binds with one moleculeof thrombin. Thrombin causes fibrinogento convert to fibrin, which is essential forclot formation.IncompatibilitiesDon’t mix lepirudin in same I.V. line withother drugs.ContraindicationsHypersensitivity to lepirudin or other hirudinsInteractionsDRUGSoral anticoagulants, platelet aggregationinhibitors, thrombolytics: Increased risk ofbleeding complications and enhancedeffects of lepirudinAdverse ReactionsCNS: Chills, fever, intracranial hemorrhageCV: Heart failureEENT: EpistaxisGI: GI or rectal bleeding, hepatic dysfunctionGU: Hematuria, vaginal bleedingHEME: Anemia, easy bruising, hematomaRESP: Hemoptysis, pneumoniaSKIN: Excessive bleeding from wounds,rash, pruritus, urticariaOther: Anaphylaxis, injection site bleeding,sepsis

starting. If APTT is below target range,expect to increase rate in 20% incrementsand recheck APTT in 4 hours.• Avoid I.M. injections or needle sticks duringlepirudin therapy to minimize risk ofhematoma.• Observe I.M. injection sites, I.V. infusionsites, and wounds for bleeding.• Monitor patient for ecchymoses on armsand legs, epistaxis, hematemesis, hematuria,melena, and vaginal bleeding.• Be aware that when patient is scheduled toswitch to an oral anticoagulant, lepirudindosage may need to be tapered over a periodof days, as ordered, until APTT is justabove 1.5, before starting oral anticoagulant.In addition, INR and PT will need tobe monitored closely, as ordered, to preventbleeding adverse effects.PATIENT TEACHING• Tell patient to report unexpected bleeding,such as blood in urine, easy bruising, nosebleeds,tarry stools, and vaginal bleeding.• Advise patient to avoid bumping arms andlegs because of the risk of bruising.• Instruct patient to use electric razor andsoft toothbrush to reduce risk of bleeding.leuprolide acetateEligard 7.5 mg, Eligard 22.5 mg,Lupron, Lupron Depot, Lupron Depot-3 Month 11.25 mg, Lupron Depot-3Month 22.5 mg, Lupron Depot-4Month 30 mg, Lupron Depot-Ped,Lupron-3 Month SR Depot 22.5 mgClass and CategoryChemical class: Synthetic peptidegonadotropin-releasing hormone analogueTherapeutic class: Antianemic, antiendometrionicagent, antineoplastic,gonadotropin inhibitorPregnancy category: XIndications and Dosages To treat prostate cancerI.M. INJECTION (LEUPROLIDE ACETATE FORINJECTION)Adults. 7.5 mg/mo, 22.5 mg every 3 mo, or45 mg every 4 mo.SUBCUTANEOUS INJECTION (LEUPROLIDE ACETATEFOR INJECTABLE SUSPENSION)Adults. 7.5 mg/mo.leuprolide acetate 575SUBCUTANEOUS INJECTION (LEUPROLIDE ACETATEINJECTION)Adults. 1 mg daily. To provide palliative treatment ofadvanced prostate cancerSUBCUTANEOUS INJECTION (ELIGARD FORINJECTABLE SUSPENSION)Adults. 7.5 mg/mo. 22.5 mg every 3 mo, or45 mg every 6 mo. To treat precocious central pubertyI.M. INJECTION (LEUPROLIDE ACETATE FORINJECTION)Children weighing more than 37.5 kg(83 lb). Initial: 15 mg every 4 wk.Maintenance: Dosage increased as neededin increments of 3.75 mg every 4 wk.Maximum: 15 mg every 4 wk.Children weighing 25 to 37.5 kg (55 to83 lb). Initial: 11.25 mg every 4 wk.Maintenance: Dosage increased as neededin increments of 3.75 mg every 4 wk.Maximum: 15 mg every 4 wk.Children weighing less than 25 kg. Initial:7.5 mg every 4 wk. Maintenance: Dosageincreased as needed in increments of3.75 mg every 4 wk. Maximum: 15 mgevery 4 wk.SUBCUTANEOUS INJECTION (LEUPROLIDE ACETATEINJECTION)Children. 50 mcg/kg daily. Dosageincreased in increments of 10 mcg/kg daily. To treat endometriosisI.M. INJECTION (LEUPROLIDE ACETATE FORINJECTION)Adults. 3.75 mg every mo or 11.25 mgevery 3 mo for up to 6 mo. Maximum:33.75 mg total dose. As adjunct to treat anemia due to uterineleiomyomasI.M. INJECTION (LEUPROLIDE ACETATE FORINJECTION)Adults. 3.75 mg every mo up to 3 mo or11.25 mg single dose. Maximum: 11.25 mgtotal dose.Mechanism of ActionAfter stimulating follicle-stimulating hormone(FSH) and luteinizing hormone(LH), continuous leuprolide therapy suppressessecretion of gonadotropin-releasinghormone, decreasing testosterone andestradiol levels. In children with centralprecocious puberty, this stops menses andreproductive organ development.JKL

576leuprolide acetateIn adult men, continuous suppressiondecreases testosterone levels and causespharmacologic castration, which slows theactivity of prostatic neoplastic cells. Inwomen with endometriosis or uterineleiomyomas, leuprolide suppresses ovarianfunction, inactivating endometrial tissuesand resulting in amenorrhea.Route Onset Peak DurationI.M., 1 wk Unknown 4–12 wkSubQ*aftertherapyI.M., 2–4 wk After 1– 60–90SubQ† 2 mo days aftertherapyContraindicationsWomen and children (leuprolide acetateinjectable suspension); hypersensitivity tobenzyl alcohol, gonadorelin, andgonadotropin-releasing hormone analogues,including leuprolide, and theircomponents; pregnancy; undiagnosedabnormal vaginal bleedingAdverse ReactionsCNS: Depression, dizziness, fatigue, headache,insomnia, lethargy, malaise, memoryloss, paresthesia, peripheral neuropathy, rigors,seizures, syncope, weakness; anxiety,mood changes, nervousness (adult women)CV: Arrhythmias, edema, hypertension,hypotension, palpitations, vasodilation;angina, MI, thrombophlebitis (adult men)EENT: Blurred visionENDO: Amenorrhea, androgenic effects inwomen. breast tenderness or swelling,decreased testicle size, gynecomastia, hotflashes, hyperglycemia, pituitary apoplexyGI: Colitis, constipation in adult men, dyspepsia,gastroenteritis, hepatic dysfunction,nausea, vomitingGU: Bladder spasm, decreased libido,decreased penis size, dysuria, endometriosisflareup, impotence, incontinence, nocturia,prostate cancer flareup, prostate pain, uterinebleeding, vaginal discharge in girls,vaginitisHEME: LeukopeniaMS: Arthralgia, body pain in children, bone*Gonadotropin inhibitor.†Antiendometrionic, antineoplastic.density loss, bone or limb pain, fibromyalgia,myalgia, tenosynovitisRESP: Asthma, dyspnea, pulmonaryembolismSKIN: Alopecia, clamminess, night sweats,photosensitivity, rash, urticariaOther: Anaphylaxis; weight gain; injectionsite abscess, burning, edema, induration,itching, pain, or rednessNursing Considerations• Let drug come to room temperaturebefore using. Reconstitute leuprolideacetate depot suspension with diluent providedby manufacturer. Add diluent topowder for suspension and thoroughlyshake vials to disperse particles into a uniformmilky suspension. Use within30 minutes after mixing, and discard anyunused portion. If using a prefilled dualchambersyringe, follow manufacturer’sinstructions to release diluent into chambercontaining powder. Shake gently afterdiluted to disperse particles evenly in solution.No dilution or reconstitution isneeded for leuprolide acetate injection forsubcutaneous administration. Rotateinjection sites.WARNING Leuprolide acetate for injectablesuspension (Eligard) is approved only foruse in men for palliative treatment ofprostate cancer. Use provided syringes anddelivery system, and read and followinstructions carefully to ensure propermixing of product; shaking alone is inadequateto mix it.WARNING Monitor patient for possibleallergic reaction (erythema and induration)at injection site because leuprolideinjections contain benzyl alcohol.Manufacturer recommends that injectionbe given by physician.• During first weeks of leuprolide therapy,monitor patient being treated for prostatecancer for initial worsening of symptoms,such as increased bone pain, difficult urination,and paresthesia or paralysis (inpatients with vertebral metastasis).• During treatment for prostate cancer,monitor patient’s serum testosterone andPSA levels periodically, as ordered, todetermine response to leuprolide therapy.• Expect to stop drug before age 11 infemale patients and age 12 in male

patients treated for precocious centralpuberty.• Monitor bone density test results, asordered, of women at risk for osteoporosiswho are receiving leuprolide because ofpossible drug-induced estrogen loss, whichmay result in decreased bone density.• Be aware that therapeutic doses of leuprolidesuppress the pituitary-gonadal systemand that normal function doesn’t returnfor 4 to 12 weeks after drug is stopped.WARNING Monitor patient for evidence ofpituitary apoplexy, such as suddenheadache, vomiting, visual changes, ophthalmoplegia,altered mental status, andpossibly cardiovascular collapse. Althoughrare, it may occur within 2 weeks of firstdose, sometimes within the first hour.Notify prescriber immediately and providesupportive care.PATIENT TEACHING• Instruct patient who is self-administeringleuprolide injection to use syringe providedby manufacturer. If manufacturer’ssyringe is unavailable, advise her to useonly a 0.5-ml disposable, low-dose, U-100insulin syringe to ensure accurate dosage.Substitution of syringes is not recommendedfor leuprolide acetate forinjectable suspension.• Advise women to immediately reportmonthly menses or breakthrough bleedingto prescriber.• Instruct female patient of childbearing ageto use a nonhormonal form of contraceptionduring leuprolide therapy. Advise herto stop taking drug and notify prescriberat once if she becomes pregnant.• Inform patient with osteoporosis or at riskfor developing it that drug may increasebone density loss.• Inform parents of child being treated forcentral precocious puberty that theyshould expect normal gonadal-pituitaryfunction to return 4 to 12 weeks aftertherapy ends.• Advise patient to report symptoms ofdepression or memory problems.• Caution patient being treated for prostatecancer that drug may initially worsen suchsymptoms as bone pain and that it maycause new signs or symptoms to occurduring first few weeks of treatment.Reassure patient that this is transient.levalbuterol hydrochloride 577levalbuterolhydrochlorideXopenex, Xopenex HFAClass and CategoryChemical class: Sympathomimetic amineTherapeutic class: BronchodilatorPregnancy category: CIndications and Dosages To prevent or treat bronchospasm inreversible obstructive airway diseaseINHALATION AEROSOLAdults and children age 4 and over. 45 or90 mcg (1 or 2 inhalations) every 4 to 6 hr.INHALATION SOLUTIONAdults and children age 12 and over.0.63 to 1.25 mg t.i.d. every 6 to 8 hr.Maximum: 1.25 mg t.i.d.Children ages 6 to 11. 0.31 to 0.63 mg t.i.d.Maximum: 0.63 mg t.i.d.DOSAGE ADJUSTMENT For elderly patients,dosage limited to 0.63 mg t.i.d. every 6 to8hr.Route Onset Peak DurationInhalation 10–17 min 1.5 hr 5–6 hrMechanism of ActionAttaches to beta 2 receptors on bronchial cellmembranes, which stimulates the intracellularenzyme adenyl cyclase to convertadenosine triphosphate to cAMP. Increasedintracellular cAMP level relaxes bronchialsmooth muscle and inhibits histaminerelease from mast cells.ContraindicationsHypersensitivity to levalbuterol, other sympathomimeticamines, or their componentsInteractionsDRUGSbeta blockers: Blocked effects of both drugsdigoxin: Decreased blood digoxin levelloop or thiazide diuretics: Increased risk ofhypokalemiaMAO inhibitors, sympathomimetics, tricyclicantidepressants: Increased risk of adversecardiovascular effectsAdverse ReactionsCNS: Anxiety, chills, dizziness, hypertonia,JKL

578levetiracetaminsomnia, migraine headache, nervousness,paresthesia, syncope, tremorCV: Chest pain, hypertension, hypotension,tachycardiaEENT: Dry mouth and throat, rhinitis,sinus-itisGI: Diarrhea, indigestion, nausea, vomitingMS: Leg cramps, myalgiaRESP: Asthma exacerbation, cough, dyspnea,paradoxical bronchospasmOther: Flulike symptoms, lymphadenopathyNursing Considerations• Use levalbuterol cautiously in patientswith arrhythmias, diabetes mellitus,hypertension, hyperthyroidism, or a historyof seizures.• Give oral solution form only by nebulizer.• Monitor pulse rate and blood pressurebefore and after nebulizer treatment.• Because drug may provoke paradoxicalbronchospasm, observe for dyspnea,wheezing, and increased coughing.PATIENT TEACHING• Teach patient how to use levalbuterol nebulizerand to measure correct dose.• Intsruct patient to prime inhaler beforeusing it for the first time or when it hasn’tbeen used for more than 3 days by releasing4 test sprays into the air, aiming itaway from her face.• Show patient how to clean nebulizer orinhaler, and explain the need to do so atleast once weekly.• Instruct patient to notify prescriber ifdrug fails to work or if she needs moretreatments because asthma is worsening.• Instruct patient not to increase dosage orfrequency unless told by prescriber.• Urge patient to stop drug and call prescriberif she has paradoxical bronchospasm.• Instruct patient to use inhalation solutionwithin 2 weeks of opening the foil pouchand to protect drug from light and heat.•Urge patient to consult prescriber beforeusing OTC or other drugs.levetiracetamKeppra, Keppra XRClass and CategoryChemical: Pyrrolidine derivativeTherapeutic: AnticonvulsantPregnancy category: CIndications and Dosages As adjunct to treat partial seizuresORAL SOLUTION, TABLETSAdults and adolescents over age 16. Initial:500 mg b.i.d., increased by 1,000 mg dailyevery 2 wk if needed. Maximum: 3,000 mgdaily.Children ages 4 to 16. Initial: 10 mg/kgb.i.d., increased by 20 mg/kg daily every2 wk until recommended daily dose of60 mg/kg is reached.XR TABLETSAdults and adolescents over age 16.1,000 mg once daily, increased by 1,000 mgdaily every 2 wk until recommended dailydose of 3,000 mg is reached.I.V. INFUSIONAdults and adolescents over age 16. Initial:500 mg infused over 15 minutes b.i.d.,increased by 1,000 mg daily every 2 wk, ifneeded. Maximum: 3,000 mg daily. As adjunct to treat myoclonic seizures inpatients with juvenile myoclonic epilepsyORAL SOLUTION, TABLETSAdults and children age 12 and over.Initial: 500 mg b.i.d., increased by 1,000 mgdaily every 2 wk, if needed. Maximum:3,000 mg daily. As adjunct to treat primary generalizedtonic-clonic seizures in patients withidiopathic generalized epilepsyORAL SOLUTION, TABLETSAdults and children age 6 and over. Initial:500 mg b.i.d., increased by 1,000 mg dailyevery 2 wk, as needed. Maximum: 3,000 mgdaily.DOSAGE ADJUSTMENT Maximum dosagereduced to 2,000 mg daily for patients withcreatinine clearance of 50 to 80 ml/min/1.73 m 2 ; to 1,500 mg daily for clearance of30 to 49 ml/min/1.73 m 2 ; and to 1,000 mgdaily for clearance less than 30 ml/min/1.73 m 2 . For patients with end-stage renaldisease who are having dialysis, expect togive another 250 to 500 mg, as prescribed,after each dialysis session. For children whocan’t tolerate 60 mg/kg daily, dosagereduced to point of tolerance.Mechanism of ActionMay protect against secondary generalizedseizure activity by preventing coordination

of epileptiform burst firing. Levetiracetamdoesn’t seem to involve inhibitory and excitatoryneurotransmission.ContraindicationsHypersensitivity to levetiracetam or itscomponentsAdverse ReactionsCNS: Abnormal gait, aggression, agitation,anger, anxiety, apathy, asthenia, ataxia,behavioral difficulties (children), confusion,coordination difficulties, depersonalization,depression, dizziness, emotional lability,fatigue, hallucinations, headache, hostility,increased reflexes, insomnia, irritability,mental or mood changes, nervousness, neurosis,paresthesia, personality disorder, psychosis,seizures, somnolence, suicidalideation, vertigoEENT: Amblyopia, conjunctivitis, diplopia,ear pain, nasopharyngitis, pharyngitis,rhinitis, sinusitisGI: Anorexia, constipation, diarrhea, elevatedliver enzyme levels, gastroenteritis,hepatic failure, hepatitis, pancreatitis, vomitingGU: AlbuminuriaHEME: Decreased hemtatocrit, hemoglobin,and total mean RBC count; leukopenia;neutropenia; pancytopenia; thrombocytopeniaMS: Neck painRESP: Asthma, coughSKIN: Alopecia, ecchymosis, pruritus, skindiscoloration, vesiculobullous rashOther: Dehydration, facial edema, infection,influenza, weight lossNursing Considerations• Children weighing 20 kg or less should begiven only the oral solution form.• For I.V. use, dilute parenteral levetiracetamin 100 ml of compatible diluent, such asnormal saline injection, lactated Ringer’sinjection, or dextrose 5% injection. Usewithin 24 hours.• Assess compliance during first 4 weeks oftherapy, when adverse reactions are mostcommon.• Monitor patient for seizure activity duringtherapy. As appropriate, implement seizureprecautions according to facility policy.• Stopping drug may increase seizure activity.Expect to taper dosage gradually.• Certain adverse effects, including somnolence,fatigue, coordination problems, andabnormal behaviors may be more likely inpatieints taking levetiracetam for partialseizure disorders.• Monitor patient closely for evidence ofsuicidal thinking or behavior, especiallywhen therapy starts or dosage changes.PATIENT TEACHING• Caution patient that levetiracetam maycause dizziness and drowsiness, especiallyduring first 4 weeks of therapy.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Caution patient not to stop taking levetiracetamabruptly; inform her that drugdosage should be tapered under prescriber’sdirection to reduce the risk ofbreakthrough seizures.• Explain that levetiracetam may causemental and behavioral changes, such asaggression, depresison, irritability, andrarely psychotic symptoms. Urge her tocontact prescriber about any bothersomechanges.• Advise patient to keep taking other anticonvulsants,as ordered, while taking levetiracetam.• Encourage patient to avoid alcohol duringtherapy because alcohol can increase incidenceof drowsiness and dizziness.• Instruct patient to see prescriber regularlyso that her progress can be monitored.• Urge caregivers to watch patient closely forevidence of suicidal tendencies, especiallywhen therapy starts or dosage changes,and to report concerns immediately.• Urge woman who becomes pregnant whiletaking levetiracetam to enroll in the NorthAmerican antiepileptic drug pregnancyregistry by calling 1-888-233-2334.Explain that registry is collecting informationabout safety of antiepileptic drugsduring pregnancy.levocetirizineXyzallevocetirizine 579Class and CategoryChemical class: H 1 -receptor antagonistTherapeutic class: AntihistaminePregnancy category: BJKL

580levodopaIndications and Dosages To treat chronic idiopathic urticaria; totreat allergic rhinitisTABLETS, ORAL SOLUTIONAdults and children age 12 and over. 2.5 to5 mg once daily in evening. Maximum:5 mg daily.DOSAGE ADJUSTMENT For patient with mildrenal impairment (creatinine clearance50 to 80 ml/min/1.73 m 2 ), dosage shouldn’texceed 2.5 mg daily. For patient with moderaterenal impairment (creatinine clearance30 to 50 ml/min/1.73 m 2 ), dosageshouldn’t exceed 2.5 mg once every otherday. For patient with severe renal impairment(creatinine clearance 10 to 30 ml/min/1.73 m 2 ), dosage shouldn’t exceed2.5 mg once every 3 to 4 days.Children ages 6 to 11. 2.5 mg once daily inevening. Maximum: 2.5 mg daily.Mechanism of ActionBinds to central and peripheral H 1 receptors,competing with histamine for thesesites and preventing it from reaching its siteof action. By blocking histamine, levocetirizineproduces antihistamine effects,inhibiting respiratory, vascular, and GIsmooth-muscle contraction; decreasingcapillary permeability, which reduceswheals, flares, and itching; and decreasingsalivary and lacrimal gland secretions torelieve chronic urticaria and signs andsymptoms of allergic rhinitis.ContraindicationsChildren ages 6 to 11 with impaired renalfunction; creatinine clearance less than10 ml/min/1.73 m 2 ; end-stage renal diseasein adults and children age 12 and over;hypersensitivity to levocetirizine, cetirizineor their components; renal failureInteractionsDRUGSCNS depressants: Possibly increased CNSdepressionMAO inhibitors: Possibly prolonged andintensified anticholinergic effectsritonavir: Possibly increased risk of adverseeffects of levocetirizinetheophylline: Possibly decreased clearance oflevocetirizineACTIVITIESalcohol use: Possibly increased CNS depressionAdverse ReactionsCNS: Aggression, agitation, asthenia,fatigue, fever, seizures, somnolence, syncopeCV: PalpitationsEENT: Dry mouth, epistaxis, nasopharyngitis,pharyngitis, visual disturbancesGI: Hepatitis, nauseaMS: MyalgiaRESP: Cough, dyspneaSKIN: Pruritus, rash, urticariaOther: Anaphylaxis, angioedema, weightgainNursing Considerations• Expect to stop drug at least 72 hoursbefore skin tests for allergies because drugmay inhibit cutaneous histamine response,thus producing false-negative results.PATIENT TEACHING• Instruct patient to take drug exactly asprescribed. For oral solution, patientshould use appropriate measuring device.• Urge patient to avoid alcohol while takinglevocetirizine• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.levodopaDopar, LarodopaClass and CategoryChemical class: Dihydroxyphenylalanineisomer, metabolic precursor of dopamineTherapeutic class: AntidyskineticPregnancy category: Not ratedIndications and Dosages To manage symptoms of primary Parkinson’sdisease, postencephalitic parkinsonism,and parkinsonism caused byCNS injury from carbon monoxide ormanganese intoxicationCAPSULES, TABLETSAdults and children age 12 and over.Initial: 250 mg daily in divided doses b.i.d.to q.i.d. Increased by 100 to 750 mg every3 to 7 days, as indicated. Maximum: 8 gdaily.ContraindicationsAngle-closure glaucoma, history of melanoma,hypersensitivity to levodopa or itscomponents, suspicious undiagnosed skin

levodopa 581Mechanism of ActionBy supplementing a low level of endogenousdopamine, levodopa helps controlalterations in voluntary muscle movement(such as tremors and rigidity) inParkinson’s disease. Dopamine, a neurotransmittersynthesized and released byneurons leading from substantia nigra tobasal ganglia, is essential for normalmotor function. By stimulating peripheraland central dopaminergic 2 (D 2 ) receptorson postsynaptic cells, dopamineinhibits the firing of striatal neurons(such as cholinergic neurons). InParkinson’s disease, progressive degenerationof these neurons substantiallyreduces the supply of intrasynapticdopamine. Levodopa, a dopamine precursor,increases the dopamine supply inneurons, making more available to stimulatedopaminergic receptors.LevodopaD 2 receptorPostsynapticneuronBasalganglionneuronDopamineJKLlesions, use within 14 days of MAOinhibitor therapyRoute Onset Peak DurationP.O. 14–21 days* Unknown 5 hrInteractionsDRUGSantacids: Increased blood levodopa levelantihypertensives: Risk of orthostatic hypotensionbenzodiazepines: Possibly decreased therapeuticeffects of levodopabromocriptine: Possibly additive effects oflevodopafurazolidone, MAO inhibitors, procarbazine:Risk of severe hypertensionhaloperidol, loxapine, molindone, papaverine,phenothiazines, phenytoin, rauwolfiaalkaloids: Decreased effects of levodopainhaled anesthetics, sympathomimetics:Increased risk of arrhythmiasiron salts: Possibly decreased blood leveland effectiveness of levodopa* With multiple doses.methyldopa: Possibly toxic CNS effectsmetoclopramide: Possibly worsening of Parkinson’sdisease and decreased therapeuticeffects of metoclopramidepyridoxine (vitamin B 6 ): Decreased antidyskineticeffect of levodopaFOODShigh-protein food: Decreased levodopaabsorptionACTIVITIEScocaine use: Increased risk of arrhythmiasAdverse ReactionsCNS: Aggressiveness, anxiety, ataxia, confusion,delusions, dizziness, dream disturbances,dyskinesia, dystonia, euphoria, hallucinations,headache, increased tremor,insomnia, malaise, mood changes, severedepression, suicidal tendencies, syncope,weaknessCV: Arrhythmias, hot flashes, orthostatichypotension, palpitationsEENT: Bitter aftertaste, blurred vision,darkened saliva, diplopia, dry mouth,increased salivation, mydriasis, toothclenching and grinding

582levofloxacinGI: Abdominal pain, anorexia, constipation,diarrhea, flatulence, GI bleeding, hepatotoxicity,hiccups, indigestion, nausea, vomitingGU: Darkened urine, priapism, urine retentionSKIN: Darkened sweat, diaphoresis, rashNursing Considerations• Expect to discontinue levodopa 6 to8 hours before surgery to avoid interactionswith anesthetics.• Observe patient for mental or behavioralchanges and suicidal tendencies. Notifyprescriber immediately if they occur.• Watch for muscle twitching and blepharospasm(eyelid spasm), which are earlysigns of levodopa overdose. Report themat once.• Expect patient to be tested for acromegalyand diabetes during long-term levodopatherapy. Also expect to monitor hematopoietic,hepatic, and renal function.PATIENT TEACHING• Advise patient to take levodopa with mealsif she experiences adverse GI reactions.• Because protein impairs drug absorption,instruct patient to avoid high-proteinmeals during levodopa therapy and to distributeprotein intake equally throughoutthe day.• Caution patient to avoid excessive use ofvitamins and fortified cereals that containvitamin B 6 or iron, which can reduce levodopa’seffects.• Instruct patient to report fainting, increasedmuscle tremor, difficult urination, andsevere or persistent nausea and vomiting.• Urge patient to continue taking drug asprescribed even if results of therapy aren’tevident immediately.• Inform patient that saliva, sweat, andurine may darken but that this isn’t harmful.• Direct patient to protect drug from heat,light, and moisture and to discard darkenedpills because they have lost theirpotency.• Advise patient to change position slowly tominimize orthostatic hypotension.• Caution male patient about risk of priapism(persistent, painful erection), andurge him to seek medical help immediatelyif it occurs.levofloxacinLevaquinClass and CategoryChemical class: FluoroquinoloneTherapeutic class: AntibioticPregnancy category: CIndications and Dosages To reduce incidence or progression ofinhalation anthrax after exposure toaerosolized Bacillus anthracisTABLETS, I.V. INFUSION, ORAL SOLUTIONAdults and children weighing more than50 kg (110 lb). 500 mg (over 60 min for I.V.infusion) daily for 60 days.Children weighing less than 50 kg. 8 mg/kg(over 60 min for I.V. infusion) every 12 hrfor 60 days. Maximum: 250 mg/dose. To treat acute maxillary sinusitis causedby Haemophilus influenzae, Moraxellacatarrhalis, or Streptococcus pneumoniaeTABLETS, I.V. INFUSION, ORAL SOLUTIONAdults. 500 mg daily (over 60 to 90 min forI.V. infusion) for 10 to 14 days. Or 759 mgdaily for 5 days. To treat acute exacerbation of chronicbacterial bronchitis caused by H.influenzae, H. parainfluenzae, M.catarrhalis, S. pneumoniae, orStaphylococcus aureusTABLETS, I.V. INFUSION, ORAL SOLUTIONAdults. 500 mg daily (over 60 to 90 min forI.V. infusion) for 7 days. To treat community-acquired pneumoniacaused by Chlamydia pneumoniae,H. influenzae, H. parainfluenzae,Klebsiella pneumoniae, Legionellapneumophila, M. catarrhalis,Mycoplasma pneumoniae, S. aureus, orS. pneumoniaeTABLETS, I.V. INFUSION, ORAL SOLUTIONAdults. 500 mg daily (over 60 to 90 min forI.V. infusion) for 7 to 14 days. Alternatively,for infection caused by C. pneumoniae, H.influenzae, H. parainfluenzae, M. pneumoniae,or S. pneumoniae, 750 mg daily (over60 to 90 min for I.V. infusion) for 5 days. To treat uncomplicated UTI caused byEscherichia coli, K. pneumoniae, orStaphylococcus saprophyticus

levofloxacin 583TABLETS, I.V. INFUSION, ORAL SOLUTIONAdults. 250 mg daily (over 60 to 90 min forI.V. infusion) for 3 days. To treat complicated UTI caused byEnterococcus faecalis, E. cloacae, E.coli, K. pneumoniae, Proteus mirabilis,or Pseudomonas aeruginosa or acutepyelonephritis caused by E. coliTABLETS, I.V. INFUSION, ORAL SOLUTIONAdults. 250 mg daily (over 60 to 90 min forI.V. infusion) for 10 days. To treat complicated UTI caused by E.coli, K. pneumoniae, or P. mirabilis oracute pyelonephritis caused by E. coliTABLETS, I.V. INFUSION, ORAL SOLUTIONAdults. 750 mg daily (over 90 min for I.V.infusion) for 5 days. To treat mild to moderate skin and softtissueinfections caused by S. aureus orStreptococcus pyogenesTABLETS, I.V. INFUSION, ORAL SOLUTIONAdults. 500 mg daily (over 60 to 90 min forI.V. infusion) for 7 to 10 days. To treat complicated skin and soft-tissueinfections caused by methicillin-sensitiveEnterococcus faecalis, Proteus mirabilis,S. aureus, or S. pyogenes; to treatnosocomial pneumonia caused by S.aureus, Pseudomonas aeruginosa,Serratia marcescens, E. coli, K. pneumoniae,H. influenzae, or S. pneumoniaeTABLETS, I.V. INFUSION, ORAL SOLUTIONAdults. 750 mg daily (over 60 to 90 min forI.V. infusion) for 7 to 14 days. To treat chronic bacterial prostatitiscaused by E. coli, E. faecalis, or S. epidermidisTABLETS, I.V. INFUSION, ORAL SOLUTIONAdults. 500 mg daily (over 60 to 90 min forI.V. infusion) for 28 days.DOSAGE ADJUSTMENT For complicated UTIin patients with creatinine clearance of10 to 19 ml/min/1.73 m 2 , 250 mg initiallyand then maintenance dosage of 250 mgevery 48 hr. For complicated skin and softtissueinfections and nosocomial pneumoniawhen creatinine clearance is 19 ml/min/1.73 m 2 or less, 750 mg initially andthen maintenance dosage of 500 mg every48 hr; when creatinine clearance is 20 to49 ml/min/1.73 m 2 , 750 mg initially andthen maintenance dosage of 750 mg every48 hr. For all other indications, when creatinineclearance is 19 ml/min/1.73 m 2 or less,500 mg initially and then maintenance of250 mg every 48 hr; when creatinine clearanceis 20 to 49 ml/min/1.73 m 2 , 500 mginitially and then maintenance dosage of250 mg every 24 hr.Mechanism of ActionInterferes with bacterial cell replication byinhibiting the bacterial enzyme DNAgyrase, which is essential for replication andrepair of bacterial DNA.ContraindicationsHypersensitivity to levofloxacin, other fluoroquinolones,or their componentsInteractionsDRUGSaluminum-, calcium-, or magnesium-containingantacids; didanosine; iron; sucralfate;zinc: Reduced GI absorption of levofloxacinantineoplastics: Decreased blood levofloxacinlevelcimetidine: Increased blood levofloxacinlevelcyclosporine: Increased risk of nephrotoxicityNSAIDs: Possibly increased CNS stimulationand risk of seizuresoral anticoagulants: Increased anticoagulanteffect and risk of bleedingoral antidiabetic drugs: Possibly hyperglycemiaor hypoglycemiatheophylline: Increased blood theophyllinelevel and risk of toxicityACTIVITIESsun exposure: Increased risk of photosensitivityAdverse ReactionsCNS: Anxiety, CNS stimulation, dizziness,fever, headache, increased ICP, insomnia,light-headedness, nervousness, paranoia,peripheral neuropathy, psychosis, seizures,sleep disturbance, suicidal ideationCV: Arrhythmias, leukocytoclastic vasculitis,prolonged QT interval, torsades depointes, vasculitis, vasodilationEENT: Blurred vision, decreased visual acuity,diplopia, dysphonia, scotoma, taste perversion,tinnitusENDO: Hyperglycemia, hypoglycemiaGI: Abdominal pain, acute hepatic necrosisor failure, anorexia, constipation, diarrhea,flatulence, hepatitis, hepatotoxicity, indigestion,jaundice, nausea, pseudomembranousJKL

584levofloxacincolitis, vomitingGU: Acute renal failure or insufficiency,crystalluria, interstitial nephritis, vaginalcandidiasisHEME: Agranulocytosis, aplastic anemia,eosinophilia, hemolytic anemia, leukopenia,pancytopenia, thrombocytopeniaMS: Arthralgia, back pain, myalgia, rhabdomyolysis,tendon or muscle ruptureRESP: Allergic pneumonitisSKIN: Photosensitivity, pruritus, rash,Stevens-Johnson syndrome, toxic epidermalnecrolysis, urticariaOther: Anaphylaxis, angioedema, multiorganfailure, serum sicknessNursing Considerations• Use levofloxacin cautiously in patientswith renal insufficiency. Monitor renalfunction as appropriate during treatment.• Use drug cautiously in patients with CNSdisorders, such as epilepsy, that may lowerthe seizure threshold. Also use cautiouslyin patients taking corticosteroids, especiallyelderly patients, because of increasedrisk of tendon rupture.• Expect to obtain culture and sensitivitytests before levofloxacin treatment begins.• Avoid giving drug within 2 hours ofantacids.• Give parenteral form over 60 to 90 minutes,depending on dosage, because bolusor rapid I.V. delivery may cause hypotension.WARNING Stop levofloxacin at first sign ofhypersensitivity, including rash and jaundice,because drug may lead to anaphylaxis.Reaction may occur after first dose.Expect to give epinephrine and providesupportive care.• Monitor blood glucose level, especially indiabetic patient who takes an oral antidiabeticor uses insulin, because levofloxacinmay alter blood glucose level. If so, notifyprescriber, stop drug immediately ifpatient has hypoglycemia, and provideprescribed treatment.• Monitor QT interval if needed. If itlengthens, notify prescriber at once andstop drug. Patients with hypokalemia, significantbradycardia, or cardiomyopathyand those receiving a class IA or III antiarrhythmicshouldn’t receive levofloxacin.• Notify prescriber if patient has symptomsof peripheral neuropathy (pain; burning;tingling; numbness; weakness; altered sensationsof light touch, pain, temperature,position sense, or vibration sense), whichcould be permanent; or CNS abnormalities(seizures, psychosis, increased ICP orCNS stimulation), which may lead tomore serious adverse reactions, such assuicidal ideation. In each case, expect todiscontinue levofloxacin.• Watch for evidence of tendon rupture(inflammation, pain, swelling) during andup to several months after therapy, especiallyin children, elderly patients, patientsreceiving corticosteroids, and patients withkidney, heart, and lung transplants. Notifyprescriber about suspected tendon rupture,and have patient rest and refrainfrom exercise until tendon rupture hasbeen ruled out. If present, expect to providesupportive care, as ordered.• Monitor patient’s bowel elimination. Ifdiarrhea develops, obtain stool culture tocheck for pseudomembranous colitis. Ifconfirmed, expect to stop drug and givefluid, electrolytes, and antibiotics effectiveagainst Clostridium difficile.PATIENT TEACHING• If patient will take oral solution form oflevofloxacin, tell him to take it 1 hourbefore or 2 hours after eating.• Advise patient to increase fluid intake duringtherapy to prevent crystalluria.• Direct patient to take an antacid, didanosine,iron, sucralfate, or zinc at least 2hours before or after levofloxacin.• Tell patient to complete the drug as prescribed,even if symptoms subside.• Urge patient to avoid excessive sun exposureand to wear sunscreen because ofincreased risk of photosensitivity. Tellpatient to notify prescriber at first sign.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Tell patient to stop drug and notify prescriberif he develops tendon pain orinflammation or abnormal changes inmotor or sensory function.• Urge patient to stop drug and tell prescriberabout rash or other allergic reaction.• Advise diabetic patient to monitor bloodglucose level and reportchanges.• Urge patient to tell prescriber about severe

diarrhea, even if it’s more than 2 monthsafter drug therapy ends. Additional treatmentmay be needed.• Advise patient to notify prescriber aboutheart palpitations or loss of consciousness.An ECG may be needed to detect adversedrug effects on the patient’s heart.levorphanol tartrateLevo-DromoranClass, Category, and ScheduleChemical class: Morphinan derivativeTherapeutic class: Analgesic, anesthesiaadjunctPregnancy category: Not ratedControlled substance schedule: IIIndications and Dosages To relieve moderate to severe painTABLETSAdults. 2 mg every 6 to 8 hr, p.r.n. Increasedto 3 mg every 6 to 8 hr, if indicated.I.V. INJECTIONAdults. Up to 1 mg every 3 to 6 hr, p.r.n.Maximum: 8 mg daily for non–opioiddependentpatients.I.M. OR SUBCUTANEOUS INJECTIONAdults. 1 to 2 mg every 6 to 8 hr, p.r.n.Maximum: 8 mg daily for non–opioiddependentpatients. To provide preoperative sedationI.M. OR SUBCUTANEOUS INJECTIONAdults. 1 to 2 mg 60 to 90 min before procedure.Route Onset Peak DurationP.O. 10–60 min 90–120 min 4–5 hrI.V. Unknown In 20 min 4–5 hrI.M. Unknown 60 min 4–5 hrSubQ Unknown 60–90 min 4–5 hrMechanism of ActionDecreases intracellular level of cyclic adenosinemonophosphate by inhibiting adenylatecyclase, which regulates release of painneurotransmitters, such as substance P,gamma-aminobutyric acid, dopamine,acetylcholine, and noradrenaline. Levorphanolalso stimulates mu and kappa opioidreceptors, altering perception of andemotional response to pain.levorphanol tartrate 585IncompatibilitiesDon’t mix levorphanol tartrate withsolutions that contain aminophylline,ammonium chloride, amobarbital sodium,chlorothiazide sodium, heparin sodium,methicillin sodium, nitrofurantoin sodium,novobiacin sodium, pentobarbital sodium,perphenazine, phenobarbital sodium,phenytoin, secobarbital sodium, sodiumbicarbonate, sodium iodide, sulfadiazinesodium, sulfisoxazole diethanolamine, orthiopental sodium.ContraindicationsAcute alcoholism, acute or severe asthma,anoxia, hypersensitivity to levorphanol tartrateor its components, increased intracranialpressure, respiratory depression, upperairway obstructionInteractionsDRUGSalfentanil, CNS depressants, fentanyl, sufentanil:Possibly increased CNS and respiratorydepression and hypotensionanticholinergics: Increased risk of severeconstipationantidiarrheals, such as difenoxin and atropine,kaolin, and loperamide: Increased riskof severe constipation and increased CNSdepressionantihypertensives: Increased risk ofhypotensionbuprenorphine: Possibly decreased therapeuticeffects of levorphanol and increasedrisk of respiratory depressionhydroxyzine: Increased risk of CNS depressionand hypotensionmetoclopramide: Possibly antagonizedeffects of metoclopramidenaloxone, naltrexone: Decreased therapeuticeffects of levorphanolneuromuscular blockers: Increased risk ofprolonged CNS and respiratory depressionACTIVITIESalcohol use: Possibly increased CNS and respiratorydepression and hypotensionAdverse ReactionsCNS: Amnesia, coma, confusion, delusions,depression, dizziness, drowsiness, dyskinesia,hypokinesia, insomnia, nervousness,personality disorder, seizuresCV: Bradycardia, cardiac arrest, hypotension,orthostatic hypotension, palpitations,shock, tachycardiaJKL

586levothyroxine sodiumEENT: Abnormal vision, diplopia, drymouthGI: Abdominal pain, biliary tract spasm,constipation, hepatic failure, indigestion,nausea, vomitingGU: Dysuria, urine retentionRESP: Apnea, hyperventilationSKIN: Cyanosis, pruritus, rash, urticariaOther: Injection site pain, redness, andswelling; physical and psychological dependenceNursing ConsiderationsWARNING Be aware that levorphanol maybe habit-forming.• Give drug with food if GI distress occurs.• If respiratory depression occurs, expect toadminister naloxone to reverse it.• Monitor supine and standing blood pressure,and notify prescriber of orthostatichypotension.• Carefully assess for adverse reactions inelderly patients; they are especially sensitiveto drug and are at increased risk forconstipation.PATIENT TEACHING• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to avoid alcoholic beverageswhile taking levorphanol.• Direct patient to change position slowly tominimize orthostatic hypotension.• Advise patient to notify prescriber if constipation,nausea, or vomiting occurs.• If patient reports dry mouth, suggest thatshe use sugarless candy or gum or icechips.levothyroxinesodium(L-thyroxine sodium, T 4 ,thyroxine sodium)Eltroxin (CAN), Levo-T, Levothroid,Levoxyl, PMS-Levothyroxine Sodium(CAN), Synthroid, UnithroidClass and CategoryChemical class: Synthetic thyroxine (T 4 )Therapeutic class: Thyroid hormonereplacementPregnancy category: AIndications and Dosages To treat mild hypothyroidismTABLETSAdults. Initial: 50 mcg daily, increased by25 to 50 mcg every 2 to 3 wk until desiredresponse occurs or therapeutic blood levelis reached. Maintenance: 75 to 125 mcgdaily.DOSAGE ADJUSTMENT For elderly patientsand those with cardiovascular disease orchronic hypothyroidism, initial dosage usuallyreduced to 12.5 to 25 mcg daily andthen increased by 12.5 to 25 mcg every 3 to4 wk until desired response occurs. For elderlypatients, maintenance dosage is limitedto 75 mcg daily.Children over age 10. 2 to 3 mcg/kg daily.Usual: 150 to 200 mcg daily.Children ages 6 to 10. 4 to 5 mcg/kg daily.Usual: 100 to 150 mcg daily.Children ages 1 to 5. 3 to 5 mcg/kg daily.Usual: 75 to 100 mcg daily.Infants ages 6 to 12 months. 5 to 6 mcg/kgdaily. Usual: 50 to 75 mcg daily.Infants under age 6 months. 5 to 6 mcg/kgdaily. Usual: 25 to 50 mcg daily. To treat severe hypothyroidismTABLETSAdults. Initial: 12.5 to 25 mcg daily.Increased by 25 mcg every 2 to 3 wk untildesired response occurs or therapeuticblood level is reached. Maintenance: 75 to125 mcg daily. Maximum: 200 mcg daily.Children over age 10. 2 to 3 mcg/kg daily.Usual: 150 to 200 mcg daily.Children ages 6 to 10. 4 to 5 mcg/kg daily.Usual: 100 to 150 mcg daily.Children ages 1 to 5. 3 to 5 mcg/kg daily.Usual: 75 to 100 mcg daily.Infants ages 6 to 12 months. 5 to 6 mcg/kgdaily. Usual: 50 to 75 mcg daily.Infants under age 6 months. 5 to 6 mcg/kgdaily. Usual: 25 to 50 mcg daily.I.V. OR I.M. INJECTIONAdults. 50 to 100 mcg daily until therapeuticblood level is reached.Children. 75% of usual P.O. dose daily untiltherapeutic blood level is reached. To treat myxedema comaI.V. INJECTIONAdults. 200 to 500 mcg on day 1. If no significantimprovement, 100 to 300 mcg onday 2. Daily dose continued as prescribeduntil therapeutic blood level is reached and

P.O. administration is tolerated.Children. 75% of usual P.O. dose daily untiltherapeutic blood level is reached and P.O.administration is tolerated.Route Onset Peak DurationP.O. 3–5 days 3–4 wk 1–3 wkI.V. 6–8 hr 24 hr UnknownI.M. Unknown Unknown 1–3 wkMechanism of ActionReplaces endogenous thyroid hormone,which may exert its physiologic effects bycontrolling DNA transcription and proteinsynthesis. Levothyroxine has all the followingactions of endogenous thyroid hormone.The drug:• increases energy expenditure• accelerates the rate of cellular oxidation,which stimulates body tissue growth, maturation,and metabolism• regulates differentiation and proliferationof stem cells• aids in myelination of nerves and developmentof synaptic processes in the nervoussystem• regulates growth• decreases blood and hepatic cholesterolconcentrations• enhances carbohydrate and proteinmetabolism, increasing gluconeogenesisand protein synthesis.ContraindicationsAcute MI (unless caused or complicated byhyperthyroidism), hypersensitivity to levothyroxineor its components, uncorrectedadrenal insufficiency, untreated thyrotoxicosisInteractionsDRUGSadrenocorticoids: Possibly adrenocorticoiddosage adjustments as thyroid statuschangesaluminum- and magnesium-containingantacids, bile acid sequestrants, calcium carbonate,cation exchange resins, cholestyramine,colestipol, ferrous sulfate, kayexalate,orlistat, sucralfate: Possibly reduced effectsof levothyroxineamiodarone, iodide: Possibly hyperthyroidismbeta blockers: Possibly impaired action oflevothyroxine sodium 587beta blockers and decreased conversion ofT 4 to triiodothyronine (T 3 )cholestyramine, colestipol: Delayed or inhibitedlevothyroxine absorptiondigoxin: Reduced digoxin effectsestrogen, phenylbutazone, phenytoin:Reduced binding of levothyroxine to protein,possibly requiring increased levothyroxinedosageinsulin, oral antidiabetic drugs: Possiblyuncontrolled diabetes mellitus, requiringincreased dosage of insulin or oral antidiabeticdrugketamine: Possibly hypertension and tachycardiamaprotiline: Increased risk of arrhythmiasoral anticoagulants: Altered anticoagulantactivity, possibly need for anticoagulantdosage adjustmentselective serotonin reuptake inhibitors, tricyclicand tetracyclic antidepressants:Increased therapeutic and toxic effects ofboth drugssympathomimetics: Increased risk of coronaryinsufficiency in patients with coronaryartery diseasetheophylline: Decreased theophylline clearanceFOODSdietary fiber, soybean flour (infant formula),walnuts: Possibly decreased absorption oflevothyroxine from GI tractAdverse ReactionsCNS: Fatigue, headache, insomnia, somnolenceENDO: Hyperthyroidism (with overdose)GI: DysphagiaMS: Muscle weakness, myalgia, slipped capitalfemoral epiphysisSKIN: Alopecia (transient), rash, urticariaOther: Weight gainNursing Considerations• Administer levothyroxine tablets as a singledaily dose 30 to 60 minutes beforebreakfast. If patient has difficulty swallowing,crush tablet and suspend in a smallamount of water or food.• To prevent decreased drug absorption,give oral levothyroxine at least 4 hoursbefore or after aluminum- or magnesiumcontainingantacids, bile acid sequestrants,calcium carbonate, cation exchange resins,cholestyramine, colestipol, ferrous sulfate,JKL

588Indications and Dosages To treat ventricular tachycardia or ventricularfibrillationI.V. INFUSION AND INJECTIONAdults. Loading: 50 to 100 mg (or 1 to1.5 mg/kg), given at 25 to 50 mg/min. Ifdesired response isn’t achieved after 5 to10 min, second dose of 25 to 50 mg (or0.5 to 0.75 mg/kg) given every 5 to 10 minuntil maximum loading dose (300 mg in1 hr) has been given. Maintenance: 20 to50 mcg/kg/min (1 to 4 mg/min) by continuousinfusion. Smaller bolus dose repeated15 to 20 min after start of infusion if neededto maintain therapeutic blood level.Maximum: 300 mg (or 3 mg/kg) over 1 hr.Children. Loading: 1 mg/kg. Maintenance:30 mcg/kg/min by continuous infusion.Maximum: 3 mg/kg.DOSAGE ADJUSTMENT For elderly patientsreceiving I.V. lidocaine to treat arrhythmiasand for patients with acute hepatitis ordecompensated cirrhosis, loading dose andcontinuous infusion rate reduced by 50%.I.M. INJECTIONAdults. 300 mg, repeated after 60 to90 min, if needed. To provide topical anesthesia for skin ormucous membranesFILM-FORMING GEL, JELLY, OR OINTMENTAdults. Thin layer applied to skin ormucous membranes as needed before procedure.TRANSDERMAL PATCHAdults. 1 to 3 patches applied over mostpainful area only once for up to 12 hr withlidocainehydrochloridekayexalate, or sucralfate.• Expect to give drug I.V. or I.M. if patientcan’t take tablets. Be aware that drugshouldn’t be given subcutaneously.• For I.V. use, reconstitute drug by adding5 ml of normal saline solution.• Monitor PT of patient who is receivinganticoagulants; she may require a dosageadjustment.• Monitor blood glucose level of diabeticpatient. Prescriber may reduce antidiabeticdrug dosage as thyroid hormone levelenters therapeutic range.• Expect patient to undergo thyroid functiontests regularly during levothyroxinetherapy.PATIENT TEACHING• Inform patient that levothyroxine replacesa hormone that is normally produced bythe thyroid gland and that she’ll probablyneed to take drug for life.• Instruct patient to take drug at least30 minutes before breakfast because drugabsorption is increased on an empty stomachand evening doses may cause insomnia.• Stress the need to take levothyroxine witha full glass of water to avoid choking, gagging,having tablet stick in throat, anddeveloping heartburn afterward.• Instruct patient to separate iron and calciumsupplements and antacids by at least 4hours from levothyroxine doses.• Inform patient that drug may require afew weeks to take effect.• Advise patient not to stop drug or changedosage unless instructed by prescriber.• Instruct patient to report signs of hyperthyroidism,such as diarrhea, excessivesweating, heat intolerance, insomnia, palpitations,weight loss, chest pain, shortnessof breath, leg cramps, headache, nervousness,irritability, tremors, changes inappetite, vomiting, fever, and changes inmenstrual periods.• Tell patient to notify prescriber if rash orhives develop during drug use.• Inform patient that transient hair loss mayoccur during first few months of levothyroxinetherapy.• Instruct female patient of childbearing ageto notify prescriber immediately if shebecomes pregnant because levothyroxinedosage may need to be increased.lidocainehydrochloride(lignocainehydrochloride)Alphacaine (CAN), Anestacon,DermaFlex, Dilocaine, L-Caine,Lidoderm, Xylocaine, Xylocard (CAN),ZingoClass and CategoryChemical class: AminoacetamideTherapeutic class: Class IB antiarrhythmic,local anestheticPregnancy category: B

in a 24-hr period. To provide topical anesthesia beforevenous access proceduresPOWDERChildren ages 3 to 18. Compressed gasapplication of powder to selected skin site1 to 3 minutes before procedure.Route Onset Peak DurationI.V. 45–90 sec Immediate 10–20 minI.M. 5–15 min Unknown 60–90 minTopical 2–5 min Unknown 0.5–1 hrMechanism of ActionCombines with fast sodium channels inmyocardial cell membranes, which inhibitssodium influx into cells and decreases ventriculardepolarization, automaticity, andexcitability during diastole. Lidocaine alsoblocks nerve impulses by decreasing thepermeability of neuronal membranes tosodium, which produces local anesthesia.ContraindicationsAdams-Stokes syndrome; hypersensitivityto lidocaine, amide anesthetics, or theircomponents; severe heart block (withoutartificial pacemaker); Wolff-Parkinson-White syndromeInteractionsDRUGSbeta blockers, cimetidine: Increased bloodlidocaine level and risk of toxicityMAO inhibitors, tricyclic antidepressants:Risk of severe, prolonged hypertensionmexiletine, tocainide: Additive cardiaceffectsneuromuscular blockers: Possibly increasedneuromuscular blockadephenytoin, procainamide: Increased cardiacdepressionAdverse ReactionsCNS: Anxiety, confusion, difficulty speaking,dizziness, hallucinations, lethargy,paresthesia, seizuresCV: Bradycardia, cardiac arrest, hypotension,new or worsening arrhythmiasEENT: Blurred vision, diplopia, tinnitusGI: NauseaMS: Muscle weakness, myalgiaRESP: Respiratory arrest or depressionOther: Hypersensitivity; injection siteburning, irritation, petechiae, redness,lidocaine hydrochloride 589stinging, swelling, and tenderness; worsenedpainNursing Considerations• Observe for respiratory depression afterbolus injection and during I.V. infusion oflidocaine.• Keep life-support equipment and vasopressorsnearby during I.V. use in case ofrespiratory depression or other reactions.• Carefully check prefilled syringes beforeusing. Use only syringes labeled “for cardiacarrhythmias” for I.V. administration.• As ordered, titrate I.V. dose to minimumamount needed to prevent arrhythmias.• During I.V. administration, place patienton cardiac monitor, as ordered, and closelyobserve her at all times. Monitor for worseningarrhythmias, widening QRS complex,and prolonged PR interval—possiblesigns of drug toxicity.• Check blood drug level, as ordered.Therapeutic level is 2 to 5 mcg/ml.• If signs of toxicity, such as dizziness, occur,notify prescriber and expect to discontinueor slow infusion.• Give I.M. injection in deltoid muscle only.• Apply lidocaine jelly or ointment to gauzeor bandage before applying to skin.• Monitor vital signs as well as BUN andserum creatinine and electrolyte levelsduring and after therapy.PATIENT TEACHING• Inform patient who receives lidocaine asan anesthetic that she’ll feel numbness.• Advise patient to report difficulty speaking,dizziness, injection site pain, nausea,numbness or tingling, and vision changes.• Caution patient to keep lidocaine topicalpreparations and patches out of reach ofchildren and pets.• Tell patient to wash hands thoroughlyafter handling lidocaine topical forms orpatch and to avoid getting drug in eyes.• If patient uses patches, tell her to storethem in their sealed envelopes until neededand to apply immediately after removingfrom the envelope. Tell patient toremove patch if irritation or burningoccurs at the site and not to reapply untilirritation is gone.• Tell patient to fold used patches so that theadhesive side sticks to itself and discardwhere children or pets cannot get to them.JKL

590lincomycin hydrochloridelincomycinhydrochlorideLincocinClass and CategoryChemical class: LincosamideTherapeutic class: Bacteriostatic or bactericidalantibioticPregnancy category: CIndications and Dosages To treat serious respiratory, skin, andsoft-tissue infections caused by susceptiblestrains of streptococci, pneumococci,and staphylococciCAPSULESAdults and adolescents. 500 mg every 6 to8 hr.Children over age 1 month. 7.5 to 15 mg/kg every 6 hr; or, 10 to 20 mg/kg every 8 hr.I.V. INFUSIONAdults. 600 mg to 1 g every 8 to 12 hr.Maximum: 8 g daily in divided doses forlife-threatening infection.Children over age 1 month. 10 to 20 mg/kg/day in divided doses every 8 to 12 hr,depending on severity of infection.I.M. INJECTIONAdults and adolescents. 600 mg every 12 to24 hr.Children over age 1 month. 10 mg/kg every12 to 24 hr.DOSAGE ADJUSTMENT Dosage reduced by25% to 30% for patients with severelyimpaired renal function.Mechanism of ActionInhibits protein synthesis in susceptiblebacteria by binding to 50S subunit of bacterialribosomes and preventing peptide bondformation, causing bacterial cells to die.IncompatibilitiesDon’t give lincomycin with novobiocin orkanamycin.ContraindicationsHypersensitivity to lincomycin, clindamycin,or their componentsInteractionsDRUGSantimyasthenic drugs: Possibly antagonizedeffects of these drugschloramphenicol, clindamycin, erythromycin:Possibly blocked access of lincomycin to itssite of actionhydrocarbon inhalation anesthetics, neuromuscularblockers: Increased neuromuscularblockade, possibly severe respiratorydepressionopioid analgesics: Increased risk of prolongedor increased respiratory depressionAdverse ReactionsCNS: Fever, vertigoCV: Cardiac arrest and hypotension (withrapid administration)EENT: Glossitis, stomatitis, tinnitusGI: Abdominal cramps, colitis, diarrhea,nausea, pseudomembranous colitis, rectalcandidiasis, vomitingGU: Vaginal candidiasisHEME: Agranulocytosis, eosinophilia,leukopenia, neutropenia, thrombocytopenicpurpuraSKIN: Erythema multiforme, rash, Stevens-Johnson syndrome, urticariaOther: Anaphylaxis, angioedema, superinfectionNursing Considerations• Expect to obtain a specimen for cultureand sensitivity testing before giving firstdose of lincomycin.WARNING Be aware that some lincomycinpreparations contain benzyl alcohol,which can cause a fatal toxic syndrome inneonates or premature infants characterizedby CNS, respiratory, circulatory, andrenal impairment and metabolic acidosis.Because drug enters breast milk, breastfeedingpatient may need to stop drug orstop breast-feeding.• Dilute 600-mg dose in at least 100 mlD 5 W, D 10 W, normal saline solution, dextrose5% in normal saline solution, orother compatible diluent recommended bymanufacturer. Dilute higher doses in100 ml of a compatible diluent for eachgram being given—for example, dilute a3-g dose in at least 300 ml of diluent. Usediluted solution within 24 hours if storedat room temperature.WARNING Give lincomycin over at least1 hour for each gram being administered.For example, infuse 1 g over 1 hour and3 g over 3 hours. Too-rapid infusion mayresult in cardiac arrest or hypotension.

WARNING Monitor patient for hypersensitivityreaction, such as rash, pruritus,wheezing, and dysphagia from laryngealedema. If a reaction occurs, stop infusionand notify prescriber immediately. If anaphylaxisoccurs, give epinephrine, antihistamines,oxygen, and corticosteroids, asprescribed. Be aware that patients with ahistory of asthma or significant allergiesare at increased risk of hypersensitivity.• Observe patient for evidence of superinfection,such as vaginal itching and soremouth.• Monitor patient for signs of pseudomembranouscolitis, such as watery, loosestools. Patients with a history of GI disease,particularly colitis or regional enteritis,are at increased risk for colitis. In elderlypatients, antibiotic-related diarrheamay be more severe and less well tolerated.Notify prescriber if severe or prolongeddiarrhea develops; it may indicatepseudomembranous colitis caused byClostridium difficile. Expect to withholdlincomycin and treat with fluids, electrolytes,protein, and an antibiotic effectiveagainst C. difficile.• Monitor results of liver and renal functiontests, CBC, and platelet counts periodicallyduring lincomycin therapy.• Before diluting drug, store it at a controlledroom temperature of 68° to 77° F(20° to 25° C).PATIENT TEACHING• Advise patient to take lincomycin capsuleswith a full glass of water on an emptystomach 1 hour before or 2 hours aftermeals to maximize drug’s effectiveness.• Review with patient possibly seriousadverse reactions, such as difficultybreathing, rash, and chest tightness, andtell her to report any that occur.• Inform patient that yogurt or buttermilkcan help maintain intestinal flora and maydecrease the risk of diarrhea.• Urge patient to tell prescriber about diarrheathat’s severe or lasts longer than3 days. Remind patient that watery orbloody stools can occur 2 or more monthsafter antibiotic therapy and can be serious,requiring prompt treatment.• Stress the importance of following dosageregimen and keeping follow-up medicaland laboratory appointments.lindanelindane 591Bio-Well, GBH, G-well, Hexit (CAN),Kildane, Kwell, Kwellada (CAN),Kwildane, PMS-Lindane (CAN),Scabene, ThionexClass and CategoryChemical class: Benzene derivativeTherapeutic class: Pediculicide, scabicidePregnancy category: BIndications and Dosages To treat scabies and pediculosisCREAM, LOTIONAdults and children. For scabies, thin layerapplied once over entire skin surface. Forpediculosis, thin layer applied once toaffected skin and hair.SHAMPOOAdults and children. 30 ml (for short hair)or 45 ml (for long hair) applied to dry hairand worked into lather for 4 to 5 min.Mechanism of ActionPenetrates parasite skeleton and inhibitsneuronal membrane function, causingseizures and death. Lindane also kills parasiteeggs.ContraindicationsHypersensitivity to lindane or its components,prematurity (in neonates), seizuredisordersInteractionsACTIVITIESuse of oil-based hair products: Possiblyincreased absorption of lindaneAdverse ReactionsCNS: Dizziness, irritability, nervousness,restlessness, seizures, unsteadinessSKIN: Erythema, pruritus, rash, urticariaNursing Considerations• Use lindane cautiously in patients at riskfor CNS toxicity, such as infants, elderlypatients, and patients weighing less than110 lb (50 kg).• Wear gloves when applying drug. If anotherperson will apply drug, supply glovesfor use.• For scabies, apply thin layer of preparationto dry skin and rub in thoroughly. Trimpatient’s nails, and apply under nails withJKL

592linezolidtoothbrush. Apply to body from neckdown, including soles. Leave drug on for 8to 12 hours (usually overnight), and thenremove with bath or shower.• Expect to reduce application time forinfants and children to 6 to 8 hours, asprescribed, because of risk of systemicabsorption.• Keep lindane away from mouth and eyes.Don’t use on open wounds, cuts, or sores.• Expect to give topical steroids or oral antihistaminesto reduce pruritus, which maycontinue for several weeks with scabies.• For hospitalized patients, use speciallinen-handling precautions until treatmentis completed.WARNING Be aware that lindane may causeseizures or other adverse CNS reactions.Use it only after other treatments havebeen tried.• Monitor immunocompromised patientsclosely because they’re at increased risk foradverse reactions.PATIENT TEACHING• Inform patient that lindane is for onetimeuse but may be reapplied after 1 weekif she finds live lice or nits (eggs).• Caution patient to avoid eyes, mucousmembranes, and open areas of skin whenapplying drug and not to inhale vapors.• Instruct patient (or parents of a child) towear gloves when applying drug.• For scabies, instruct patient to shakelotion bottle well before using and toapply lotion or cream in a thin layer allover body from neck down, avoiding faceand scalp. Direct her to leave drug on for 8to 12 hours and then wash it off in thebath or shower. Explain that itching maypersist for several weeks after treatment.• For pubic lice, instruct patient to shakelotion bottle well before using and toapply a thin layer of lotion to pubic hairand skin as well as to groin, thighs, andlower stomach if they’re also affected.Direct her to leave lotion on for 12 hoursand then thoroughly wash it off in thebath or shower.• For head lice, instruct patient to shakelotion bottle well before using and toapply lotion to affected areas of head andscalp as well as nearby hairy areas and rubit in well. Tell her to leave lotion on for12 hours and then thoroughly wash it off.• For head or pubic lice, instruct patient towash and dry her hair before applying lindaneshampoo, especially if she uses oilbasedhair products. Instruct her to shakebottle well before using and then applyshampoo to dry hair, working it in thoroughlyand adding a small amount ofwater if needed to form good lather.Direct her to wait 4 minutes, rinse her hairwell, and then dry it with a clean towel.Instruct her to use a fine-toothed comb ortweezers to remove nits or nit shells.Direct patient not to use shampoo againfor 7 days and then only if she finds livelice. Caution patient not to use shampooin the shower to avoid getting it in hereyes and mouth.• Advise patient to wash lindane off her skinand to contact prescriber if irritation(severe itching, hives, or redness) occurs.• Explain that if lice come back, the problemis probably reinfestation rather thantreatment failure.• Advise patient to notify family membersand sexual contacts about infestation.linezolidZyvoxClass and CategoryChemical class: OxazolidinoneTherapeutic class: AntibioticPregnancy category: CIndications and Dosages To treat vancomycin-resistantEnterococcus faecium infections,including bacteremiaORAL SUSPENSION, TABLETS, I.V. INFUSIONAdults and adolescents. 600 mg every12 hr for 14 to 28 days.Infants and children. 10 mg/kg every 8 hrfor 14 to 28 days. To treat nosocomial pneumonia causedby Staphylococcus aureus (methicillinsusceptibleand -resistant strains) orStreptococcus pneumoniae (penicillinsusceptiblestrains only) and communityacquiredpneumonia, including accompanyingbacteremia, caused by S. aureus(methicillin-susceptible strains only) orS. pneumoniae (penicillin-susceptiblestrains only); to treat complicated skin

linezolid 593Mechanism of ActionLinezolid inhibits bacterial protein synthesisby interfering with translation ofribonucleic acid (RNA) to protein. Inbacteria, protein synthesis begins withbinding of a 30S ribosomal subunit and a50S ribosomal subunit to a messengerRNA (mRNA) molecule to form a 70Sinitiation complex. The 50S ribosomalsubunit consists of 23S ribosomal RNA(rRNA) and other ribosomal subunits.Then translation begins. Transfer RNA(tRNA) attaches to the 50S subunit andbrings specific amino acids into place. Asthe tRNA and amino acids fall into place,they are joined together by peptide bondsand elongate to form a polypeptidechain, as shown below left. This chaineventually combines with other polypeptidechains to form a complete proteinmolecule. After translation is complete,the ribosomal subunits fall away and areready to combine with more mRNA tostart the translation process over again.Linezolid binds to a site on the bacterial23S rRNA of the 50S subunit. Thisaction prevents formation of a functional70S initiation complex, an essential componentof the bacterial translation.Without proper protein production, asshown below right, susceptible bacteriaare unable to multiply. Linezolid is bacteriostaticagainst staphylococci and enterococciand bactericidal against most streptococci.70S initiationcomplexPolypeptide chainAmino acidtRNANonfunctioning70S initiationcomplexJKLMessenger RNA23SrRNA30S subunit50S subunitLinezolidand soft-tissue infections, including diabeticfoot infections without concomitantosteomyelitis, caused by S. aureus(methicillin-susceptible and -resistantstrains), Streptococcus pyogenes, orStreptococcus agalactiaeORAL SUSPENSION, TABLETS, I.V. INFUSIONAdults and adolescents. 600 mg every 12 hrfor 10 to 14 days.Infants and children. 10 mg/kg every 8 hrfor 10 to 14 days. To treat uncomplicated skin and softtissueinfections caused by S. aureus(methicillin-susceptible strains only) orS. pyogenesORAL SUSPENSION, TABLETSAdults. 400 mg every 12 hr for 10 to14 days.Adolescents. 600 mg every 12 hr for 10 to14 days.Children age 5 to 11. 10 mg/kg every 12 hrfor 10 to 14 days.Infants and children to age 5. 10 mg/kgevery 8 hr.IncompatibilitiesDon’t add other drugs to linezolid solution.Don’t infuse linezolid in same I.V. line asamphotericin B, chlorpromazine hydrochloride,co-trimoxazole, diazepam, erythromycinlactobionate, pentamidineisethionate, or phenytoin sodium becausethese drugs are physically incompatible.Don’t infuse linezolid with ceftriaxone sodiumbecause these drugs are chemicallyincompatible.ContraindicationsCarcinoid syndrome; concurrent therapy

594linezolidwith buspirone, dopaminergic agents,meperidine, sympathomimetic agents, serotonin5-HT 1 receptor agonists, serotoninreuptake inhibitors, tricyclic antidepressants,or vasopressive agents without carefulmonitoring; hypersensitivity to linezolid orits components; phenylketonuria; thyrotoxicosis;uncontrolled hypertension; use within14 days of an MAO inhibitorInteractionsDRUGSadrenergics, including pseudoephedrine andphenylpropanolamine: Possibly increasedblood pressurebuspirone, meperidine, serotonergics, tricyclicantidepressants: Possibly serotonin syndromecarbamazepine, phenytoin, phenobarbital,rifampin: Possibly decreased plasma linezolidlevelMAO inhibitors: Increased risk of lifethreateningadverse effectsFOODStyramine-containing foods and beverages:Possibly hypertensionAdverse ReactionsCNS: Dizziness, fever, headache, insomnia,optic and peripheral neuropathy, serotoninsyndromeCV: HypertensionEENT: Oral candidiasis, tooth or tonguediscolorationGI: Abdominal pain, constipation, diarrhea,indigestion, nausea, pseudomembranouscolitis, vomitingGU: Vaginal candidiasisHEME: Anemia, leukopenia, pancytopenia,thrombocytopeniaSKIN: Pruritus, rashOther: Lactic acidosisNursing Considerations• Obtain body tissue and fluid specimensfor culture and sensitivity tests, as ordered,before giving first dose of linezolid. Expectto start drug before test results are known.• Be aware that linezolid shouldn’t be usedto treat catheter-related bloodstreaminfections, catheter-site infections, orinfections caused by gram-negative bacteriabecause the risk of death is higher inthese infections.• Infuse I.V. solution over 30 to 120 minuteswith D 5 W, normal saline solution, or lactatedRinger’s solution.WARNING Monitor CBC weekly, as ordered,to detect or track worsening myelosuppressionin patients who need more than2 weeks of therapy, who have preexistingmyelosuppression and are receiving drugsthat produce bone marrow suppression, orwho have chronic infection and are receivingor have received antibiotic therapy.• Notify prescriber if patient develops visualimpairment that suggests optic neuropathy,such as changes in visual acuity orcolor vision, blurred vision, lost vision, orvisual field defect. If optic or peripheralneuropathy develops, the drug may needto be stopped.• If patient takes a dopaminergic agent,sympathomimetic agent, or vasopressiveagent, monitor blood pressure closely; ifmonitoring isn’t possible, linezolidshouldn’t be prescribed.• If patient takes buspirone, meperidine, aserotinergic, or a tricyclic antidepressant,watch closely for signs and symptoms ofserotonin syndrome; if monitoring isn’tpossible, linezolid shouldn’t be prescribed.• Assess bowel pattern daily. Also watch forsecondary infection, including oral candidiasisand profuse, watery diarrhea.PATIENT TEACHING• Caution patient with phenylketonuria thatoral suspension contains phenylalanine.• Advise patient not to take OTC cold remedieswithout consulting prescriber becausemedications that contain pseudoephedrineor propanolamine may cause or worsenhypertension.• Instruct patient to avoid foods and beveragesthat contain large amounts of tyramine,including aged cheese, fermented orair-dried meats, sauerkraut, soy sauce, tapbeers, red wines, and protein-rich foodsthat have been stored for long periods orpoorly refrigerated.• Instruct patient to notify prescriber atonce about severe diarrhea, even up to2 months after linezolid therapy hasended, because additional treatment maybe needed.• Also tell patient to report vision changesand changes in limb sensation (such aspins and needles, numbness, or tingling)because drug may need to be stopped.

• Reassure patient with tooth discolorationthat professional dental cleaning canrestore tooth color.liothyronine sodium(L-triiodothyronine,sodiumL-triiodothyronine, T 3 ,thyronine sodium)Cytomel, TriostatClass and CategoryChemical class: Synthetic triiodothyronine(T 3 )Therapeutic class: Thyroid hormonereplacementPregnancy category: AIndications and Dosages To treat mild hypothyroidismTABLETSAdults. Initial: 25 mcg daily. Increased by12.5 to 25 mcg every 1 to 2 wk untilresponse occurs. Maintenance: 25 to 50 mcgdaily.DOSAGE ADJUSTMENT For elderly patientsand those with cardiovascular disease, initialdose reduced to 5 mcg daily and thenincreased by 5 mcg every 2 wk. To treat congenital hypothyroidismTABLETSAdults and children. Initial: 5 mcg daily.Increased by 5 mcg every 3 to 4 days untildesired response occurs. Maintenance:Highly individualized. To treat simple nontoxic goiterTABLETSAdults. Initial: 5 mcg daily. Increased by5 to 10 mcg every 1 to 2 wk up to 25 mcgdaily. Then increased by 12.5 to 25 mcg/wk,as indicated. Maintenance: 50 to 100 mcgdaily. To treat myxedemaTABLETSAdults. Initial: 2.5 to 5 mcg daily. Increased5 to 10 mcg every 1 to 2 wk up to 25 mcgdaily. Then increased by 12.5 to 25 mcgevery 1 to 2 wk, as indicated. Maintenance:25 to 50 mcg daily. To treat myxedema coma or premyxedemacoma (severe hypothyroidism)I.V. INJECTIONliothyronine sodium 595Adults. Initial: 25 to 50 mcg. Repeatedevery 4 to 12 hr according to patient’sresponse. Then P.O. therapy is resumed assoon as possible.DOSAGE ADJUSTMENT When treating myxedemacoma in patients with known or suspectedcardiovascular disease, initial dosedecreased to 10 to 20 mcg. To differentiate hyperthyroidism fromeuthyroidism (T 3 suppression test)TABLETSAdults. 75 to 100 mcg daily for 7 days.Route Onset Peak DurationP.O. 24–72 hr 48–72 hr Up to 72 hrI.V. 2–4 hr 2 days UnknownMechanism of ActionReplaces endogenous thyroid hormone,which may exert its physiologic effects bycontrolling DNA transcription and proteinsynthesis. Like endogenous thyroid hormone,liothyronine:• increases energy expenditure• accelerates the rate of cellular oxidation,which stimulates body tissue growth, maturation,and metabolism• regulates differentiation and proliferationof stem cells• aids in myelination of nerves and developmentof synaptic processes in the nervoussystem• regulates growth• decreases blood and hepatic cholesterolconcentrations• enhances carbohydrate and proteinmetabolism, increasing gluconeogenesisand protein synthesis.ContraindicationsAcute MI (unless caused or complicated byhypothyroidism), hypersensitivity to liothyronineor its components, uncorrected adrenalinsufficiency, untreated thyrotoxicosisInteractionsDRUGSadrenocorticoids: Possibly need for adrenocorticoiddosage adjustments as thyroid statuschangesbeta blockers: Possibly impaired action ofbeta blockerscholestyramine, colestipol: Decreased liothyronineabsorptionJKL

596liraglutidedigoxin: Reduced therapeutic effects of digoxinestrogen, phenylbutazone, phenytoin:Reduced binding of liothyronine to protein,possibly requiring increased liothyroninedosageinsulin, oral antidiabetic: Possibly uncontrolleddiabetes mellitus, requiring increaseddosage of insulin or oral antidiabeticketamine: Possibly hypertension and tachycardiamaprotiline: Increased risk of arrhythmiasoral anticoagulants: Altered anticoagulantactivity, possibly need for anticoagulantdosage adjustmentsympathomimetics: Increased risk of coronaryinsufficiency in patients with coronaryartery diseasetheophylline: Decreased theophylline clearancetricyclic antidepressants: Increased therapeuticand toxic effects of both drugsAdverse ReactionsCNS: InsomniaENDO: Hyperthyroidism (with overdose)SKIN: Alopecia (transient), rash, urticariaNursing Considerations• Be aware that liothyronine is used mostoften for rapid onset or rapidly reversiblethyroid hormone replacement.• Administer tablet as a single daily dosebefore breakfast.• Give I.V. injections more than 4 hours butless than 12 hours apart.• Evaluate response to therapy by monitoringpulse rate and blood pressure.• Expect patient to undergo regular tests ofthyroid function during therapy.• Monitor PT of patient receiving anticoagulantsbecause she may require a dosageadjustment.• Frequently monitor blood glucose level ofdiabetic patient. Prescriber may reduceantidiabetic drug dosage as thyroid hormonelevel enters therapeutic range.• Be aware that liothyronine is used in T 3suppression test to differentiate hyperthyroidismfrom euthyroidism (normalthyroid function). For this test, 131 I uptaketest is performed before and after liothyronineadministration. Suppression of 131 Iuptake by 50% indicates normal thyroidfunction.PATIENT TEACHING• Inform patient that liothyronine usually istaken for life. Caution her not to discontinuedrug or change dosage unlessinstructed by prescriber.• Instruct patient to take drug before breakfast;evening doses may cause insomnia.• Advise patient to report signs of hyperthyroidism,such as chest pain, excessivesweating, heat intolerance, increased pulserate, nervousness, and palpitations.• Inform patient that transient hair loss mayoccur during first few months of therapy.• Instruct diabetic patient to monitor bloodglucose level frequently because antidiabeticdrug dosage may need to be reduced.• Inform patient of need for periodic bloodtests to monitor drug effectiveness.liraglutideVictozaClass and CategoryChemical class: Acylated human glucagonlikepeptide-1Therapeutic class: AntidiabeticPregnancy category: CIndications and Dosages To improve glycemic control as anadjunct to diet and exercise in patientswith type 2 diabetes mellitusSUBCUTANEOUS INJECTIONAdults. Initial: 0.6 mg daily for 1 wk., thenincreased to 1.2 mg daily. Maximum:1.8 mg daily.Route Onset Peak DurationSubQ Unknown 8–12 hr UnknownMechanism of ActionActivates the glucagon-like peptide-1 siteon pancreatic beta cells, which increasesintracellular cyclic AMP, which increasesinsulin release when blood glucose level iselevated. In addition, because insulin andglucagon levels occur in an inverse relationshipto plasma glucose level, increasedinsulin level will decrease glucagon level,which inhibits glucagon stimulation of theliver that increases plasma glucose level.Although its exact mechanism is unclear,

liraglutide also delays gastric emptying,which helps prevent a sudden rise in plasmaglucose level after eating. Together theseactions work to lower plasma glucose level.ContraindicationsHistory or presence of medullary thyroidcancer or multiple endocrine neoplasia syndrometype 2, hypersensitivity to liraglutideor its components, ketoacidosis, type 1 diabetesmellitusInteractionsDRUGSoral hypoglycemic agents such as sulfonylureas:Increased risk of hypoglycemiaorally administered drugs: Possiblydecreased absorption of these drugsAdverse ReactionsCNS: Dizziness, fatigue, headacheCV: HypertensionEENT: Nasopharyngitis, sinusitisENDO: Elevated calcitonin levels, thyroidC-cell hyperplasia, thyroid cancerGI: Anorexia, constipation, diarrhea, dyspepsia,nausea, pancreatitis, slowed gastricemptying, vomitingGU: UTIMS: Back painRESP: Upper respiratory tract infectionSKIN: UrticariaOther: Angioedema, anti-liraglutide antibodies,influenzaNursing Considerations• Be aware that liraglutide isn’t recommendedas first-line therapy for patients withtype 2 diabetes mellitus not well controlledwith diet and exercise. It also isn’t asubstitute for insulin therapy.• Liraglutide shouldn’t be given to a patientwith a history of thyroid C-cell tumors,including medullary thyroid carcinoma, orto patients with multiple endorcrine neoplasiasyndrome type 2 because drug maystimulate tumor growth.• Use liraglutide cautiously in patients witha history of pancreatitis because drug cancause pancreatitis and in patients withimpaired hepatic or renal functionbecause drug effects in these patients areunknown.• Dosage of liraglutide given during firstweek of therapy isn’t enough to provideglycemic control but is given to minimizelisdexamfetamine dimesylate 597adverse effects when dosage is increased.• Monitor patient’s serum calcitonin levels,as indicated. Be aware that elevationsoccur more often when liraglutide dosageis 1.8 mg daily.• Monitor patient for pancreatitis, especiallywhen therapy starts or dosage increases.Report persistent severe abdominal pain; itmay radiate to the back and may beaccompanied by vomiting. If pancreatitisis confirmed, expect to stop drug and notrestart it after episode has been resolved.• Monitor patient for hypoglycemia, especiallyif he takes another antidiabetic, suchas a sulfonylurea. Report any episode ofhypoglycemia because dosage of otherantidiabetic may need adjustment. Treathypoglycemia with a glucose-containingfood or beverage or give glucagons, asordered, to raise blood glucose level.• Monitor patient’s blood glucose level andhemoglobin A 1C regularly, as ordered toassess effectiveness of drug.• Monitor effectiveness of all other oraldrugs because liraglutide slows gastricemptying and may impair their absorption.Alert prescriber to any concerns.PATIENT TEACHING• Teach patient how to use prefilled multidosepen and how to give a subcutaneousinjection. Explain that he’ll need to injectdrug daily but that he can do it at anytime of day, independent of meals. Tellpatient to inject drug into his abdomen,thigh, or upper arm and to rotate sites tominimize injection site reactions.• Advise patient of possible risk of medullarythyroid cancer and need to report anysymptoms, such as a neck mass, dysphagia,dyspnea, or persistent hoarseness.• Stress that liraglutide therapy isn’t a substitutefor diet and exercise but is used toenhance effectiveness of these measures.lisdexamfetaminedimesylateVyvanseClass and CategoryChemical class: Sympathomimetic amineTherapeutic class: CNS stimulantJKL

598Nursing ConsiderationsWARNING Chest pain or fainting should bereported to presciber immediately.WARNING Lisdexamfetamine shouldn’t begiven to patients with structural cardiacabnormalities, cardiomyopathy, or otherserious heart problems or rhythm abnormalitiesbecause even usual CNSlisdexamfetaminedimesylatePregnancy category: CIndications and Dosages To treat attention deficit hyperactivitydisorder (ADHD)CAPSULESAdults and children ages 6 to 12. Initial:30 mg once daily in the morning, increasedas needed in increments of 10 or 20 mgdaily every wk. Maximum: 70 mg daily.Route Onset Peak DurationP.O. Unknown 1 hr UnknownMechanism of ActionProduces CNS stimulant effects, probablyby facilitating release and blocking reuptakeof norepinephrine at adrenergic nerve terminalsand by stimulating alpha and betareceptors in peripheral nervous system. Thedrug also releases and blocks reuptake ofdopamine in limbic regions of brain. Theseactions cause decreased motor restlessnessand increased alertness.ContraindicationsAdvanced arteriosclerosis; agitation; glaucoma;history of drug abuse, hypersensitivity,or idiosyncratic reaction to lisdexamfetamine,other sympathomimetic amines, ortheir components; hyperthyroidism; MAOinhibitor therapy within 14 days; moderateto severe hypertension; symptomatic cardiovasculardisease; history of seizuresInteractionsDRUGSadrenergic blockers: Inhibited adrenergicblockadeacetazolamide, alkalinizers (such as sodiumbicarbonate), some thiazides: Increasedblood level and effects of lisdexamfetamineantihistamines: Possibly reduced sedationfrom antihistamineantihypertensives: Possibly decreased antihypertensiveeffectschlorpromazine: Inhibited CNS stimulanteffects of lisdexamfetamineethosuximide: Possibly delayed ethosuximideabsorptionGI acidifiers (such as ascorbic acid), reserpine:Decreased amphetamine absorptionguanethine: Decreased antihypertensiveeffect and decreased lisdexamfetamineabsorptionhaloperidol: Decreased CNS stimulationlithium carbonate: Possibly decreasedanorectic and stimulant effects of lisdexamfetamineMAO inhibitors: Potentiated effects of lisdexamfetamine,possibly hypertensive crisismeperidine: Increased analgesiamethenamine: Increased urine excretionand decreased effects of lisdexamfetaminenorepinephrine: Possibly increased adrenergiceffect of norepinephrinephenobarbital, phenytoin: Synergistic anticonvulsantactionpropoxyphene: Increased CNS stimulation,potentially fatal seizuressympathomimetic drugs: Increased stimulanteffecttricyclic antidepressants: Possibly increasedantidepressant effects and decreased lisdexamfetamineeffectsurinary acidifiers (such as ammonium chlorideand sodium acid phosphate): Increasedamphetamine excretion and decreasedamphetamine blood level and effectsveratrum alkaloids: Decreased hypotensiveeffectAdverse ReactionsCNS: Affect lability, aggression, agitation,anxiety, dizziness, fever, hallucinations,headache, insomnia, irritability, jittery feeling,mania, psychomotor hyperactivity, psychoticepisodes, seizures, somnolence, tic,tremorCV: Hypertension, tachycardia, ventricularhyperthrophyEENT: Blurred vision, dry mouthGI: Anorexia, diarrhea, nausea, vomiting,upper abdominal painGU: Decreased libido, erectile dysfunctionRESP: DyspneaSKIN: Diaphoresis, rash, Stevens-Johnsonsyndrome, toxic epidermal necrolysis,urticariaOther: Anaphylaxis, angioedema, physicalor psychological dependence, weight loss

stimulant dosages increase risk of suddendeath in patients with these conditions.• Use lisdexamfetamine cautiously inpatients with hypertension, heart failure,recent MI, or ventricular arrhythmiabecause drug may increase blood pressureand worsen these conditions.• Monitor patient’s blood pressure closely;stimulant drugs such as lisdexamfetaminemay increase it.• Monitor patients with psychosis, bipolarillness, or a history of aggression or hostility;CNS stimulation may worsen symptoms.• Assess growth pattern in pediatric patientsbecause stimulants such as lisdexamfetaminemay suppress growth. If so, notifyprescriber and expect therapy to be halted.• If patient has a history of seizures or EEGabnormality, watch for seizure activitybecause stimulants may lower seizurethreshold. Rarely, lisamfetamine may causeseizures in a patient with no history ofthem. Take seizure precautions in allpatients, and notify prescriber if a seizureoccurs. Expect to discontinue lisdexamfetamine,as prescribed.• Take safety precautions because stimulantsmay alter accommodation and causeblurred vision. Although these effectshaven’t been reported with lisdexamfetamine,the drug is a known stimlulant.• Be aware that therapy may be stoppedtemporarily to assess continued need forit, as evidenced by a return of hyperactivityand attention deficit.PATIENT TEACHINGWARNING Tell patient with symptoms suchas chest pain or fainting to contactpresciber immediately.• Warn patient or caregiver that drug mustbe taken exactly as prescribed and dosageincreased only at prescriber’s instructionbecause drug can be abused or lead todependence.• Instruct patient or caregiver that capsulemay be opened and contents dissolved in aglass of water and drunk immediately.• Tell patient or caregiver that drug shouldonly be taken in the morning because takingit later in the day may cause insomnia.• Advise patient or caregiver to report anysymptoms that suggest heart disease, suchas such as exertional chest pain or unexplainedsyncope.• Urge patient to avoid hazardous activitiesuntil drug effects are known.•Tell female patient of childbearing age tonotify prescriber if pregnancy is suspected.lisinoprilPrinivil, Zestrillisinopril 599Class and CategoryChemical class: Lysine ester of enalaprilatTherapeutic class: Antihypertensive, vasodilatorPregnancy category: C (first trimester), D(later trimesters)Indications and Dosages To manage uncomplicated essentialhypertensionTABLETSAdults. Initial: 10 mg daily. Maintenance:20 to 40 mg daily. Maximum: 80 mg daily.DOSAGE ADJUSTMENT For patients withrenal failure, initial dosage reduced to 5 mgdaily if creatinine clearance is 10 to 30 ml/min/1.73 m 2 and to 2.5 mg daily if creatinineclearance is less than 10 ml/min/1.73 m 2 . For patients receiving a diuretic,initial dosage reduced to 5 mg daily.Children age 6 and over with a GFR of atleast 30 ml/min/1.73 m 2 . Initial: 0.07 mg/kg daily, adjusted according to blood pressureresponse up to 5 mg daily. Maximum:0.61 mg/kg or 40 mg daily. To treat heart failure, along with digoxinand diureticsTABLETSAdults. Initial: 5 mg daily. Maintenance:5 to 20 mg daily. Maximum: 80 mg daily.DOSAGE ADJUSTMENT For patients withhyponatremia or creatinine clearance of30 ml/min/1.73 m 2 or less, initial dosagereduced to 2.5 mg daily. To improve survival in hemodynamicallystable patient after acute MITABLETSAdults. 5 mg within 24 hr after onset ofsymptoms, followed by 5 mg after 24 hrand 10 mg after 48 hr. Maintenance: 10 mgdaily for 6 wk. Maximum: 80 mg daily.DOSAGE ADJUSTMENT For patients withbaseline systolic blood pressure of 120 mmJKL

600Nursing Considerations• Use lisinopril cautiously in patients withfluid volume deficit, heart failure, impairedrenal function, or sodium depletion.• To prepare pediatric suspension, add10 ml purified water to a polyethyleneterephthalate (PET) bottle containing ten20-mg tablets and shake for at least1 minute. Add 30 ml of Bicitra diluent and160 ml of Ora-Sweet SF to concentrate inPET bottle and shake gently for severalseconds. Refrigerate up to 4 weeks. Shakesuspension before each use.• Monitor blood pressure often, especiallyearly in treatment. If excessive hypotensiondevelops, expect to withhold drugfor several days.WARNING If angioedema affects face, glottis,larynx, limbs, lips, mucous memlisinoprilHg or less, initial dosage decreased to2.5 mg daily for first 3 days after MI. If systolicblood pressure falls to 100 mm Hg orless during therapy, maintenance dosagedecreased to 2.5 to 5 mg as tolerated; if systolicblood pressure is 90 mm Hg or less formore than 1 hr, drug is discontinued.Route Onset Peak DurationP.O. 1 hr 6–8 hr 24 hrMechanism of ActionMay reduce blood pressure by inhibitingconversion of angiotensin I to angiotensinII. Angiotensin II is a potent vasoconstrictorthat also stimulates adrenal cortex tosecrete aldosterone. Lisinopril may alsoinhibit renal and vascular production ofangiotensin II. Decreased release of aldosteronereduces sodium and water reabsorptionand increases their excretion, therebyreducing blood pressure.ContraindicationsHypersensitivity to lisinopril, other ACEinhibitors, or their components; history ofangioedema related to previous treatmentwith an ACE inhibitor; hereditary or idiopathicangioedemaInteractionsDRUGSallopurinol, bone marrow depressants (suchas methotrexate), procainamide, systemiccorticosteroids: Increased risk of potentiallyfatal neutropenia or agranulocytosiscyclosporine, potassium-sparing diuretics,potassium supplements: Increased risk ofhyperkalemiadiuretics, other antihypertensives: Increasedhypotensive effectinsulin, oral antidiabetics: Increased risk ofhypoglycemialithium: Increased blood lithium level andrisk of lithium toxicityNSAIDs: Possibly reduced antihypertensiveeffect, reduced renal function in patientswith preexisting renal dysfunctionsympathomimetics: Possibly reduced antihypertensiveeffectFOODShigh-potassium diet, potassium-containingsalt substitutes: Increased risk of hyperkalemiaACTIVITIESalcohol use: Possibly increased hypotensiveeffectAdverse ReactionsCNS: Ataxia, confusion, depression, dizziness,fatigue, headache, mood alterations,nervousness, stroke, syncope, transientischemic attack, vertigoCV: Arrhythmias, chest pain, hypotension,MI, orthostatic hypotension, palpitations,peripheral edema, vasculitisENDO: Hyperglycemia, syndrome of inappropriateADH secretionEENT: Olfactory disturbanceGI: Abdominal pain, anorexia, cholestaticjaundice, diarrhea, elevated liver enzymelevels, fulminant hepatic necrosis, gastritis,hepatitis, indigestion, nausea, pancreatitis,vomitingGU: Acute renal failure, decreased libido,impotence, pyelonephritisHEME: Agranulocytosis, anemia, hemolyticanemia, neutropenia, thrombocytopeniaMS: Muscle spasms, myalgiaRESP: Bronchospasm, cough, dyspnea,paroxysmal nocturnal dyspnea, pulmonaryembolism and infarction, upper respiratorytract infectionSKIN: Alopecia, cutaneous pseudolymphoma,diaphoresis, erythema, flushing,herpes zoster, infections, pemphigus, photosensitivity,pruritus, rash, Stevens-Johnson syndrome, toxic epidermal necrolysis,urticariaOther: Anaphylaxis, angioedema

anes, or tongue, notify prescriber immediatelyand expect to stop lisinopril andstart appropriate therapy at once. If airwayobstruction threatens, promptly give 0.3 to0.5 ml of epinephrine 1:1,000 solutionsubcutaneously, as prescribed.• Monitor patient for anaphylaxis, especiallypatient being dialyzed with high-fluxmembranes and treated with an ACEinhibitor such as lisinopril. If anaphylaxisoccurs, stop dialysis immediately and treataggressively (antihistamines are ineffectivein this situation), as ordered. Anaphylaxishas also occurred with some patientsundergoing low-density lipoproteinapheresis with dextran sulfate absorption.• Notify prescriber if patient has persistent,nonproductive cough, a common adverseeffect of ACE inhibitors such as lisinopril.• Monitor for dehydration, which can leadto hypotension. Be aware that diarrheaand vomiting can cause dehydration.• Monitor patient for hepatic dysfunctionbecause lisinopril, an ACE inhibitor, mayrarely cause a syndrome that starts withcholestatic jaundice or hepatitis and progressesto fulminant hepatic necrosis. Ifpatient develops jaundice or a marked elevationin liver enzyme levels, withholddrug and notify prescriber.• If patient takes insulin or an oral antidiabetic,monitor blood glucose level closelybecause risk of hypoglycemia increases,especially during first month of therapy.PATIENT TEACHING• Explain that lisinopril helps to control butdoesn’t cure hypertension and that patientmay need lifelong therapy.• Advise patient to take lisinopril at thesame time every day.• Emphasize need to take drug as ordered,even if patient feels well; caution her notto stop drug without consulting prescriber.• Instruct patient to report dizziness, especiallyduring first few days of therapy.• Inform patient that persistent, nonproductivecough may develop during lisinopriltherapy. Urge her to notify prescriberimmediately if cough becomes difficult totolerate.• Advise patient to drink adequate fluid andavoid excessive sweating, which can lead todehydration and hypotension. Make surelithium 601she understands that diarrhea and vomitingalso can cause hypotension.• Caution patient not to use salt substitutesthat contain potassium.• Instruct patient to report signs of infection,such as fever and sore throat, whichmay indicate neutropenia.• Advise patient to change position slowly tominimize orthostatic hypotension.• If patient has diabetes and takes insulin oran oral antidiabetic, urge her to monitorher blood glucose level closely and watchfor symptoms of hypoglycemia.• Caution female patient to notify prescriberimmediately if she is or could be pregnant.lithium carbonateCarbolith (CAN), Duralith (CAN),Eskalith, Eskalith CR, Lithane,Lithizine (CAN), Lithobid, Lithonate,Lithotabslithium citrateCibalith-SClass and CategoryChemical class: Alkaline metal, monovalentcationTherapeutic class: Antidepressant, antimanicPregnancy category: DIndications and Dosages To treat recurrent bipolar affective disorder,to prevent bipolar disorderdepressionCAPSULES, TABLETSAdults and children age 12 and over. Initial:300 to 600 mg t.i.d. Maintenance: 300 mgt.i.d. or q.i.d. Maximum: 2,400 g daily.Children up to age 12. 15 to 20 mg/kg dailyin divided doses b.i.d. or t.i.d.E.R. TABLETSAdults and children age 12 and over. Initial:900 to 1,800 mg daily in divided doses b.i.d.or t.i.d. Maintenance: 450 mg b.i.d. or300 mg t.i.d. Maximum: 2,400 g daily.SLOW-RELEASE CAPSULESAdults and children age 12 and over. 600 to900 mg on day 1, increased to 1,200 to1,800 mg daily in divided doses t.i.d.Maintenance: 900 to 1,200 mg daily individed doses t.i.d. Maximum: 2,400 g daily.JKL

602lithiumSYRUP (LITHIUM CITRATE)Adults and children age 12 and over. 8 to16 mEq (equivalent of 300 to 600 mg oflithium carbonate) t.i.d. Maintenance:Equivalent of 300 mg of lithium carbonatet.i.d. or q.i.d. Maximum: Equivalent of2,400 g daily of lithium carbonate.Children up to age 12. 0.4 to 0.5 mEq(equivalent of 15 to 20 mg of lithium carbonate)/kg daily in divided doses b.i.d. ort.i.d.Route Onset Peak DurationP.O. 1–3 wk Unknown UnknownMechanism of ActionMay increase presynaptic degradation ofthe catecholamine neurotransmitters serotonin,dopamine, and norepinephrine;inhibit their release at neuronal synapses;and decrease postsynaptic receptor sensitivity.These actions may correct overactivecatecholamine systems in patients withmania.Antidepressant action may result fromenhanced serotonergic activity.ContraindicationsBlood dyscrasias, bone marrow depression,brain damage, cerebrovascular disease,coma, coronary artery disease, excessiveintake of other CNS depressants, hypersensitivityto lithium or its components,impaired hepatic function, myeloproliferativedisorders, severe depression, severehypertension or hypotensionInteractionsDRUGSACE inhibitors, NSAIDs, piroxicam: Possiblyincreased blood lithium level and increasedrisk of toxicityacetazolamide, sodium bicarbonate, urea,xanthines: Decreased blood lithium levelcalcium channel blockers, molindone:Increased risk of neurotoxicity from lithiumcalcium iodide, iodinated glycerol, potassiumiodide: Possibly increased hypothyroideffects of both drugscarbamazepine: Possibly increased therapeuticeffects of carbamazepine and neurotoxiceffect of lithiumchlorpromazine, other phenothiazines:Possibly impaired GI absorption anddecreased blood levels of these drugs; possiblymasking of early signs of lithium toxicitydesmopressin, lypressin, vasopressin: Possiblyimpaired antidiuretic effects of these drugsdiuretics (loop and osmotic): Increased lithiumreabsorption by kidneys, possibly leadingto lithium toxicityfluoxetine, methyldopa, metronidazole:Increased risk of lithium toxicity fromreduced renal clearance of lithiunhaloperidol and other antipyschotics:Increased risk of irreversible neurotoxicityand brain damageneuromuscular blockers: Risk of prolongedparalysis or weaknessnorepinephrine: Possibly decreased therapeuticeffects of norepinephrine and severerespiratory depressionselective serotonin reuptake inhibitors:Increased risk of adverse effects, such asdiarrhea, confusion, dizziness, agitation,and tremorthyroid hormones: Possibly hypothyroidismtricyclic antidepressants: Possibly severemood swings from mania to depressionFOODShigh-sodium foods: Increased excretion andpossibly decreased therapeutic effects oflithiumAdverse ReactionsCNS: Ataxia, coma, confusion, depression,dizziness, drowsiness, headache, lethargy,seizures, syncope, tremor (in hands), vertigoCV: Arrhythmias (including bradycardiaand tachycardia), ECG changes, edemaEENT: Dental caries, dry mouth, exophthalmosENDO: Diabetes insipidus, euthyroid goiter,hypothyroidism, myxedemaGI: Abdominal distention and pain, anorexia,diarrhea, nausea, thirstGU: Stress incontinence, urinary frequencyHEME: LeukocytosisMS: Muscle twitching and weaknessRESP: DyspneaSKIN: Acne; alopecia; dry, thin hair; pruritus;rashOther: Cold sensitivity, weight gain or lossNursing Considerations• Administer lithium after meals to slowabsorption from GI tract and reduceadverse reactions. Dilute syrup with juice

or other flavored drink before giving.• Note that 5 ml of lithium citrate equals8 mEq of lithium ion or 300 mg of lithiumcarbonate.• Expect to monitor blood lithium level twoor three times weekly during first month,and then weekly to monthly during maintenancetherapy and when starting orstopping NSAID therapy. In uncomplicatedcases, plan to monitor lithium levelevery 2 to 3 months.• Be aware that lithium has a narrow therapeuticrange. Even a slightly high bloodlevel is dangerous, and some patients showsigns of toxicity at normal levels.• Expect prescriber to decrease dosage afteracute manic episode is controlled.WARNING Be aware that lithium affectsintracellular and extracellular potassiumion shift, which can cause ECG changes,such as flattened or inverted T waves; italso can increase the risk of cardiac arrest.• Monitor ECGs, renal and thyroid functiontest results, and serum electrolyte levels, asappropriate, during lithium treatment.WARNING Be aware that lithium can causereversible leukocytosis, which usuallypeaks within 7 to 10 days of starting therapy;WBC count typically returns to baselinewithin 10 days after therapy stops.• Weigh patient daily to detect suddenweight changes.• Monitor blood glucose level often in diabeticpatient because lithium alters glucosetolerance.• Palpate thyroid gland to detect enlargementbecause drug may cause goiter.• Ensure that patient’s fluid and sodiumintake is adequate during treatment.lomefloxacin hydrochloride 603PATIENT TEACHING• Advise patient to take lithium with or aftermeals to minimize adverse reactions.• Instruct patient to swallow E.R. or slowreleaseform whole.• Direct patient to mix syrup form withjuice or other flavored drink before taking.• Inform patient that frequent urination,nausea, and thirst may occur during thefirst few days of treatment.• Caution patient not to stop taking lithiumor adjust dosage without first consultingprescriber.• Instruct patient to report signs of toxicity,such as diarrhea, drowsiness, muscle weakness,tremor, uncoordinated body movements,and vomiting.• Urge patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to maintain normal fluidand sodium intake.• Emphasize importance of complying withscheduled checkups and laboratory tests.lomefloxacinhydrochlorideMaxaquinClass and CategoryChemical class: FluoroquinoloneTherapeutic class: AntibioticPregnancy category: CIndications and Dosage To treat mild to moderate lower respiratorytract infections caused by susceptibleorganisms, including Haemophilusinfluenzae and Moraxella catarrhalisTABLETSAdults. 400 mg daily for 10 days. To treat uncomplicated cystitis caused byEscherichia coli; to treat uncomplicatedcystitis caused by Klebsiella pneumoniae,Proteus mirabilis, orStaphylococcus saprophyticusTABLETSAdults. 400 mg daily for 3 days. To treat complicated UTI caused byCitrobacter diversus, Enterobacteriaceae,E. coli, K. pneumoniae, P.mirabilis, or Pseudomonas aeruginosaTABLETSAdults. 400 mg daily for 14 days. To provide prophylaxis for transurethralsurgeryTABLETSAdults. 400 mg as a single dose 2 to 6 hrbefore surgery. To provide prophylaxis for transrectalbiopsyTABLETSAdults. 400 mg as a single dose 1 to 6 hrbefore surgery. To treat gonorrhea (as alternative tociprofloxacin or ofloxacin)TABLETSAdults. 400 mg as a single dose.JKL

604given to patients with QT-interval prolongationor hypokalemia or to patients takingclass IA antiarrhythmics (such asquinidine or procainamide) or class IIIantiarrhythmics (such as amiodarone orsotalol) because of increased risk of torsadesde pointes.• Expect to obtain body fluid or tissue samplefor culture and sensitivity testing andto review results, if possible, before lomefloxacintherapy begins.•If patient’s culture test results are positivefor gonorrhea, expect to obtain serologictest for syphilis at diagnosis and to repeattest 3 months after lomefloxacin therapy.• Give drug with meals and a full glass ofwater.• Ensure that patient maintains adequatefluid intake during therapy.• Monitor for evidence of secondary infections,such as sore mouth or vaginal discharge.• Notify prescriber if patient experiencessevere or prolonged diarrhea, which mayindicate pseudomembranous colitis.• Be aware that prolonged use may lead togrowth of drug-resistant organisms.• Notify prescriber and expect to stop lomefloxacinif patient develops symptoms ofperipheral neuropathy (pain, burning, tingling,numbness, weakness, or changes insensations of light touch, pain, temperature,position, or vibration) to prevent anirreversible condition or tendon rupturethat requires immediate rest and avoidanceof exercise involving affected area.PATIENT TEACHING• Advise patient to take lomefloxacin atsame time each day with meals and with afull glass of water.• Caution patient not to take antacids, iron,sucralfate, or zinc 1 hour before or 2 hoursafter taking lomefloxacin because thesepreparations impair drug absorption.• Urge patient to drink plenty of fluids duringtreatment.• Instruct patient to complete full course oftherapy, even if symptoms subside.• Advise patient to notify prescriber ifsymptoms don’t improve within a fewdays after starting lomefloxacin or if severeGI distress or diarrhea develops.• Instruct patient to notify prescriber andstop taking drug if she has tendon inflamlomefloxacinhydrochlorideDOSAGE ADJUSTMENT For patients with creatinineclearance between 11 and 39 ml/min/1.73 m 2 , loading dose of 400 mg givenon day 1 and followed by 200 mg daily.Mechanism of ActionInhibits the bacterial enzyme DNA gyrase,which normally is responsible for unwindingand supercoiling of bacterial DNAbefore it replicates. By inhibiting thisenzyme, lomefloxacin interferes with bacterialcell replication and causes cell death.ContraindicationsHistory of tendinitis or tendon rupture,hypersensitivity to lomefloxacin or anyquinolone derivativeInteractionsDRUGSaluminum-, calcium-, or magnesiumcontainingantacids; iron salts; sucralfate;zinc: Decreased absorption and blood levelof lomefloxacincyclosporine: Possibly increased bloodcyclosporine level, increased nephrotoxicityprobenecid: Decreased lomefloxacin excretion,increased risk of toxicitywarfarin: Possibly increased anticoagulanteffect and risk of bleedingAdverse ReactionsCNS: Ataxia, cerebral thrombosis, dizziness,drowsiness, hallucinations, headache,insomnia, nervousness, peripheral neuropathy,phobia, vertigoCV: Prolonged QT interval, torsades depointes, vasculitisEENT: Diplopia, laryngeal edema, oral candidiasis,painful oral mucosa, taste perversionGI: Abdominal pain, diarrhea, hepatitis,indigestion, nausea, pseudomembranouscolitis, vomitingGU: Interstitial nephritis, polyuria, renalfailure, urine retention, vaginal candidiasisHEME: Hemolytic anemiaMS: Tendinitis, tendon ruptureRESP: Pulmonary edemaSKIN: Exfolitaive dermatitis, hyperpigmentation,photosensitivity, Stevens-Johnsonsyndrome, toxic epidermal necrolysisOther: AnaphylaxisNursing Considerations• Know that lomefloxacin shouldn’t be

mation or pain; advise her to rest untiltendinitis and tendon rupture have beenruled out.• Urge patient to avoid direct sunlight, towear protective clothing, and to use sunscreenbecause photosensitivity reactionscan occur during therapy and for severaldays afterward.• Explain that risk of photosensitivity can bedecreased by taking lomefloxacin at least12 hours before sun exposure. Urgepatient to stop drug and notify prescriberat first sign of photosensitivity, such asskin burning, redness, swelling, blisters,rash, itching, or dermatitis.• Inform patient that an allergic reactionmay occur after a single dose. Tell patientto stop lomefloxacin and notify prescriberif rash or other allergic reaction develops.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.loracarbefLorabidClass and CategoryChemical class: CarbacephemTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat acute bronchitis caused byHaemophilus influenzae, Moraxellacatarrhalis, or Streptococcus pneumoniaeCAPSULES, ORAL SUSPENSIONAdults and adolescents. 200 to 400 mgevery 12 hr for 7 days. To treat chronic bronchitis exacerbationscaused by H. influenzae, M. catarrhalis,or S. pneumoniaeCAPSULES, ORAL SUSPENSIONAdults and adolescents. 400 mg every12 hr for 7 days. To treat pneumonia caused by H.influenzae or S. pneumoniaeCAPSULES, ORAL SUSPENSIONAdults and adolescents. 400 mg every12 hr for 14 days. To treat pharyngitis, sinusitis, or tonsillitiscaused by Streptococcus pyogenesCAPSULES, ORAL SUSPENSIONAdults and adolescents. 200 to 400 mgloracarbef 605every 12 hr for 10 days.Children. 7.5 mg/kg every 12 hr for 10 days. To treat acute otitis media caused by H.influenzae, M. catarrhalis, S. pneumoniae,or S. pyogenesORAL SUSPENSIONChildren. 15 mg/kg every 12 hr for 10 days. To treat uncomplicated skin and softtissueinfections caused by Staphylococcusaureus or S. pyogenesCAPSULES, ORAL SUSPENSIONAdults and adolescents. 200 mg every12 hr for 7 days.ORAL SUSPENSIONChildren. 7.5 mg/kg every 12 hr for 7 days. To treat uncomplicated cystitis caused byEscherichia coli or Staphylococcus saprophyticusCAPSULES, ORAL SUSPENSIONAdults and adolescents. 200 mg daily for7 days. To treat uncomplicated pyelonephritiscaused by E. coliCAPSULES, ORAL SUSPENSIONAdults and adolescents. 400 mg every12 hr for 14 days.DOSAGE ADJUSTMENT If creatinine clearanceis 10 to 49 ml/min/1.73 m 2 , 50% of usualdose given at normal interval or usual dosegiven at twice the normal interval; if clearanceis less than 10 ml/min/1.73 m 2 , usualadult dosage given every 3 to 5 days.Mechanism of ActionInterferes with bacterial cell wall synthesisby inhibiting final step in the cross-linkingof peptidoglycan strands. Peptidoglycanmakes bacterial cell membrane rigid andprotective. Without it, bacterial cells ruptureand die.ContraindicationsHypersensitivity to loracarbef, othercephalosporins, or their componentsInteractionsDRUGSprobenecid: Inhibited renal excretion ofloracarbef, resulting in increased blood levelFOODSall foods: Inhibited drug absorptionAdverse ReactionsCNS: Dizziness, drowsiness, headache,insomnia, nervousness, seizuresEENT: Oral candidiasisJKL

606lorazepamGI: Abdominal pain, anorexia, diarrhea, nausea,pseudomembranous colitis, vomitingGU: Vaginal candidiasisSKIN: Pruritus, rash, urticariaNursing Considerations• Expect to obtain body fluid or tissue samplefor culture and sensitivity testing andto review results, if possible, before givingfirst dose of loracarbef.• Be aware that oral suspension is absorbedmore rapidly and produces a higher peakplasma level than capsules.• Monitor patient for signs of secondaryinfections, such as sore mouth and vaginaldischarge.• Watch for seizures, especially if patient hasimpaired renal function.PATIENT TEACHING• Advise patient to take loracarbef at least1 hour before or 2 hours after meals.• Tell patient to complete full course of drugas prescribed, even if symptoms decrease.• Instruct patient to discard unused oralsolution after 14 days.• Advise patient to report diarrhea, hives, orsevere rash to prescriber.lorazepamApo-Lorazepam (CAN), Ativan,Lorazepam Intensol, Novo-Lorazem(CAN), Nu-Loraz (CAN)Class, Category, and ScheduleChemical class: BenzodiazepineTherapeutic class: Amnestic, antianxiety,anticonvulsant, sedativePregnancy category: D (parenteral), Notrated (oral)Controlled substance schedule: IVIndications and Dosages To treat anxietyORAL CONCENTRATE, TABLETSAdults and adolescents. 1 to 3 mg b.i.d. ort.i.d. Maximum: 10 mg daily.DOSAGE ADJUSTMENT For elderly or debilitatedpatients, initial dosage may be reducedto 0.5 to 2 mg daily in divided doses. To treat insomnia caused by anxietyORAL CONCENTRATE, TABLETSAdults and adolescents. 2 to 4 mg at bedtime.DOSAGE ADJUSTMENT Dosage possiblyreduced for elderly or debilitated patients. To provide preoperative sedationI.V. INJECTIONAdults and adolescents. 0.044 mg/kg or2 mg, whichever is less, given 2 hr beforeprocedure. Maximum: 0.05 mg/kg or totalof 4 mg.I.M. INJECTIONAdults and adolescents. 0.05 mg/kg 2 hrbefore procedure. Maximum: 4 mg. To treat status epilepticusI.V. INJECTIONAdults and adolescents. Initial: 4 mg at arate of 2 mg/min. Repeated in 10 to 15 minif seizures don’t subside. Maximum: 8 mg/24 hr.Route Onset Peak DurationI.V. 5 min Unknown 12–24 hrI.M. 15–30 min Unknown 12–24 hrMechanism of ActionMay potentiate the effects of gammaaminobutyricacid (GABA) and otherinhibitory neurotransmitters by binding tospecific benzodiazepine receptors in limbicand cortical areas of CNS. GABA inhibitsexcitatory stimulation, which helps controlemotional behavior. Limbic system containsa highly dense area of benzodiazepinereceptors, which may explain drug’santianxiety effects. Also, lorazepam hyperpolarizesneuronal cells, thereby interferingwith their ability to generate seizures.IncompatibilitiesDon’t mix I.V. lorazepam in same syringe asbuprenorphine.ContraindicationsAcute angle-closure glaucoma, hypersensitivityto lorazepam, its components, or benzodiazepines;intra-arterial delivery; psychosisInteractionsDRUGSaminophylline, theophylline: Possiblyreduced sedative effects of lorazepamclozapine: Increased risk of marked sedation,excessive salivation, hypotension, ataxia,delirium, and respiratory arrestCNS depressants: Additive CNS depression,potentially fatal respiratory depression

digoxin: Possibly increased blood digoxinlevel and risk of digitalis toxicityfentanyl: Possibly decreased therapeuticeffects of fentanylprobenecid: Possibly increased therapeuticand adverse effects of lorazepamACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Amnesia, anxiety, ataxia, coma, confusion,delusions, depression, dizziness,drowsiness, euphoria, extrapyramidalsymptoms, fatigue, headache, hypokinesia,irritability, malaise, nervousness, seizures,slurred speech, suicidal ideation, tremor,unsteadiness, vertigoCV: Chest pain, palpitations, tachycardiaEENT: Blurred vision, diplopia, dry mouth,increased salivation, photophobiaENDO: Syndrome of inappropriate ADHGI: Abdominal pain, constipation, diarrhea,increased liver enzyme levels, jaundice, nausea,thirst, vomitingGU: Libido changesHEME: Agranulocytosis, pancytopenia,thrombocytopeniaRESP: Apnea, respiratory depression, worseningof sleep apnea or obstructve pulmonarydiseaseSKIN: DiaphoresisOther: Anaphylaxis, injection site pain(I.M.) or phlebitis (I.V.), physical and psychologicaldependence, withdrawal symptomsNursing Considerations• Before starting lorazepam therapy in apatient with depression, make sure healready takes an antidepressant because ofincreased risk of suicide in patients withuntreated depression.• Use extreme caution when giving lorazepamto elderly patients, especially thosewith compromised respiratory function,because drug can cause hypoventilation,sedation, unsteadiness, and respiratorydepression.• Use drug cautiously in patients with a historyof alcohol or drug abuse or a personalitydisorder because of an increased riskof physical and psychological dependence.Also use cautiously in patients with severehepatic insufficiency or encephalopathybecause drug may worsen hepaticlosartan potassium 607encephalopathy.• For I.M. use, inject lorazepam deep intolarge muscle mass, such as gluteus maximus.• For I.V. use, dilute lorazepam with equalamount of sterile water for injection, sodiumchloride for injection, or D 5 W. Givediluted lorazepam slowly, at no more than2 mg/min.• During I.V. use, monitor patient’s respirationsevery 5 to 15 minutes and keepemergency resuscitation equipment readilyavailable.WARNING Monitor patient’s respiratory statusclosely because drug may cause lifethreateningrespiratory depression.• Because stopping drug abruptly increasesrisk of withdrawal symptoms, expect totaper dosage gradually, especially inepileptic patients.PATIENT TEACHING• Instruct patient to take lorazepam exactlyas prescribed and not to stop without consultingprescriber because of risk of withdrawalsymptoms.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Urge patient to avoid alcohol while takinglorazepam because it increases drug’s CNSdepressant effects.• Instruct patient to report excessive drowsinessand nausea.• Inform pregnant patient that lorazepamtherapy will need to be discontinued earlyin third trimester to avoid possible withdrawalsymptoms in newborn.losartan potassiumCozaarClass and CategoryChemical class: Angiotensin II receptorantagonistTherapeutic class: AntihypertensivePregnancy category: C (first trimester), D(later trimesters)Indications and Dosages To manage hypertensionTABLETSAdults. Initial: 50 mg daily. Maintenance:25 to 100 mg as a single dose or in divideddoses b.i.d.JKL

608lovastatin To treat nephropathy in patients withtype 2 diabetes and hypertensionTABLETSAdults. Initial: 50 mg daily, increased to100 mg daily, as needed. To reduce stroke risk in patients withhypertension and left ventricular hypertrophyTABLETSAdults. Initial: 50 mg daily, followed by12.5 mg hydrochlorothiazide daily. Dosageincreased to 100 mg daily, as needed, followedby 25 mg hydrochlorothiazide daily,as needed.Children age 6 and over. Initial: 0.7 mg/kgto a maximum of 50 mg daily. Maximum:1.4 mg/kg or 100 mg daily.DOSAGE ADJUSTMENT Initial losartan dosagereduced to 25 mg daily for patients withimpaired hepatic function or volume depletion.Route Onset Peak DurationP.O. Unknown 6 hr Over 24 hrMechanism of ActionBlocks binding of angiotensin II to receptorsites in many tissues, including vascularsmooth muscle and adrenal glands.Angiotensin II is a potent vasoconstrictorthat also stimulates the adrenal cortex tosecrete aldosterone. The inhibiting effects ofangiotensin II reduce blood pressure.ContraindicationsHypersensitivity to losartan or its componentsInteractionsDRUGSantihypertensives, diuretics: Possibly hypotensioncyclosporine, potassium-sparing diuretics,potassium supplements: Increased risk ofhyperkalemiaindomethacin, sympathomimetics: Possiblydecreased antihypertensive effect of losartanNSAIDs: Possibly decreased renal functionin patients already compromised; possiblydecreased effectiveness of losartanFOODShigh-potassium diet, potassium-containingsalt substitutes: Increased risk of hyperkalemiaAdverse ReactionsCNS: Dizziness, fatigue, headache, insomnia,malaiseCV: HypotensionEENT: Nasal congestionGI: Diarrhea, indigestion, nausea, vomitingHEME: ThrombocytopeniaMS: Back pain, leg pain, muscle spasmsRESP: Cough, upper respiratory tract infectionSKIN: ErythrodermaOther: Angioedema, hyperkalemia,hyponatremiaNursing Considerations• In some patients, losartan is more effectivewhen given in two divided doses daily; itmay be used with other antihypertensives.• Know that patients of African descent withhypertension and left ventricular hypertrophymay not benefit from losartan toreduce stroke risk.WARNING Be aware that patients who havesevere heart failure or renal artery stenosismay experience acute renal failure fromlosartan therapy because losartan inhibitsthe angiotensin-aldosterone system, onwhich renal function depends.• Monitor blood pressure and renal functionstudies to evaluate drug effectiveness.• Periodically monitor patient’s serumpotassium level, as appropriate, to detecthyperkalemia.• Monitor patient for muscle pain; rarely,rhabdomyolysis develops in patients takingother angiotensin II receptor blockers.PATIENT TEACHING• Instruct patient to avoid potassiumcontainingsalt substitutes because thaymay increase risk of hyperkalemia.• Advise patient to avoid exercising in hotweather and drinking excessive amountsof alcohol; instruct her to notify prescriberif she has prolonged diarrhea, nausea, orvomiting.lovastatin(mevinolin)Altoprev, MevacorClass and CategoryChemical class: Mevinic acid derivative

Therapeutic class: AntihyperlipidemicPregnancy category: XIndications and Dosages To reduce LDL and total cholesterol levelsin patients with primary hypercholesterolemiaTABLETSAdults. Initial: 20 mg as a single dose withevening meal. Maintenance: 20 to 80 mgdaily as a single dose or in divided doseswith meals. Maximum: 80 mg daily.DOSAGE ADJUSTMENT For patients who alsotake immunosuppressants, initial dosagedecreased to 10 mg daily and maximumdosage limited to 20 mg daily.E.R. TABLETSAdults. Initial: 10 mg, 20 mg, 40 mg, or60 mg as single dose at bedtime, increased,as needed, every 4 wk, up to maximumdose. Maintenance: 10 to 60 mg daily as singledose. Maximum: 60 mg daily. To reduce LDL, total cholesterol, andapolipoprotein B levels in adolescentswith heterozygous familial hypercholesterolemiaTABLETSAdolescents 1 yr postmenarche (ages 10 to17). Initial: 20 mg daily for LDL reductionof 20% or more, 10 mg daily for LDLreduction of less than 20%; dosage adjustedafter at least 4 wk. Maintenance: 10 to40 mg daily. Maximum: 40 mg daily.DOSAGE ADJUSTMENT For patients who alsotake amiodarone or verapamil, maximumdosage limited to 40 mg daily. For patientswho also take cyclosporine, gemfibrozil orother fibrates, or lipid-lowering drugs suchas niacin (1 g or more daily), maximumdosage of lovastatin limited to 20 mg daily.For patients with creatinine clearance lessthan 30 ml/min/1.73 m 2 , maximum dosagelimited to 20 mg daily.Route Onset Peak DurationP.O. In 2 wk Unknown 4–6 wkAdverse ReactionsCNS: Dizziness, fatigue, headache, insomniaEENT: Blurred vision, cataracts, pharyngitis,rhinitis, sinusitisGI: Abdominal cramps and pain, constipation,diarrhea, elevated liver function testresults, flatulence, indigestion, nausea, vomitingMS: Arthritis, back pain, myalgia, myopathy,myositis, rhabdomyolysisRESP: Cough, upper respiratory tract infectionSKIN: Dermatomyositis, erythema multiforme,pruritus, rash, Stevens-Johnson synlovastatin609Mechanism of ActionInterferes with the hepatic enzymehydroxymethylglutaryl-coenzyme A reductase.By doing so, lovastatin reduces formationof mevalonic acid (a cholesterol precursor),thus interrupting the pathway bywhich cholesterol is synthesized. When cholesterollevel declines in hepatic cells, LDLsare consumed, which also reduces amountof circulating total cholesterol and serumtriglycerides. The decrease in LDLs mayresult in decreased level of apolipoproteinB, which is found in each LDL particle.ContraindicationsAcute hepatic disease, breastfeeding, hypersensitivityto lovastatin or its components,pregnancy, unexplained elevated liver functiontest resultsInteractionsDRUGSamiodarone, clarithromycin, cyclosporine,danazol, erythromycin, fibric acid derivatives,gemfibrozil and other fibrates, HIV proteaseinhibitors, immunosuppressants, itraconazole,ketoconazole, nefazodone, niacin (1 gdaily or more), telithromycin, verapamil:Increased risk of severe myopathy orrhabdomyolysisbile acid sequestrants, cholestyramine, colestipol:Decreased bioavailability of lovastatinisradipine: Increased hepatic clearance oflovastatinitraconazole, ketoconazole: Increased lovastatinblood leveloral anticoagulants: Increased anticoagulanteffect and risk of bleedingFOODSall foods: Increased lovastatin absorptiongrapefruit juice (more than 1 qt daily):Increased risk of myopathy or rhabdomyolysisACTIVITIESalcohol use: Increased lovastatin blood levelJKL

610loxapinedrome, toxic epidermal necrolysisOther: Anaphylaxis, angioedemaNursing Considerations• Give lovastatin cautiously in patients whohave a history of liver disease and patientswho consume large amounts of alcohol.• Monitor liver function test results beforeand during therapy. If serum transaminaselevels rise, expect to measure them moreoften, as ordered. If AST or ALT levelreaches or exceeds three times upper limitof normal and persists at that level, expectto discontinue lovastatin.• Give drug 1 hour before or 4 hours afterbile acid sequestrant, cholestyramine, orcolestipol.• Expect patient to be prescribed a standardlow-cholesterol diet during therapy.• Be aware that drug affects mainly total cholesteroland LDL levels; it has only slighteffects on HDL and triglyceride levels.PATIENT TEACHING• Tell patient who takes drug once daily todo so with evening meal to enhanceabsorption.• Advise patient to report muscle aches,pains, tenderness, or weakness; severe GIdistress; and vision changes.• Urge patient to avoid consuming alcoholor more than 1 quart of grapefruit juicedaily while taking drug.• Direct patient to follow a low-cholesteroldiet during therapy. Recommend weightloss and exercise programs as appropriate.• Stress the importance of periodic eyeexaminations during therapy.• Teach female patients appropriate contraceptivemethods and the need to reportsuspected pregnancy immediately.loxapinehydrochlorideLoxapac (CAN), Loxitane, Loxitane C,Loxitane IMloxapine succinateLoxapac (CAN), LoxitaneClass and CategoryChemical class: Dibenzoxazepine derivativeTherapeutic class: AntipsychoticPregnancy category: CIndications and Dosages To treat psychotic disorders and schizophreniaCAPSULES, ORAL SOLUTIONAdults. Initial: 10 mg b.i.d., increased over7 days. Maintenance: 15 to 25 mg b.i.d. toq.i.d. Maximum: 250 mg daily.DOSAGE ADJUSTMENT For elderly patients,dosage reduced to 3 to 5 mg b.i.d. To treat acute exacerbations of psychoticdisordersI.M. INJECTIONAdults. 12.5 to 50 mg every 4 to 6 hr orlonger. Maximum: 250 mg daily.Route Onset Peak DurationP.O. 20–30 min 1.5–3 hr 12 hrMechanism of ActionMay treat psychotic disorders by blockingdopamine at postsynaptic receptors in thebrain. With prolonged use, loxapineenhances antipsychotic effects by causingdepolarization blockade of dopaminetracts, resulting in decreased dopamineneurotransmission.ContraindicationsBlood dyscrasias, bone marrow depression,cerebrovascular disease, coma, coronaryartery disease, hypersensitivity to loxapineor its components, impaired hepatic function,myeloproliferative disorders, severedrug-induced CNS depression, severehypertension or hypotensionInteractionsDRUGSamphetamines, ephedrine: Decreased effectsof these drugsantacids, antidiarrheals (adsorbent): Possiblydecreased absorption of oral loxapineanticholinergics: Possibly increased anticholinergiceffectsanticonvulsants: Lowered seizure threshold,increased risk of seizuresantidyskinetics: Possibly antagonized therapeuticeffects of these drugsbromocriptine: Possibly decreased therapeuticeffects of bromocriptineCNS depressants: Increased effects of CNSdepression

dopamine: Possibly decreased alphaadrenergiceffects of dopamineepinephrine: Possibly severe hypotension ortachycardia, decreased epinephrine effectsguanadrel, guanethidine, levodopa: Possiblydecreased therapeutic effects of these drugsMAO inhibitors, tricyclic antidepressants:Possibly increased blood levels of thesedrugs, increased CNS depressant andanticholinergic effectsmetaraminol: Possibly decreased vasopressoreffect of metaraminolmethoxamine: Possibly decreased vasopressoreffect and methoxamine duration ofactionACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Confusion, drowsiness, dystonia,involuntary motor activity, neurolepticmalignant syndrome, pseudoparkinsonism,sleep disturbance, tardive dyskinesiaCV: Orthostatic hypotensionEENT: Blurred vision, dry mouthENDO: Galactorrhea, gynecomastiaGI: Constipation, ileus, nausea, vomitingGU: Menstrual irregularities, sexual dysfunction,urine retentionSKIN: Photosensitivity (mild), rashOther: Weight gainNursing Considerations• Be aware that loxapine’s full antipsychoticeffect may require weeks.• Loxapine shouldn’t be given to treatdementia-related psychosis in the elderlybecause of an increased mortality risk.• Assess for signs of tardive dyskinesia,including involuntary protrusion oftongue and chewing movements. Thesesigns may appear months or years afterloxapine therapy begins and may not disappearwith dosage reduction.• Observe for extrapyramidal reactions orparkinsonian symptoms, such as excessivesalivation, masklike facies, rigidity, andtremor, especially in first few days of treatment.Prescriber may reduce dosage tocontrol these symptoms.WARNING Monitor patient for neurolepticmalignant syndrome, a rare but possiblyfatal adverse reaction. Early evidenceincludes altered mental status, arrhythmias,fever, and muscle rigidity.PATIENT TEACHING• Instruct patient to dilute loxapine oralsolution with orange or grapefruit juicejust before taking. Advise her to use calibrateddropper that accompanies solutionto ensure correct dosage.• Tell patient not to take antacids and antidiarrhealswithin 2 hours of loxapine.• Caution patient to avoid alcohol whiletaking loxapine.• Advise patient to change position slowly tominimize orthostatic hypotension.• Urge patient to avoid hazardous activitiesuntil CNS effects of loxapine are known.• Advise patient to avoid prolonged sunexposure and to use sunscreen to minimizerisk of photosensitivity.• Urge patient to have periodic eye examinationsduring therapy.lubiprostoneAmitizalubiprostone 611Class and CategoryChemical class: Chloride channel activatorTherapeutic class: Intestinal motilityenhancerPregnancy category: CIndications and Dosages To treat chronic idiopathic constipationCAPSULESAdults. 24 mcg b.i.d. with food and water. To treat irritable bowel syndrome withconstipationCAPSULESAdults. 8 mcg b.i.d. with food and water.Mechanism of ActionEnhances chloride-rich intestinal fluidsecretion by locally activating chloridechannels. By increasing intestinal fluidsecretion, lubiprostone increases intestinalmotility, which aids passage of stool, alleviatingconstipation.ContraindicationsDiarrhea, hypersensitivity to lubiprostoneor components, mechanical GI obstructionInteractionsDRUGSantidiarrheals: Decreased GI motilityJKL

612lypressinAdverse ReactionsCNS: Asthenia, dizziness, fatigue, headache,malaiseCV: Chest discomfort or pain, edema,increased heart rateEENT: Dry mouth, throat tightnessGI: Abdominal distention or pain, diarrhea,dyspepsia, flatulence, nausea, vomitingMS: Muscle cramps or spasmsRESP: DyspneaSKIN: RashOther: AngioedemaNursing Considerations• Be aware that lubiprostone shouldn’t beused in patients with severe diarrhea.• Make sure woman a negative pregnancytest before starting lubiprostone becausesafety during pregnancy is unknown.• Watch closely for adverse reactions, particularlydyspnea and especially after first dose.PATIENT TEACHING• Advise patient to take drug with food tominimize risk of nausea.• Tell women to use effective contraceptionwhile taking lubiprostone and to notifyprescriber if pregnancy is suspected. Drugmay need to be discontinued.• Instruct patient to notify prescriber ifsevere diarrhea occurs.lypressinDiapidClass and CategoryChemical class: Synthetic vasopressin analogueTherapeutic class: AntidiureticPregnancy category: CIndications and Dosages To control and prevent dehydration,polydipsia, and polyuria in patientswith neurogenic diabetes insipidus thatis unresponsive to other therapyNASAL SOLUTIONAdults and adolescents. 1 or 2 sprays q.i.d.If more drug is needed, interval betweendoses is decreased rather than increasingnumber of sprays/dose.Mechanism of ActionIncreases cellular permeability of collectingducts in kidneys, leading to increased urineosmolality and decreased urine output.ContraindicationsHypersensitivity to lypressin or componentsRoute Onset Peak DurationIntranasal In 1 hr 0.5–2 hr 3–4 hrInteractionsDRUGScarbamazepine, chlorpropamide, clofibrate:Possibly increased antidiuretic effectdemeclocycline, lithium, norepinephrine:Decreased antidiuretic effect of lypressinAdverse ReactionsCNS: HeadacheEENT: Conjunctivitis; nasal congestion,irritation, and itching; periorbital edemaand itching; rhinorrheaGI: Abdominal cramps, diarrhea, heartburn(if excessive intranasal use causes drippinginto pharynx)RESP: Cough, transient dyspnea (if drug isaccidentally inhaled)Other: Water intoxicationNursing Considerations• Assess patient for nasal congestion orupper respiratory tract infection, whichcan reduce lypressin absorption andrequire larger doses or adjunct therapy.• Administer final spray of drug at bedtimeto help control nocturia.WARNING Inadvertent inhalation, althoughrare, may cause chest tightness, continuouscough, and dyspnea.• Observe for nasal irritation during longtermtherapy.• Watch for evidence of water intoxication,including coma, confusion, drowsiness,persistent headache, seizures, urine retention,and weight gain.PATIENT TEACHING• Teach patient how to administer lypressincorrectly by holding head upright and bottlein a vertical position and spraying 1 or2 sprays in each nostril with each dose.• Instruct patient to take last dose of day atbedtime to control nocturia.• Instruct patient to use drug exactly as prescribed.• Tell patient to report abdominal cramps,heartburn, persistent headache, severenasal irritation, and shortness of breath.

magnesium 613Mmagnesium chloride(contains 64 mg of elemental magnesiumper tablet, 100 mg of elemental magnesiumper enteric-coated tablet, 64 mg ofelemental magnesium per E.R. tablet, and200 mg of elemental magnesium per 1 mlof injection)Chloromag, Mag-L-100, Slow-Magmagnesium citrate(citrate of magnesia)(contains 40.5 to 47 mg elementalmagnesium per 5 ml oral solution)Citroma, Citro-Mag (CAN)magnesiumgluconate(contains 54 mg elemental magnesiumper 5 ml oral solution and 27 to 29.3 mgelemental magnesium per tablet)Almora, Maglucate ( CAN), Magonate,Magtratemagnesiumhydroxide(milk of magnesia)(contains 135 mg elemental magnesiumper tablet, 129 to 130 mg elemental magnesiumper chewable tablet, and 164 to328 mg elemental magnesium per 5 ml liquid,liquid concentrate, or oral solution)Phillips’ Chewable Tablets, Phillips’Magnesia Tablets (CAN), Phillips’ Milkof Magnesia, Phillips’ Milk of MagnesiaConcentratemagnesium lactate(contains 84 mg elemental magnesiumper E.R. tablet)Mag-Tab SR Capletsmagnesium oxide(contains 84.5 mg elemental magnesiumper capsule and 50 to 302 mg elementalmagnesium per tablet)Mag-200, Mag-Ox 400, Maox, Uro-Magmagnesium sulfate(contains 100 to 500 mg elemental magnesiumper 1 ml of injection, 1 to 5 g elementalmagnesium per 10 ml of injection,and 40 mEq per 5 mg of crystals)Class and CategoryChemical class: Cation, electrolyteTherapeutic class: Antacid, antiarrhythmic,anticonvulsant, electrolyte replacement,laxativePregnancy category: A (parenteral magnesiumsulfate), Not rated (others)Indications and Dosages To correct magnesium deficiency causedby alcoholism, magnesium-depletingdrugs, malnutrition, or restricted diet; toprevent magnesium deficiency based onU.S. and Canadian recommended dailyallowancesCAPSULES, CHEWABLE TABLETS, CRYSTALS,ENTERIC-COATED TABLETS, E.R. TABLETS, LIQUID,LIQUID CONCENTRATE, ORAL SOLUTION, TABLETS(MAGNESIUM CHLORIDE, CITRATE, GLUCONATE,HYDROXIDE, LACTATE [EXCEPT IN CHILDREN],OXIDE, SULFATE)Dosage individualized based on severity ofdeficiency and normal recommended dailyallowances listed below.Adult men and children over age 10. 270 to400 mg daily (Canada: 130 to 250 mgdaily).Adult women and children over age 10.280 to 300 mg daily (Canada: 135 to210 mg daily).Pregnant women. 320 mg daily (Canada:195 to 245 mg daily).Breast-feeding women. 340 to 355 mg daily(Canada: 245 to 265 mg daily).Children ages 7 to 10. 170 mg daily(Canada: 100 to 135 mg daily).Children ages 4 to 6. 120 mg daily(Canada: 65 mg daily).Children from birth to age 3. 40 to 80 mg/day (Canada: 20 to 50 mg daily). To treat mild magnesium deficiencyM

614magnesiumI.M. INJECTION (MAGNESIUM SULFATE)Adults and adolescents. 1 g every 6 hr for4 doses. To treat severe hypomagnesemiaI.V. INFUSION (MAGNESIUM CHLORIDE)Adults. 4 g diluted in 250 ml D 5 W andinfused at no more than 3 ml/min.Maximum: 40 g daily.I.V. INFUSION (MAGNESIUM SULFATE)Adults and adolescents. 5 g diluted in 1 LI.V. solution and infused over 3 hr. To provide supplemental magnesium intotal parenteral nutritionI.V. INFUSION (MAGNESIUM SULFATE)Adults. 1 to 3 g daily.Children. 0.25 mg to 1.25 g daily.DOSAGE ADJUSTMENT Adult dosage may beincreased to 6 g daily for certain conditions,such as short-bowel syndrome.I.M. INJECTION (MAGNESIUM SULFATE)Adults and adolescents. Up to 250 mg/kgevery 4 hr, p.r.n. To prevent and control seizures inpreeclampsia or eclampsia as well asseizures caused by epilepsy, glomerulonephritis,or hypothyroidismI.V. INFUSION OR INJECTION (MAGNESIUM SULFATE)Adults. Loading: 4 g diluted in 250 ml compatiblesolution and infused over 30 min.Maintenance: 1 to 2 g/hr by continuousinfusion.I.M. INJECTION (MAGNESIUM SULFATE)Adults. 4 to 5 g every 4 hr, p.r.n.Children. 20 to 40 mg/kg, repeated p.r.n. To relieve indigestion with hyperacidityCHEWABLE TABLETS, LIQUID, LIQUID CONCENTRATE,ORAL SOLUTION TABLETS (MAGNESIUM HYDROXIDE)Adults and adolescents. 400 to 1,200 mg(5 to 15 ml liquid or 2.5 to 7.5 ml liquidconcentrate) up to 4 times daily with water,or 622 to 1,244 mg (tablets or chewabletablets) up to 4 times daily.CAPSULES, TABLETS (MAGNESIUM OXIDE)Adults and adolescents. 140 mg (capsules)t.i.d. or q.i.d. with water or milk, or 400 to800 mg daily (tablets). To relieve constipation, to evacuatecolon for rectal or bowel examinationLIQUID, LIQUID CONCENTRATE (MAGNESIUMHYDROXIDE)Adults and children age 12 and over. 2.4 to4.8 g (30 to 60 ml) daily as single dose ordivided doses.Children ages 6 to 11. 1.2 to 2.4 g (15 to30 ml)/day as a single dose or in divideddoses.Children ages 2 to 5. 0.4 to 1.2 g (5 to15 ml) daily as single dose or divided doses.ORAL SOLUTION (MAGNESIUM CITRATE)Adults and children age 12 and over. 11 to25 g daily as single dose or divided doses.Children ages 6 to 11. 5.5 to 12.5 g daily assingle dose or divided doses.Children ages 2 to 5. 2.7 to 6.25 g daily assingle dose or divided doses.CRYSTALS (MAGNESIUM SULFATE)Adults and children age 12 and over. 10 to30 g daily as single dose or divided doses.DOSAGE ADJUSTMENT Dosage limited to20 g of magnesium sulfate every 48 hr forpatients with severe renal impairment.Children ages 6 to 11. 5 to 10 g daily as asingle dose or in divided doses.Children ages 2 to 5. 2.5 to 5 g daily as asingle dose or in divided doses.CAPSULES, TABLETS (MAGNESIUM OXIDE)Adults. 2 to 4 g with a full glass of water ormilk, usually at bedtime.Route Onset Peak DurationP.O.* 0.5–3 hr Unknown UnknownP.O.† 20 min Unknown 20–180 minI.M.‡ 1 hr Unknown 3–4 hrI.V.‡ Immediate Unknown About 30minMechanism of ActionAssists all enzymes involved in phosphatetransfer reactions that use adenosine triphosphate(ATP). Magnesium is requiredfor normal function of the ATP-dependentsodium-potassium pump in muscle membranes.It may effectively treat digitalis glycoside–inducedarrhythmias because correctionof hypomagnesemia improves thesodium-potassium pump’s ability to distributepotassium into intracellular spacesand because magnesium decreases calciumuptake and potassium outflow throughmyocardial cell membranes.As a laxative, magnesium exerts a hyperosmoticeffect in the small intestine. Itcauses water retention that distends thebowel and causes the duodenum to secrete* For laxative effect.† For antacid effect.‡ For anticonvulsant effect.

cholecystokinin. This substance stimulatesfluid secretion and intestinal motility.As an antacid, magnesium reacts withwater, converting magnesium oxide to magnesiumhydroxide. Magnesium hydroxiderapidly reacts with gastric acid to formwater and magnesium chloride, whichincreases gastric pH.As an anticonvulsant, magnesiumdepresses the CNS and blocks peripheralneuromuscular impulse transmission bydecreasing available acetylcholine.IncompatibilitiesDon’t combine magnesium sulfate withalkali carbonates and bicarbonates, alkalihydroxides, arsenates, calcium, clindamycinphosphate, dobutamine, fat emulsions,heavy metals, hydrocortisone sodium succinate,phosphates, polymyxin B, procainehydrochloride, salicylates, sodium bicarbonate,strontium, and tartrates.ContraindicationsHypersensitivity to magnesium salts or anycomponent of magnesium-containingpreparationsFor magnesium chloride: Coma, heart disease,renal impairmentFor magnesium sulfate: Heart block, MI,preeclampsia 2 hours or less before delivery(I.V. form)For use as laxative: Acute abdominal problem(as indicated by abdominal pain, nausea,or vomiting), diverticulitis, fecalimpaction, intestinal obstruction or perforation,colostomy or ileostomy, severe renalimpairment, ulcerative colitisInteractionsDRUGSamphotericin B, cisplatin, cyclosporine, gentamicin:Possibly magnesium wasting andneed for magnesium dosage adjustmentanticholinergics: Possibly decreased absorptionand therapeutic effects of these drugscalcium salts (I.V.): Possibly neutralizationof magnesium sulfate’s effectscellulose sodium phosphate: Possibly bindingwith magnesium, possibly decreased therapeuticeffectiveness of celluloseCNS depressants: Increased CNS depressiondigoxin (I.V.): Possibly heart block and conductionchanges, especially when calciumsalts are also administeredmagnesium 615digoxin, fluoroquinolones, folic acid, H 2 -receptor blockers, iron preparations, isoniazid,ketoconazole, penicillamine, phenothiazines,phenytoin, phosphates (oral), tetracyclines:Possibly decreased absorption andblood levels of these drugsdiuretics (loop or thiazide): Possibly hypomagnesemiaedetate sodium, sodium polystyrene sulfonate:Possibly binding with magnesiumenteric-coated drugs: Possibly quicker dissolutionof these drugs and increased risk ofadverse GI reactionsetidronate (oral): Decreased etidronateabsorptionmecamylamine: Possibly prolonged effectsof mecamylaminemethenamine, streptomycin, sucralfate, tetracyclines,tobramycin (oral), urinary acidifiers:Possibly decreased therapeutic effects ofthese drugsmisoprostol: Increased misoprostol-induceddiarrheaneuromuscular blockers: Possibly increasedneuromuscular blockadenifedipine: Possibly increased hypotensiveeffects when taken with magnesium sulfatepotassium-sparing diuretics: Increased riskof hypermagnesemiasalicylates: Possibly increased excretion andlower blood levels of salicylatessodium polystyrene sulfonate resin: Possiblymetabolic alkalosisFOODShigh glucose intake: Increased urinary excretionof magnesiumACTIVITIESalcohol use: Increased urinary excretion ofmagnesiumAdverse ReactionsCNS: Confusion, decreased reflexes, dizziness,syncopeCV: Arrhythmias, hypotensionGI: Flatulence, vomitingMS: Muscle crampsRESP: Dyspnea, respiratory depression orparalysisSKIN: DiaphoresisOther: Allergic reaction, hypermagnesemia,injection site pain or irritation (I.M. form),laxative dependence, magnesium toxicityNursing Considerations• Be aware that magnesium sulfate is theM

616mannitolelemental form of magnesium. Oralpreparations aren’t all equivalent.• Be aware that drug isn’t metabolized. Drugremaining in the GI tract produces waterystool within 30 minutes to 3 hours.• Make sure patient chews chewable tabletsthoroughly before swallowing.• Avoid giving other oral drugs within2 hours of magnesium-containing antacid.• Before giving drug as laxative, shake oralsolution, liquid, or liquid concentrate welland give with a large amount of water.WARNING Observe for and report early evidenceof hypermagnesemia: bradycardia,depressed deep tendon reflexes, diplopia,dyspnea, flushing, hypotension, nausea,slurred speech, vomiting, and weakness.WARNING Be aware that magnesium mayprecipitate myasthenic crisis by decreasingpatient’s sensitivity to acetylcholine.• Frequently assess cardiac status of patienttaking drugs that lower heart rate, such asbeta blockers, because magnesium mayaggravate symptoms of heart block.WARNING Magnesium chloride for injectioncontains the preservative benzyl alcohol,which may cause fatal toxic syndrome inneonates and premature infants.• Provide adequate diet, exercise, and fluidsfor patient being treated for constipation.• Monitor serum electrolyte levels inpatients with renal insufficiency becausethey’re at risk for magnesium toxicity.• Be aware that magnesium salts aren’tintended for long-term use.PATIENT TEACHING• Advise patient to chew magnesium chewabletablets thoroughly before swallowingthen drink a full glass of water. Mentionthat tablets have a chalky taste.• Instruct patient to take magnesiumcontainingantacid between meals and atbedtime. Urge him not to take other drugswithin 2 hours of the antacid.• Tell patient to notify prescriber and avoidusing magnesium-containing laxative if hehas abdominal pain, nausea, or vomiting.• Instruct patient to refrigerate magnesiumcitrate solution.• Caution patient about risk of dependencewith long-term laxative use.• Teach patient to prevent constipation byincreasing dietary fiber and fluid intakeand exercising regularly.• Inform patient that magnesium supplementsused to replace electrolytes cancause diarrhea.mannitolOsmitrol, ResectisolClass and CategoryChemical class: Hexahydroxy alcoholTherapeutic class: Antiglaucoma, diagnosticagent, osmotic diuretic, urinary irrigantPregnancy category: BIndications and Dosages To reduce intracranial or intraocularpressureI.V. INFUSIONAdults and adolescents. 0.25 to 2 g/kg as15% to 25% solution given over 30 to60 min. If used before eye surgery, 1.5 to2 g/kg 60 to 90 min before procedure.Maximum: 6 g/kg daily.DOSAGE ADJUSTMENT For small or debilitatedpatients, dosage reduced to 0.5 g/kg. To diagnose oliguria or inadequate renalfunctionI.V. INFUSIONAdults and adolescents. 200 mg/kg or12.5 g as 15% to 20% solution given over3 to 5 min. Second dose given only ifpatient fails to excrete 30 to 50 ml of urinein 2 to 3 hr. Drug discontinued if noresponse after second dose. Or, 100 ml of20% solution diluted in 180 ml normalsaline solution (forming 280 ml of 7.2%solution) and infused at 20 ml/min; followedby measurement of urine output.Maximum: 6 g/kg daily. To prevent oliguria or acute renal failureI.V. INFUSIONAdults and adolescents. 50 to 100 g as 5%to 25% solution. Maximum: 6 g/kg daily. To treat oliguriaI.V. INFUSIONAdults and adolescents. 50 to 100 g as 15%to 25% solution given over 90 min to severalhr. Maximum: 6 g/kg daily. To promote diuresis in drug toxicityI.V. INFUSIONAdults and adolescents. Loading: 25 g.Maintenance: Up to 200 g as 5% to 25%solution given continuously to maintain

urine output of 100 to 500 ml/hr with positivefluid balance of 1 to 2 L. Maximum:6 g/kg daily. To promote diuresis in hemolytic transfusionreactionI.V. INFUSIONAdults. 20 g given over 5 min and repeatedif needed. Maximum: 6 g/kg daily. To provide irrigation during transurethralresection of prostate glandIRRIGATION SOLUTIONAdults. 2.5% or 5% solution, as needed.Route Onset Peak DurationI.V.* 1–3 hr Unknown Up to 8 hrI.V.† 30–60 min Unknown 4–8 hrI.V.‡ In 15 min Unknown 3–8 hrMechanism of ActionElevates plasma osmolality, causing water toflow from tissues, such as brain and eyes,and from CSF, into extracellular fluid,thereby decreasing intracranial and intraocularpressure.As an osmotic diuretic, mannitolincreases the osmolarity of glomerular filtrate,which decreases water reabsorption.This leads to increased excretion of water,sodium, chloride, and toxic substances.As an irrigant, mannitol minimizes thehemolytic effects of water used as an irrigantand reduces the movement of hemolyzedblood from the urethra to the systemiccirculation, which prevents hemoglobinemiaand serious renal complications.IncompatibilitiesDon’t administer mannitol through sameI.V. line as blood or blood products.ContraindicationsActive intracranial bleeding (except duringcraniotomy), anuria, hepatic failure, hypersensitivityto mannitol or its components,pulmonary edema, severe dehydration,severe heart failure, severe pulmonary congestion,severe renal insufficiencyInteractionsDRUGSdigoxin: Increased risk of digitalis toxicity* To produce diuresis.† To decrease intraocular pressure.‡ To decrease intracranial pressure.maprotiline hydrochloride 617from hypokalemiadiuretics: Possibly increased therapeuticeffects of mannitolAdverse ReactionsCNS: Chills, dizziness, fever, headache, seizuresCV: Chest pain, heart failure, hypertension,tachycardia, thrombophlebitisEENT: Blurred vision, dry mouth, rhinitisGI: Diarrhea, nausea, thirst, vomitingGU: Polyuria, urine retentionRESP: Pulmonary edemaSKIN: Extravasation with edema and tissuenecrosis, rash, urticariaOther: Dehydration, hyperkalemia, hypernatremia,hypervolemia, hypokalemia,hyponatremia (dilutional), metabolic acidosis,water intoxicationNursing Considerations• If crystals form in mannitol solutionexposed to low temperature, place solutionin hot-water bath to redissolve crystals.• Use a 5-micron in-line filter when administeringdrug solution of 15% or greater.• During I.V. infusion of mannitol, monitorvital signs, central venous pressure, andfluid intake and output every hour.Measure urine output with indwelling urinarycatheter, as appropriate.• Check weight and monitor BUN andserum creatinine electrolyte levels daily.• Provide frequent mouth care to relievethirst and dry mouth.PATIENT TEACHING• Inform patient that he may experiencedry mouth and thirst during mannitoltherapy.• Instruct patient to report chest pain, difficultybreathing, or pain at I.V. site.maprotilinehydrochlorideLudiomilClass and CategoryChemical class: DibenzobicyclooctadienederivativeTherapeutic class: Antidepressant, tricyclicantidepressantPregnancy category: BM

618maprotiline hydrochlorideIndications and Dosages To treat mild to moderate depressionTABLETSAdults and adolescents. Initial: 75 mg dailyin divided doses for 2 wk. Increased in25-mg increments as needed and tolerated.Maintenance: 150 to 225 mg daily in divideddoses; for prolonged therapy, possibly75 to 150 mg daily in divided doses. To treat hospitalized patients withsevere depressionTABLETSAdults and adolescents. Initial: 100 to150 mg daily in divided doses, increased asneeded and tolerated. Maintenance: 150 to225 mg daily in divided doses; for prolongedtherapy, possibly 75 to 150 mg dailyin divided doses.DOSAGE ADJUSTMENT For patients over age60, initial dosage reduced to 25 mg dailyand then increased by 25 mg/wk up tomaintenance dosage of 50 to 75 mg daily individed doses.Route Onset Peak DurationP.O. 1–3 wk 3–6 wk UnknownMechanism of ActionBlocks norepinephrine’s reuptake at adrenergicnerve fibers. Normally, when a nerveimpulse reaches an adrenergic nerve fiber,norepinephrine is released from storagesites and metabolized in the nerve or at thesynapse. Some norepinephrine reachesreceptor sites on target organs and tissues,but most is taken back into the nerve andstored by way of reuptake mechanism. Byblocking norepinephrine reuptake, maprotilineincreases its level at nerve synapses.Elevated norepinephrine level may improvemood and decrease depression.ContraindicationsHypersensitivity to maprotiline, mirtazapine,or their components; use within14 days of MAO inhibitor therapyInteractionsDRUGSanticholinergics, antihistamines: Increasedatropine-like adverse effects, such asblurred vision, constipation, dizziness, anddry mouthanticonvulsants: Increased risk of CNSdepression, possibly lower seizure threshholdand increased risk of seizuresbupropion, clozapine, haloperidol, loxapine,molindone, other tricyclic antidepressants,phenothiazines, pimozide, thioxanthenes, trazodone:Possibly increased anticholinergiceffects, possibly lowered seizure threshholdand increased risk of seizurescimetidine: Possibly increased blood maprotilinelevelclonidine, guanadrel, guanethidine: Possiblydecreased antihypertensive effects of thesedrugs, possibly increased CNS depression(with clonidine)CNS depressants: Increased risk of CNSdepressionestrogens, oral contraceptives containingestrogen: Possibly decreased therapeuticeffects and increased adverse effects ofmaprotilineMAO inhibitors: Increased risk of hyperpyrexia,hypertensive crisis, severe seizures, ordeathsympathomimetics: Increased risk ofarrhythmias, hyperpyrexia, hypertension, ortachycardiathyroid hormones: Increased risk of arrhythmiasACTIVITIESalcohol use: Increased risk of CNS depressionAdverse ReactionsCNS: Agitation, dizziness, drowsiness,fatigue, headache, insomnia, seizures, suicidalideation, tremor, weaknessEENT: Blurred vision, dry mouth, increasedintraocular pressureENDO: GynecomastiaGI: Constipation, diarrhea, epigastric distress,increased appetite, nausea, vomitingGU: Impotence, libido changes, testicularswelling, urinary hesitancy, urine retentionHEME: AgranulocytosisSKIN: Diaphoresis, photosensitivity, pruritus,rashOther: Weight lossNursing Considerations• Give largest dose of maprotiline at bedtimeif daytime drowsiness occurs.• Check CBC, as ordered, if fever, sorethroat, or other evidence of agranulocytosisdevelops.• Take seizure precautions according tofacility policy.

• Watch patient (especially children, adolescents,and young adults) closely for suicidaltendencies, particularly when therapystarts and dosage changes, because depressionmay worsen temporarily during thesetimes, possibly leading to suicidal ideation.• Expect to taper drug gradually becausestopping abruptly may produce withdrawalsymptoms.PATIENT TEACHING• Advise patient to take maprotiline exactlyas prescribed. Caution him not to stopdrug abruptly because of risk of withdrawalsymptoms, including headache,nausea, nightmares, and vertigo.• Inform patient that he may not feel drug’seffects for several weeks.• Suggest that patient take drug with food ifadverse GI reactions develop.• Urge patient to report difficulty urinating,excessive drowsiness, fever, or sore throat.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Caution patient to avoid alcohol and otherCNS depressants while taking drug.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes andparticularly if patient is a child, teenager,or young adult.meclizinehydrochloride(meclozinehydrochloride)Antivert, Bonamine (CAN), Bonine,Dizmiss, Dramamine II, Meclicot,Medivert, Meni-DClass and CategoryChemical class: Piperazine derivativeTherapeutic class: Antiemetic, antivertigoPregnancy category: BIndications and Dosages To prevent and treat vertigoCAPSULES, CHEWABLE TABLETS, TABLETSAdults and adolescents. 25 to 100 mg daily,p.r.n., in divided doses. To treat motion sicknessCAPSULES, TABLETSmeclizine hydrochloride 619Adults. 25 to 50 mg 1 hr before travel andthen every 24 hr, p.r.n., for duration of trip.Route Onset Peak DurationP.O. 1 hr Unknown 8–24 hrMechanism of ActionMay inhibit nausea and vomiting by reducingsensitivity of labyrinthine apparatusand blocking cholinergic synapses in thebrain’s vomiting center.ContraindicationsHypersensitivity to meclizine or its componentsInteractionsDRUGSanticholinergics: Possibly potentiated anticholinergiceffectsapomorphine: Possibly decreased emeticresponse to apomorphineCNS depressants: Possibly potentiated CNSdepressionACTIVITIESalcohol use: Possibly potentiated CNSdepressionAdverse ReactionsCNS: Dizziness, drowsiness, euphoria,excitement, fatigue, hallucinations,headache, insomnia, nervousness, restlessness,vertigoCV: Hypotension, palpitations, tachycardiaEENT: Blurred vision; diplopia; dry mouth,nose, and throat; tinnitusGI: Abdominal pain, anorexia, constipation,diarrhea, nausea, vomitingGU: Urinary frequency and hesitancy, urineretentionRESP: Bronchospasm, thickening of respiratorysecretionsSKIN: Jaundice, rash, urticariaNursing Considerations• Use meclizine cautiously in patients withasthma, glaucoma, or prostate glandenlargement.• Be aware that drug may mask signs ofbrain tumor, intestinal obstruction, orototoxicity.PATIENT TEACHING• Explain that meclizine works best formotion sickness when taken before travel.• Instruct patient to chew meclizine chewabletablets thoroughly before swallowing.M

620Adverse ReactionsCNS: Dizziness, drowsiness, fatigue, headache,insomnia, seizures, strokeCV: Hypertension, MI, peripheral edema,tachycardiaEENT: Stomatitis, tinnitusGI: Abdominal pain; anorexia; constipation;diarrhea; diverticulitis; dyspepsia; dysphagia;elevated liver function test results;esophagitis; flatulence; gastritis; gastroenmeclofenamatesodium• Instruct patient to report blurred vision ordrowsiness.• Urge patient to avoid alcohol while takingdrug.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to have regular eye examinationsduring long-term therapy.meclofenamatesodiumMeclomenClass and CategoryChemical class: Fenamate (anthranilic acid)derivativeTherapeutic class: Analgesic, antidysmenorrheal,anti-inflammatory, antirheumaticPregnancy category: Not ratedIndications and Dosages To relieve pain and inflammation inrheumatoid arthritis and osteoarthritisCAPSULESAdults and adolescents over age 14. 50 to100 mg every 6 to 8 hr, p.r.n. Maximum:400 mg/day. To relieve mild to moderate painCAPSULESAdults and adolescents over age 14. 50 mgevery 4 to 6 hr, p.r.n. Increased to 100 mgevery 4 to 6 hr, if needed. Maximum:400 mg daily. To treat hypermenorrhea and primarydysmenorrheaCAPSULESAdults and adolescents over age 14.100 mg t.i.d. for up to 6 days.Route Onset Peak DurationP.O.* 1 hr 0.5–2 hr 4–6 hrP.O.† Few days 2–3 wk UnknownMechanism of ActionBlocks cyclooxygenase, the enzyme neededto synthesize prostaglandins, which mediatethe inflammatory response and cause localvasodilation, swelling, and pain. By inhibitingprostaglandins, this NSAID reduces* For analgesic effect.† For antirheumatic effect.inflammatory symptoms. It also relievespain because prostaglandins promote paintransmission from periphery to spinal cord.ContraindicationsHypersensitivity to aspirin, iodides, meclofenamate,other NSAIDs, or their componentsInteractionsDRUGSacetaminophen: Increased risk of adverserenal effects with long-term use of bothdrugsanticoagulants, thrombolytics: Prolonged PTand increased risk of bleedingantihypertensives: Decreased effectiveness ofantihypertensivesbeta blockers: Impaired antihypertensiveeffect of beta blockerscefamandole, cefoperazone, cefotetan, plicamycin,valproic acid: Hypoprothrombinemiaand increased risk of bleedingcimetidine: Altered meclofenamate levelcolchicine, glucocorticoids, potassium supplements:Increased GI irritability and bleedingcyclosporine, gold compounds, nephrotoxicdrugs: Increased risk of nephrotoxicitydigoxin: Increased blood digoxin levelinsulin, oral antidiabetic drugs: Decreasedeffectiveness of these drugslithium: Increased risk of lithium toxicityloop diuretics: Decreased effects of thesedrugsmethotrexate: Increased risk of methotrexatetoxicityNSAIDs, salicylates: Increased GI irritabilityand risk of bleeding, decreased meclofenamateeffectivenessphenytoin: Increased blood phenytoin levelprobenecid: Increased risk of meclofenamatetoxicityACTIVITIESalcohol use: Increased GI irritability andbleeding

teritis; gastroesophageal reflux disease; GIbleeding, perforation, and ulceration;hepatic failure; indigestion; jaundice; melena;nausea; perforation of stomach or intestines;stomatitis; vomitingGU: Acute renal failure, dysuria, elevatedBUN and serum creatinine levelsHEME: Agranulocytosis, anemia, easybruising, hemolytic anemia, leukopenia,neutropenia, pancytopenia, thrombocytopeniaRESP: Asthma, respiratory depressionSKIN: Erythema multiforme, pruritus, rash,Stevens-Johnson syndrome, toxic epidermalnecrolysis, urticariaOther: Anaphylaxis, angioedemaNursing Considerations• Use meclofenamate with extreme cautionin patients with a history of ulcer diseaseor GI bleeding because NSAIDs such asmeclofenamate increase risk of GI bleedingand ulceration. Expect to use drug forshortest time possible in these patients.• Be aware that serious GI tract ulceration,bleeding, and perforation may occur withoutwarning symptoms. Elderly patientsare at greater risk. To minimize risk, givedrug with food and a full glass of water. IfGI distress occurs, withhold drug andnotify prescriber immediately.• Use meclofenamate cautiously in patientswith hypertension, and monitor bloodpressure closely throughout therapy. Drugmay cause hypertension or worsen it.WARNING Monitor patient closely forthrombotic events, including MI andstroke, because NSAIDs increase the risk.• Monitor patient—especially if he’s elderlyor taking meclofenamate long-term—forless common but serious adverse GI reactions,including anorexia, constipation,diverticulitis, dysphagia, esophagitis, gastritis,gastroenteritis, gastroesophagealreflux disease, hemorrhoids, hiatal hernia,melena, stomatitis, and vomiting.• Monitor liver function test results because,rarely, elevations may progress to severehepatic reactions, including fatal hepatitis,liver necrosis, and hepatic failure.• Monitor BUN and serum creatinine levelsin elderly patients, patients taking diureticsor ACE inhibitors, and patients withheart failure, impaired renal function, ormeclofenamate sodium 621hepatic dysfunction; drug may cause renalfailure.• Monitor CBC for decreased hemoglobinand hematocrit because drug may worsenanemia.WARNING If patient has bone marrow suppressionor is receiving an antineoplasticdrug, monitor laboratory results (includingWBC count), and watch for evidenceof infection because anti-inflammatoryand antipyretic actions of meclofenamatemay mask signs and symptoms, such asfever and pain.• Assess patient’s skin regularly for rash orother hypersensitivity reaction becausemeclofenamate is an NSAID and maycause serious skin reactions without warning,even in patients with no history ofNSAID sensitivity. At first sign of reaction,stop drug and notify prescriber.•Expect lower doses of meclofenamate to beused for long-term therapy.PATIENT TEACHING• Tell patient to take drug with a full glass ofwater to keep it from lodging in esophagusand causing irritation. Suggest taking drugwith food or milk to avoid GI distress.• Instruct patient to report itching, rash,severe diarrhea, and swelling in ankles orfingers.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Caution pregnant patient not to takeNSAIDs such as meclofenamate duringlast trimester because they may cause prematureclosure of fetal ductus arteriosus.• Explain that meclofenamate may increaserisk of serious adverse cardiovascular reactions;urge patient to seek immediatemedical attention if signs or symptomsarise, such as chest pain, shortness ofbreath, weakness, or slurring of speech.• Explain that meclofenamate may increaserisk of serious adverse GI reactions; stressimportance of seeking immediate medicalattention for such signs and symptoms asepigastric or abdominal pain, indigestion,black or tarry stools, or vomiting blood ormaterial that looks like coffee grounds.• Alert patient to rare but serious skin reactionsto meclofenamate. Urge him to seekimmediate medical attention for rash, blisters,itching, fever, or other indications ofhypersensitivity.M

622meloxicammeloxicamMobicClass and CategoryChemical class: Oxicam derivativeTherapeutic class: Anti-inflammatoryPregnancy category: CIndications and Dosages To relieve signs and symptoms ofosteoarthritis and rheumatoid arthritisORAL SUSPENSION, TABLETSAdults. 7.5 mg daily. Maximum: 15 mgdaily. To relieve pauciarticular or polyarticularsigns and symptoms of juvenile rheumatoidarthritisORAL SUSPENSION, TABLETSChildren age 2 and over. 0.125 mg/kg daily.Maximum: 7.5 mg daily.Mechanism of ActionBlocks cyclooxygenase, the enzyme neededto synthesize prostaglandins, which mediatethe inflammatory response and cause localvasodilation, swelling, and pain. By inhibitingprostaglandins, the NSAID meloxicamreduces inflammatory symptoms. It alsorelieves pain because prostaglandins promotepain transmission from the peripheryto the spinal cord.ContraindicationsAngioedema, asthma, bronchospasm, nasalpolyps, rhinitis, or urticaria induced byhypersensitivity to aspirin, meloxicam,other NSAIDs, or their componentsInteractionsDRUGSACE inhibitors: Decreased antihypertensiveeffect, increased risk of renal failureaspirin: Increased risk of GI ulcerationfurosemide: Decreased diuretic effect offurosemide, possibly renal impairmentlithium: Elevated blood lithium level,possibly lithium toxicityoral anticoagulants, warfarin: Increased riskof bleedingACTIVITIESalcohol use, smoking: Increased risk of GIbleedingAdverse ReactionsCNS: Confusion, dizziness, fever, headache,insomnia, mood alteration, seizures, strokeCV: Chest pain, edema, heart failure, hypertension,MI, tachycardia, vasculitisEENT: Laryngitis, pharyngitis, sinusitisGI: Abdominal pain, anorexia, colitis, constipation,diarrhea, diverticulitis, dyspepsia,dysphagia, elevated liver function testresults, esophagitis, flatulence, gastritis, gastroenteritis,gastroesophageal reflux disease,GI bleeding and ulceration, hepatic failure,hepatitis, indigestion, melena, nausea, pancreatitis,perforation of stomach or intestines,stomatitis, vomitingGU: Acute renal failure, acute urine retention(children), urinary frequency, UTIHEME: Agranulocytosis, anemia, easybruising, hemolytic anemia, leukopenia,neutropenia, pancytopenia, thrombocytopeniaMS: Arthralgia; back pain; joint crepitation,effusion, or swelling; muscle spasms; myalgiaRESP: Asthma, bronchospasm, cough, dyspnea,respiratory depression, upper respiratorytract infectionSKIN: Erythema multiforme, exfoliativedermatitis, photosensitivity, pruritus, rash,Stevens-Johnson syndrome, toxic epidermalnecrolysisOther: Anaphylaxis, angioedema, flulikesymptomsNursing Considerations• Use meloxicam with extreme caution inpatients with history of ulcer disease or GIbleeding because NSAIDs such as meloxicamincrease risk of GI bleeding andulceration. Expect to use drug for shortesttime possible in these patients.• Be aware that serious GI tract ulceration,bleeding, and perforation may occur withoutwarning symptoms. Elderly patientsare at greater risk. To minimize risk, givedrug with food and a full glass of water. IfGI distress occurs, withhold drug andnotify prescriber immediately.• Use meloxicam cautiously in patients withhypertension, and monitor blood pressureclosely throughout therapy. Drug maycause hypertension or worsen it.WARNING Monitor patient closely forthrombotic events, including MI andstroke, because NSAIDs increase the risk.• Monitor patient—especially if elderly ortaking meloxicam long-term—for less

common but serious adverse GI reactions,including anorexia, constipation, diverticulitis,dysphagia, esophagitis, gastritis, gastroenteritis,gastroesophageal reflux disease,hemorrhoids, hiatal hernia, melena,stomatitis, and vomiting.• Monitor liver function test results because,rarely, elevations may progress to severehepatic reactions, including fatal hepatitis,liver necrosis, and hepatic failure.• Monitor BUN and serum creatinine levelsin elderly patients; patients taking diuretics,angiotensin II receptor antagonists, orACE inhibitors; and patients with heartfailure, impaired renal function, or hepaticdysfunction; drug may cause renal failure.• Monitor CBC for decreased hemoglobinand hematocrit. Drug may worsen anemia.WARNING If patient has bone marrow suppressionor is receiving an antineoplasticdrug, monitor laboratory results (includingWBC count), and watch for evidenceof infection because anti-inflammatoryand antipyretic actions of meloxicam maymask signs and symptoms, such as feverand pain.• Assess patient’s skin regularly for rash orother hypersensitivity reaction becausemeloxicam is an NSAID and may causeserious skin reactions without warning,even in patients with no history of NSAIDsensitivity. At first sign of reaction, stopdrug and notify prescriber.• Monitor patient for adequate hydrationbefore beginning meloxicam therapy todecrease risk of renal dysfunction.PATIENT TEACHING• Instruct patient to take meloxicam withfood or after meals if he has stomach upset.• For oral suspension, tell patient to shakecontainer gently before use.• Caution patient to avoid using otherNSAIDs, aspirin, or products containingaspirin while taking meloxicam.• Advise patient to refrain from smokingand alcohol use because these activitiesmay increase risk of adverse GI reactions.• Instruct patient to notify prescriber if hedevelops signs or symptoms of hepaticdysfunction, such as dark yellow or brownurine, fatigue, fever, itching, lethargy, nausea,or yellowing of eyes or skin.• Advise patient, especially if he’s taking anoral anticoagulant such as warfarin, tomemantine hydrochloride 623report immediately signs of bleeding, suchas easy bruising, stomach pain, blood inurine, or black tarry stools.• Caution pregnant patient not to takeNSAIDs such as meloxicam during the lasttrimester because they may cause prematureclosure of ductus arteriosus.• Explain that meloxicam may increase riskof serious adverse cardiovascular reactions;urge patient to seek immediatemedical attention if signs or symptomsarise, such as chest pain, shortness ofbreath, weakness, and slurring of speech.• Explain that meloxicam may increase riskof serious adverse GI reactions; stressimportance of seeking immediate medicalattention for such signs and symptoms asepigastric or abdominal pain, indigestion,black or tarry stools, or vomiting blood ormaterial that looks like coffee grounds.• Alert patient to rare but serious skin reactions.Urge him to seek immediate medicalattention for rash, blisters, itching, fever,or other indications of hypersensitivity.memantinehydrochlorideNamendaClass and CategoryChemical class: N-methyl-D-aspartate(NMDA) receptor antagonistTherapeutic class: Antidementia agentPregnancy category: BIndications and Dosages To treat moderate-to-severe dementia ofthe Alzheimer’s typeTABLETSAdults. Initial: 5 mg daily P.O., increased by5 mg/wk, as needed, to 10 mg daily in twodivided doses; then 15 mg daily with one 5-mg and one 10-mg dose daily; then 20 mgdaily in two divided doses. Maintenance:20 mg daily.DOSAGE ADJUSTMENT Dosage reductionprobable for patients with renal impairment.ContraindicationsHypersensitivity to memantine, amantadine,or their componentsM

624memantine hydrochlorideMechanism of ActionMemantine blocks the excitatory aminoacid glutamate on N-methyl-D-aspartate(NMDA) receptor cells in the CNS. InAlzheimer’s disease, glutamate levels areabnormally high when brain cells areboth at rest and active. Normally, whencertain brain cells are resting, magnesiumions block NMDA receptors and preventinflux of sodium and calcium ions andoutflow of potassium ions. When learningand memory cells in the brain are active,glutamate engages with NMDA receptors,magnesium ions are removed fromNMDA receptors, and cells are depolarized.During depolarization, sodium andcalcium ions enter brain cells, and potassiumions leave. In Alzheimer’s disease,excessive circulating glutamate permanentlyremoves magnesium ions andopens ion channels. Excessive influx ofcalcium may damage brain cells and playa major role in Alzheimer’s disease.What’s more, dying brain cells releaseadditional glutamate, worsening the cycleof brain cell destruction.Memantine replaces magnesium onNMDA receptors of brain cells, closingion channels and preventing calciuminflux and the resulting damage to braincells. By preventing excessive brain celldeath, memantine slows progression ofAlzheimer’s disease.Cell exteriorGlutamateGlutamateMemantineMg ++Ca ++Na +Ca ++NMDAreceptorCell membraneCell interiorK + K +Closed ion channelInteractionsDRUGSamantadine, dextromethorphan, ketamine:Possibly additive effectscarbonic anhydrase inhibitors, sodium bicarbonate:Decreased memantine clearance,leading to increased blood drug levels andrisk of adverse effectscimetidine, hydrochlorothiazide, metformin,nicotinic acid, quinidine, ranitidine, triamterene:Possibly increased blood levels ofboth agentsAdverse ReactionsCNS: Abnormal gait, agitation, akathisia,anxiety, confusion, delirium, delusions,depression, dizziness, drowsiness, dyskinesia,fatigue, hallucinations, headache, hyperexcitability,insomnia, neuroleptic malignantsyndrome, psychosis, restlessness,seizures, somnolence, stroke, tardive dyskinesiaCV: AV block, chest pain, hypertension,peripheral edema, prolonged QT interval,supraventricular tachycardia, tachycardiaENDO: HypoglycemiaGI: Acute pancreatitis, anorexia, colitis,constipation, diarrhea, hepatic failure, ileus,nausea, vomitingGU: Acute renal failure, impotence, urinaryincontinence, UTIHEME: ThrombocytopeniaMS: Arthralgia, back painRESP: Bronchitis, cough, dyspnea, upperrespiratory tract infectionSKIN: Stevens-Johnson syndromeOther: Generalized pain, flulike symptoms

Nursing Considerations• Use memantine cautionly in patients withrenal tubular acidosis or severe UTIbecause these conditions make urine alkaline,reducing memantine excretion andincreasing the risk of adverse reactions.• Use cautiously in patients with severehepatic impairment because drug undergoespartial hepatic metabolism, whichmay increase risk of adverse reactions.• Monitor patient’s response to memantine,and notify prescriber if serious or bothersomeadverse reactions occur.PATIENT TEACHING• Advise patient to avoid a diet excessivelyhigh in fruits and vegetables because thesefoods contribute to alkaline urine, whichcan alter memantine clearance andincrease adverse reactions.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.meperidinehydrochloride(pethidinehydrochloride)DemerolClass, Category, and ScheduleChemical class: Phenylpiperidine derivativeopioidTherapeutic class: AnalgesicPregnancy category: CControlled substance schedule: IIIndications and Dosages To relieve moderate to severe painSYRUP, TABLETS, I.M. OR SUBCUTANEOUS INJECTIONAdults. 50 to 150 mg every 3 to 4 hr, p.r.n.Children. 1.1 to 1.8 mg/kg every 3 to 4 hr,p.r.n. To provide preoperative sedationI.V. INJECTIONAdults. 15 to 35 mg/hr, p.r.n.I.M. OR SUBCUTANEOUS INJECTIONAdults. 50 to 100 mg 30 to 90 min beforesurgery.Children. 1 to 2 mg/kg 30 to 90 min beforesurgery. Maximum: 100 mg every 3 to 4 hr. As adjunct to anesthesiaI.V. INFUSION OR INJECTIONmeperidine hydrochloride 625Adults. Individualized. Repeated slow injectionsof 10 mg/ml solution or continuousinfusion of dilute solution (1 mg/ml) titratedas needed. To provide obstetric analgesiaI.M. OR SUBCUTANEOUS INJECTIONAdults. 50 to 100 mg given with regular,painful contractions; repeated every 1 to3hr.DOSAGE ADJUSTMENT For patients withcreatinine clearance of 10 to 50 ml/min/1.73 m 2 , 75% of usual dose is used; withcreatinine clearance of less than 10 ml/min/1.73 m 2 , 50% of usual dose is used.Route Onset Peak DurationP.O. 15 min 1–1.5 hr 2–4 hrI.V. 1 min 5–7 min 2–4 hrI.M., 10–15 30–50 2–4 hrSubQ min minMechanism of ActionBinds with opiate receptors in the spinalcord and higher levels of the CNS. In thisway, meperidine stimulates mu and kappareceptors, which alters the perception ofand emotional response to pain.IncompatibilitiesDon’t mix meperidine in same syringe withaminophylline, barbiturates, heparin,iodides, methicillin, morphine sulfate,phenytoin, sodium bicarbonate, sulfadiazine,or sulfisoxazole.ContraindicationsAcute asthma; hypersensitivity to meperidine,opioids, or their components;increased intracranial pressure; severe respiratorydepression; upper respiratory tractobstruction; use within 14 days of MAOinhibitor therapyInteractionsDRUGSacyclovir, ritonavir: Possibly increased bloodmeperidine levelalfentanil, CNS depressants, fentanyl, sufentanil:Increased risk of CNS and respiratorydepression and hypotensionamphetamines, MAO inhibitors: Risk ofincreased CNS excitation or depressionwith possibly fatal reactionsanticholinergics: Increased risk of severeconstipationM

626mephentermine sulfateantidiarrheals (such as loperamide anddifenoxin and atropine): Increased risk ofsevere constipation and increased CNSdepressionantihypertensives: Increased risk of hypotensionbuprenorphine: Possibly decreased therapeuticeffects of meperidine and increasedrisk of respiratory depressioncimetidine: Reduced clearance and volumeof distribution of meperidinehydroxyzine: Increased risk of CNS depressionand hypotensionmetoclopramide: Possibly decreased effectsof metoclopramidenaloxone, naltrexone: Decreased pharmacologiceffects of meperidineneuromuscular blockers: Increased risk ofprolonged respiratory and CNS depressionoral anticoagulants: Possibly increased anticoagulanteffect and risk of bleedingphenytoin: Possibly enhanced hepaticmetabolism of meperidineACTIVITIESalcohol use: Possibly increased CNS and respiratorydepression and hypotensionAdverse ReactionsCNS: Confusion, depression, dizziness,drowsiness, euphoria, headache, increasedintracranial pressure, lack of coordination,malaise, nervousness, nightmares, restlessness,seizures, syncope, tremorCV: Hypotension, orthostatic hypotension,tachycardiaEENT: Blurred vision, diplopia, dry mouthGI: Abdominal cramps or pain, anorexia,constipation, ileus, nausea, vomitingGU: Dysuria, urinary frequency, urineretentionRESP: Dyspnea, respiratory arrest ordepression, wheezingSKIN: Diaphoresis, flushing, pruritus, rash,urticariaOther: Anaphylaxis, injection site pain, redness,and swelling; physical and psychologicaldependenceNursing Considerations• Use meperidine with extreme caution inpatients with acute abdominal conditions,hepatic or renal disorders, hypothyroidism,prostatic hyperplasia, seizures, orsupraventricular tachycardia.• To minimize local anesthetic effect, dilutemeperidine syrup with water before use.• Give I.V. dose slowly by direct injection oras a slow continuous infusion. Mix withD 5 W, normal saline solution, or Ringer’sor lactated Ringer’s solution.• Keep naloxone available when giving I.V.meperidine.• Be aware that subcutaneous injection ispainful and isn’t recommended.• Be aware that oral form of meperidine isless than half as effective as parenteralmeperidine. Give I.M. form when possible,and expect to increase dosage whenswitching patient to oral form.• Monitor patient’s respiratory and cardiovascularstatus during treatment. Notifyprescriber immediately and expect to discontinuedrug if respiratory rate falls toless than 12 breaths/minute or if respiratorydepth decreases.• Monitor patient’s bowel function to detectconstipation, and assess the need for stoolsofteners.• Assess for signs of physical dependenceand abuse.• Expect withdrawal symptoms to occur ifdrug is abruptly withdrawn after longtermuse.PATIENT TEACHING• Inform patient that meperidine is a controlledsubstance and that he’ll need identificationto purchase it.• Advise patient to take drug exactly as prescribed.• Instruct patient to report constipation,severe nausea, and shortness or breath.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to prevent postoperativeatelectasis by turning, coughing, and deepbreathing.• Urge patient to avoid alcohol, sedatives,and tranquilizers during therapy.mephenterminesulfateWyamineClass and CategoryChemical class: Sympathomimetic amineTherapeutic class: Vasopressor

Pregnancy category: CIndications and Dosages To treat hypotension secondary to spinalanesthesiaI.V. INJECTIONAdults. 30 to 45 mg (15 mg for obstetricpatients); may be repeated, as needed, tomaintain blood pressure.I.V. INFUSIONAdults. Dosage individualized based onpatient response to therapy. Average dose is1 to 5 mg/min.Route Onset Peak DurationI.V. Almost Unknown 15–30 minimmediateMechanism of ActionStimulates alpha-adrenergic receptorsdirectly and indirectly, resulting in positiveinotropic and chronotropic effects. Indirectstimulation occurs by release of norepinephrinefrom its storage sites in the heartand other tissues. By enhancing cardiaccontraction, mephentermine improves cardiacoutput, thereby increasing blood pressure.Increased peripheral resistance fromperipheral vasoconstriction may also contributeto increased blood pressure. Drugcan affect heart rate but change is variable,based on vagal tone. It also may stimulatebeta-adrenergic receptors.ContraindicationsHypersensitivity to mephentermine,phenothiazine-induced hypotension, usewithin 14 days of MAO inhibitor therapyInteractionsDRUGSalpha blockers and other drugs with alphablockingeffects: Possibly decreased peripheralvasoconstrictive and hypertensive effectsof mephenterminebeta blockers (ophthalmic): Decreased effectsof mephentermine; increased risk of bronchospasm,wheezing, decreased pulmonaryfunction, and respiratory failurebeta blockers (systemic): Increased risk ofbronchospasm and decreased effects ofboth drugsdiuretics and other antihypertensives:Possibly reduced effectiveness of thesedrugsmephentermine sulfate 627doxapram: Possibly increased vasopressoreffects of either drugergot alkaloids: Increased vasopressor effectsguanadrel, guanethidine, mecamylamine,methyldopa, reserpine: Possibly decreasedeffects of these drugs and increased risk ofadverse effectshydrocarbon inhalation anesthetics:Increased risk of atrial and ventriculararrhythmiasMAO inhibitors: Increased, lengthened cardiacstimulation and vasopressor effects,and possibly severe headache and hypertensivecrisismaprotiline, tricyclic antidepressants:Increased vasopressor response; increasedrisk of prolonged QTc interval, arrhythmias,hypertension, and hyperpyrexiamethylphenidate: Possibly increased vasopressoreffect of mephenterminenitrates: Possibly reduced antianginal effectsof nitrates and decreased vasopressor effectother sympathomimetics (such as dopamine):Possibly increased cardiac effects andadverse reactionsoxytocin: Possibly severe hypertensionthyroid hormones: Increased effects of bothdrugs, increased risk of coronary insufficiencyin patients with coronary artery diseaseAdverse ReactionsCNS: Anxiety, dizziness, drowsiness, euphoria,headache, incoherence, nervousness,psychosis, restlessness, seizures, weaknessCV: Angina, arrhythmias (including bradycardia,tachycardia, and ventricular arrhythmias),hypertension, hypotension, palpitations,peripheral vasoconstrictionGI: Nausea, vomitingRESP: DyspneaSKIN: Peripheral necrosisNursing Considerations• Before giving mephentermine, expect tointervene, as ordered, to correct hemorrhage,hypovolemia, metabolic acidosis, orhypoxia.• Discard vial if you observe discolorationor precipitate.• Using D 5 W or normal saline solution, preparea 1-mg/ml solution for infusion.• Administer drug using an infusion pumpto provide a controlled rate.• Monitor blood pressure, cardiac rate andM

628InteractionsDRUGSacetaminophen: Increased risk of hepatotoxicitywith long-term acetaminophen useamiodarone: Possibly increased blood mephenytoinlevel and risk of toxicityantacids: Possibly decreased mephenytoineffectivenessantineoplastics: Increased mephenytoinmetabolismbupropion, clozapine, loxapine, MAO inhibitors,maprotiline, phenothiazines, pimozide,thioxanthenes: Possibly lowered seizurethreshold and decreased therapeutic effectsof mephenytoin, possibly intensified CNSdepressant effects of these drugscalcium channel blockers, fluconazole, itraconazole,ketoconazole, miconazole, omeprazole:Possibly increased phenytoin levelcarbamazepine: Decreased blood carbamazepinelevel, possibly increased blood phenmephenytoinrhythm, central venous pressure (if appropriate),and urine output during administration.Adjust infusion rate according topatient response, as ordered. Be aware thatpatients with a history of cardiovasculardisease (including hypertension) or hyperthyroidismand chronically ill patients areat increased risk for mephentermine’sadverse cardiovascular effects.• Assess patients with angle-closure glaucomafor signs of an exacerbation, such aseye pain or blurred vision.• Assess circulation in patients with a historyof occlusive vascular disease, such asatherosclerosis and Raynaud’s disease,because mephentermine may causedecreased circulation and increase risk ofnecrosis or gangrene. Inspect I.V. site periodicallyfor signs of extravasation.WARNING Be aware that weeping, excitability,seizures, and hallucinations are some ofthe symptoms of mephentermine overdose.Contact prescriber immediately ifpatient has such symptoms, and expect toprovide supportive treatment.• Be aware that mephentermine can increasecontractions in pregnant women, especiallyduring third trimester. Expect drug tobe prescribed only when benefits outweighpotential adverse effects.• Store drug at 59° to 86° F (15° to 30° C);don’t freeze.PATIENT TEACHING• Instruct patient receiving mephentermineto report adverse reactions, including chestpain, difficulty breathing, dizziness, irregularheartbeat, headache, and weakness.mephenytoinMesantoinClass and CategoryChemical class: Hydantoin derivativeTherapeutic class: AnticonvulsantPregnancy category: Not ratedIndications and Dosages To control generalized tonic-clonic, focal,and jacksonian seizures when otherdrugs are ineffectiveTABLETSAdults. Initial: 50 to 100 mg daily duringfirst wk. Increased by 50 to 100 mg at 1-wkintervals until desired response is reached.Maintenance: 200 to 600 mg daily in equallydivided doses. Maximum: 1.2 g daily.Children. Initial: 20 to 50 mg daily.Increased by 25 to 50 mg at 1-wk intervalsuntil desired response occurs. Maintenance:100 to 400 mg daily in equally divideddoses. Maximum: 400 mg daily. To replace other anticonvulsantsTABLETSAdults. 50 to 100 mg daily during first wk.Dosage gradually increased while decreasingdosage of other drug over 3 to 6 wk.Route Onset Peak DurationP.O. 30 min Unknown 24–48 hrMechanism of ActionLimits spread of seizure activity and start ofnew seizures by:• regulating voltage-dependent sodium andcalcium channels in neurons• inhibiting calcium movement across neuronalmembranes• enhancing sodium-potassium adenosinetriphosphatase activity in neurons andglial cells.These actions may reflect a slowed recoveryrate of inactivated sodium channels.ContraindicationsHypersensitivity to mephenytoin, phenytoin,other hydantoins, or their components

ytoin level and risk of toxicitychloramphenicol, cimetidine, disulfiram, isoniazid,methylphenidate, metronidazole,phenylbutazone, ranitidine, salicylates, sulfonamides,trimethoprim: Possibly impairedmetabolism of these drugs and increasedrisk of mephenytoin toxicitycorticosteroids, cyclosporine, digoxin, disopyramide,doxycycline, furosemide, levodopa,mexiletine, quinidine: Decreased therapeuticeffects of these drugsdiazoxide: Possibly decreased therapeuticeffects of both drugsestrogens, progestins: Decreased therapeuticeffects of these drugs, increased bloodphenytoin levelfelbamate: Possibly impaired metabolismand increased blood level of phenytoinfluoxetine: Possibly increased blood phenytoinlevel and risk of toxicityfolic acid: Increased mephenytoin metabolism,decreased seizure controlhaloperidol: Possibly lowered seizure thresholdand decreased therapeutic effects ofmephenytoin; possibly decreased bloodhaloperidol levelinsulin, oral antidiabetic drugs: Possiblyincreased blood glucose level and decreasedtherapeutic effects of these drugslamotrigine: Possibly decreased therapeuticeffects of lamotriginelithium: Increased risk of lithium toxicitymethadone: Possibly increased methadonemetabolism and withdrawal symptomsmolindone: Possibly lowered seizure threshold,impaired absorption, and decreasedtherapeutic effects of mephenytoinoral anticoagulants: Possibly impairedmetabolism of these drugs and increasedrisk of mephenytoin toxicity; possiblyincreased anticoagulant effect initially, butdecreased effect with prolonged therapyoral contraceptives containing estrogen andprogestin: Possibly breakthrough bleedingand decreased contraceptive effectivenessrifampin: Possibly decreased therapeuticeffects of mephenytoinstreptozocin: Possibly decreased therapeuticeffects of streptozocinsucralfate: Possibly decreased mephenytoinabsorptiontricyclic antidepressants: Possibly loweredseizure threshold and decreased therapeuticeffects of mephenytoin; possibly decreasedmephenytoin 629blood level of tricyclic antidepressantsvalproic acid: Decreased blood phenytoinlevel, increased blood valproic acid levelvitamin D analogues: Decreased vitamin Danalogue activity, risk of anticonvulsantinducedrickets and osteomalaciaxanthines: Possibly inhibited mephenytoinabsorption and increased clearance of xanthineszaleplon: Increased clearance and decreasedeffectiveness of zaleplonACTIVITIESalcohol use: Possibly decreased mephenytoineffectivenessAdverse ReactionsCNS: Ataxia, choreoathetoid movements,confusion, dizziness, drowsiness, excitement,fatigue, fever, headache, peripheralneuropathy, sedation, slurred speech, stuttering,tremorEENT: Gingival hyperplasia, nystagmusGI: Constipation, diarrhea, nausea, vomitingHEME: Agranulocytosis, leukopenia,thrombocytopeniaMS: Muscle twitchingSKIN: Rash, Stevens-Johnson syndrome,toxic epidermal necrolysisOther: Lymphadenopathy, systemic lupuserythematosusNursing Considerations• Because of mephenytoin’s potentially dangerousadverse effects, expect to use it onlywhen other drugs are ineffective.• Keep in mind that mephenytoin doesn’tcontrol absence seizures.WARNING Be aware that drug shouldn’t bediscontinued abruptly because doing somay cause status epilepticus. Plan toreduce dosage gradually or substituteanother drug, as prescribed.• Obtain CBC and differential before treatment,after 2 weeks, and then monthlyduring first year of treatment, as ordered.• If patient has depressed blood counts,enlarged lymph nodes, or rash, notify prescriberimmediately and expect to stopmephenytoin and substitute another drug.PATIENT TEACHING• Urge patient to take mephenytoin exactlyas prescribed and not to stop abruptly.• Advise patient to take drug with food toenhance absorption and reduce adverse GIreactions.M

630mephobarbital• Caution patient on once-a-day therapy tobe especially careful not to miss a dose.• Advise patient to report impaired coordination,persistent headache, rash, severeGI distress, swollen gums or lymph nodes,or unusual bleeding or bruising.• Encourage patient to maintain good oralhygiene and to have regular dental checkupsto reduce risk of gum disease.• Instruct patient to keep medical appointmentsto monitor drug effectiveness andcheck for adverse reactions. Explain theneed for periodic laboratory tests.• Advise patient to wear medical identificationstating that he has epilepsy and takesmephenytoin to prevent seizures.mephobarbitalMebaralClass, Category, and ScheduleChemical class: Barbiturate derivativeTherapeutic class: Anticonvulsant, sedativePregnancy category: DControlled substance schedule: IVIndications and Dosages To treat seizuresTABLETSAdults. 400 to 600 mg daily as a single doseor in divided doses, usually beginning withlow dose and increasing over 4 to 5 daysuntil optimum dosage is determined.Children over age 5. 32 to 64 mg t.i.d. orq.i.d.Children under age 5. 16 to 32 mg t.i.d. orq.i.d. To provide sedationTABLETSAdults. 32 to 100 mg t.i.d. or q.i.d.Children. 16 to 32 mg t.i.d. or q.i.d.Route Onset Peak DurationP.O. 30–60 min Unknown 10–16 hrMechanism of ActionMay reduce seizure activity by reducingtransmission of monosynaptic and polysynapticnerve impulses, which decreasesexcitability in nerve cells. As a sedative,mephobarbital inhibits upward conductionof nerve impulses to the reticular formationof the brain, which disrupts impulse transmissionto the cortex. As a result, mephobarbitaldepresses the CNS and producesdrowsiness, hypnosis, and sedation.ContraindicationsHepatic disease or failure; history of addictionto sedatives or hypnotics; hypersensitivityto mephobarbital, other barbiturates,or their components; nephritis; porphyria;severe respiratory disease with obstructionor dyspneaInteractionsDRUGSacetaminophen: Possibly decreased effects ofacetaminophen (with long-term mephobarbitaluse)anesthetics (halogenated hydrocarbon):Increased risk of hepatotoxicity (with longtermmephobarbital use)carbamazepine, chloramphenicol, corticosteroids,cyclosporine, dacarbazine, digoxin,disopyramide, doxycycline, griseofulvin,metronidazole, oral contraceptives, phenylbutazone,quinidine, theophyllines, vitaminD: Decreased effectiveness of these drugsCNS depressants: Increased CNS depressiondivalproex sodium, valproic acid: Increasedrisk of CNS depression and neurotoxicityguanadrel, guanethidine: Increased risk oforthostatic hypotensionhaloperidol: Possibly decreased blood haloperidollevel and change in seizure patternhydantoins: Possibly interference withhydantoin metabolismleucovorin: Possibly decreased anticonvulsanteffect of mephobarbitalmaprotiline: Possibly increased CNS depressionand decreased therapeutic effects ofmephobarbitalmexiletine: Possibly decreased blood mexiletineleveloral anticoagulants: Possibly decreased therapeuticeffects of anticoagulants, possiblyincreased risk of bleeding when mephobarbitalis discontinuedtricyclic antidepressants: Possibly decreasedtherapeutic effects of tricyclic antidepressantsACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Agitation, anxiety, ataxia, confusion,

delusions, depression, dizziness, drowsiness,fever, hallucinations, headache, insomnia,irritability, nervousness, nightmares, paradoxicalstimulation, seizures, syncope,tremorCV: Orthostatic hypotensionEENT: Vision changesGI: Anorexia, constipation, hepatic dysfunction,nausea, vomitingHEME: AgranulocytosisMS: Arthralgia, bone pain, muscle twitchingor weaknessRESP: Respiratory depressionSKIN: Exfoliative dermatitis, rash, Stevens-Johnson syndromeOther: Physical and psychological dependence,weight lossNursing Considerations• Observe patient for signs of physical andpsychological dependence, especially withprolonged use at high doses.• Observe for signs of chronic barbiturateintoxication, including confusion, insomnia,poor judgment, slurred speech, andunsteady gait.• Assess for paradoxical stimulation inpatient who receives drug for acute orchronic pain.WARNING Expect to taper mephobarbitalgradually when discontinuing. Be awarethat withdrawal symptoms can be severeand may cause death. Mild signs andsymptoms may include anxiety, muscletwitching, nausea, orthostatic hypotension,and progressive weakness and mayappear 8 to 12 hours after last dose. Moresevere signs include delirium and seizures.PATIENT TEACHING• Advise patient to take mephobarbitalexactly as prescribed. Caution him not tostop taking drug abruptly because of possiblewithdrawal symptoms and, forepileptic patients, seizures.• Instruct patient to avoid alcohol, sleepingpills, and other sedatives while takingmephobarbital because of the risk ofincreased CNS depression.• Advise patient to avoid hazardous activitiesuntil CNS effects of drug are known.• Advise patient to change position slowly tominimize orthostatic hypotension.• Urge patient to report confusion, fever,rash, or severe dizziness.meprobamate 631meprobamateApo-Meprobamate (CAN), Equanil, MB-Tab, Meprospan, Miltown, NeuramateClass, Category, and ScheduleChemical class: Carbamate derivativeTherapeutic class: AntianxietyPregnancy category: Not ratedControlled substance schedule: IVIndications and Dosages To treat anxietyS.R. CAPSULESAdults and adolescents. 400 to 800 mgevery morning and bedtime. Maximum:2,400 mg daily.Children ages 6 to 12. 200 mg every morningand bedtime.TABLETSAdults and adolescents. 1,200 to 1,600 mg/day in divided doses t.i.d. or q.i.d.Maximum: 2,400 mg daily.DOSAGE ADJUSTMENT For patients with creatinineclearance of 10 to 50 ml/min/1.73 m 2 , drug given every 12 hr; with creatinineclearance less than 10 ml/min/1.73 m 2 , drug given every 18 hr.Children ages 6 to 12. 200 to 600 mg dailyin divided doses b.i.d. or t.i.d.Route Onset Peak DurationP.O. 1 hr Unknown UnknownMechanism of ActionMay act at multiple sites in CNS, includingthalamus and limbic system. Meprobamateinhibits spinal reflexes, causing CNS relaxation;its sedative effects may account for itsanticonvulsant action. It also has musclerelaxant properties.ContraindicationsHypersensitivity to meprobromate or relateddrugs, such as carisoprodol; porphyriaInteractionsDRUGSCNS depressants: Increased CNS depressionACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Ataxia, dizziness, drowsiness, euphoria,headache, paradoxical stimulation,M

632meropenemparesthesia, slurred speech, syncope, vertigo,weaknessCV: Arrhythmias, including tachycardia;hypotension; palpitationsEENT: Impaired visual accommodationGI: Diarrhea, nausea, vomitingSKIN: Erythematous maculopapular rash,pruritus, urticariaOther: Physical dependenceNursing Considerations• Use meprobamate cautiously in patientswith impaired hepatic or renal function,seizure disorders, or suicidal tendencies.• Also use drug cautiously in patients withhistory of drug dependence or abusebecause meprobamate use can lead tophysical dependence and abuse.• Observe for evidence of chronic drugintoxication, such as ataxia, slurredspeech, and vertigo.WARNING When stopping therapy, expect totaper dosage over 2 weeks because stoppingabruptly can worsen previous symptoms,such as anxiety, or cause withdrawalsymptoms, such as confusion, hallucinations,muscle twitching, tremor, and vomiting.PATIENT TEACHING• Instruct patient to take meprobamateexactly as directed and not to stop takingit abruptly.• Advise patient not to crush or chew S.R.capsules.• Instruct patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Direct patient to avoid alcohol, sedatives,and other CNS depressants while takingmeprobamate.• Inform patient that drug may become lesseffective after several months of treatment.• Instruct patient to report rash.meropenemMerrem I.V.Class and CategoryChemical class: CarbapenemTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat complicated appendicitis andperitonitis caused by susceptible strainsof alpha-hemolytic streptococci, Bacteroidesfragilis, Bacteroides thetaiotaomicron,Escherichia coli, Klebsiellapneumoniae, Peptostreptococcusspecies, or Pseudomonas aeruginosaI.V. INFUSION OR INJECTIONAdults and children weighing more than50 kg (110 lb). 1 g every 8 hr infused over15 to 30 min or given as a bolus over 3 to5 min.Children over age 3 months weighing lessthan 50 kg. 20 mg/kg every 8 hr infusedover 15 to 30 min or given as bolus over3 to 5 min. Maximum: 1 g every 8 hr.DOSAGE ADJUSTMENT For patients with creatinineclearance of 26 to 50 ml/min/1.73 m 2 , dosage reduced to 1 g every 12 hr.For those with clearance of 10 to 25 ml/min/1.73 m 2 , dosage reduced to 500 mgevery 12 hr. For those with clearance lessthan 10 ml/min/1.73 m 2 , dosage reduced to500 mg every 24 hr. To treat complicated skin and skin structureinfections caused by Staphylococcusaureus, Streptococcus agalactiae,Streptococcus pyogenes, viridans groupstreptococci, Enterococcus faecalis(excluding vancomycin-resistant isolates),Pseudomonas aeruginosa,Escherichia coli, Proteus mirabilis,Bacteroides fragilis, and PeptostreptococcusspeciesI.V. INFUSIONAdults and children weighing more than50 kg (110 lb). 500 mg every 8 hr infusedover 15 to 30 min.Children over age 3 months weighing lessthan 50 kg. 10 mg/kg every 8 hr infusedover 15 to 30 min. Maximum: 500 mg every8 hr.DOSAGE ADJUSTMENT For patients with creatinineclearance of 26 to 50 ml/min/1.73 m 2 , dosage reduced to 500 mg every12 hr. For those with clearance of 10 to25 ml/min/1.73 m 2 , dosage reduced to250 mg every 12 hr. For those with clearanceless than 10 ml/min/1.73 m 2 , dosagereduced to 250 mg every 24 hr. To treat bacterial meningitis caused byHaemophilus influenzae, Neisseriameningitidis, or Streptococcus pneumoniaein childrenI.V. INFUSION OR INJECTION

Children weighing more than 50 kg. 2 gevery 8 hr infused over 15 to 30 min orgiven as a bolus over 3 to 5 min.Children over age 3 months weighing lessthan 50 kg. 40 mg/kg every 8 hr infusedover 15 to 30 min or given as bolus over3 to 5 min. Maximum: 2 g every 8 hr.Mechanism of ActionPenetrates cell walls of most gramnegativeand gram-positive bacteria, inactivatingpenicillin-binding proteins. Thisaction inhibits bacterial cell wall synthesisand causes cell death.IncompatibilitiesDon’t mix meropenem in same solutionwith other drugs.ContraindicationsHypersensitivity to meropenem, othercarbapenem drugs, beta lactams, or theircomponentsInteractionsDRUGSprobenecid: Inhibited renal excretion ofmeropenemvalproic acid: Possibly reduced blood levelof valproic acid to subtherapeutic levelAdverse ReactionsCNS: Headache, seizuresCV: ShockEENT: Epistaxis, glossitis, oral candidiasisGI: Anorexia, constipation, diarrhea, elevatedliver function test results, nausea,pseudomembranous colitis, vomitingGU: Elevated BUN and serum creatininelevels, hematuria, renal failureHEME: Agranulocytosis, hemolytic anemia,leukopenia, neutropenia, positive Coombs’testRESP: Apnea, dyspneaSKIN: Diaper rash from candidiasis (children),erythema multiforme, pruritus, rash,Stevens-Johnson syndrome, toxic epidermalnecrolysisOther: Anaphylaxis; angioedema; injectionsite inflammation, pain, phlebitis, orthrombophlebitis; sepsisNursing Considerations• Obtain body fluid and tissue samples, asordered, for culture and sensitivity testing.Expect to review test results, if possible,before giving first dose of meropenem.• For I.V. bolus, add 10 ml sterile water forinjection to 500 mg/20-ml vial, or 20 mldiluent to 1 g/30-ml vial of drug. Shake todissolve.WARNING Be aware that fatal hypersensitivityreactions have occurred with meropenemuse. Determine whether patient hashad previous reactions to antibiotics orother allergens. Monitor patient closelyand stop drug immediately if signs andsymptoms of anaphylaxis occur. Notifyprescriber, and expect to provide supportiveemergency care that may include epinephrineand I.V. steroid administration,oxygen, and airway management.• Monitor patient closely for diarrhea,which may indicate pseudomembranouscolitis caused by Clostridium difficile. Ifdiarrhea occurs, notify prescriber andexpect to withhold meropenem and treatwith fluids, electrolytes, protein, and anantibiotic effective against C. difficile.• Take seizure precautions according tofacility policy, especially for patients withbacterial meningitis or CNS or renal disordersbecause of an increased risk ofseizures with meropenem.• Monitor patient with creatinine clearanceof 10 to 26 ml/min/1.73 m 2 for signs andsymptoms of seizures, heart failure, renalfailure, or shock.PATIENT TEACHING• Tell patient to report trouble breathing,injection site pain, and sore mouth.• Urge patient to tell prescriber about diarrheathat’s severe or lasts longer than3 days. Remind patient that watery orbloody stools can occur 2 or more monthsafter antibiotic therapy and can be serious,requiring prompt treatment.mesalaminemesalamine 633Asacol, Canasa, Lialda, Mesasal (CAN),Pentasa, Rowasa, Salofalk (CAN)Class and CategoryChemical class: 5-Aminosalicylic acidderivativeTherapeutic class: Anti-inflammatoryPregnancy category: BIndications and Dosages To treat and maintain remission ofM

634mesalamineulcerative colitisDELAYED-RELEASE TABLETS (ASACOL)Adults. Initial: 0.8 g t.i.d. for 6 wk.Maintenance: 1.6 g daily in divided doses.DELAYED-RELEASE TABLETS (MESASAL)Adults. 1.5 to 3 g daily in divided doses for6 wk.DELAYED-RELEASE TABLETS (SALOFALK)Adults. 1 g t.i.d. or q.i.d. for 6 wk.E.R. CAPSULESAdults. 1 g q.i.d. for up to 8 wk. To treat mild to moderate distal ulcerativecolitis, proctitis, and proctosigmoiditisRECTAL SUSPENSIONAdults. 4 g (60 ml) daily at bedtime for 3 to6 wk. To treat active ulcerative proctitisSUPPOSITORIES (CANASA)Adults. 0.5 g b.i.d. or t.i.d. for 3 to 6 wk. Or1 g at bedtime for 3 to 6 wk. To induce remission in patients with activemild to moderate ulcerative colitis.TABLETSAdults. 2.4 or 4.8 g once daily with a mealfor up to 8 wk.Mechanism of ActionMay reduce inflammation by inhibiting theenzyme cyclooxygenase and decreasing productionof arachidonic acid metabolites,which may be increased in patients withinflammatory bowel disease. Cyclooxygenaseis needed to form prostaglandins fromarachidonic acid. Prostaglandins mediateinflammatory activity and produce signsand symptoms of inflammation. Mesalaminealso may reduce inflammation byinterfering with leukotriene synthesis andinhibiting the enzyme lipoxygenase, both ofwhich take part in inflammatory response.ContraindicationsHypersensitivity to mesalamine, salicylates,or their componentsInteractionsDRUGSdigoxin: Possibly decreased absorption andbioavailability of digoxinlactulose: Possibly interference withdelayed-release tablets or E.R. capsulesomeprazole: Increased mesalamine absorptionAdverse ReactionsCNS: Chills, confusion, depression, dizziness,emotional lability, fatigue, fever, headache(severe), somnolence, tremor, vertigo,weaknessCV: Myocarditis, pericarditisEENT: Blurred vision, dry mouth, rhinitis,taste perversion, tinnitusGI: Abdominal cramps or pain (severe),anorexia, bloody diarrhea, cholecystitis,colitis, diarrhea, elevated liver function testresults, flatulence, gastritis, hepatotoxicity,hepatitis, indigestion, nausea, pancreatitis,rectal pain, vomitingGU: Acute or chronic renal failure, interstitialnephritis, nephrotoxicityHEME: Agranulocytosis, anemia includingaplastic anemia, eosinophilia, granulocytopenia,leukopenia, lymphadenopathy,thrombocytopeniaMS: Back pain, dysarthria, goutRESP: Allergic alveolitis, asthma exacerbation,fibrosing alveolitis, pleuritis, pneumonitisSKIN: Acne, alopecia, dryness, erythemanodosum, pruritus, rash, urticariaOther: Angioedema, drug fever, systemiclupus erythematosusNursing Considerations• Use mesalamine cautiously in patientswith sulfite sensitivity. Some drug formulationscontain sulfites, which may causehypersensitivity reactions in these patients.• Use mesalamine cautiously in patientswith liver disease because hepatic dysfunctionmay occur.• Ensure that suppository is firm beforeinserting it. If it’s too soft, chill in refrigeratorfor 30 minutes or run under coldwater before removing wrapper. Moistenwith water-soluble lubricant or tap waterbefore insertion. Have patient retain suppositoryfor 1 to 3 hours, as directed.• Give rectal suspension at bedtime, andhave patient retain for prescribed time—about 8 hours, if possible. Retention timeranges from 3.5 to 12 hours.• Be aware that rectal suspension may darkenslightly over time but that this changedoesn’t affect potency. Discard rectal suspensionthat turns dark brown.• Assess patient for evidence of acute intolerancesimilar to flare-up of inflammatorybowel disease: acute abdominal crampsand pain, bloody diarrhea, and, possibly,fever, headache, and rash.

• For patients with impaired renal function,expect to monitor renal function testresults periodically during long-term therapybecause drug may cause nephrotoxicity.• Monitor patient’s CBC with differentialfor eosinophilia, which may indicate anallergic reaction.PATIENT TEACHING• Instruct patient taking oral drug to swallowtablets or capsules whole and not tobreak outer coating by cutting or chewing.• Tell patient taking extended-release productto take it with a meal.• Teach patient how to use rectal suspensionor suppositories correctly. Stress shakingsuspension bottle well before using.• Advise patient to notify prescriber immediatelyabout abdominal cramps or pain,bloody diarrhea, fever, headache, or rash.mesoridazinebesylateSerentilClass and CategoryChemical class: Alkylpiperidine phenothiazinederivativeTherapeutic class: AntipsychoticPregnancy category: Not ratedIndications and Dosages To treat schizophrenia in patients whofailed to respond to other antipsychoticdrugs, either because they were ineffectiveor because intolerable adverse effectsprevented attainment of effective doseORAL SOLUTION, TABLETSAdults and adolescents. 50 mg t.i.d.,increased as needed and tolerated.Maximum: 400 mg daily.I.M. INJECTIONAdults and adolescents. 25 mg, repeatedin 30 to 60 min, as needed. Maximum:200 mg/day.Route Onset Peak DurationP.O., I.M. Up to 6 wk– 4–8 hrseveral wk 6 moMechanism of ActionDepresses brain areas that control activitymesoridazine besylate 635and aggression—including cerebral cortex,hypothalamus, and limbic system—by anunknown mechanism.ContraindicationsBlood dyscrasias; bone marrow depression;cerebral arteriosclerosis; coma; concurrentuse of high doses of CNS depressants; concurrentuse of other drugs that prolong QTcinterval, such as disopyramide, procainamide,and quinidine; congenital long-QTsyndrome; coronary artery disease; hepaticdysfunction; history of arrhythmias; hypersensitivityto mesoridazine, other phenothiazines,or their components; myeloproliferativedisorders; severe CNS depression;severe hypertension or hypotension; subcorticalbrain damageInteractionsDRUGSaluminum- or magnesium-containing antacids,antidiarrheals (adsorbent): Decreasedmesoridazine absorptionamantadine, anticholinergics: Increasedanticholinergic effects, possibly decreasedtherapeutic effects of mesoridazineaminoglycosides, ototoxic drugs: Maskedsymptoms of ototoxicity, such as dizziness,tinnitus, and vertigoanticonvulsants: Possibly lowered seizurethresholdantithyroid drugs: Increased risk of agranulocytosisappetite suppressants: Possibly antagonizedanorectic effectastemizole, cisapride, disopyramide, erythromycin,pimozide, probucol, procainamide,quinidine: Increased risk of prolonged QTinterval and life-threatening arrhythmiasbeta blockers: Increased blood levels of bothdrugs, possibly resulting in additive hypotension,retinopathy, arrhythmias, and tardivedyskinesiaCNS depressants, general anesthetics:Increased CNS depressiondextroamphetamine: Possibly interferencewith action of either druglevodopa: Possibly inhibited levodopa effectslithium: Possibly decreased absorption ofmesoridazineopioid analgesics: Possibly decreased mesoridazineeffects; increased CNS and respiratorydepression and orthostatic hypotension;increased risk of severe constipationM

636metaproterenol sulfateoral anticoagulants: Possibly decreased therapeuticeffects of anticoagulantssympathomimetics: Possibly decreased therapeuticeffects of these drugs and increasedrisk of hypotensionthiazide diuretics: Possibly orthostatic hypotension,hyponatremia, and water intoxicationtricyclic antidepressants: Increased tricyclicantidepressant levels, inhibited mesoridazinemetabolism, increased risk of neurolepticmalignant syndromeACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Ataxia, dizziness, drowsiness, extrapyramidalreactions (tardive dyskinesia,pseudoparkinsonism), fever, neurolepticmalignant syndrome, restlessness, seizures,slurred speech, syncope, tremor, weaknessCV: Hypotension, orthostatic hypotension,prolonged QTc interval, torsades de pointesEENT: Blurred vision, dry mouth, hypertrophicpapillae of tongue, increased salivation,photophobiaENDO: Galactorrhea, gynecomastiaGI: Constipation, hepatotoxicity, nausea,vomitingGU: Dysuria, ejaculation disorders, impotence,menstrual irregularities, priapismHEME: Agranulocytosis, leukopenia,thrombocytopeniaSKIN: Contact dermatitis, decreased sweating,jaundice, photosensitivity, rashOther: Injection site pain, weight gainNursing Considerations• Before starting mesoridazine, expect toobtain a 12-lead ECG to detect prolongedQTc interval. If patient’s QTc interval isgreater than 450 milliseconds (msec),expect to withhold drug because of risk oflife-threatening torsades de pointes.• Wear gloves when working with liquid andparenteral forms of mesoridazine, andavoid contact with clothing or skin; drugmay cause contact dermatitis.• Discard injection solution if it’s franklydiscolored or contains precipitate; slightlyyellow color is acceptable.• Inject I.M. drug deep into upper outerquadrant of buttocks; massage area afterwardto prevent sterile abscess.• Implement continuous ECG monitoring,as ordered, to detect arrhythmias. Expectto discontinue mesoridazine if the QTcinterval exceeds 500 msec.• Monitor serum potassium level before andduring therapy, and administer potassiumsupplements as prescribed.• Assess patient for hypotension and orthostatichypotension, especially during I.M.use. Notify prescriber if either develops.WARNING Monitor patient for neurolepticmalignant syndrome, a potentially fatalreaction to antipsychotic drugs, and notifyprescriber about such early signs as alteredmental status, fever, hypertension or hypotension,muscle rigidity, and tachycardia.• Assess patient for signs of blood dyscrasias,including cellulitis, fever, and pharyngitis.If they develop, expect to stop drug.• Monitor patient for signs of tardive dyskinesia,even after treatment stops. Notifyprescriber if they develop.• Expect to taper drug dosage before discontinuationto avoid adverse reactions, suchas dizziness, nausea, tremor, and vomiting.PATIENT TEACHING• Instruct patient to take drug exactly asprescribed and not to stop abruptly.• Explain that I.M. injection may be painful.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to change position slowly tominimize orthostatic hypotension.• Tell patient to report fever, involuntaryfacial movements, sore throat, unusualbleeding or bruising, and yellowing of eyesor skin.• Urge patient to avoid alcohol and prolongedsun exposure during therapy.• If patient need long-term therapy, explainthe risk of tardive dyskinesia. Also advisehim to have regular eye examinations.metaproterenolsulfateAlupent, Arm-a-Med Metaproterenol,Dey-Lute MetaproterenolClass and CategoryChemical class: Sympathomimetic amineTherapeutic class: Antiasthmatic, bronchodilator

Pregnancy category: CIndications and Dosages To treat bronchospasmSYRUP, TABLETSAdults and children age 9 or over weighingmore than 27 kg (59 lb). 20 mg every 6 to8hr.Children ages 6 to 9 weighing 27 kg or less.10 mg every 6 to 8 hr.INHALATION AEROSOLAdults and adolescents. 2 to 3 inhalations(1.3 to 1.95 mg) every 3 to 4 hr. Maximum:12 inhalations daily.Children ages 6 to 12. 1 to 3 inhalations(0.65 to 1.95 mg) every 3 to 4 hr.Maximum: 12 inhalations daily.INHALATION NEBULIZERAdults and adolescents. 0.2 to 0.3 ml of5% solution diluted in 2.5 ml normal salinesolution t.i.d. or q.i.d., p.r.n., but no morethan every 4 hr.Children ages 6 to 12. 0.1 to 0.2 ml of 5%solution diluted in normal saline solutionto a total volume of 3 ml t.i.d. or q.i.d.,p.r.n., but no more than every 4 hr.Route Onset Peak DurationP.O. 15 min 1 hr 4 hr orlongerInhalation 1 min 1 hr 4 hr or(aerosol)longerInhalation 5–30 Unknown 4 hr or(nebulizer) min longerMechanism of ActionAttaches to beta 2 receptors on bronchial cellmembranes, which stimulates intracellularenzyme adenyl cyclase to convert adenosinetriphosphate to cyclic adenosine monophosphate(cAMP). Increased intracellularcAMP level relaxes bronchial smooth-musclecells and inhibits histamine release.ContraindicationsAngina, cerebral arteriosclerosis, dilatedheart failure, heart block from digitalis toxicity,hypersensitivity to metaproterenol orits components, labor, local anesthesia,organic brain damage, tachyarrhythmiasInteractionsDRUGSbeta blockers: Increased risk of bronchospasmMAO inhibitors, tricyclic antidepressants:Possibly potentiated cardiovascular effectsof metaproterenolother sympathomimetics: Possibly additiveeffects of both drugs and risk of toxicitytheophylline: Increased risk of arrhythmiasAdverse ReactionsCNS: Dizziness, fatigue, headache, insomnia,malaise, nervousness, tremorCV: ECG changes, hypertension, palpitations,tachycardiaEENT: Dry mouth, pharyngitis, taste perversionGI: Diarrhea, nausea, vomitingRESP: Asthma exacerbation, coughNursing Considerations• Anticipate that a single dose of nebulizedmetaproterenol may not completely stopan acute asthma attack.• Monitor for adverse reactions and signs oftoxicity, especially if patient uses tabletsand aerosol. Notify prescriber if theydevelop.• Be aware that tolerance may occur withcontinued use.PATIENT TEACHING• Caution patient not to use metaproterenolinhaler or nebulizer more often than prescribed.• Teach patient to use metaproterenolinhaler correctly, to hold breath duringsecond half of inhalation, and to wait 2minutes between inhalations.• Instruct parents to use spacer with theirchild’s metered-dose inhaler.• Advise patient to use metaproterenol5 minutes before using corticosteroidinhaler, if prescribed, to maximize airwayopening and drug effects.• Instruct patient to immediately reportdiarrhea, increased shortness of breath,insomnia, or irregular heartbeat.• Instruct patient to notify prescriber ifdrug becomes less effective.metaxaloneSkelaxinmetaxalone 637Class and CategoryChemical class: Oxazolidinone derivativeTherapeutic class: Skeletal muscle relaxantPregnancy category: Not ratedM

638metformin hydrochlorideIndications and Dosages To relieve discomfort caused by acute,painful musculoskeletal conditionsTABLETSAdults and children over age 12. 800 mgt.i.d. or q.i.d.Route Onset Peak DurationP.O. Usually Unknown 4–6 hrin 1 hrMechanism of ActionMay depress CNS, causing sedation, whichin turn may reduce skeletal muscle spasmsto provide pain relief. Metaxalone doesn’tdirectly relax tense skeletal muscles.ContraindicationsHypersensitivity to metaxalone or its components,significant renal or hepatic disease,tendency to develop drug-induced, hemolytic,or other anemiasInteractionsDRUGSCNS depressants: Increased CNS depressionACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Dizziness, drowsiness, excitement,general CNS depression, headache, insomnia,irritability, nervousness, restlessnessGI: Abdominal cramps or pain, GI upset,jaundice, hepatotoxicity, nausea, vomitingHEME: Hemolytic anemia, leukopeniaSKIN: Pruritus, rashNursing Considerations• Metaxalone may not be prescribed forwomen who are or may become pregnantunless potential benefits outweigh risksbecause drug’s effect on fetus is unknown.• Expect to avoid giving metaxalone withfood because food may increase CNSdepression, especially in elderly patients.• Monitor patient for excessive drowsiness,which may lead to respiratory depression.• Caution patient to consult prescriberbefore taking other drugs, such as sleepingpills, cold or allergy preparations, opioidanalgesics, and antidepressants.• Monitor liver function test results for elevations,especially in patients with preexistinghepatic disease.• Monitor renal function test results, as prescribed,for signs of impaired renal functionbecause drug is excreted by kidneys.• Provide rest and other pain-relief measures.• Store drug at 59° to 86° F (15° to 30° C).PATIENT TEACHING• Advise patient to take metaxalone tabletsexactly as prescribed and not to increasedosage or frequency.• Instruct patient to take metaxalone tabletson an empty stomach.• Caution patient to avoid hazardous activities,such as driving or operating machinery,until drug’s CNS effects are known.• Instruct patient to avoid alcohol and otherCNS depressants during therapy.• Urge patient to notify prescriber if henotices a rash or itching, which may signifya hypersensitivity reaction, or if hedevelops signs of hepatotoxicity, such astiredness, nausea, yellow skin, or flulikesymptoms.metforminhydrochlorideFortamet, Gen-Metformin (CAN),Glucophage, Glucophage XR,Glumetza, Glycon (CAN), Novo-Metformin (CAN), RiometClass and CategoryChemical class: DimethylbiguanideTherapeutic class: AntidiabeticPregnancy category: BIndications and Dosages To reduce blood glucose level in type 2diabetes mellitusORAL SOLUTION, TABLETSAdults and children age 10 and over.Initial: 500 mg b.i.d. or 850 mg daily,increased as prescribed by 500 mg/wk or by850 mg every 2 wk until desired responseoccurs. Usual: 500 to 850 mg b.i.d. or t.i.d.Maximum: 2,550 mg daily (adults and adolescentsage 17 and over); 2,000 mg daily(children ages 10 to 16).DOSAGE ADJUSTMENT If patient uses insulin,initial dosage reduced to 500 mg daily andthen increased as prescribed by 500 mgweekly until blood glucose level is controlled.E.R. TABLETS (GLUCOPHAGE XR, GLUMETZA)

Adults and adolescents age 18 and over.Initial: 500 mg daily (Glucophage XR) or1,000 mg daily (Glumetza) with eveningmeal. Increased as prescribed by 500 mg/wk. Maximum: 2,000 mg daily.DOSAGE ADJUSTMENT If control isn’tachieved with maximum once-daily E.R.dosage, regimen may be changed to1,000 mg b.i.d. If control isn’t achieved after4 wk of maximum dosage, an oral sulfonylureamay be prescribed.E.R. TABLETS (FORTAMET)Adults and adolescents age 17 and over.Initial: 500 to 1,000 mg once daily inevening. Increased in increments of 500 mgweekly, as needed. Maximum: 2,500 mgdaily. If control isn’t achieved after 4 wk atmaximum dosage, an oral sulfonylurea maybe prescribed. As adjunct to insulin therapy in type 2diabetes mellitusORAL SOLUTION, TABLETS, E.R. TABLETSAdults. Initial: 500 mg (Glucophage,Glucophage XR, Fortamet) or 1,000 mg(Glumetza) daily in addition to currentdose of insulin. Increased by 500 mg/wk, asneeded. Maximum: 2,000 mg for GlucophageXR and Glumetza; 2,500 mg forGlucophage and Fortamet.DOSAGE ADJUSTMENT If fasting blood glucoselevel drops below 120 mg/dl, insulindosage decreased by 10% to 25%. Subsequentinsulin dosage decrease may beneeded based upon patient’s continuedresponse.Route Onset Peak DurationP.O. Unknown Up to 2 wk after(tablets) 2 wk drug discontinuedMechanism of ActionMay promote storage of excess glucose asglycogen in the liver, which reduces glucoseproduction. Metformin also may improveglucose use by skeletal muscle and adiposetissue by increasing glucose transport acrosscell membranes. This drug also mayincrease the number of insulin receptors oncell membranes and make them more sensitiveto insulin. In addition, metforminmodestly decreases blood triglyceride andtotal cholesterol levels.metformin hydrochloride 639ContraindicationsHypersensitivity to metformin or its components,impaired renal function, metabolicacidosis, use of iodinated contrast mediawithin preceding 48 hoursInteractionsDRUGScalcium channel blockers, corticosteroids,estrogens, isoniazid, nicotinic acid, oral contraceptives,phenothiazines, phenytoin, sympathomimetics,thiazide and other diuretics,thyroid drugs: Possibly hyperglycemiacationic drugs (such as amiloride, cimetidine,digoxin, morphine, procainamide, quinidine,quinine, ranitidine, triamterene, trimethoprim,vancomycin), nifedipine: Increasedblood metformin levelclofibrate, MAO inhibitors, probenecid, propranolol,rifabutin, rifampin, salicylates, sulfonamides,sulfonylureas: Increased risk ofhypoglycemiaFOODSall foods: Possibly delayed metforminabsorptionACTIVITIESalcohol use: Increased risk of hypoglycemiaand lactate formationAdverse ReactionsCNS: HeadacheEENT: Metallic tasteENDO: HypoglycemiaGI: Abdominal distention, anorexia, constipation,diarrhea, flatulence, indigestion,nausea, vomitingHEME: Aplastic anemia, megaloblastic anemia,thrombocytopeniaSKIN: Photosensitivity, rashOther: Lactic acidosis, weight lossNursing Considerations• Give metformin tablets with food, whichdecreases and slightly delays absorption,thus reducing risk of adverse GI reactions.Give E.R. tablets with evening meal; don’tbreak or crush them.• Expect prescriber to alter dosage if patienthas a condition that decreases or delaysgastric emptying, such as diarrhea, gastroparesis,GI obstruction, ileus, or vomiting.• Expect to assess BUN and serum creatininelevel before and during long-termtherapy in those at increased risk for lacticacidosis.M

640ContraindicationsAcute or postoperative pain, acute or severeasthma, chronic respiratory disease, diarmethadonehydrochloride• Monitor patient’s hepatic function, asordered, because impaired hepatic functionmay significantly reduce the liver’sability to clear lactate, predisposing thepatient to lactic acidosis.• Monitor patient’s blood glucose level toevaluate drug effectiveness. Assess forhyperglycemia and the need for insulinduring times of increased stress, such asinfection and surgery.• Withhold drug, as ordered, if patientbecomes dehydrated or develops hypoxemiaor sepsis because these conditionsincrease the risk of lactic acidosis.• Iodinated contrast media used in radiographicstudies increases risk of renalfailure and lactic acidosis during metformintherapy. Expect to withhold drugfor 48 hours before and after testing.PATIENT TEACHING• Instruct patient to take metformin tabletat breakfast if taking drug once a day or atbreakfast and dinner if taking drug twice aday. Instruct him to take E.R. tablets oncedaily with evening meal and to swallowthem whole without crushing or chewing.• Direct patient to take drug exactly as prescribedand not to change the dosage orfrequency unless instructed.• Stress importance of following prescribeddiet, exercising regularly, controllingweight, and checking blood glucose level.• Teach patient how to measure blood glucoselevel and recognize hyperglycemiaand hypoglycemia. Urge him to notify prescriberof abnormal blood glucose level.• Caution patient to avoid alcohol, whichcan increase the risk of hypoglycemia.• Instruct patient to report early signs of lacticacidosis, including drowsiness, hyperventilation,malaise, and muscle pain.• Advise patient to expect laboratory testingof glycosylated hemoglobin every3 months until blood glucose is controlled.methadonehydrochlorideDolophine, MethadoseClass, Category, and ScheduleChemical class: PhenylheptylamineTherapeutic class: Synthetic opiate agonistPregnancy category: CControlled substance schedule: IIIndications and Dosages To manage opioid detoxificationDISPERSIBLE TABLETS, ORAL CONCENTRATE,I.M. OR SUBCUTANEOUS INJECTIONAdults. Initial: 15 to 40 mg daily or as needed.Usual: Dosage individualized based onclinical response. Maximum: 120 mg daily.Children. Dosage individualized based onage and size. Maximum: 120 mg daily. To maintain opioid abstinenceDISPERSIBLE TABLETS, ORAL CONCENTRATEAdults. Dosage individualized based onclinical response. Maximum: 120 mg daily.Children. Dosage individualized based onage and size. Maximum: 120 mg daily. To treat severe or chronic painORAL CONCENTRATE, ORAL SOLUTIONAdults. 5 to 20 mg every 4 to 8 hr. Dosageincreased or dosing interval decreased, asprescribed and as needed. Maximum:120 mg/day.Children. Dosage individualized based onage and size.TABLETS, I.M. OR SUBCUTANEOUS INJECTIONAdults. 2.5 to 10 mg every 3 to 4 hr asneeded. For chronic pain, dosage and dosinginterval may be adjusted, as prescribedand as needed.Children. Dosage individualized based onage and size.DOSAGE ADJUSTMENT Elderly patients,debilitated patients, and patients withsevere hepatic or renal dysfunction,hypothyroidism, Addison’s disease, prostatichyperplasia, or urethral stricture need individualizedreduced dosages.Route Onset Peak DurationP.O. 30–60 min 1.5–2 hr 4–6 hrI.M. 10–20 min 1–2 hr 4–5 hrMechanism of ActionBinds with and activates opioid receptors(primarily mu receptors) in spinal cord andhigher levels of CNS to produce analgesiaand euphoric effects.

hea related to pseudomembranous colitisor poisoning, hypersensitivity to methadoneor its components, respiratory depression,severe inflammatory bowel diseaseInteractionsDRUGSammonium chloride, ascorbic acid, potassium,sodium phosphate: May precipitatemethadone withdrawal symptomsamitriptyline, chloripramine, nortriptyline:Increased CNS and respiratory depressionanticholinergics: Possibly severe constipationleading to ileus; urine retentionantiemetics, general anesthetics, hypnotics,phenothiazines, sedatives, tranquilizers:Possibly coma, hypotension, respiratorydepression, and severe sedationantihistamines, choral hydrate, glutethimide,MAO inhibitors, methocarbamol: IncreasedCNS and respiratory depressant effects ofmethadoneantihypertensives, hypotension-producingdrugs: Increased hypotension, risk of orthostatichypotensionazole antifungals, macrolide antibiotics:Increased or prolonged opioid effectbuprenorphine: Decreased therapeutic effectof methadone, increased respiratory depression,possibly withdrawal symptomscalcium channel blockers, class IA and classIII antiarrhythmics, diuretics, laxatives, mineralocorticoidhormones, neuroleptics, tricyclicantidepressants: Increased risk of electrolytedisturbances and prolonged QTintervalcarbamazepine, phenobarbital, St. John’swort: Possibly precipitation of withdrawalsymptomscimetidine: Increased analgesic and CNSand respiratory depressant effects ofmethadonedesipramine: Increased plasma desipramineleveldidanosine, stavudine: Decreased plasmalevels of these drugsdiuretics: Decreased diuresisefavirenz, nevirapine, ritonavir, ritonavir andlopinavir: Decreased blood methadone levelhydroxyzine: Increased analgesic, CNSdepressant, and hypotensive effects ofmethadoneloperamide, paregoric: Increased CNSdepression, possibly severe constipationMAO inhibitors: Possibly increased risk ofmethadone hydrochloride 641severe adverse reactionsmetoclopramide: Possibly antagonizedmetoclopramide effects on GI motilitymixed agonist-antagonist analgesics: Possiblywithdrawal symptomsnaloxone: Antagonized analgesic and CNSand respiratory depressant effects of methadone,and possibly withdrawal symptomsnaltrexone: Possibly induction or worseningof withdrawal symptoms if methadonegiven within 7 days before naltrexoneneuromuscular blockers: Increased or prolongedrespiratory depressionopioid analgesics (such as alfentanil andsufentanil): Increased CNS and respiratorydepression, increased hypotensionphenytoin, rifampin: May precipitate withdrawalsymptomsselective serotonin reuptake inhibitors:Possibly increased blood methadone levelsand increased risk of methadone toxicityzidovudine: Increased blood zidovudinelevel and risk of toxicityACTIVITIESalcohol use: Increased CNS and respiratorydepression, possibly hypotensionAdverse ReactionsCNS: Agitation, amnesia, anxiety, asthenia,coma, confusion, decreased concentration,delirium, delusions, depression, dizziness,drowsiness, euphoria, fever, hallucinations,headache, insomnia, lethargy, light-headedness,malaise, psychosis, restlessness, sedation,seizures, syncope, tremorCV: Bradycardia, cardiac arrest, cardiomyopathy,edema, heart failure, hypotension,orthostatic hypotension, palpitations,phlebitis, prolonged QT interval, shock,tachycardia, torsades de pointes, T-waveinversion on ECG, ventricular fibrillation ortachycardiaEENT: Blurred vision, diplopia, dry mouth,glossitis, laryngeal edema or laryngospasm(allergic), miosis, nystagmus, rhinitisGI: Abdominal cramps or pain, anorexia,biliary tract spasm, constipation, diarrhea,dysphagia, elevated liver function testresults, gastroesophageal reflux, hiccups,ileus and toxic megacolon (in patients withinflammatory bowel disease), indigestion,nausea, vomitingGU: Amenorrhea, decreased ejaculatepotency, decreased libido, difficult ejaculation,impotence, prolonged labor, urinaryM

642ical and psychological dependence.• Monitor patient for pain because maintenancedosage doesn’t provide pain relief;patients with tolerance to opiate agonists,including those with chronic cancer pain,may require a higher dosage.• Monitor patients who are pregnant orwho have liver or renal impairment forincreased adverse effects from methadonebecause drug may have a prolonged durationand cumulative effect in thesepatients. Methadone may prolong labor byreducing strength, duration, and frequencyof uterine contractions, so expect dosageto be tapered before third trimester ofpregnancy. Breast-feeding mothers onmaintenance therapy put their infants atrisk of withdrawal symptoms if theyabruptly stop breast-feeding or discontinuemethadone therapy. Methadone alsoaccumulates in CNS tissue, increasing therisk of seizures in infants.• Check plasma amylase and lipase levels inpatients who develop biliary tract spasmsbecause levels may increase up to 15 timesnormal. Notify prescriber immediately ofany significant or sustained increase.• Monitor patients who have head injuriesor other conditions that may increaseintracranial pressure (ICP) becausemethadone may further increase ICP.• Assess patient for withdrawal symptomsand tolerance to therapy because physiologicdependence can occur with longtermmethadone use. Avoid abrupt discontinuationbecause withdrawal symptomswill occur within 3 to 4 days after lastdose.• Monitor patients, especially the elderly, forcardiac arrhythmias, hypotension,hypovolemia, orthostatic hypotension, andvasovagal syncope because methadonemay produce cholinergic effects in patientswith cardiac disease, resulting in bradycardiaand peripheral vasodilation; dosagedecrease may be indicated.• Monitor patients with prostatic hypertrophy,urethral stricture, or renal disease forurine retention and oliguria becausemethadone can increase tension of detrusormuscle.• Be prepared to treat patient’s symptoms ofanxiety, and be aware that anxiety may beconfused with symptoms of opioid abstimethadonehydrochloridehesitancy, urine retentionHEME: Anemia, leukopenia, thrombocytopeniaMS: ArthralgiaRESP: Apnea, asthma exacerbation, atelectasis,bronchospasm, depressed coughreflex, hypoventilation, pulmonary edema,respiratory arrest and depression, wheezingSKIN: Diaphoresis, flushingOther: Allergic reaction; facial edema;hypokalemia; hypomagnesemia; injectionsite edema, pain, rash, or redness; physicaland psychological dependence; weight gain;withdrawal symptomsNursing Considerations• Before giving methadone, make sure opioidantagonist and equipment for administeringoxygen and controlling respirationare nearby.• Before therapy begins, assess patient’s currentdrug use, including all prescriptionand OTC drugs.WARNING Give drug cautiously to patientsat risk for a prolonged QT interval, such asthose with cardiac hypertrophy, hypokalemia,or hypomagnesemia; those with ahistory of cardiac conduction abnormalities;and those taking diuretics or medicationsthat affect cardiac conduction.• Dilute oral concentrate with water oranother liquid to volume of at least 30 ml,but preferably to 90 ml or more, beforeadministration. Dissolve dispersible tabletsin water or another liquid before giving.• Monitor patient for expected excessivedrowsiness, unsteadiness, or confusionduring first 3 to 5 days of therapy, andnotify prescriber if effects continue toworsen or persist beyond this time.WARNING Monitor respiratory and circulatorystatus carefully and often duringmethadone therapy because respiratorydepression, circulatory depression, respiratoryarrest, shock, hypotension, and cardiacarrest are risks. Monitor childrenoften for respiratory depression and paradoxicalCNS excitation because of theirincreased sensitivity to drug. Assesspatient for excessive or persistent sedation;dosage may need to be adjusted.• Watch for drug tolerance, especially inpatients with a history of chronic drugabuse, because methadone can cause phys-

nence and that methadone doesn’t haveantianxiety effects.PATIENT TEACHING• Instruct patient taking oral concentrateform of methadone to dilute it with wateror another liquid to a volume of at least 30ml and preferably to 90 ml or more beforeadministration.• Instruct patient to dissolve dispersibletablets in water or other liquid beforeadministration.• Advise patient to notify prescriber of allother drugs he’s currently taking and toavoid alcohol and other depressants, suchas sleeping pills and tranquilizers, becausethey may increase drug’s CNS depressanteffects.• Instruct patient to take drug only as prescribedand not to change dosage withoutprescriber approval. Inform patient thatabrupt cessation of methadone therapycan precipitate withdrawal symptoms.Urge him to notify prescriber if he developsany concerns over therapy.• Urge patient to notify prescriber if heexperiences palpitations, dizziness, lightheadedness,or syncope, which may becaused by methadone-induced arrhythmias.• Instruct patient to avoid potentially hazardousactivities or those that requiremental alertness because methadone therapymay cause drowsiness or sleepiness.• Teach patient to change positions slowly tominimize the effects of orthostatic hypotension.• Instruct patient to notify prescriber ofworsening or breakthrough pain becausedosage may need to be adjusted.• Inform parents that a child on methadonemaintenance therapy may become unusuallyexcited or restless; advise them tonotify prescriber of changes in child’sbehavior.• Instruct female patient to notify prescriberimmediately if she becomes pregnant duringmethadone therapy because drug maycause physical dependence in fetus andwithdrawal symptoms in neonate.• Caution patient who is breast-feeding notto stop doing so abruptly and not to stoptaking methadone without prescriber’sapproval because infant may experiencewithdrawal symptoms.methamphetamine hydrochloride 643methamphetaminehydrochlorideDesoxyn, Desoxyn GradumetClass, Category, and ScheduleChemical class: AmphetamineTherapeutic class: CNS stimulantPregnancy category: CControlled substance schedule: IIIndications and Dosages To treat attention-deficit hyperactivitydisorder (ADHD)E.R. TABLETSChildren age 6 and over. 20 to 25 mg daily.TABLETSChildren age 6 and over. Initial: 5 mg onceor twice daily. Increased by 5 mg every wk.Maintenance: 20 to 25 mg daily in divideddoses b.i.d.Route Onset Peak DurationP.O. Unknown Unknown 6–24 hrMechanism of ActionMay produce CNS stimulation by facilitatingrelease and blocking reuptake of norepinephrineat adrenergic nerve terminals andby stimulating alpha and beta receptors inthe peripheral nervous system. Methamphetaminealso promotes dopamine releaseand blocks its reuptake in the brain’s limbicregions. It appears to act mainly in cerebralcortex and, possibly, reticular activating system.Its actions decrease motor restlessness,increase alertness, and reduce drowsinessand fatigue. Peripheral actions includeincreased blood pressure and mild bronchodilationand respiratory stimulation.ContraindicationsAdvanced arteriosclerosis; glaucoma; hypersensitivityto methamphetamine, sympathomimeticamines, or their components;hyperthyroidism; history of drug abuse;moderate to severe hypertension; severeagitation; symptomatic cardiovascular disease;use within 14 days of MAO inhibitorInteractionsDRUGSascorbic acid: Decreased methamphetamineM

644methamphetamine hydrochlorideabsorption and therapeutic effectbeta blockers: Increased risk of heart block,hypotension, and severe bradycardiaCNS stimulants: Increased CNS stimulationand risk of adverse reactionsdigoxin, levodopa: Increased risk of arrhythmiasdiuretics, other antihypertensives: Possiblydecreased antihypertensive effectethosuximide, phenobarbital, phenytoin:Possibly delayed absorption of these drugshaloperidol, phenothiazines: Possibly interferencewith effects of these drugs and withmethamphetamine’s CNS stimulant effectsinhalation anesthetics: Increased risk of ventriculararrhythmiasinsulin: Altered insulin requirementslithium: Possibly antagonized CNS stimulanteffects of methamphetamineMAO inhibitors: Possibly severe hypertension,risk of hypertensive crisis, increasedvasopressor effect of methamphetaminemeperidine: Increased risk of hypotensionand life-threatening interactions, such assevere respiratory depression and comametrizamide (intrathecal): Increased risk ofseizuresthyroid hormones: Enhanced effects of bothdrugstricyclic antidepressants: Increased risk ofarrhythmias and severe hypertensionurinary acidifiers: Increased metabolismand shortened pharmacologic effects ofmethamphetamineurinary alkalinizers: Decreased metabolismand prolonged pharmacologic effects ofmethamphetamineFOODScaffeine: Increased methamphetamineeffectsAdverse ReactionsCNS: Dizziness, euphoria, headache, hyperactivity,insomnia, irritability, mania, nervousness,psychotic episodes, restlessness,stroke, talkativeness, tremorCV: Arrhythmias, chest pain, hypertension,hypotension, MI, palpitations, tachycardiaEENT: Accommodation abnormality,blurred vision, dry mouth, taste perversionENDO: Stunted growthGI: Abdominal cramps, anorexia, constipation,diarrhea, nausea, vomitingGU: Impotence, libido changesSKIN: Diaphoresis, urticariaOther: Physical and psychological dependenceNursing Considerations• Methamphetamine shouldn’t be used in apatient (especially a child or an adolesccent)with a serious heart condition, suchas a structural heart defect, cardiomyopathy,or a serious heart rhythm abnormality.• Use methamphetamine cautiously inpatients with a history of psychiatric problemsor suicidal or homicidal tendencies.• Assess for seizures in patients with a historyof seizure disorders because drug maylower seizure threshold.• Observe patient for evidence of drug toleranceand, possibly, extreme dependence,which may develop after a few weeks. Beaware that methamphetamine abuse mayoccur.• Expect treatment for ADHD to includepsychological, educational, and socialmeasures in addition to drug therapy.• Monitor child’s growth pattern. If growthappears to be delayed, notify prescriberbecause methamphetamine therapy mayneed to be interrupted temporarily.• Watch for signs of chronic methamphetamineintoxication, including hyperactivity,insomnia, irritability, and personalitychanges. Notify prescriber if they occur.• Monitor patient for exertional chest pain,unexplained syncope, and other evidencethat could suggest heart disease. If present,notify prescriber. A cardiac evaluation willbe needed, and therapy may need to stop.PATIENT TEACHING• Instruct parent of patient to give methamphetamineat least 6 hours before bedtimeto prevent insomnia.• Explain high risk of abuse with this drug.Instruct parent of patient not to increasedosage unless advised by prescriber andnot to give drug to prevent fatigue.WARNING Advise patient to take methamphetamineexactly as prescribed becausemisuse may cause serious heart effects oreven death.• Caution parent that patient should notcrush or chew E.R. tablets.• Advise parent that patient should avoidcaffeine, which increases drug’s effects.• Instruct parent of patient to report signsof overstimulation, such as diarrhea,hyperactivity, insomnia, and irritability.

methazolamideMZM, NeptazaneClass and CategoryChemical class: Sulfonamide derivativeTherapeutic class: AntiglaucomaPregnancy category: CIndications and Dosages To treat open-angle glaucomaTABLETSAdults. 50 to 100 mg b.i.d. or t.i.d.Route Onset Peak DurationP.O. 2–4 hr 6–8 hr 10–18 hrMechanism of ActionInhibits the enyzme carbonic anhydrase,which normally appears in renal proximaltubule cells, choroid plexus of the brain,and ciliary processes of the eye. By inhibitingthis enzyme in the eyes, methazolamidedecreases aqueous humor secretion, whichreduces intraocular pressure.ContraindicationsCirrhosis; hyperchloremic acidosis; hypersensitivityto methazolamide, other carbonicanhydrase inhibitors, or their components;hypokalemia; hyponatremia; severe adrenocortical,hepatic, or renal impairmentmethazolamide; methenamine 645InteractionsDRUGSamphetamines, anticholinergics, mecamylamine,procainamide, quinidine: Decreasedrenal clearance of these drugs, increasedrisk of toxicityamphotericin B, corticosteroids: Increasedrisk of severe hypokalemiabarbiturates, carbamazepine, phenytoin,primidone: Increased risk of osteopeniadigoxin: Increased risk of hypokalemia anddigitalis toxicityephedrine: Possibly prolonged duration ofaction of ephedrineinsulin, oral antidiabetic drugs: Increasedrisk of glycosuria and hyperglycemialithium: Increased lithium excretionmannitol: Increased diuresis and furtherreduction of intraocular pressuremethenamine compounds: Decreased methenamineeffectivenessmexiletine: Possibly impaired renal excretionof mexiletineneuromuscular blockers: Possibly prolongedduration of action of blockers from methazolamide-inducedhypokalemia, increasedrisk of prolonged respiratory paralysis anddepressionsalicylates: Possibly CNS depression andmetabolic acidosis, increased risk of methazolamidetoxicityAdverse ReactionsCNS: Confusion, depression, drowsiness,fatigue, fever, malaise, paresthesia, seizures,weaknessEENT: Hearing loss, myopia (transient),taste perversion, tinnitusGI: Anorexia, diarrhea, nausea, vomitingGU: Crystalluria, nephrotoxicity, renal calculiSKIN: Photosensitivity, pruritus, rash,Stevens-Johnson syndrome, urticariaOther: Metabolic acidosisNursing Considerations•Use methazolamide cautiously in patientswith obstructive pulmonary disease.•Monitor fluid intake and output, weight,and serum electrolyte levels during methazolamidetherapy.PATIENT TEACHING•Direct patient to take methazolamideexactly as prescribed because increasingdosage may lead to metabolic acidosis.•Advise patient to take drug with food if GIdistress occurs.•Instruct patient to report if rash develops.•Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.•Emphasize need to have regular eye examinationsduring methazolamide therapy.methenaminehippurateHiprex, UrexmethenaminemandelateMandelamineClass and CategoryChemical class: Formaldehyde precursor,M

646methicillin sodiumhexamethylenetetramineTherapeutic class: AntibioticPregnancy category: CIndications and Dosages To prevent or suppress frequently recurringUTI caused by a wide variety ofgram-negative and gram-positive bacteria(including enterococci, Escherichiacoli, Micrococcus pyogenes, and staphylococci)in intermittently catheterizedpatients with neurogenic bladderENTERIC-COATED TABLETS, ORAL SUSPENSION(METHENAMINE MANDELATE)Adults and adolescents. 1 g q.i.d. beforemeals and at bedtime.Children ages 6 to 12. 500 mg q.i.d., or50 mg/kg daily in divided doses.Children under age 6. 18.4 mg/kg q.i.d.TABLETS (METHENAMINE HIPPURATE)Adults and adolescents. 1 g b.i.d.Children ages 6 to 12. 0.5 to 1 g every 12 hr.Mechanism of ActionHydrolyzes to formaldehyde and ammoniain an acidic environment, such as urine,producing greater amounts of formaldehydeas pH decreases. Formaldehyde hasbactericidal action, possibly by denaturingproteins. To facilitate hydrolysis, methenamineis formulated with weak organic acid,such as hippuric acid or mandelic acid.ContraindicationsConcurrent therapy with sulfonamides,hypersensitivity to methenamine, renalinsufficiency, severe dehydration, severehepatic diseaseInteractionsDRUGSbicarbonate-containing antacids, urinaryalkalinizers: Decreased methenamine effectsulfonamides, such as sulfamethizole:Possibly formation of insoluble precipitatein urineFOODSmilk, milk products, most fruits: Possiblydecreased effectiveness of methenamineAdverse ReactionsCNS: HeadacheCV: EdemaEENT: StomatitisGI: Abdominal cramps, anorexia, diarrhea,nausea, vomitingGU: Bladder irritation, crystalluria, dysuria,hematuria, proteinuria, urinary frequencyRESP: Pulmonary hypersensitivity (dyspnea,pneumonitis)SKIN: Pruritus, rash, urticariaNursing Considerations• Be aware that methenamine is used forprophylaxis; it isn’t recommended as primarytreatment for UTI.• Drug shouldn’t be given to patients withcreatinine clearance less than 50 ml/min/1.73 m 2 .• Before giving first dose, expect to obtainurine specimen for culture and sensitivitytests and to review test results if available.• Plan to give methenamine mandelatearound the clock to maintain a therapeuticblood level.• Make sure patient receives adequate fluids.• Expect to repeat culture and sensitivitytests if patient fails to improve.PATIENT TEACHING• Instruct patient to take methenamine withfood to avoid GI distress.• Direct patient to drink extra fluids; avoidalkaline foods, such as milk, milk products,and most fruits; and avoid antacidsthat contain sodium bicarbonate or carbonateduring methenamine therapy.• Instruct patient to report painful urination,rash, or severe GI distress.• Urge patient to comply with urine testingbefore and during long-term therapy.methicillin sodiumStaphcillinClass and CategoryChemical: Penicillinase-resistant penicillinTherapeutic: AntibioticPregnancy category: BIndications and Dosages To treat general infections, such as sepsis,sinusitis, and skin and soft-tissueinfections, caused by susceptible organisms(including penicillinase-producingand non–penicillinase-producing strainsof Staphylococcus epidermidis,Staphylococcus saprophyticus, andStreptococcus pneumoniae)I.V. INFUSION, I.M. INJECTIONAdults and children weighing 40 kg (88 lb)

or more. 1 g every 4 to 6 hr (I.M.) or 1 gevery 6 hr (I.V.). Maximum: 24 g daily.Children weighing less than 40 kg. 25 mg/kg every 6 hr.DOSAGE ADJUSTMENT For adults and childrenwith cystic fibrosis, dosage adjusted to50 mg/kg every 6 hr. To treat bacterial meningitisI.V. INFUSION, I.M. INJECTIONNeonates weighing 2 kg (4.4 lb) or more.50 mg/kg every 8 hr for first wk after birthand then 50 mg/kg every 6 hr.Neonates weighing less than 2 kg. 25 to50 mg/kg every 12 hr for first wk after birthand then 50 mg/kg every 8 hr.Mechanism of ActionKills bacteria by inhibiting cell wall synthesis.In susceptible bacteria, the rigid, crosslinkedcell wall is assembled in several steps.In final stage of cross-linking, methicillinbinds with and inactivates penicillin-bindingproteins (enzymes responsible for linkingcell wall strands), resulting in bacterialcell lysis and death. Staphylococcus aureushas developed resistance to methicillin byaltering its penicillin-binding proteins.IncompatibilitiesDon’t mix methicillin in same syringe orI.V. solution with other drugs. Don’t mixmethicillin with dextrose solutions becausetheir low acidity may damage drug. Givemethicillin at least 1 hour before or afteraminoglycosides and at different sites; otherwise,mutual inactivation can occur.ContraindicationsHypersensitivity to methicillin sodium,other penicillins, or their componentsInteractionsDRUGSaminoglycosides: Substantial aminoglycosideinactivationchloramphenicol, erythromycins, sulfonamides,tetracyclines: Possibly decreasedtherapeutic effects of methicillinmethotrexate: Increased risk of methotrexatetoxicityprobenecid: Possibly decreased renal clearance,increased blood level, and increasedrisk of toxicity of methicillinAdverse ReactionsCNS: Aggressiveness, agitation, anxiety,confusion, depression, headache, seizuresEENT: Oral candidiasisGI: Abdominal pain, diarrhea, hepatotoxicity,nausea, pseudomembranous colitis,vomitingGU: Interstitial nephritis, vaginitisHEME: Leukopenia, neutropenia, thrombocytopeniaSKIN: Exfoliative dermatitis, pruritus, rash,urticariaOther: Anaphylaxis; infusion site redness,swelling, and tenderness; injection site pain,redness, and swelling; serum sicknesslikereactionNursing ConsiderationsWARNING Be aware that methicillin isn’t afirst-line treatment for the indicationsabove because of the prevalence of methicillin-resistantStaphylococcus aureus.• Before giving first dose, obtain appropriatebody fluid or tissue specimens for cultureand sensitivity tests, as ordered, andreview test results if available.• Inject I.M. form deep into gluteal muscle.• In I.V. use, observe infusion site closely forredness, swelling, and tenderness.• Monitor fluid intake and output and renalfunction test results during therapy.• Observe for signs of superinfection, suchas diarrhea, vaginal itching, and whitepatches or sores in mouth or on tongue.Notify prescriber if they occur.• Closely monitor renal function test results,including serum creatinine level; aboutone-third of patients have interstitial nephritisafter 10 days of methicillin therapy.• Monitor liver function test results, andreport evidence of hepatotoxicity, such asfever and nausea.PATIENT TEACHING• Explain that I.M. injection may be painful.• Unless contraindicated, instruct patient todrink extra fluids during therapy.• Advise patient to report diarrhea, injectionsite pain, mouth sores, or rash.methimazoleTapazolemethimazole 647Class and CategoryChemical class: Thioimidazole derivativeM

648methimazoleTherapeutic class: AntithyroidPregnancy category: DIndications and Dosages To treat mild hyperthyroidismTABLETSAdults and adolescents. Initial: 15 mg dailyas a single dose or in divided doses b.i.d. for6 to 8 wk or until euthyroid level is reached.Maintenance: 5 to 30 mg daily as a singledose or in divided doses b.i.d.Children. Initial: 0.4 mg/kg daily as a singledose or in divided doses b.i.d. Maintenance:0.2 mg/kg daily as a single dose or in divideddoses b.i.d. To treat moderate hyperthyroidismTABLETSAdults and adolescents. Initial: 30 to 40 mg/day as a single dose or in divided dosesb.i.d. for 6 to 8 wk or until euthyroid levelis reached. Maintenance: 5 to 30 mg daily asa single dose or in divided doses b.i.d.Children. Initial: 0.4 mg/kg daily as a singledose or in divided doses b.i.d. Maintenance:0.2 mg/kg daily as a single dose or in divideddoses b.i.d. To treat severe hyperthyroidismTABLETSAdults and adolescents. Initial: 60 mg dailyas a single dose or in divided doses b.i.d. for6 to 8 wk or until euthyroid level is reached.Maintenance: 5 to 30 mg daily as a singledose or in divided doses b.i.d.Children. Initial: 0.4 mg/kg daily as a singledose or in divided doses b.i.d. Maintenance:0.2 mg/kg daily as a single dose or in divideddoses b.i.d. As adjunct to treat thyrotoxicosisSUPPOSITORIESAdults and adolescents. 15 to 20 mg every4 hr on first day and then adjusted based onpatient response.Children. 0.4 mg/kg daily as a single doseor in divided doses b.i.d.Route Onset Peak DurationP.O. 5 days 7 wk UnknownMechanism of ActionDirectly interferes with thyroid hormonesynthesis in the thyroid gland by inhibitingiodide incorporation into thyroglobulin.Iodination of thyroglobulin is an importantstep in synthesizing the thyroid hormonesthyroxine and triiodothyronine. Eventually,thyroglobulin is depleted and the circulatingthyroid hormone level drops.ContraindicationsBreast-feeding; hypersensitivity to methimazole,other antithyroid drugs, or theircomponentsInteractionsDRUGSamiodarone, iodine, potassium iodide:Decreased response to methimazoledigoxin: Possibly increased blood digoxinleveloral anticoagulants: Possibly a need foraltered anticoagulant dosageAdverse ReactionsCNS: Drowsiness, headache, paresthesia,vertigoCV: EdemaEENT: Loss of tasteENDO: HypothyroidismGI: Diarrhea, indigestion, nausea, vomitingHEME: Agranulocytosis, aplastic anemia,leukopenia, thrombocytopeniaMS: Arthralgia, myalgiaSKIN: Alopecia, jaundice, pruritus, rash,skin discoloration, urticariaOther: Lupus-like symptoms, lymphadenopathyNursing Considerations• Closely monitor thyroid function testresults during methimazole therapy.• Check CBC results to detect abnormalitiescaused by inhibition of myelopoiesis.• Watch for signs and symptoms ofhypothyroidism, such as cold intolerance,depression, and edema.• Be aware that hyperthyroidism mayincrease metabolic clearance of beta blockersand theophylline and that dosages ofthese drugs may need to be reduced as thepatient’s thyroid condition becomes corrected.PATIENT TEACHING• Instruct patient to take drug with meals toavoid adverse GI reactions.• Explain about possible hair loss or thinningduring and for months after therapy.• Instruct patient to notify prescriber immediatelyabout cold intolerance, fever, sorethroat, tiredness, and unusual bleeding orbruising.

methocarbamolCarbacot, Robaxin, Robaxin 750, SkelexClass and CategoryChemical class: Carbamate derivative ofguaifenesinTherapeutic class: Skeletal muscle relaxantPregnancy category: CIndications and Dosages To relieve discomfort caused by acute,painful musculoskeletal conditionsTABLETSAdults and adolescents. Initial: 1,500 mgq.i.d. for 2 to 3 days; for severe discomfort,8,000 mg daily. Maintenance: 750 mg every4 hr, 1,000 mg q.i.d., or 1,500 mg t.i.d.I.V. INJECTION (100 MG/ML)Adults and adolescents. Up to 3,000 mgdaily administered at 8-hr intervals for 3consecutive days. Regimen repeated as prescribedafter patient is drug-free for 48 hr.I.M. INJECTION (100 MG/ML)Adults and adolescents. 1,000 to 3,000 mg/day administered at 8-hr intervals for 3consecutive days. Regimen repeated as prescribedafter patient is drug-free for 48 hr. To provide supportive therapy for tetanusTABLETSAdults and adolescents. 24,000 mg dailygiven by NG tube.I.V. INFUSION OR INJECTION (100 MG/ML)Adults and adolescents. 1,000 to 3,000 mgby infusion or 1,000 to 2,000 mg by directinjection every 6 hr. Maximum: 300 mg(3 ml)/min.Children. 15 mg/kg every 6 hr.Route Onset Peak DurationP.O. 30 min Unknown UnknownI.V. Immediate Unknown UnknownMechanism of ActionMay depress CNS, which leads to sedationand reduced skeletal muscle spasms. Methocarbamolalso alters perception of pain.ContraindicationsHypersensitivity to methocarbamol or itscomponents, renal disease (injectable form)InteractionsDRUGSmethocarbamol 649CNS depressants: Increased CNS depressionACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Dizziness, drowsiness, fever,headache, light-headedness, seizures (I.V.),syncope, vertigo, weaknessCV: Bradycardia, hypotension, and thrombophlebitis(parenteral)EENT: Blurred vision, conjunctivitis, diplopia,metallic taste, nasal congestion, nystagmusGI: NauseaGU: Black, brown, or green urineSKIN: Flushing, pruritus, rash, urticariaOther: Anaphylaxis (parenteral), angioedema,injection site irritation or pain (I.M.),injection site sloughing (I.V.)Nursing Considerations• If needed, crush methocarbamol tabletsand mix with water for administration byNG tube.• Give I.V. form directly through infusionline at 3 ml/min. To prepare solution, add10 ml to no more than 250 ml D 5 W ornormal saline solution. Infuse at no morethan 300 mg (3 ml)/ min to avoid hypotensionand seizures.• Keep patient recumbent during I.V.administration and for at least 15 minutesafterward. Then have him rise slowly.• Monitor I.V. site regularly for signs ofphlebitis.• Inject I.M. form deep into large muscle,such as the gluteus. Give no more than5 ml/dose every 8 hours. One dose is usuallyadequate.• Don’t give methocarbamol by subcutaneousroute.• Keep epinephrine, antihistamines, andcorticosteroids available in case patientexperiences anaphylactic reaction.• Be aware that the parenteral dosage formshouldn’t be used in patients with renaldysfunction because the polyethylene glycol300 vehicle is nephrotoxic.PATIENT TEACHING• Tell patient to take drug exactly as prescribed.• Advise patient to take drug with food ormilk to avoid nausea.• Inform patient that urine may turn green,black, or brown until mehtocarbamol isM

650methotrexatediscontinued.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to avoid alcohol and otherCNS depressants during therapy.methotrexate(amethopterin)RheumatrexmethotrexatesodiumFolex, Folex PFS, Mexate, Mexate-AQClass and CategoryChemical class: Folic acid analogueTherapeutic class: Antipsoriatic, antirheumaticPregnancy category: XIndications and Dosages To treat severe psoriasis unresponsive toother therapyTABLETS (METHOTREXATE)Adults. 2.5 to 5 mg every 12 hr for 3 doses/wk, increased as ordered by 2.5 mg/wk.Maximum: 20 mg/wk.I.V. OR I.M. INJECTION (METHOTREXATE SODIUM)Adults. 10 mg/wk. Maximum: 25 mg/wk. To treat severe rheumatoid arthritisunresponsive to other therapyTABLETS (METHOTREXATE)Adults. 2.5 to 5 mg every 12 hr for 3 doses/wk, increased as ordered by 2.5 mg/wk.Maximum: 20 mg/wk.Route Onset Peak DurationP.O., I.V., 3–6 wk Unknown UnknownI.M.Mechanism of ActionMay exert immunosuppressive effects byinhibiting replication and function of T andpossibly B lymphocytes. Methotrexate alsoslows rapidly growing cells, such as epithelialskin cells in psoriasis. This action mayresult from the drug’s inhibition of dihydrofolatereductase, the enzyme thatreduces folic acid to tetrahydrofolic acid.Inhibition of tetrahydrofolic acid interfereswith DNA synthesis and cell reproductionin rapidly proliferating cells.ContraindicationsBreast-feeding, hypersensitivity tomethotrexate or its components, pregnancyInteractionsDRUGSbone marrow depressants: Possibly increasedbone marrow depressionco-trimoxazole: Possibly increased bonemarrow suppressionfolic acid: Possibly decreased effectiveness ofmethotrexatehepatotoxic drugs: Increased risk of hepatotoxicitychloramphenicol, neomycin, tetracycline:Possibly decreased methotrexate absorptionNSAIDs, penicillins, phenylbutazone, phenytoin,probenecid, salicylates, sulfonamides:Increased risk of methotrexate toxicityoral anticoagulants: Increased bleeding risksulfonamides: Increased risk of hepatotoxicitytheophylline: Possibly increased risk of theophyllinetoxicityvaccines: Risk of disseminated infectionwith live-virus vaccines, risk of suppressedresponse to killed-virus vaccinesACTIVITIESalcohol use: Increased risk of hepatotoxicityAdverse ReactionsCNS: Aphasia, cerebral thrombosis, chills,dizziness, drowsiness, fatigue, fever, headache,hemiparesis, leukoencephalopathy,malaise, paresis, seizuresCV: Chest pain, deep vein thrombosis,hypotension, pericardial effusion, pericarditis,thromboembolismENDO: GynecomastiaEENT: Blurred vision, conjunctivitis, gingivitis,glossitis, pharyngitis, stomatitis,transient blindness, tinnitusGI: Abdominal pain, anorexia, cirrhosis,diarrhea, elevated liver function test results,enteritis, GI bleeding and ulceration, hepatitis,hepatotoxicity, nausea, pancreatitis,vomitingGU: Cystitis, hematuria, infertility, menstrualdysfunction, nephropathy, renal failure,tubular necrosis, vaginal dischargeHEME: Anemia, aplastic anemia, leukopenia,neutropenia, pancytopenia, thrombocytopenia

MS: Arthralgia, dysarthia, myalgia, stressfractureRESP: Dry nonproductive cough, dyspnea,interstitial pneumonitis, pneumonia, pulmonaryfibrosis or failure, pulmonary infiltratesSKIN: Acne, alopecia, altered skin pigmentation,ecchymosis, erythema multiforme,exfoliative dermatitis, furunculosis, necrosis,photosensitivity, pruritus, psoriaticlesions, rash, Stevens-Johnson syndrome,telangiectasia, toxic epidermal necrolysis,ulceration, urticariaOther: Anaphylaxis, increased risk of infection,lymphadenopathy, lymphoproliferativediseaseNursing Considerations• Follow facility policy for preparing andhandling drug; parenteral form poses arisk of carcinogenicity, mutagenicity, andteratogenicity. Avoid skin contact.• Monitor results of CBC, chest X-ray, liverand renal function tests, and urinalysisbefore and during treatment.• Unless contraindicated, increase patient’sfluid intake to 2 to 3 L daily to reduce therisk of adverse GU reactions.• Assess patient for bleeding and infection.WARNING Expect renal impairment toseverely alter drug elimination.• Be aware that high doses of methotrexatecan impair renal elimination by formingcrystals that obstruct urine flow. To preventdrug precipitation, alkalinize patient’surine with sodium bicarbonate tablets, asordered.• Follow standard precautions because drugcan cause immunosuppression.• If patient becomes dehydrated from vomiting,notify prescriber and expect to withholddrug until patient recovers.• If patient receives high doses of drug, keepleucovorin readily available as antidote.• Be aware that methotrexate resistance maydevelop with prolonged use.PATIENT TEACHING• Prepare a calendar of treatment days forpatient, and stress importance of followinginstructions exactly.• Instruct patient to avoid alcohol duringmethotrexate therapy.• Encourage frequent mouth care to reducethe risk of mouth sores.methoxypolyethylene glucol-epoetin beta 651• Instruct patient to use sunblock whenexposed to sunlight.• Advise patient to notify prescriber aboutbruising, chills, cough, fever, dark orbloody urine, mouth sores, shortness ofbreath, sore throat, and yellow skin oreyes.• Urge women of childbearing age to usereliable contraception during methotrexatetherapy.methoxypolyethyleneglycol-epoetin betaMirceraClass and CategoryChemical class: Continuous erythropoietinreceptor activatorTherapeutic class: AntianemicPregnancy category: CIndications and Dosages To treat anemia associated with chronicrenal failure in dialysis-dependent anddialysis-independent patientsI.V. INJECTION, SUBCUTANEOUS INJECTIONAdults not currently being treated with anerythropoiesis-stimulating agent. Initial:0.6 mcg/kg every 2 wk, increased ordecreased by 25% monthly as needed.Maintenance: 1.2 mcg/kg every 4 wk.Adults stabilized on less than 8,000 units/wk of epoetin alfa or 40 mcg/wk of darbepoetinalfa. 60 mcg every 2 wk or 120 mcgevery 4 wk.Adults stabilized on 8,000 to 16,000 units/wk of epoetin alfa or 40 to 80 mcg/wk ofdarbepoetin alfa. 100 mcg every 2 wk or200 mcg every 4 wk.Adults stabilized on more than 16,000units/wk of epoetin alfa or more than80 mcg/wk of darbepoetin alfa. 180 mcgevery 2 wk or 360 mcg every 4 wk.DOSAGE ADJUSTMENT If hemoglobinincrease is greater than 1 g/dl during any 2-wk period or hemoglobin is increasing andapproaching 12 g/dl, dosage reduced by25%. If hemoglobin continues to increasedespite this reduction, drug discontinueduntil hemoglobin begins to decrease; thendrug restarted at a dose 25% less than previouslygiven. If hemoglobin doesn’tM

652methoxypolyethylene glucol-epoetin betaincrease by 1 g/dl after 4 wk of therapy,dosage increased by 25%.Route Onset Peak DurationI.V., SubQ 7–15 72 hr 4 wkdaysMechanism of ActionStimulates release of reticulocytes frombone marrow into the bloodstream, wherethey develop into mature RBCs.IncompatiblitiesDon’t mix methoxypolyethylene glycol-epoetinbeta with any other drug.ContraindicationsHemoglobin greater than 12 g/dl, hypersensitivityto methoxypolyethylene glycolepoetinbeta or its components, red cellaplasia, uncontrolled hypertensionAdverse ReactionsCNS: Headache, seizures, strokeCV: Chest pain, congestive heart failure,deep vein thrombosis, hypertension,hypotension, MI, tachycardia, vascularaccess thrombosisEENT: NasopharyngitisGI: Constipation, diarrhea, GI bleeding,vomitingGU: UTIHEME: Pure red cell aplasia, severe anemiaMS: Back or limb pain, muscle spasmsRESP: Cough, upper respiratory tract infectionSKIN: Erythema, pruritus, rashOther: Anaphylaxis, antibody formation todrugNursing Considerations• Use drug cautiously in patients who haveconditions that could decrease or delayresponse to drug, such as aluminumintoxication, folic acid deficiency, hemolysis,infection, inflammation, iron deficiency,malignant neoplasm, osteitis (birrosacystica), or vitamin B 12 deficiency.• Also use drug cautiously in patients with acardiovascular disorder caused by hypertension,a history of seizures, vascular disease,or a hematologic disorder, such ashypercoagulation, myelodysplastic syndromeor sickle cell disease.• Be aware that if patient’s blood pressure isdifficult to control even with drug therapyor dietary measures, dose of methoxypolyethyleneglycol-epoetin beta should bereduced or drug withheld until bloodpressure is controlled.• Don’t shake vial during preparation toavoid denaturing glycoprotein, inactivatingdrug. Protect vials and prefilledsyringes from light by storing in originalcartons.• Discard unused portion of single-dose vialbecause it contains no preservatives.WARNING Target hemoglobin shouldn’texceed 12 g/dl because it increases risk oflife-threatening adverse cardiovasculareffects.• Monitor drug effectiveness by checkinghemoglobin every 2 weeks until stabilizedat 10 to 12 g/dl and maintenance dose hasbeen established. Then expect hemoglobinto be monitored at least monthly unlessdosage adjustment is needed.• Expect to give an iron supplement becauseiron requirements rise when erythropoiesisconsumes existing iron stores.• Notify prescriber if patient has sudden lossof response to drug, evidenced by severeanemia and a low reticulocyte count. Antierythropoietinantibody-related anemiamay be present, which requires stoppingdrug and any other erythropoietic proteins.• Take seizure precautions, especially duringthe first couple months of therapy.• Risk of hypertensive or thrombotic complicationsincreases if hemoglobin risesmore than 1 g/dl over 2 weeks.PATIENT TEACHING• Teach patient how to administer drug andhow to dispose of needles properly.Caution against reusing needles.• Stress importance of complying withdosage regimen and keeping follow-upmedical and laboratory appointments.• Review possible adverse reactions, andurge patient to notify prescriber aboutchest pain, headache, hives, rapid heartbeat,rash, seizures, shortness of breath, orswelling.• Advise patient that the risk of seizures ishighest during the first couple of monthsof methoxypolyethylene glycol-epoetinbeta therapy. Urge him to avoid hazardousactivities during this time.• Encourage patient to eat iron-rich foods.

methscopolamine bromide; methsuximide 653methscopolaminebromidePamine, Pamine ForteClass and CategoryChemical class: Quaternary ammoniumderivative of scopolamineTherapeutic class: AnticholingericPregnancy category: CIndications and Dosages As adjunct to treat peptic ulcerTABLETSAdults. For mild to moderate symptoms,2.5 mg 30 min before meals and 2.5 to 5 mgat bedtime; for severe symptoms, 5 mg30 min. before meals and at bedtime.Route Onset Peak DurationP.O. 1 hr Unknown 4–6 hrMechanism of ActionReduces volume and total acid content ofgastric secretions, which may have a beneficialeffect in treating peptic ulcer. Drug alsoreduces GI motility and inhibits salivation,which may have additional benefits.ContraindicationsGlaucoma, hypersensitivity to methscopolaminebromide or its components, intestinalatony (elderly or debilitated patients),myasthenia gravis, obstructive disease of GIor GU tract, paralytic ileus, severe ulcerativecolitis, toxic megacolon complicating ulcerativecolitis, unstable cardiovascular statusin acute hemorrhageInteractionsDRUGSantacids: Possibly decreased methscopolamineabsorptionanticholinergics, antipsychotics, tricyclic antidepressants:Possibly increased anticholinergiceffectsAdverse ReactionsCNS: Confusion, dizziness, drowsiness,headache, insomnia, nervousness, weaknessCV: Palpitations, tachycardiaEENT: Blurred vision, cycloplegia, drymouth, increased intraocular pressure, lossof taste, pupil dilationENDO: Suppression of lactationGI: Bloating, constipation, nausea, vomitingGU: Impotence, urinary hesitancy, urineretentionSKIN: Decreased sweating, urticariaOther: AnaphylaxisNursing Considerations• Use with caution in elderly patients and inpatients with autonomic neuropathy, congestiveheart failure, coronary artery disease,hepatic or renal disease, hypertension,hyperthyroidism, prostatic hypertrophy,tachycardia, or ulcerative colitis.• Notify prescriber if diarrhea occursbecause it may be an early sign of incompleteintestinal obstruction.PATIENT TEACHING• Advise patient to avoid excessive exposureto heat to reduce the risk of heat prostrationand heatstroke because methscopolaminedecreases sweating.• Caution patient to avoid antacids becausethey may interfere with drug’s absorption.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.methsuximideCelontinClass and CategoryChemical class: Succinimide derivativeTherapeutic class: AnticonvulsantPregnancy category: Not ratedIndications and Dosages To treat absence seizures unresponsive toother drugsCAPSULESAdults and children. Initial: 300 mg daily.Increased by 150 to 300 mg daily every 1 to2 wk until control is achieved with minimaladverse reactions. Maximum: 1.2 g daily individed doses.Mechanism of ActionElevates seizure threshold and reduces frequencyof seizures by depressing motor cortexand elevating threshold of CNSresponse to convulsive stimuli. Methsuximideis metabolized to active metabolite N-demethylmethsuximide, which may add tothe anticonvulsant effects of the drug.M

654methyldopaContraindicationsHypersensitivity to methsuximide, succinimides,or their componentsInteractionsDRUGScarbamazepine, phenobarbital, phenytoin,primidone: Possibly decreased blood methsuximidelevelCNS depressants: Possibly increased CNSdepressionhaloperidol: Altered seizure pattern; possiblydecreased blood haloperidol levelloxapine, MAO inhibitors, maprotiline,molindone, phenothiazines, pimozide, thioxanthenes,tricyclic antidepressants: Possiblylowered seizure threshold and reduced therapeuticeffect of methsuximideACTIVITIESalcohol use: Possibly increased CNS depressionAdverse ReactionsCNS: Aggressiveness, ataxia, decreased concentration,dizziness, drowsiness, fatigue,fever, headache, insomnia, irritability, mentaldepression, nightmares, seizures, suicidalideationEENT: Periorbital edema, pharyngitisGI: Abdominal and epigastric pain, abdominalcramps, abnormal liver function testresults, anorexia, diarrhea, hiccups, nausea,vomitingGU: Microscopic hematuria, proteinuriaHEME: Agranulocytosis, aplastic anemia,eosinophilia, leukopenia, pancytopeniaMS: Muscle painSKIN: Erythematous and pruritic rash,Stevens-Johnson syndrome, systemic lupuserythematosus, urticariaOther: LymphadenopathyNursing Considerations• Monitor CBC and platelet count andassess patient for signs of infection, suchas cough, fever, and pharyngitis, becausemethsuximide may cause blood dyscrasias.• Monitor liver function test results andurinalysis results in patients with a historyof hepatic or renal disease; methsuximidemay cause functional changes in liver andkidneys.• When giving drug to patient with a historyof mixed-type epilepsy, institute seizureprecautions because drug may increaserisk of generalized tonic-clonic seizures.• Expect the dosage to be carefully andslowly adjusted according to patient’sresponse and needs and withdrawn slowlyto avoid precipitating seizures.• Plan to use 150-mg capsule when makingdosage adjustments for small children.• Notify prescriber if patient developsdepression or aggressiveness.• Monitor patient closely for evidence ofsuicidal thinking or behavior, especiallywhen therapy starts or dosage changes.PATIENT TEACHING• Advise patient to take a missed dose assoon as he remembers unless it’s nearlytime for the next dose. Warn him not todouble the dose.• Instruct patient to take drug with milk orfood to reduce gastric irritation.• Advise patient to notify prescriber if hedevelops cough, fever, or pharyngitis.• Urge patient to avoid alcohol because ofincreased risk of CNS depression.• Instruct patient to avoid hazardous activitiesuntil drug’s adverse effects are known.• Caution patient not to stop taking drugabruptly to avoid risk of absence seizures.• Urge caregivers to watch patient closely forevidence of suicidal tendencies, especiallywhen therapy starts or dosage changes,and to report concerns immediately.• Urge woman who becomes pregnant whiletaking methsuximide to enroll in theNorth American antiepileptic drug pregnancyregistry by calling 1-888-233-2334.Explain that this registry is collectinginformation about the safety of antiepilepticdrugs during pregnancy.methyldopaAldomet, Apo-Methyldopa (CAN),Dopamet (CAN), Nu-Medopa (CAN)methyldopatehydrochlorideAldometClass and CategoryChemical class: 3,4-dihydroxyphenylalanine(DOPA) analogueTherapeutic class: Antihypertensive

Pregnancy category: B (oral form), C (parenteralform)Indications and Dosages To manage hypertension, to treat hypertensivecrisisORAL SUSPENSION, TABLETS (METHYLDOPA)Adults. Initial: 250 mg b.i.d. or t.i.d. forfirst 48 hr, increased as ordered after 2 days.Maintenance: 500 to 2,000 mg daily individed doses b.i.d. to q.i.d. Maximum:3,000 mg daily.Children. Initial: 10 mg/kg daily in divideddoses b.i.d. to q.i.d. for first 48 hr, increasedas ordered after 2 days. Maximum: 65 mg/kg or 3,000 mg daily.I.V. INFUSION (METHYLDOPATE HYDROCHLORIDE)Adults. 250 to 500 mg diluted in D 5 W andinfused over 30 to 60 min every 6 hr.Maximum: 1,000 mg every 6 hr.Children. 20 to 40 mg/kg infused over30 to 60 min every 6 hr. Maximum: 65 mg/kg or 3,000 mg daily.Route Onset Peak DurationP.O. Unknown 4–6 hr* 12–24 hr†I.V. Unknown 4–6 hr 10–16 hrMechanism of ActionIs decarboxylated in the body to producealpha-methylnorepinephrine, a metabolitethat stimulates central inhibitory alphaadrenergicreceptors. This action mayreduce blood pressure by decreasing sympatheticstimulation of heart and peripheralvascular system.IncompatibilitiesDon’t administer methyldopa through sameI.V. line as barbiturates or sulfonamides.ContraindicationsActive hepatic disease, hypersensitivity tomethyldopa or its components, impairedhepatic function from previous methyldopatherapy, use within 14 days of MAO inhibitor* For single dose; 2 to 3 days for multipledoses.† For single dose; 24 to 48 hr for multipledoses.methyldopa 655InteractionsDRUGSantihypertensives: Increased hypotensionappetite suppressants, NSAIDs, tricyclic antidepressants:Possibly decreased therapeuticeffects of methyldopacentral anesthetics: Possibly need forreduced anesthetic dosageCNS depressants: Possibly increased CNSdepressionhaloperidol: Increased risk of adverse CNSeffectslevodopa: Possibly decreased therapeuticeffects of levodopa and increased risk ofadverse CNS effectslithium: Increased risk of lithium toxicityMAO inhibitors: Possibly hallucinations,headaches, hyperexcitability, and severehypertensionoral anticoagulants: Possibly increased therapeuticeffects of anticoagulantssympathomimetics: Possibly decreased therapeuticeffects of methyldopa and increasedvasopressor effects of sympathomimeticsACTIVITIESalcohol use: Possibly increased CNS depressionAdverse ReactionsCNS: Decreased concentration, depression,dizziness, drowsiness, fever, headache,involuntary motor activity, memory loss(transient), nightmares, paresthesia, parkinsonism,sedation, vertigo, weaknessCV: Angina, bradycardia, edema, heart failure,myocarditis, orthostatic hypotensionEENT: Black or sore tongue, dry mouth,nasal congestionENDO: GynecomastiaGI: Constipation, diarrhea, flatulence,hepatic necrosis, hepatitis, nausea, pancreatitis,vomitingGU: Decreased libido, impotenceHEME: Agranulocytosis, hemolytic anemia,leukopenia, positive Coombs’ test, positivetests for ANA and rheumatoid factor,thrombocytopeniaSKIN: Eczema, rash, urticariaOther: Weight gainNursing Considerations• For I.V. infusion, add methyldopate to100 ml of D 5 W and administer over 30 to60 minutes.• Expect to monitor CBC and differentialresults before and periodically duringmethyldopa therapy.• Monitor blood pressure regularly duringtherapy.M

656methylnaltrexone bromide• Monitor results of Coombs’ test; a positiveresult after several months of treatmentindicates that patient has hemolytic anemia.Expect to discontinue drug.• Assess for weight gain and edema. If theydevelop, give a diuretic, as prescribed.• Notify prescriber if patient has signs ofheart failure (dyspnea, edema, hypertension)or involuntary, rapid, jerky movements.• Be aware that hypertension may returnwithin 48 hours after stopping drug.PATIENT TEACHING• Instruct patient to take methyldopa exactlyas prescribed and not to skip a dose.Explain that hypertension can returnwithin 48 hours after stopping drug.• Suggest that patient take drug at bedtimeto minimize daytime drowsiness.• Instruct patient to weigh himself daily andto report a gain of more than 5 lb (2.3 kg)in 2 days.• Advise patient to change position slowly tominimize orthostatic hypotension.• Direct patient to notify prescriber aboutbruising, chest pain, fever, involuntaryjerky movements, prolonged dizziness,rash, and yellow eyes or skin.• Caution patient not to stop drug abruptly;doing so may cause withdrawal symptoms,such as headache, hypertension, increasedsweating, nausea, and tremor.methylnaltrexonebromideRelistorClass and CategoryChemical class: Noroxymorphone methobromideTherapeutic class: Peripheral mu-opioidreceptor antagonistPregnancy category: BIndications and Dosages To treat opioid-induced constipation inpatients receiving palliative care andnot responsive to laxative therapy.SUBCUTANEOUS INJECTIONAdults weighing more than 114 kg(251 lb): 0.15 mg/kg every other day asneeded. Maximum: 0.15 mg/kg daily.Adults weighing 62 to 114 kg (136 to251 lb): 12 mg every other day as needed.Maximum: 12 mg daily.Adults weighing 38 to less than 62 kg(84 to less than 136 lb): 8 mg every otherday as needed. Maximum: 8 mg daily.Adults weighing less than 38 kg: 0.15 mg/kg every other day as needed. Maximum:0.15 mg/kg daily.DOSAGE ADJUSTMENT For patients withsevere renal failure (creatinine clearance lessthan 30 ml/min/1.73 m 2 ), dosage reducedby half.Route Onset Peak DurationSubQ Unknown 0.5 hr UnknownMechanism of ActionBinds to peripherally acting mu-opioidreceptors in the GI tract, preventing opioidinducedslowing of GI transit time andmotility. When transit time and motility isrestored to normal, constipation is relieved.ContraindicationsHypersensitivity to methylnaltrexone bromideor its components, I.V. administration,mechanical GI obstructionAdverse ReactionsCNS: DizzinessGI: Abdominal pain, diarrhea, flatulence,nauseaSkin: DiaphoresisNursing Considerations• To determine volume of drug to givepatients who weigh more than 114 kg(251 lb) or less than 38 kg (84 lb), multiplypatient’s weight in pounds by 0.0034and round up to the nearest 0.1 ml. Or.multiply patient’s weight in kilograms by0.0075 and round up to the nearest 0.1 ml.For patients who weigh 62 to 114 kg(136 to 251 lb), injection volume administeredshould be 0.6 ml. For patients whoweigh 38 to less than 62 kg (84 to less than136 lb), injection volume administeredshould be 0.4 ml.• Inspect vial before giving drug to makesure solution is clear and colorless to paleyellow.• Give drug only as subcutaneous injectioninto patient’s upper arm, abdomen, orthigh and no more than once in 24 hours.

Make sure to rotate injection sites.• Once drug is drawn into syringe, it shouldbe given immediately. However, if needed,it may be stored at room temperature forup to 24 hours.• Notify prescriber about severe or persistentdiarrhea, and expect drug to be discontinued.PATIENT TEACHING• Teach patient or caregiver how to prepareand give methylnaltrexone subcutaneously.Stress need to rotate injection sites.• Inform patient that a bowel movementmay occur within 30 minutes after drughas been administered.• Advise patient that if severe or persistentdiarrhea occurs, prescriber should be notifiedand drug discontinued.• Reassure patient that drug is not a controlledsubstance.• Tell patient to stop taking methylnaltrexoneif she stops taking opioid pain medication.methylphenidatehydrochlorideConcerta, Daytrana Ritalin LA,Metadate, Metadate CD, Metadate ER,Methylin, Methylin ER, PMS-Methylphenidate(CAN), Riphenidate (CAN),Ritalin, Ritalin-LA, Ritalin SR (CAN),Ritalin-SRClass, Category, and ScheduleChemical class: Piperidine derivativeTherapeutic class: CNS stimulantPregnancy category: CControlled substance schedule: IIIndications and Dosages To treat attention-deficit hyperactivitydisorder (ADHD)CAPSULES, E.R. TABLETS, ORAL SOLUTION,S.R. TABLETS, TABLETSAdults and adolescents. 5 to 20 mg b.i.d. ort.i.d. Maximum: 90 mg daily.Children ages 6 to 12. 5 mg b.i.d. beforebreakfast and lunch; increased by 5 to10 mg daily at 1-wk intervals. Maximum:60 mg daily.E.R. ONCE-DAILY TABLETS (CONCERTA)Adults and adolescents. 18 mg daily;ContraindicationsAngina pectoris, anxiety, cardiac arrhythmias,depression, fructose intolerance, glaumethylphenidatehydrochloride 657increased in 18-mg increments at 1-wkintervals. Maximum: 72 mg daily, not toexceed 2 mg/kg daily.Children ages 6 to 12. 18 mg daily.Maximum: 54 mg daily.E.R. ONCE-DAILY CAPSULES (METADATE CD)Children age 6 and over. 20 mg daily.Dosage titrated to 40 or 60 mg daily basedon individual response. Maximum: 60 mgdaily.DOSAGE ADJUSTMENT Dosage reduced ordrug stopped if no improvement in 1 mo.When maintenance dosage is achieved withtablets, may be switched to E.R. or S.R.tablets.TRANSDERMAL PATCHChildren ages 6 to 12. Initial: 10-mg (12.5-cm 2 ) patch worn 9 hr daily; after 1 wk,increased to 15-mg (18.75-cm 2 ) patch worn9 hr daily; after 1 more wk, increased to20-mg (25-cm 2 ) patch worn 9 hr daily;after 1 more wk, increased to 30-mg (37.5-cm 2 ) patch worn 9 hr daily. Maximum: 30-mg (37.5-cm 2 ) patch worn 9 hr daily. To treat narcolepsyORAL SOLUTION, TABLETSAdults and adolescents. 5 to 20 mg b.i.d. ort.i.d. Maximum: 90 mg daily.Route Onset Peak DurationP.O. Unknown Unknown 3–6 hr(tablets)P.O. Unknown Unknown About(E.R., S.R.)8 hrP.O. Unknown Unknown About(E.R.12 hronce-daily)Mechanism of ActionBlocks the reuptake mechanism of dopaminergicneurons in the cerebral cortex andsubcortical structures of the brain, includingthe thalamus, decreasing motor restlessnessand improving concentration.Methylphenidate also may trigger sympathomimeticactivity. This action producesincreased motor activity, alertness, mildeuphoria, and decreased fatigue in patientswith narcolepsy.M

658methylphenidate hydrochloridecoma, glucose-galactose malabsorption,heart failure, hypersensitivity to methylphenidateor its components, hyperthyroidism,motor tics, recent MI, severe agitation,severe hypertension, sucrase-isomaltaseinsufficiency, tension, thyrotoxicosis,Tourette’s syndrome or family history of it,use of halogenated anethestics, use within14 days of an MAO inhibitorInteractionsDRUGSanticholinergics: Possibly increased anticholinergiceffects of both drugsanticonvulsants, oral anticoagulants, phenylbutazone,tricyclic antidepressants:Inhibited metabolism and increased bloodlevels of these drugsdiuretics, antihypertensives: Decreased therapeuticeffects of these drugshalogenated anesthetics: Possibly suddendecrease in blood pressure during surgeryMAO inhibitors: Possibly increased adverseeffects of methylphenidate, possibly severehypertensionFOODScaffeine: Increased methylphenidate effectsAdverse ReactionsCNS: Agitation, aggressiveness, anxiety,confusion, depression, dizziness, dyskinesia,emotional lability, fever, hallucinations,headache, hyperactivity, insomnia, irritability,ischemic neurologic defects (reversible),mania, migraine, motor tics, nervousness,obsessive-compulsive disorder, paresthesia,psychosis, sedation, seizures, stroke, suicidalideation, transient mood depression, tension,tremor, Tourette’s syndrome, vertigoCV: Angina, arrhythmias, bradycardia, cardiacarrest, chest pain, extrasystoles, hypertension,hypotension, MI, palpitations,Raynaud’s phenomenon, sudden death,tachycardiaEENT: Accommodation abnormality,blurred vision, diplopia, dry mouth orthroat, mydriasis, pharyngitis, rhinitis,sinusitis, vision changesENDO: Dysmenorrhea, growth suppressionin children with long-term useGI: Abdominal pain, anorexia, constipation,diarrhea, dyspepsia, hepatotoxicity, nausea,vomitingGU: Decreased libidoHEME: Anemia, decreased platelet count,leukopenia, pancytopenia, thrombocytopenia,thrombocytopenic purpuraMS: Arthralgia, myalgia, muscle tightnessor twitchingRESP: Increased cough, upper respiratorytract infectionSKIN: Allergic contact dermatitis, alopecia,application site reactions (transdermalpatch), diaphoresis, erythema multiforme,exfoliative dermatitis, pruritus, rash,urticariaOther: Anaphylaxis, angioedema, physicaland psychological dependence, weight lossNursing ConsiderationsWARNING Be aware that methylphenidatemay induce CNS stimulation and psychosisand may worsen behavior disturbancesand thought disorders in patientswho already have psychosis. Use drug cautiouslyin patients with psychosis.• Keep in mind that, when signs and symptomsof ADHD occur with acute stressreactions or with pre-existing structuralcardiac abnormalities or other seriousheart problems, methylphenidate usuallyisn’t indicated because of possible worsenedreaction or sudden death.• Monitor children and adolescents for firsttimepsychotic or manic symptoms. Ifpresent, notify prescriber and expect drugto be discontinued.WARNING Know that the E.R. tablet form(Concerta) shouldn’t be given to patientswith esophageal motility disorders; drugmay cause GI obstruction because tabletdoesn’t change shape in GI tract.• Monitor blood pressure and pulse rate todetect hypertension and excessive stimulation.Notify prescriber if present. Forpatient with hypertension, expect toincrease antihypertensive dosage or addanother antihypertensive to regimen.WARNING Watch for signs of physical orpsychological dependence. Methylphenidate’sabuse potential is similar to that ofamphetamines; use cautiously in patientswith a history of drug abuse.• Stopping drug abruptly after long-termuse may unmask dysphoria, paranoia,severe depression, or suicidal thoughts.• Monitor growth in children. Report failureto grow or gain weight, and expect to stopdrug.

• Watch closely (especially children, adolescents,and young adults), for suicidal tendencies,particularly when therapy startsand dosage changes, because depressionmay worsen temporarily during thesetimes, possibly leading to suicidal ideation.• Monitor transdermal patch applicationsite for erythema. If more intense reactionsoccur with erythema, such as localedema or papule or vesicle formation thatdon’t improve within 48 hours after patchis removed from irritated site or thatspread beyond the patch site, expect furtherdiagnostic testing to determine presenceof allergic contact dermatitis.• Patients with allergic contact dermatitisfrom transdermal patch may develop systemicallergy reaction if methylphenidateis taken by another route, such as bymouth. Monitor patient closely if route ofadministration changes, and report anyevidence of flare-up of previous dermatitisor positive patch-test sites, generalizedskin eruptions in previously unaffectedskin, headache, fever, malaise, arthralgia,diarrhea, or vomiting because drug mayneed to be discontinued.PATIENT TEACHING• Stress need to take drug exactly as prescribedbecause misuse may cause seriousadverse cardiovascular reactions, includingsudden death.• For transdermal form, teach patient toapply patch to a clean, dry location in hiship area 2 hours before effect is neededand to remove it 9 hours after application.• Caution patient to avoid applying patch toskin that’s oily, damaged, or irritated andto avoid the waistline, where clothing maydislodge the patch. Tell patient to rotateapplication sites between hips.• Instruct patient to apply patch immediatelyafter opening pouch and removing protectiveliner. Tell him to press patch firmlyin place with palm of his hand for about30 seconds. Reassure patient that exposingsite to water shouldn’t cause patch to falloff. If a patch does fall off, explain that anew patch may be applied but that thetotal exposure time for the day shouldn’texceed 9 hours.• Urge patient not to chew or crush E.R.tablets.• Tell patient to take tablets at least 6 hoursIndications and Dosages To treat ulcerative colitisI.V. INFUSION (METHYLPREDNISOLONE SODIUMSUCCINATE)Adults. 40 to 120 mg 3 to 7 times/wk for2 or more wk. Later doses given I.V. or I.M.,based on patient’s condition and response.Children. 0.14 to 0.84 mg/kg daily in dividmethylprednisolone659before bedtime to avoid insomnia and totake E.R. once-daily tablets in the morning.• Advise patient taking E.R. once-dailytablets (Concerta) that he may see intacttablet in stool. Explain that drug is slowlyreleased from nonabsorbable tablet shell.• Tell patient taking capsule form to swallowit whole or sprinkle contents onto a tablespoonof applesauce and take immediately,followed by a liquid such as water.• Direct patient to notify prescriber aboutexcessive nervousness, fever, insomnia,palpitations, rash, or vomiting.• Warn patient with seizure disorder thatdrug may cause seizures.• Inform parents of children on long-termtherapy that drug may delay growth.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes andparticularly if patient is a child, teenager,or young adult.methylprednisoloneMedrol, MeprolonemethylprednisoloneacetatedepMedalone, Depoject, Depo-Medrol,Depopred, Depo-Predate,Methylcotolonemethylprednisolonesodium succinateA-methaPred, Solu-MedrolClass and CategoryChemical class: Synthetic glucocorticoidTherapeutic class: Anti-inflammatory,immunosuppressantPregnancy category: CM

660methylprednisoloneed doses every 12 to 24 hr. To treat a wide range of immune andinflammatory disorders, including allergicrhinitis, asthma, Crohn’s disease, andsystemic lupus erythematosusTABLETS (METHYLPREDNISOLONE)Adults. 4 to 48 mg daily as a single dose orin divided doses.Children. 0.42 to 1.67 mg/kg daily in divideddoses t.i.d. or q.i.d.I.V. INFUSION, I.M. INJECTION(METHYLPREDNISOLONE SODIUM SUCCINATE)Adults. Initial: 10 to 40 mg infused overseveral min. Later doses given I.V. or I.M.,based on patient’s condition and response.Children. 0.14 to 0.84 mg/kg every 12 to24 hr.I.M. INJECTION (METHYLPREDNISOLONE ACETATE)Adults. 40 to 120 mg daily to every 2 wk,according to clinical response.Children. 0.14 to 0.84 mg/kg every 12 to24 hr.INTRA-ARTICULAR, INTRALESIONAL, OR SOFT-TISSUE INJECTION (METHYLPREDNISOLONEACETATE)Adults. 4 to 80 mg every 1 to 5 wk, accordingto clinical response. To treat adrenal hyperplasiaI.M. INJECTION (METHYLPREDNISOLONE ACETATE)Adults. 40 mg every 2 wk.Children. 0.14 to 0.84 mg/kg every 12 to24 hr. To treat acute exacerbations of multiplesclerosisTABLETS (METHYLPREDNISOLONE)Adults. 160 mg daily for 7 days followed by64 mg every other day for 1 mo.I.V. OR I.M. INJECTION (METHYLPREDNISOLONEACETATE, METHYLPREDNISOLONE SODIUMSUCCINATE)Adults. 160 mg daily for 1 wk followed by64 mg every other day for 1 mo. To treat adrenocortical insufficiencyTABLETS (METHYLPREDNISOLONE), I.M. INJECTION(METHYLPREDNISOLONE SODIUM SUCCINATE)Children. 0.18 mg/kg daily in divided dosest.i.d.I.M. INJECTION (METHYLPREDNISOLONE ACETATE)Children. 0.12 mg/kg every 3 days or0.039 to 0.059 mg/kg daily.Mechanism of ActionBinds to intracellular glucocorticoid receptorsand suppresses inflammatory andimmune responses by inhibiting accumulationof neutrophils and monocytes atinflammation sites, stabilizing lysosomalmembranes, suppressing the antigenresponse of macrophages and helper T cells,and inhibiting the synthesis of inflammatoryresponse mediators, such as cytokines,interleukins, and prostaglandins.Route Onset Peak DurationP.O. In 60 min 1–2 hr 1.25–1.5daysI.V. Rapid 30 min UnknownI.M. 6–48 hr 4–8 days 1–4 wkIncompatibilitiesDon’t mix methylprednisolone with anydrug without first consulting pharmacist.Don’t dilute methylprednisolone acetatewith any other drug.ContraindicationsFungal infection, hypersensitivity to methylprednisoloneor its components, idiopathicthrombocytopenic purpura (I.M.)InteractionsDRUGSacetaminophen: Increased risk of hepatotoxicityaminoglutethimide: Possibly loss of methylprednisolone-inducedadrenal suppressionamphotericin B, carbonic anhydrase inhibitors:Possibly severe hypokalemiaanabolic steroids, androgens: Increased riskof edema and worsening of acneanticholinergics: Possibly increased intraocularpressureasparaginase: Increased risk of hyperglycemiaand toxicityaspirin, NSAIDs: Increased risk of adverseGI effects and bleedingbarbiturates, carbamazepine, phenytoin,rifampin: Decreased blood methylprednisolonelevelcholestyramine: Possibly increased methylprednisoloneclearancecyclosporine: Increased risk of seizuresdigoxin: Possibly hypokalemia-inducedarrhythmias and digitalis toxicityestrogens, oral contraceptives: Possiblyincreased therapeutic and toxic effects ofmethylprednisoloneinsulin, oral antidiabetic drugs: Possibly

increased blood glucose levelisoniazid: Possibly decreased therapeuticeffects of isoniazidketoconazole, macrolide antibiotics such aserythromycin and troleandomycin:Decreased methylprednisolone clearanceand increased risk of adverse effectsmexiletine: Possibly decreased blood mexiletinelevelneuromuscular blockers: Possibly increasedneuromuscular blockade, causing respiratorydepression or apneaoral anticoagulants, thrombolytics: Increasedrisk of GI ulceration and hemorrhage, possiblydecreased therapeutic effects of thesedrugspotassium supplements: Possibly decreasedeffects of these supplementssomatrem, somatropin: Possibly decreasedtherapeutic effects of these drugsstreptozocin: Increased risk of hyperglycemiatroleandomycin: Increased blood methylprednisolonelevelvaccines: Decreased antibody response andincreased risk of neurologic complicationsACTIVITIESalcohol use: Increased risk of adverse GIeffects and bleedingAdverse ReactionsCNS: Ataxia, behavioral changes, depression,dizziness, euphoria, fatigue, headache,increased intracranial pressure with papilledema,insomnia, malaise, mood changes,neuropathy, paresthesia, restlessness,seizures, steroid psychosis, syncope, vertigoCV: Arrhythmias (from hypokalemia), cardiacarrest, edema, fat embolism, heart failure,hypertension, hypertrophic cardiomyopathy(premature infants), hypotension,myocardial rupture following recent MI,tachycardia, thromboembolism, thrombophlebitisEENT: Exophthalmos, glaucoma, increasedintraocular pressure, nystagmus, posteriorsubcapsular cataractsENDO: Adrenal insufficiency, cushingoidsymptoms (moon face, buffalo hump, centralobesity, supraclavicular fat pad enlargement),diabetes mellitus, growth suppressionin children, hyperglycemia, negativenitrogen balance from protein catabolismGI: Abdominal distention, elevated liverenzymes, hepatomegaly, hiccups, increasedmethylprednisolone 661appetite, melena, nausea, pancreatitis, pepticulcer, ulcerative esophagitis, vomitingGU: Amenorrhea, glycosuria, menstrualirregularities, perineal burning or tinglingHEME: Easy bruising, leukocytosisMS: Arthralgia; aseptic necrosis of femoraland humeral heads; Charcot-like arthropathy;compression fractures; muscle atrophy,twitching, or weakness; myalgia; osteoporosis;spontaneous fractures; steroid myopathy;tendon ruptureRESP: Pulmonary edemaSKIN: Acne; allergic dermatitis; altered skinpigmentation; diaphoresis; dry, scaly skin;erythema; hirsutism; necrotizing vasculitis;petechiae; purpura; rash; scarring; sterileabscess; striae; subcutaneous fat atrophy;thin, fragile skin; urticariaOther: Activation of latent infections, anaphylaxis,angioedema, exacerbation of systemicfungal infections, hypernatremia,hypocalcemia, hypokalemia, hypokalemicalkalosis, impaired wound healing, maskingof signs of infection, metabolic alkalosis,suppressed skin test reaction, weight gainNursing Considerations• Use cautiously in patients with congestiveheart failure or renal insufficiency becausesodium retention and edema can occur inpatients taking a corticosteroid. Also usecautiously in patients with peptic ulcer,diverticulitis, fresh intestinal anastomoses,or nonspecific ulcerative colitis; these conditionsincrease risk of perforation duringcorticosteroid therapy.• Give methylprednisolone tablets with foodto minimize indigestion and GI irritation.For once-daily dosing, give in the morningto coincide with normal cortisol secretion.Expect prescriber to add an antacid or H 2 -receptor antagonist to regimen.• Discard parenteral products that are discoloredor contain particles. Discard anyremaining Depo-Medrol suspension afterprescribed dose is drawn from vial.• Inject I.M. form deep into gluteal muscle.Avoid injecting into deltoid musclebecause of risk of subcutaneous atrophy.• Arrange for low-sodium diet with addedpotassium, as prescribed.• Protect patient from falling, especially elderlypatient at risk for fractures fromosteoporosis.M

662Mechanism of ActionAntagonizes the inhibitory effect ofdopamine on GI smooth muscle. This causesgastric contraction, which promotes gasmetoclopramidehydrochloride• Closely monitor patient for signs of infectionbecause drug may mask them or mayworsen systemic fungal infections or activelatent disease. Be aware that chickenpoxand measles can become life-threateningin patients taking a corticosteroid.• Assess for possible depression or psychoticepisodes during therapy.• Monitor blood glucose level; dosage ofinsulin or oral antidiabetic drug may needto be adjusted in diabetic patient.WARNING To avoid possibly fatal acute adrenocorticalinsufficiency, expect to taperlong-term therapy when discontinuing it,but expect dosage to be increased duringtimes of stress.• Be aware that changes in thyroid functionsuch as development of hypothyroidismor hyperthyroidism may require dosageadjustment in chronic therapy becausemetabolic clearance of methylprednisoloneis affected by thyroid activity.• Avoid skin testing during methylprednisolonetherapy because drug may suppressreaction.PATIENT TEACHING• Caution patient not to stop taking methylprednisoloneabruptly or to change dosagewithout consulting prescriber.• Tell patient to take a missed dose as soonas he remembers unless it’s nearly time forthe next dose. Caution against doubledosing.• Urge patient to notify prescriber immediatelyabout dark or tarry stools; signs ofimpending adrenocortical insufficiency,such as anorexia, dizziness, fainting,fatigue, fever, joint pain, muscle weakness,or nausea; and sudden weight gain orswelling.• Instruct patient not to obtain vaccinationsunless approved by prescriber.• Urge patient to take vitamin D, calciumsupplements, or both if recommended byprescriber.• Inform patient that insomnia and restlessnessusually resolve after 1 to 3 weeks.• Caution patient to avoid people with contagiousdiseases.• Explain the need for regular exercise orphysical therapy to maintain muscle mass.• Advise patient to carry medical identificationthat documents his need for longtermcorticosteroid therapy.metoclopramidehydrochlorideApo-Metoclop (CAN), Maxeran (CAN),Metoclopramide Intensol, Octamide,PMS-Metoclopramide (CAN), ReglanClass and CategoryChemical class: BenzamideTherapeutic class: Antiemetic, upper GIstimulantPregnancy category: BIndications and Dosages To treat diabetic gastroparesisORAL SOLUTION, ORAL SOLUTION CONCENTRATE,TABLETSAdults and adolescents. 10 mg 30 minbefore meals and at bedtime up to q.i.d.I.V. OR I.M. INJECTIONAdults and adolescents. 10 mg t.i.d. orq.i.d. for severe symptoms; dosage adjustedas needed. To treat gastroesophageal reflux diseaseORAL SOLUTION, ORAL SOLUTION CONCENTRATE,TABLETSAdults and adolescents. 10 to 15 mg30 min before meals and at bedtime. To prevent chemotherapy-induced vomitingI.V. INFUSIONAdults and adolescents. 3 mg/kg beforechemotherapy and then 0.5 mg/kg/hr for8 hr.I.V. INJECTIONAdults and adolescents. 1 to 2 mg/kg30 min before chemotherapy and thenrepeated every 2 to 3 hr, as needed.Children. 1 mg/kg as a single dose, repeatedin 1 hr. Maximum: 2 mg/kg. To prevent postoperative nausea andvomitingI.M. INJECTIONAdults and adolescents. 10 to 20 mg nearend of procedure.DOSAGE ADJUSTMENT Reduced by half ifcreatinine clearance is less than 40 ml/min/1.73 m 2 .

tric emptying and peristalsis, thus reducinggastroesophageal reflux. Metoclopramidealso blocks dopaminergic receptors in thechemoreceptor trigger zone, preventingnausea and vomiting.Route Onset Peak DurationP.O. 30–60 min Unknown 1–2 hrI.V. 1–3 min Unknown 1–2 hrI.M. 10–15 min Unknown 1–2 hrIncompatibilitiesDon’t administer metoclopramide throughsame I.V. line as calcium gluconate,cephalothin sodium, chloramphenicol sodium,cisplatin, erythromycin lactobionate,furosemide, methotrexate, penicillin Gpotassium, or sodium bicarbonate.ContraindicationsConcurrent use of butyrophenones, phenothiazines,or other drugs that may causeextrapyramidal reactions; GI hemorrhage,mechanical obstruction, or perforation;hypersensitivity to metoclopramide or itscomponents; pheochromocytoma; seizuredisordersInteractionsDRUGSanticholinergics, opioid analgesics: Possiblydecreased metoclopramide effectsapomorphine: Possibly decreased antiemeticeffect of apomorphine, possibly increasedCNS depressionbromocriptine, pergolide: Possibly decreasedtherapeutic effects of these drugscimetidine: Possibly decreased absorptionand therapeutic effects of cimetidineCNS depressants: Possibly increased CNSdepressioncyclosporine: Increased cyclosporine leveldigoxin: Decreased gastric digoxin absorptionlevodopa: Possibly decreased levodopaeffectsMAO inhibitors: Increased risk of severehypertension if patient has essential hypertensionmexiletine: Possibly faster mexileteneabsorptionsuccinylcholine: Possibly prolonged therapeuticaction of succinylcholineACTIVITIESalcohol use: Risk of excessive sedationmetoclopramide hydrochloride 663Adverse ReactionsCNS: Agitation, anxiety, depression, dizziness,drowsiness, extrapyramidal reactions(motor restlessness, parkinsonism, tardivedyskinesia), fatigue, headache, insomnia,irritability, lassitude, neuroleptic malignantsyndrome, panic reaction, restlessnessCV: AV block, fluid retention, heart failure,hypertension, hypotension, supraventriculartachycardiaEENT: Dry mouthENDO: Galactorrhea, gynecomastiaGI: Constipation, diarrhea, nauseaGU: Menstrual irregularitiesHEME: AgranulocytosisSKIN: RashOther: Restless leg syndromeNursing Considerations• Use metoclopramide cautiously in patientswith hypertension because it may increasecatecholamine levels.WARNING Watch closely for tardive dyskinesia,especially in the elderly, women, andpatients with diabetes, because this seriousadverse effect is often irreversible evenafter therapy stops. Therapy lasting longerthan 12 weeks isn’t recommended becauserisk of tardive dyskinesia increases thelonger the patient takes metoclopramide.Risk also has been linked to total cumulativedose so prescriber must take this intoaccount when setting dosage. At first signof involuntary movements of face, tongue,or limbs, notify prescriber and expect todiscontinue drug.• Monitor patient with NADH-cytochromeb5 reductase deficiency because metoclopramideincreases risk of methemoglobinemiaand sulfhemoglobinemia, andpatient can’t receive methylene blue.• Assess patient for signs of intestinalobstruction, such as abnormal bowelsounds, diarrhea, nausea, and vomiting,before administering metoclopramide.Notify prescriber if you detect them.• For I.V. use, you need not dilute doses of10 mg or less. Give drug over 1 to 2 minutes.For doses larger than 10 mg, dilute in50 ml normal saline solution, half-normal(0.45) saline solution, D 5 W, or lactatedRinger’s solution and infuse over at least15 minutes.• Avoid rapid I.V. delivery because it maycause anxiety, restlessness, and drowsiness.M

664metozaloneWARNING Notify prescriber if patient showssigns of toxicity, such as disorientation,drowsiness, and extrapyramidal reactions.• Monitor patient, especially one with heartfailure or cirrhosis, for possible fluidretention or volume overload due to transientincrease in plasma aldosterone level.• Monitor patient closely for neurolepticmalignant syndrome, a rare but potentiallyfatal disorder characterized by hyperthermia,muscle rigidity, altered level of consciousness,irregular pulse or blood pressure,tachycardia, diaphoresis, andarrhythmias.• Store drug in a light-resistant container;discard if discolored or contains particulate.PATIENT TEACHING• Advise against activities that require alertnessfor about 2 hours after each dose.• Urge patient to avoid alcohol and CNSdepressants while taking metoclopramide.They may increase CNS depression.• Tell patient to immediately report involuntarymovements of face, eyes, tongue, orhands, including lip smacking, chewing,puckering of mouth, frowning, scowling,sticking out tongue, blinking, moving eyes,or shaking arms and legs.• Explain that stopping metoclopramidemay cause withdrawal symptoms thatinclude dizziness, nervousness, andheadache.metolazoneDiulo, Mykrox, ZaroxolynClass and CategoryChemical class: Quinazoline derivativeTherapeutic class: Antihypertensive, diureticPregnancy category: BIndications and Dosages To manage mild to moderate hypertensionEXTENDED TABLETSAdults. 2.5 to 5 mg daily.PROMPT TABLETS (MYKROX)Adults. 0.5 mg daily. Maintenance: 0.5 to1 mg daily. Maximum: 1 mg daily. To manage edema from heart failure orrenal diseaseEXTENDED TABLETSAdults. 5 to 20 mg daily.Mechanism of ActionPromotes renal excretion of water and sodiumby inhibiting their reabsorption in distalconvoluted tubules. The resulting reductionin plasma and extracellular fluid volumereduces blood pressure. Metolazonealso helps reduce blood pressure bydecreasing peripheral vascular resistance.Route Onset Peak DurationP.O. 1 hr 2 hr 12–24 hrContraindicationsAnuria; hepatic coma; hypersensitivity tometolazone, other sulfonamide derivatives,quinethazones, thiazides, or their components;renal failureInteractionsDRUGSallopurinol: Increased risk of hypersensitivityto allopurinolamiodarone: Increased risk of arrhythmiasfrom hypokalemiaamphotericin B: Increased risk of electrolyteimbalancesanesthetics: Increased effects of anestheticsantigout drugs: Increased blood uric acidlevel and risk of gout attackantihypertensives: Increased hypotensionantineoplastics: Prolonged antineoplasticinducedleukopeniacalcium salts: Increased risk of hypercalcemiacholestyramine, colestipol: Decreased metolazoneabsorptiondiazoxide: Increased risk of hyperglycemiadigoxin: Increased risk of electrolyte imbalancesand digoxin-induced arrhythmiasdiuretics: Additive effects of both drugs,possibly leading to severe hypovolemia andelectrolyte imbalancesdopamine: Increased diuretic effectinsulin, oral antidiabetic drugs: Decreasedeffectiveness of these drugs, increased riskof hyperglycemialithium: Increased risk of lithium toxicitymethenamine: Decreased metolazone effectivenessfrom urinary alkalinizationmethyldopa: Possibly hemolytic anemianeuromuscular blockers: Increased risk ofhypokalemia and neuromuscular blockade,increased risk of respiratory depressionNSAIDs, sympathomimetics: Possiblydecreased metolazone effectiveness

oral anticoagulants: Decreased anticoagulationvitamin D: Increased vitamin D action,increased risk of hypercalcemiaAdverse ReactionsCNS: Anxiety, chills, depression, dizziness,drowsiness, headache, insomnia, neuropathy,paresthesia, restlessness, syncope,weaknessCV: Chest pain, cold extremities, orthostatichypotension, palpitations, peripheraledema, vasculitis, venous thrombosisEENT: Bitter taste, blurred vision, drymouth, epistaxis, pharyngitis, sinus congestion,tinnitusENDO: HyperglycemiaGI: Abdominal pain, anorexia, cholecystitis,constipation, diarrhea, hepatic dysfunction,hepatitis, indigestion, nausea, pancreatitis,vomitingGU: Decreased libido, glycosuria, impotenceHEME: Agranulocytosis, aplastic anemia,leukopenia, thrombocytopeniaMS: Arthralgia, gout, myalgiaRESP: CoughSKIN: Dry skin, necrosis, petechiae, photosensitivity,pruritus, rash, urticariaOther: Hypochloremia, hypokalemia, hyponatremia,hypovolemia, metabolic alkalosisNursing ConsiderationsWARNING Be aware that Mykrox prompttablets shouldn’t be substituted for Diuloor Zaroxolyn extended tablets becausethey aren’t equivalent.• Anticipate giving metolazone with a loopdiuretic if patient responds poorly to loopdiuretic alone.• To monitor drug’s diuretic effect, measurefluid intake and output and daily weight.• If response to 1 mg of Mykrox is inadequate,expect to add another drug ratherthan increase dosage.• Monitor blood chemistry test results andassess for evidence of hypochloremia,hypokalemia, and, possibly, mild metabolicalkalosis.• Monitor serum calcium and uric acid levels,especially if patient has a history ofgout or renal calculi. Metolazone mayslightly increase calcium reabsorption anddecrease uric acid excretion.PATIENT TEACHING• Inform patient that metolazone controlsmetoprolol 665but doesn’t cure hypertension. Discusspossible need for lifelong therapy and consequencesof uncontrolled hypertension.• Instruct patient to take drug at the sametime each day.• Direct patient to take drug with food ormilk to minimize adverse GI reactions.• Advise patient to change position slowly tominimize orthostatic hypotension.• Urge patient to notify prescriber aboutpersistent, severe diarrhea, nausea, orvomiting, which can cause dehydrationand orthostatic hypotension.• Stress the importance of weight and dietcontrol, especially limiting sodium intake.• Inform diabetic patient that metolazonemay increase blood glucose level and thathe should check his level often.metoprololsuccinateToprol-XLmetoprolol tartrateApo-Metoprolol (CAN), Betaloc (CAN),Betaloc Durules (CAN), Lopresor (CAN),Lopresor SR (CAN), Lopressor,Novometoprol (CAN)Class and CategoryChemical class: Beta 1 -adrenergic antagonistTherapeutic class: Antianginal, antihypertensive,MI prophylaxis and treatmentPregnancy category: CIndications and Dosages To manage hypertension, alone or withother antihypertensivesE.R. TABLETS (METOPROLOL SUCCINATE)Adults. Initial: 25 to 100 mg daily, adjustedweekly as prescribed. Maximum: 400 mgdaily.E.R. TABLETS (METOPROLOL TARTRATE)Adults. Maintenance: 100 to 400 mg dailyto maintain blood pressure control aftertherapeutic level has been achieved withimmediate-release tablets.TABLETS (METOPROLOL TARTRATE)Adults. Initial: 100 mg daily, adjusted weeklyas prescribed. Maximum: 450 mg daily asa single dose or in divided doses.M

666metoprolol To treat acute MI or evolving acute MITABLETS (METOPROLOL TARTRATE), I.V. INJECTION(METOPROLOL TARTRATE)Adults. Initial: 5 mg by I.V. bolus every2 min for 3 doses followed by 50 mg P.O.for patients who tolerate total I.V. dose(25 to 50 mg P.O. for patients who can’t toleratetotal I.V. dose) every 6 hr for 48 hr,starting 15 min after final I.V. dose; after48 hr, 100 mg b.i.d. followed by maintenancedosage. Maintenance: 100 mg P.O.b.i.d. for at least 3 mo. To treat angina pectoris and chronicstable anginaE.R. TABLETS (METOPROLOL SUCCINATE)Adults. 100 mg daily, increased weekly asprescribed. Maximum: 400 mg daily as asingle dose or in divided doses.E.R. TABLETS (METOPROLOL TARTRATE)Adults. Initial: 100 mg daily, adjusted weeklyas prescribed. Maximum: 450 mg daily.TABLETS (METOPROLOL TARTRATE)Adults. Initial: 50 mg b.i.d., adjusted weeklyas prescribed. Maximum: 450 mg daily. To treat stable, symptomatic (New YorkHeart Association [NYHA] Class II orIII), ischemic, hypertensive, or cardiomyopathicheart failureE.R. TABLETS (METOPROLOL SUCCINATE)Adults. Initial: 25 mg daily (NYHA ClassII) or 12.5 mg daily (NYHA Class III ormore severe heart failure) for 2 wk. Thendosage doubled every 2 wk as tolerated.Maximum: 200 mg daily.Route Onset Peak DurationP.O. 60 min 1–2 hr UnknownP.O. (E.R.) Unknown 6–12 hr UnknownI.V. Unknown 20 min UnknownMechanism of ActionInhibits stimulation of beta 1 -receptor sites,located mainly in the heart, resulting indecreased cardiac excitability, cardiac output,and myocardial oxygen demand. Theseeffects help relieve angina. Metoprolol alsohelps reduce blood pressure by decreasingrenal release of renin.ContraindicationsAcute heart failure; pulse less than 45 beats/minute; cardiogenic shock; hypersensitivityto metoprolol, its components, or otherbeta blockers; pheochromocytoma; secondorthird-degree AV block; severe peripheralarterial disorders; sick sinus syndromeInteractionsDRUGSaluminum salts, barbiturates, calcium salts,cholestyramine, colestipol, NSAIDs, rifampin,salicylates, sulfinpyrazone: Decreased therapeuticeffects of metoprololamiodarone, digoxin, diltiazem, verapamil:Increased risk of complete AV blockcalcium channel blockers: Increased risk ofheart failure and increased effects of bothdrugscimetidine: Increased metoprolol levelclonidine: Increased risk of hypotension;increased risk of rebound hypertensionwhen clonidine is discontinueddigoxin: Decreased heart rate and slowedatrioventricular conductionestrogens: Possibly decreased antihypertensiveeffect of metoprololgeneral anesthetics: Increased risk ofhypotension and heart failureinsulin, oral antidiabetic drugs: Decreasedblood glucose control, possibly masking ofsigns and symptoms of hypoglycemia (bymetoprolol)lidocaine: Increased risk of lidocaine toxicityMAO inhibitors: Risk of hypertensionneuromuscular blockers: Possibly enhancedand prolonged neuromuscular blockadeother antihypertensives: Additive hypotensiveeffectphenothiazines: Possibly increased bloodlevels of both drugspropafenone: Increased blood level and halflifeof metoprololsympathomimetics, xanthines: Possiblydecreased therapeutic effects of both drugsFOODSall foods: Increased bioavailability of metoprololAdverse ReactionsCNS: Anxiety, confusion, depression, dizziness,drowsiness, fatigue, hallucinations,headache, insomnia, weaknessCV: Angina, arrhythmias (including AVblock and bradycardia), chest pain,decreased HDL level, increased triglyceridelevels, gangrene of extremity, heart failure,hypertension, orthostatic hypotensionEENT: Nasal congestion, rhinitis, taste disturbance

GI: Constipation, diarrhea, hepatitis, nausea,vomitingGU: ImpotenceHEME: Leukopenia, thrombocytopeniaMS: Arthralgia, back pain, myalgiaRESP: Bronchospasm, dyspneaSKIN: Diaphoresis, photosensitivity, rash,urticaria, worsening of psoriasisNursing Considerations• Use metoprolol with extreme caution inpatients with bronchospastic disease whodon’t respond to or can’t tolerate otherantihypertensives. Expect to give smallerdoses more often to avoid the higher plasmalevels in longer dosage intervals.• Use cautiously in patients with hypertensionor angina who have congestive heartfailure because beta blockers such asmetoprolol can further depress myocardialcontractility, worsening heart failure.• For patient with acute MI who can’t tolerateinitial dosage or who delays treatment,start with maintenance dosage, as prescribedand tolerated.• Before starting therapy for heart failure,expect to give a diuretic, an ACE inhibitor,and digoxin to stabilize patient.• If patient has pheochromocytoma, alphablocker therapy should start first, followedby metoprolol to prevent paradoxicalincrease in blood pressure from attenuationof beta-mediated vasodilation inskeletal muscle.• Be aware that metoprolol dosage for heartfailure is highly individualized. Monitorpatient for evidence of worsening heartfailure during dosage increases. If heartfailure worsens, expect to increase diureticdosage and possibly decrease metoprololdosage or temporarily discontinue drug, asprescribed. Metoprolol dosage shouldn’tbe increased until worsening heart failurehas been stabilized.• If patient with heart failure developssymptomatic bradycardia, expect todecrease the metoprolol dosage.WARNING If dosage exceeds 400 mg daily,monitor patient for bronchospasm anddyspnea because metoprolol competitivelyblocks beta 2 -adrenergic receptors inbronchial and vascular smooth muscles.WARNING When substituting metoprolol forclonidine, expect to gradually reduceclonidine and increase metoprolol dosagemetronidazole 667over several days. Given together, thesedrugs have additive hypotensive effects.• Patients who take metoprolol may be atrisk for AV block. If AV block results fromdepressed AV node conduction, prepare togive appropriate drug, as ordered, or assistwith insertion of temporary pacemaker.• Check for signs of poor glucose control inpatient with diabetes mellitus. Metoprololmay interfere with therapeutic effects ofinsulin and oral antidiabetic drugs. It alsomay mask evidence of hypoglycemia, suchas palpitations, tachycardia, and tremor.• Monitor patient with peripheral vasculardisease for evidence of arterial insufficiency(pain, pallor, and coldness in affectedextremity) Metoprolol can precipitate oraggravate peripheral vascular disease.WARNING Expect to taper dosage over 1 to2 weeks when drug is discontinued; stoppingabruptly can cause myocardialischemia, MI, ventricular arrhythmias, orsevere hypertension, especially in patientswith cardiac disease. Abrupt withdrawalalso may cause thyroid storm in a patientwith hyperthyroidism or thyrotoxicosis.PATIENT TEACHING• Instruct patient to take metoprolol withfood at the same time each day—oncedaily for E.R. tablets. Explain that he mayhalve tablets but not chew or crush them.• Advise patient to notify prescriber if pulserate falls below 60 beats/minute or is significantlylower than usual.• Urge diabetic patient to check blood glucoselevel often during therapy.• Caution patient not to stop drug abruptly.metronidazoleApo-Metronidazole (CAN), Flagyl,Flagyl I.V. RTU, Metric 21, MetroGel,MetroGel-Vaginal, Nidagel (CAN),Novonidazol (CAN), Protostat,Trikacide (CAN)metronidazolehydrochlorideFlagyl I.V.Class and CategoryChemical class: Nitroimidazole derivativeM

668metronidazoleTherapeutic class: Antibiotic, antiprotozoalPregnancy category: BIndications and Dosages To treat systemic anaerobic infectionscaused by Bacteroides fragilis, Clostridiumdifficile, Clostridium perfringens,Eubacterium, Fusobacterium,Peptococcus, Peptostreptococcus, andVeillonella speciesCAPSULES, TABLETSAdults and adolescents. 7.5 mg/kg up to1,000 mg every 6 hr for 7 days or longer.Maximum: 4,000 mg daily.Children. 7.5 mg/kg every 6 hr or 10 mg/kgevery 8 hr.I.V. INFUSIONAdults and adolescents. Initial: 15 mg/kgand then 7.5 mg/kg up to 1,000 mg every6 hr for 7 days or longer. Maximum:4,000 mg daily.Children. 7.5 mg/kg every 6 hr or 10 mg/kgevery 8 hr. To treat amebiasis (Entamoeba histolytica)CAPSULES, TABLETSAdults. 500 to 750 mg t.i.d. for 5 to 10 days.Children. 11.6 to 16.7 mg/kg t.i.d. for10 days. To treat trichomoniasis (Trichomonasvaginalis)CAPSULES, TABLETSAdults. 2,000 mg as a single dose, 1,000 mgb.i.d. for 24 hr, or 250 mg t.i.d. for 7 days.Children. 5 mg/kg t.i.d. for 7 days. To prevent perioperative bowel infectionI.V. INFUSIONAdults and adolescents. 15 mg/kg 1 hrbefore surgery and then 7.5 mg/kg 6 and12 hr after initial dose. To treat acne in patients with rosaceaTOPICAL GELAdults. Thin film applied to affected areab.i.d. for 9 wk. To treat bacterial vaginosisVAGINAL CREAMAdults. 500 mg (1 applicatorful) once ortwice daily for 10 to 20 days.VAGINAL GELAdults. 37.5 mg (1 applicatorful) once ortwice daily for 5 days.VAGINAL TABLETSAdults. 500 mg at bedtime for 10 to20 days.Mechanism of ActionUndergoes intracellular chemical reductionduring anaerobic metabolism. Aftermetronidazole is reduced, it damages DNA’shelical structure and breaks its strands,which inhibits bacterial nucleic acid synthesisand causes cell death.IncompatibilitiesDon’t administer I.V. metronidazole withaluminum needles or hubs or through sameI.V. line as other drugs.ContraindicationsBreast-feeding, hypersensitivity to metronidazoleor its components, trichomoniasisduring first trimester of pregnancyInteractionsDRUGScimetidine: Possibly delayed elimination andincreased blood level of metronidazoledisulfiram: Possibly combined toxicity, withconfusion and psychotic reactionsneurotoxic drugs: Increased risk of neurotoxicityoral anticoagulants: Possibly increased anticoagulanteffectphenobarbital: Increased metabolism anddecreased blood level and half-life ofmetronidazolephenytoin: Decreased phenytoin clearanceACTIVITIESalcohol use: Possibly disulfiram-like effectsAdverse ReactionsCNS: Aseptic meningitis (parenteral form),ataxia, confusion, dizziness, encephalopathy,fever, headache, incoordination, insomnia,irritability, light-headedness, peripheralneuropathy, seizures (high doses), syncope,weakness, vertigoEENT: Dry mouth, lacrimation (topicalform), metallic taste, nasal congestion, opticneuropathy, pharyngitisGI: Abdominal cramps or pain, anorexia,diarrhea, nausea, pancreatitis, vomitingGU: Dark urine, vaginal candidiasis (oral,parenteral, and topical forms); burning orirritation of sexual partner’s penis, candidalcervicitis or vaginitis, dysuria, dryness ofvagina or vulva, urinary frequency, vulvitis(vaginal form)HEME: LeukopeniaMS: Back pain, dysarthriaSKIN: Burning or stinging sensation, dry

skin (topical form); erythema, flushing,pruritus, rash, Stevens Johnson syndrome,urticaria (oral and parenteral forms)Other: Injection site edema, pain, or tendernessNursing Considerations• Give I.V. drug by slow infusion over1 hour; don’t give by direct I.V. injection.• Discontinue primary I.V. infusion duringmetronidazole infusion.WARNING If patient has adverse CNS reactions,such as seizures or peripheral neuropathy,tell prescriber and stop drugimmediately.• Monitor patient with severe liver diseasebecause slowed metronidazole metabolismmay cause drug to accumulate in bodyand increase the risk of adverse effects.• If skin irritation occurs, apply topicalmetronidazole gel less frequently or discontinueit, as ordered.• Monitor CBC and culture and sensitivitytests if therapy lasts longer than 10 days orif second course of treatment is needed.PATIENT TEACHING• Instruct female patient to notify prescriberif she is pregnant, intends to get pregnant,or is breast-feeding.• Urge patient to take metronidazole atevenly spaced intervals day and with foodto minimize adverse GI reactions.• Urge patient to complete the entire courseof therapy.• Caution patient to avoid alcohol duringtherapy and for at least 3 days afterward.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are knownand to report any abnormal neurologicsigns or symptoms, such as weakness,numbness, seizures, or vision changes.• If patient reports dry mouth, suggest icechips or sugarless hard candy or gum; suggesta dental visit if dryness lasts longerthan 2 weeks.• Instruct patient to notify prescriber if noimprovement occurs within a few days oftaking tablets or capsules.• Direct patient using topical gel to washhands and affected area with a mild, nonirritatingcleaner; to rinse well and patdry; and then to apply a thin film of drugand wash hands again.• Advise patient with rosacea to keep topicalgel away from his eyes. If drug gets intohis eyes, urge him to wash them immediatelywith large amounts of cool tap waterand to call prescriber if eyes continue tohurt or burn.• Instruct patient with rosacea to notify prescriberif no improvement occurs after3 weeks of topical use; full therapeuticeffect may take 9 weeks.• Teach patient how to fill, insert, and cleanvaginal cream or gel applicator after use.Instruct her to wash her hands before andafter administration.• To help vaginal tablets dissolve, instructpatient to run tap water over unwrappedtablet for a few seconds before insertion.• Inform patient with trichomoniasis thather male sexual partners should wear condomsduring her treatment and that theymay need treatment themselves to preventreinfection.• Caution patient that vaginal cream andtablets (not gel) may contain oils thatdamage latex condoms.• Urge patient to follow up with prescriberto make sure infection is gone.metyrosineDemsermetyrosine 669Class and CategoryChemical class: Alpha-methyl tyrosineTherapeutic class: AntipheochromocytomaagentPregnancy category: CIndications and Dosages To control hypertension and relatedsymptoms until pheochromocytomectomyis performed, to treat chronic malignantpheochromocytomaCAPSULESAdults and adolescents. Initial: 250 mgq.i.d., increased as ordered by 250 to 500 mgdaily. Maintenance: 2,000 to 3,000 mg dailyin divided doses q.i.d. Preoperative dosagegiven for at least 7 days. Maximum: 4,000mg daily in divided doses.Mechanism of ActionBlocks activity of tyrosine hydroxylase, theenzyme that controls rate of catecholaminesynthesis. This action decreases productionM

670mexiletine hydrochlorideof the catecholamines epinephrine and norepinephrine,which, in patients with pheochromocytoma,are produced in excessiveamounts.ContraindicationsHypersensitivity to metyrosine or its componentsInteractionsDRUGSCNS depressants: Increased sedationhaloperidol, phenothiazines: Increasedextrapyramidal effectsACTIVITIESalcohol use: Increased sedationAdverse ReactionsCNS: Anxiety, confusion, depression, disorientation,extrapyramidal reactions (difficultyspeaking, drooling, parkinsonism,tremor, trismus), hallucinations, headache,sedationCV: Peripheral edemaEENT: Dry mouth, nasal congestion, pharyngealedemaENDO: Galactorrhea, gynecomastiaGI: Abdominal pain, diarrhea, elevatedserum AST level, nausea, vomitingGU: Crystalluria, dysuria (transient),ejaculation failure, hematuria, impotence,urolithiasisHEME: Anemia, eosinophilia, thrombocytopenia,thrombocytosisSKIN: UrticariaNursing Considerations•Expect patient taking metyrosine to experiencemoderate to severe sedation at lowand high dosages. Sedation begins duringfirst 24 hours, peaks after 2 to 3 days, andtends to wane during next few days. Itusually subsides after 1 week unless dosageis increased or exceeds 2 g daily.•Obtain urine specimens as ordered tocheck for crystalluria and urolithiasis. Ifcrystalluria develops, increase fluid intaketo achieve daily urine output of 2,000 mlor more with doses above 2 g daily. If crystalluriapersists, reduce dosage or stopdrug, as ordered.•Expect to adjust dosage, as prescribed,based on clinical response and urine catecholaminelevel.•If signs and symptoms aren’t adequatelycontrolled by metyrosine, expect to add analpha-adrenergic blocker, such as phenoxybenzamine,as prescribed.PATIENT TEACHING•Inform patient about metyrosine’s sedativeeffects. Advise him to avoid alcohol andCNS depressants, which may increasesedation.•Instruct patient to increase fluid intake, asappropriate.•Urge patient to report drooling, severediarrhea, trembling and shaking of handsand fingers, or trouble speaking.•Inform patient that he may experiencechanges in sleep pattern for 2 to 3 daysafter stopping drug.•Advise patient to keep regular visits withprescriber to monitor progress.mexiletinehydrochlorideMexitilClass and CategoryChemical class: Lidocaine analogueTherapeutic class: Class IB antiarrhythmicPregnancy category: CIndications and Dosages To treat life-threatening ventriculararrhythmiasCAPSULESAdults. Initial: 200 mg every 8 hr, adjusted,as ordered, by 50 to 100 mg/dose every 2 to3 days, as tolerated. If patient tolerates300 mg or less every 8 hr, total dosage maybe divided and given every 12 hr. If patientcontinues to experience arrhythmias,dosage frequency may be changed to q.i.d.Maximum: 1,200 mg daily when givenevery 8 hr (400 mg/dose); 900 mg dailywhen given every 12 hr (450 mg/dose). To rapidly control life-threatening ventriculararrhythmiasCAPSULESAdults. Initial: 400 mg followed by 200 mgafter 8 hr. Maintenance: 200 mg every 8 hr,adjusted, as ordered, by 50 to 100 mg/doseevery 2 to 3 days, as tolerated. If patient tolerates300 mg or less every 8 hr, totaldosage may be divided and given every12 hr. If patient continues to experiencearrhythmias, dosage frequency may be

changed to q.i.d.DOSAGE ADJUSTMENT For patients withsevere hepatic disease or heart failure,dosage reduced and adjusted every 2 or3 days.Route Onset Peak DurationP.O. 0.5–2 hr 2–3 hr 8–12 hrMechanism of ActionProduces antiarrhythmic effect by inhibitingfast sodium channels in myocardial cellmembranes, especially in the His-Purkinjesystem. This action decreases duration ofaction potential and effective refractoryperiod of His-Purkinje system. Themyocardium, which becomes refractoryagain after resting membrane potential isrestored, is less likely to generate andrespond to ectopic ventricular impulses.ContraindicationsCardiogenic shock, second- or third-degreeAV block without a pacemakerInteractionsDRUGSaluminum- or magnesium-containing antacids:Delayed mexiletine absorptionantiarrhythmics: Increased cardiac effectscimetidine: Possibly increased or decreasedblood mexiletine levelhepatic enzyme inducers: Accelerated metabolismand decreased level of mexiletinemetoclopramide: Accelerated mexiletineabsorptionrifampin: Decreased blood mexiletine leveltheophylline: Increased theophylline levelurine acidifiers: Accelerated renal excretionof mexiletineurine alkalinizers: Delayed mexiletine excretionFOODScaffeine: Possibly decreased clearance andincreased effects of caffeinefoods that may acidify urine (such as cheese,cranberries, eggs, fish, grains, meats, plums,poultry, and prunes): Accelerated renalexcretion of mexiletinefoods that may alkalinize urine (such as milkand all vegetables and fruits except cranberries,plums, and prunes): Delayed renalexcretion of mexiletineACTIVITIESsmoking: Reduced mexiletine half-lifemexiletine hydrochloride 671Adverse ReactionsCNS: Confusion, dizziness, fatigue, headache,lack of coordination, light-headedness,nervousness, paresthesia, seizures,sleep disturbance, syncope, tremor, weaknessCV: Atrial arrhythmias, AV conduction disorders,bradycardia, cardiogenic shock,chest pain, heart failure, hypotension, palpitations,PVCs, ventricular arrhythmias(increased)EENT: Blurred vision, dry mouth, tinnitusGI: Constipation, diarrhea, heartburn, nausea,vomitingHEME: Agranulocytosis, leukopenia, thrombocytopeniaRESP: DyspneaSKIN: RashNursing Considerations• If mexiletine is replacing another antiarrhythmic,expect to give first dose 6 to12 hours after last dose of quinidine sulfateor disopyramide, 3 to 6 hours afterlast dose of procainamide, or 8 to 12 hoursafter last dose of tocainide, as prescribed.• If mexiletine is replacing parenteral lidocaine,expect to reduce or withdraw lidocaine1 to 2 hours after starting mexiletine,as prescribed.• Monitor continuous ECG and serum mexiletinelevel.• Assess patient for thrombocytopenia,which may occur within a few days aftermexiletine therapy starts. Expect plateletcount to return to normal within 1 monthafter mexiletine therapy stops.PATIENT TEACHING• Instruct patient to take mexiletine at evenlyspaced intervals, to avoid missing doses,and to take drug as prescribed, even if he’sfeeling well.• Advise patient to take drug with food toreduce adverse GI reactions.• Inform patient that nausea and vomitingmay occur within 2 hours after dose buttend to lessen as treatment continues.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Teach patient to take his pulse, and advisehim to contact prescriber if rate is below50 beats/minute or rhythm is irregular.• Urge patient to notify prescriber immediatelyabout chest pain, chills, fast or irregularheartbeat, fever, shortness of breath,M

672mezlocillin sodiumand unusual bleeding or bruising.• Advise patient to avoid greatly increasingintake of foods that may acidify urine(cheese, cranberries, eggs, fish, grains,meats, plums, poultry, prunes) or alkalinizeurine (milk, all vegetables, all fruitsexcept cranberries, plums, and prunes).• Encourage patient to keep regular visitswith prescriber to monitor progress.mezlocillin sodiumMezlinClass and CategoryChemical class: AcyclaminopenicillinTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat moderate to severe infections,including bacteremia, bone and jointinfections, gynecologic infections (suchas endometritis, pelvic cellulitis, andpelvic inflammatory disease), intraabdominalinfections (such as cholangitis,cholecystitis, hepatic abscess, intraabdominalabscess, and peritonitis),lower respiratory tract infections (suchas pneumonia and lung abscess), meningitis,septicemia caused by susceptiblebacteria, or skin and soft-tissue infections(such as cellulitis and diabetic footulcer); to manage febrile neutropeniaI.V. INFUSION, I.M. INJECTIONAdults and adolescents. 3 g every 4 hr or4 g every 6 hr. To treat life-threatening infections of thetypes listed aboveI.V. INFUSION, I.M. INJECTIONAdults and adolescents. Up to 350 mg/kgdaily. Maximum: 24,000 mg daily.Children and infants. 50 mg/kg every 4 hr(or infused over 30 min every 4 hr).Neonates over age 7 days weighing 2,000 g(4.4 lb) or less. 75 mg/kg I.V. every 8 hr.Neonates age 7 days or less weighing2,000 g or less. 75 mg/kg I.V. every 12 hr.Neonates age 7 days or less weighing morethan 2,000 g. 75 mg/kg I.V. every 6 hr. To treat uncomplicated UTII.V. INFUSION, I.M. INJECTIONAdults. 1.5 to 2 g every 6 hr. To treat complicated UTII.V. INFUSIONAdults. 3 g every 6 hr.DOSAGE ADJUSTMENT Dosing intervalextended to 6 to 8 hr if needed for patientswith creatinine clearance of 10 to 30 ml/min/1.73 m 2 . Dosing interval extended anddosage reduced to 1.5 to 2 g for patientswith creatinine clearance below 10 ml/min/1.73 m 2 . To treat uncomplicated gonorrheacaused by susceptible strains ofNeisseria gonorrhoeaeI.V. INFUSION, I.M. INJECTIONAdults. 1 to 2 g as a single dose given with1 g of probenecid P.O. (or probenecid givenup to 30 min before mezlocillin). To prevent infection from potentiallycontaminated surgical proceduresI.V. INFUSIONAdults. 4 g 30 min before surgery and then4 g every 6 hr for 2 more doses. To prevent infection in cesarean sectionI.V. INFUSIONAdults. 4 g as soon as umbilical cord isclamped; then 4 g every 4 hr for 2 moredoses, starting 4 hr after initial dose.Mechanism of ActionInhibits bacterial cell wall synthesis. In susceptiblebacteria, the rigid, cross-linked cellwall is assembled in several stages. Mezlocillinaffects final stage of cross-linkingprocess by binding with and inactivatingpenicillin-binding proteins (enzymesresponsible for linking cell wall strands).This causes bacterial cell lysis and death.IncompatibilitiesAdminister mezlocillin at separate sites andat least 1 hour before or after administeringaminoglycosides. Don’t mix mezlocillin inthe same I.V. bag, bottle, or tubing withother drugs.ContraindicationsHypersensitivity to mezlocillin, other penicillins,or their componentsInteractionsDRUGSaminoglycosides: Substantial aminoglycosideinactivationchloramphenicol, erythromycins, sulfonamides,tetracyclines: Possibly decreasedtherapeutic effects of mezlocillin

methotrexate: Increased risk of methotrexatetoxicityprobenecid: Increased blood level and prolongedhalf-life of mezlocillinAdverse ReactionsCNS: Depression, headache, seizuresEENT: Oral candidiasisGI: Abdominal pain, diarrhea, pseudomembranouscolitis, nausea, vomitingGU: VaginitisHEME: Leukopenia, neutropeniaSKIN: Exfoliative dermatitis, pruritus, rash,urticariaOther: Anaphylaxis; hypokalemia; injectionsite pain, redness, and swelling; serum sicknesslikereactionNursing ConsiderationsWARNING Before starting mezlocillin, makesure patient has had no previous hypersensitivityreactions to penicillins.• Anticipate that mezlocillin therapy willlast for at least 2 days after signs andsymptoms have resolved—typically 7 to10 days, depending on severity of infection.Complicated infections may needlonger treatment. Group A beta-hemolyticstreptococcal infections usually are treatedfor at least 10 days to reduce risk of rheumaticfever or glomerulonephritis.• For I.M. injection, reconstitute each gramof mezlocillin with 3 to 4 ml sterile waterfor injection and shake vigorously. Injectno more than 2 g into a large muscle, suchas the gluteus maximus, over 12 to 15 secondsto minimize discomfort.• Although drug may be given I.M., expectto use intermittent I.V. infusion, as directed,for serious infections.• For I.V. use, reconstitute each gram ofmezlocillin with 9 to 10 ml sterile waterfor injection, D 5 W, or sodium chloride forinjection and shake vigorously. Injectdirectly into I.V. tubing over 3 to 5 minutes.• For intermittent infusion, further dilute todesired volume (50 to 100 ml) with anappropriate I.V. solution and administerover 30 minutes. Discontinue other infusionsduring mezlocillin administration.• Be aware that mezlocillin powder andreconstituted solution may darken slightlybut that potency isn’t affected.• Periodically monitor serum potassiumlevel during long-term therapy, as ordered.micafungin sodium 673• During long-term therapy, watch for signsand symptoms of superinfection, such asoral candidiasis and vaginitis.PATIENT TEACHING• Instruct patient taking mezlocillin to notifyprescriber immediately about increasedbruising or other bleeding tendencies.• Advise patient to report diarrhea and tocheck with prescriber before taking anantidiarrheal medicine because of the riskof masking pseudomembranous colitis.micafungin sodiumMycamineClass and CategoryChemical class: Semisynthetic lipopeptideechinocandinTherapeutic class: AntifungalPregnancy category: CIndications and Dosages To treat esophageal candidiasisI.V. INFUSIONAdults. 150 mg infused over 1 hr daily. To prevent Candida infection in patientsundergoing hematopoietic stem celltransplantationI.V. INFUSIONAdults. 50 mg infused over 1 hr daily. To treat candidemia, acute disseminatedcandidiasis, and Candida peritonitisand abscessesI.V. INFUSIONAdults. 100 mg infused over 1 hr daily.Mechanism of ActionInhibits synthesis of 1,3-beta-D-glucan,which is an essential component of theCandida fungal cell wall. Without 1,3-beta-D-glucan, the fungal cell dies.ContraindicationsHypersensitivity to micafungin, its components,or other echinocandinsIncompatibilitiesMixing or infusing with other drugs maycause micafungin to precipitate.InteractionsDRUGSimmunosuppressants: Possibly additiveadverse hematologic effectsM

674midazolam hydrochlorideitraconazole, nifedipine, sirolimus: Increasedplasma levels of these drugsAdverse ReactionsCNS: Anxiety, delirium, dizziness, dysgeusia,fatigue, fever, headache, insomnia,intracranial hemorrhage, rigors, seizures,somnolenceCV: Arrhythmia, atrial fibrillation, bradycardia,cardiac arrest, deep venous thrombosis,hypertension, hypotension, MI,peripheral edema, phlebitis, tachycardia,shock, vasodilationEENT: Epistaxis, mucosal inflammationENDO: Hypoglycemia, hyperglycemiaGI: Abdominal pain, anorexia, constipation,diarrhea, dyspepsia, elevated liver enzymelevels, hepatic dysfunction, hiccups, hyperbilirubinemia,jaundice, nausea, vomitingGU: Acute renal failure, anuria, elevatedserum creatinine and blood urea levels,oliguria, renal tubular necrosisHEME: Anemia, coagulopathy, eosinophilia,hemolytic anemia, leukopenia, lymphopenia,neutropenia, pancytopenia, thrombocytopeniaMS: Arthralgia, back painRESP: Apnea, cough, cyanosis, dyspnea,hypoxia, pneumonia, pulmonary embolismSKIN: Erythema, erythema multiforme,flushing, necrosis, pruritus, rash, urticariaOther: Acidosis, anaphylaxis, angioedema,bacteremia, hyperkalemia, hypernatremia,hypocalcemia, hypokalemia, hypomagnesemia,hyponatremia, hypophosphatemia,injection site reactions including phlebitisand thrombophlebitis, sepsisNursing Considerations• Use cautiously in patients with hepatic orrenal insufficiency.• Reconstitute micafungin by adding 5 mlnormal saline solution to each 50-mg vialbeing used (to yield 10 mg micafungin/ml) or 5 ml normal saline solution to each100-mg vial (to yield 20 mg micafungin/ml). Swirl vial gently to minimize excessivefoaming. Add reconstituted solution to100 ml normal saline solution, and givesolution over 1 hour. Protect diluted solutionfrom light, although you need notcover the infusion drip chamber or tubing.• Always flush an existing intravenous linewith normal saline solution before administeringmicafungin through that line.• Monitor infusion rate carefully becauseinfusions that took less than 1 hour toinfuse have been associated with more frequenthypersensitivity reactions.WARNING Monitor patient closely forhypersensitivity reactions including anaphylaxisand angioedema. Stop infusionimmediately if present, notify prescriber,and provide supportive care, as prescribed.• Monitor patient’s liver and renal functionclosely throughout therapy because liverand renal abnormalities may occur inpatients receiving micafungin.• Monitor hematologic status closelybecause hematologic abnormalities mayoccur. If they do, monitor patient closely.If patient’s condition worsens, expectmicafungin to be discontinued.PATIENT TEACHING• Instruct patient to report any infusion sitediscomfort immediately.• Tell patient to report any unusual or persistentsigns and symptoms to prescriber.midazolamhydrochlorideVersedClass, Category, and ScheduleChemical class: BenzodiazepineTherapeutic class: Sedative-hypnoticPregnancy category: DControlled substance schedule: IVIndications and Dosages To induce preoperative sedation oramnesia, to control preoperative anxietyORAL SOLUTIONChildren ages 6 months to 16 years.0.25 to 0.5 mg/kg as a single dose 30 to45 min before surgery. Usual: 0.5 mg/kg.Maximum: 20 mg.I.V. INJECTIONAdults age 60 and over. 1.5 mg over 2 minimmediately before procedure. After 2-minwaiting period, dosage adjusted to desiredlevel in 25% increments, as ordered.Maximum: 1 mg in 2 min.Adults under age 60 and adolescents. Upto 2.5 mg over 2 min immediately beforeprocedure. After 2-min waiting period,dosage adjusted to desired level in 25%

increments, as ordered. Maximum: 5 mg.Children ages 6 to 12. Initial: 0.025 to0.05 mg/kg, up to 0.4 mg/kg, if needed.Maximum: 10 mg.Children ages 6 months to 5 years. Initial:0.05 to 0.1 mg/kg, up to 0.6 mg/kg, if needed.Maximum: 6 mg.I.M. INJECTIONAdults age 60 and over. 0.02 to 0.05 mg/kgas a single dose 30 to 60 min before surgery.Adults under age 60 and adolescents.0.07 to 0.08 mg/kg as a single dose 30 to60 min before surgery.Children ages 6 months to 12 years. 0.1 to0.15 mg/kg, up to 0.5 mg/kg for more anxiouspatients. Maximum: 10 mg. To relieve agitation and anxiety inmechanically ventilated patientsI.V. INFUSIONAdults. Initial: 0.01 to 0.05 mg/kg infusedover several min, repeated at 10- to 15-minintervals until adequate sedation occurs.Maintenance: 0.02 to 0.1 mg/kg/hr initially,adjusted to desired level in 25% to 50%increments, as ordered. After achievingdesired level of sedation, infusion ratedecreased by 10% to 25% every few hr, asordered, until minimum effective infusionrate is determined.Children. Initial: 50 to 200 mcg/kg over2 to 3 min followed by 1 to 2 mcg/kg/minby continuous infusion. Maintenance: 0.4 to6 mcg/kg/min.Infants over age 32 weeks. 1 mcg/kg/minby continuous infusion.Infants under age 32 weeks. 0.5 mcg/kg/min by continuous infusion.Route Onset Peak DurationI.V.* 1.5–5 min Rapid 2–6 hrI.M.* 5–15 min 15–60 min 2–6 hrI.M.† 30–60 Unknown UnknownminMechanism of ActionMay exert sedating effect by increasingactivity of gamma-aminobutyric acid, amajor inhibitory neurotransmitter in thebrain. As a result, midazolam produces acalming effect, relaxes skeletal muscles,and—at high doses—induces sleep.* For sedation.† For amnesia.midazolam hydrochloride 675ContraindicationsAcute angle-closure glaucoma; alcoholintoxication; coma; hypersensitivity tomidazolam, other benzodiazepines, or theircomponents; shockInteractionsDRUGSantihypertensives: Increased risk of hypotensioncimetidine, diltiazem, erythromycin, fluconazole,indinavir, itraconazole, ketoconazole,ranitidine, ritonavir, saquinavir, verapamil:Intense and prolonged sedation caused byreduced midazolam metabolismCNS depressants: Possibly increased CNSand respiratory depression and hypotensionrifampin: Decreased blood midazolam levelFOODSgrapefruit, grapefruit juice: Possibly increasedblood midazolam level and risk of toxicityACTIVITIESalcohol use: Possibly intense, prolongedsedative effect and increased respiratorydepression and hypotensionAdverse ReactionsCNS: Agitation, delirium, or dreaming duringemergence from anesthesia; anxiety;ataxia; chills; combativeness; confusion; dizziness;drowsiness; euphoria; excessive sedation;headache; insomnia; lethargy; nervousness;nightmares; paresthesia; prolongedemergence from anesthesia; restlessness;retrograde amnesia; sleep disturbance;slurred speech; weakness; yawningCV: Cardiac arrest, hypotension, nodalrhythm, PVCs, tachycardia, vasovagalepisodesEENT: Blurred vision, diplopia, or othervision changes; increased salivation;laryngospasm; miosis; nystagmus;toothacheGI: Hiccups, nausea, retching, vomitingRESP: Airway obstruction, bradypnea,bronchospasm, coughing, decreased tidalvolume, dyspnea, hyperventilation, respiratoryarrest, shallow breathing, tachypnea,wheezingSKIN: Pruritus, rash, urticariaOther: Injection site burning, edema,induration, pain, redness, and tendernessNursing Considerations• Before giving midazolam, determinewhether patient consumes alcohol or takesM

676midodrine hydrochlorideantihypertensives, antibiotics, or proteaseinhibitors because these substances canproduce an intense and prolonged sedativeeffect when taken with midazolam.WARNING I.V. midazolam is given only inhospital or ambulatory care settings thatallow continuous monitoring of respiratoryand cardiac function. Keep resuscitativedrugs and equipment at hand.• As needed, combine midazolam injectionwith D 5 W, normal saline solution, or lactatedRinger’s solution. With D 5 W andnormal saline, solution is stable 24 hours.With lactated Ringer’s, solution is stable4 hours.• As needed, mix injection in same syringewith atropine sulfate, meperidinehydrochloride, morphine sulfate, orscopolamine hydrobromide. The resultingsolution is stable for 30 minutes.• Assess level of consciousness frequentlybecause the range between sedation andunconsciousness or disorientation is narrowwith midazolam.• Be aware that recovery time is usually2 hours but may be up to 6 hours.PATIENT TEACHING• Inform patient that he may not rememberprocedure because midazolam producesamnesia.• Advise patient to avoid hazardous activitiesuntil drug’s adverse CNS effects, suchas dizziness and drowsiness, have worn off.• Instruct patient to avoid alcohol and otherCNS depressants for 24 hours after receivingdrug, as directed by prescriber.midodrinehydrochlorideProAmatineClass and CategoryChemical class: Desglymidodrine prodrugTherapeutic class: Antihypotensive, vasopressorPregnancy category: CIndications and Dosages To treat symptomatic orthostatichypotensionTABLETSAdults. 10 mg t.i.d. in 3- to 4-hr intervals.DOSAGE ADJUSTMENT Initial dose possiblyreduced to 2.5 mg for patients with renalimpairment.Route Onset Peak DurationP.O. Unknown 30 min 2–3 hrMechanism of ActionIs broken down into the active metabolitedesglymidodrine. Desglymidodrine directlystimulates alpha-adrenergic receptors inarteries and veins. This action increasestotal peripheral vascular resistance, whichin turn increases systolic and diastolicblood pressure.ContraindicationsAcute renal disease, hypersensitivity tomidodrine or its components, initial supinesystolic pressure above 180 mm Hg, persistentand excessive supine hypertension,pheo-chromocytoma, severe heart disease,thyrotoxicosis, urine retentionInteractionsDRUGSbeta blockers, digoxin: Enhanced or precipitatedbradycardia, AV block, arrhythmiascimetidine, flecainide, metformin, procainamide,quinidine, ranitidine, triamterene:Possibly decreased renal clearance of thesedrugsdihydroergotamine, ephedrine, phenylephrine,phenylpropanolamine, pseudoephedrine:Increased vasopressor effectsdoxazosin, prazosin, terazosin: Antagonizedmidodrine effectsfludrocortisone acetate: Increased risk ofsupine hypertensionAdverse ReactionsCNS: Anxiety, asthenia, chills, confusion,delusions, dizziness, feeling of pressure orfullness in head, headache, hyperesthesia,insomnia, nervousness, paresthesia, somnolenceCV: Hypertension (sitting and supine),vasodilationEENT: Canker sore, dry mouth, visionchangesGI: Flatulence, indigestion, nauseaGU: Dysuria, urinary frequency andurgency, urine retentionMS: Back pain, leg crampsSKIN: Dry skin, erythema multiforme,

facial flushing, piloerection, rash, scalp pruritusNursing Considerations• Monitor hepatic and renal function, asordered, before and during midodrinetherapy.• Give drug at 3- to 4-hour intervals, ifordered and needed to control symptoms.Don’t give after evening meal, less than4 hours before bed, or more often thanevery 3 hours.WARNING Monitor for severe, persistent systolicsupine hypertension, which maydevelop with single doses up to 20 mg.• Avoid placing patient flat in bed for anylength of time. Elevate head of bed whenpatient is supine.• Monitor supine and sitting blood pressureoften during midodrine therapy.PATIENT TEACHING• Instruct patient to take midodrine every3 to 4 hours during daytime but not totake final dose after evening meal or within4 hours of going to bed.• Advise patient to elevate head of bed whenhe lies supine. Caution him not to remainflat for any length of time.• Direct patient to notify prescriber immediatelyabout headache, increased dizziness,urine retention, or vision changes.• Encourage patient to keep follow-upappointments to monitor blood pressureand hepatic and renal function.miglitolGlysetClass and CategoryChemical class: Desoxynojirimycin derivativeTherapeutic class: Alpha-glucosidaseinhibitor, antidiabetic drugPregnancy category: BIndications and Dosages To manage type 2 diabetes mellitusTABLETSAdults. Initial: 25 mg t.i.d. with first bite ofeach meal. Or, 25 mg daily, increased graduallyto 25 mg t.i.d. Maximum: 100 mg t.i.d.DOSAGE ADJUSTMENT After 4 to 8 wk,dosage increased, if ordered, to 50 mg t.i.d.miglitol 677for about 3 mo; then dosage adjusted basedon glycosylated hemoglobin (HbA 1C ) level.Route Onset Peak DurationP.O. Rapid 2–3 hr UnknownMechanism of ActionInhibits intestinal glucoside hydrolaseenzymes, which normally hydrolyze oligosaccharidesand disaccharides to glucoseand other monosaccharides. This actiondelays carbohydrate digestion and absorptionand reduces postprandial blood glucoselevel.ContraindicationsAcute or chronic bowel disorder, diabeticketoacidosis, hypersensitivity to miglitol orits componentsInteractionsDRUGSdigestive enzyme preparations, intestinaladsorbents (activated charcoal): Decreasedmiglitol effectsdigoxin: Decreased blood digoxin levelpropranolol, ranitidine: Decreased bioavailabilityof these drugsAdverse ReactionsGI: Abdominal pain, diarrhea, flatulence,hepatotoxicityHEME: Low serum iron levelSKIN: Rash (transient)Nursing Considerations•Use miglitol cautiously in patient withserum creatinine level above 2 mg/dl.•Be aware that some patients with type 2diabetes also may receive a sulfonylurea asan adjunct to miglitol therapy.•Give miglitol with first bite of each meal.Drug must have arrived at site of enzymaticaction when carbohydrates reachsmall intestine.•Review patient’s HbA 1C level, as appropriate,to monitor long-term glucose control.•Monitor patient for evidence of overdose,such as transient increases in abdominaldiscomfort, diarrhea, and flatulence (butnot hypoglycemia).PATIENT TEACHING•Explain that miglitol is an adjunct to diet,which is the primary treatment for type 2diabetes mellitus.M

678milnacipran hydrochloride•Instruct patient to take drug with first biteof each meal.•Describe signs and symptoms of hypoglycemiaand pathophysiology of diabetesto patient and family members.•If miglitol is the only drug patient takes tocontrol blood glucose level, explain that itwon’t cause hypoglycemia.•If patient takes a sulfonylurea or insulin withmiglitol, recommend that he keep a sourceof glucose readily available to reverse hypoglycemia.•Explain importance of monitoring bloodand urine glucose levels.•Explain that adverse GI reactions usuallydecrease in frequency and intensity overtime.•Teach obese patient about weight loss,calorie restriction, diet, and regular exercise,as indicated.milnacipranhydrochlorideSavellaClass and CategoryChemical class: Selective norepinephrineand serotonin reuptake inhibitorTherapeutic class: Anti-fibromyalgiaPregnancy category: CIndications and Dosages To manage fibromyalgiaTABLETSAdults and adolescents age 17 and over.Initial: 12.5 mg on day one; 12.5 mg b.i.d.on days 2 and 3; 25 mg b.i.d. on days4 through 7; and then 50 mg b.i.d.,increased, if needed to 100 mg b.i.d.Maximum: 100 mg b.i.d.DOSAGE ADJUSTMENT For patients withsevere renal impairment (creatinine clearanceof 5 to 29 ml/min/1.73 m 2 ), maintenancedosage reduced by half.Route Onset Peak DurationP.O. Unknown 2–4 hr UnknownMechanism of ActionInhibits reuptake of norepinephrine andserotonin by CNS neurons without affectinguptake of dopamine or other neurotransmitters,thereby increasing amount ofnorepinephrine and serotonin available innerve synapses. Elevated norepinephrineand serotonin levels may improve symptomsof fibromyalgia, including by centralanalgesic effect.ContraindicationsHypersensitivity to milnacipran or its components,uncontrolled narrow-angle glaucoma,use within 14 days of MAO inhibitorInteractionsDRUGSaspirin, NSAIDs, warfarin: Increased risk ofbleedingclomipramine: Increased risk of euphoriaand postural hypotensionclonidine: Possibly inhibited antihypertensiveeffectCNS-active drugs: Possibly increased CNSeffectsdigoxin (I.V.): Possibly increased risk ofpostural hypotension and tachycardiaepinephrine, norepinephrine: Increased riskof arrhythmias and paroxysmal hypertensionlithium: Increased risk of serotonin syndromeMAO inhibitors: Possibly hyperpyreticepisodes, hypertensive crisis, serotonin syndrome,and severe seizuresserotonergic drugs such as SSRIs, triptans,and tramadol: Incrased risk of hypertensionand coronary artery vasoconstrictionACTIVITIESalcohol use: Increased risk of liver impairmentAdverse ReactionsCNS: Anxiety, chills, delirium, depression,dizziness, fatigue, fever, hallucinations,headache, hypoesthesia, insomnia, irritability,loss of consciousness, migraine, neurolepticmalignant sydrome, parkinsonism,paresthesia, seizures, serotonin syndrome,suicidal ideation, tremorCV: Chest pain, hypercholesterolemia,hypertension, hypertensive crisis, increasedheart rate, palpitations, peripheral edema,somnolence, supraventricular tachycardia,tachycardiaEENT: Accommodation abnormality,blurred vision, dry mouth, mydriasis

ENDO: Hot flashes, hyperprolactinemiaGI: Abdominal distention or pain, anorexia,constipation, diarrhea, dyspepsia, elevatedliver enzymes, gastroesophageal reflux, flatulence,hepatitis, jaundice, liver dysfunction,nausea, vomitingGU: Acute renal failure, cystitis, decreasedlibido, dysuria, ejaculation disorder, erectiledysfunction, prostatitis, scrotal or testicularpain, testicular swelling, urinary hesitation,urine retention, urethral pain, UTIHEME: Leukeopenia, neutropenia, thrombocytopeniaMS: RhabdomyolysisRESP: Dyspnea, upper respiratory infectionSKIN: Erythema multiforme, flushing,hyperhidrosis, night sweats, pruritus, rash,Stevens-Johnson syndromeOther: Hyponatremia, weight gain or lossNursing Considerations• Because milnacipran may aggravate liverdisease, it shouldn’t be given to patientswith alcohol addiction or chronic liver disease.• Use cautiously in patients with mild tomoderate renal impairment and patientswith significant hypertension or cardiacdisease. Also use cautiously in patientswith a history of dysuria, especially menwith prostatic hypertrophy, prostatitis, andother lower urinary tract obstructive disorders.• At least 14 days should elapse betweenstopping an MAO inhibitor and startingmilnacipran. At least 5 days should elapsebetween stopping milnacipran and startingan MAO inhibitor.• Measure patient’s blood pressure andheart rate before starting and periodicallyduring milnacipran therapy because drugcan raise blood pressure and heart rate. Ifhypertension or tachycardia occurs andpersists, notify prescriber and expect toreduce dosage or discontinue drug.• Watch closely for suicidal tendencies, especiallywhen therapy starts and dosagechanges.WARNING Monitor patient closely for serotoninsyndrome, a rare but serious adverseeffect of selective serotonin reuptakeinhibitors such as milnacipran. Signs andsymptoms include agitation, confusion,diaphoresis, diarrhea, fever, hyperactivereflexes, poor coordination, restlessness,milrinone lactate 679shaking, talking or acting with uncontrolledexcitement, tremor, and twitching.If symptoms occur, notify prescriberimmediately, expect to discontinue drug,and provide supportive care.• Monitor patient’s liver function. If jaundiceor signs and symptoms of liver dysfunctionoccur, notify prescriber andexpect drug to be discontinued.• Watch for hypersensitivity reactions, especiallyin patients with aspirin sensitivity,because drug contains the yellow dye tartrazine.• Check patient’s serum sodium level, asordered, because drug may cause hyponatremia,especially in elderly patients,patients taking diuretics, and patients whoare volume depleted.• Expect to taper drug when no longerneeded, as ordered, to minimize adversereactions.PATIENT TEACHING• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes.• Caution patient against stopping drugabruptly because serious adverse effectsmay result.• Instruct patient to alert all prescribers thathe takes milnacipran.• Tell patient to have his blood pressuremonitored regularly throughout milnaciprantherapy.• Advise patient to avoid activities, such asdriving, that require alertness until theCNS effects of milnacipran are known.• Caution patient to avoid aspirin andNSAIDs, if possible, while taking milnacipran.milrinone lactatePrimacorClass and CategoryChemical class: Bipyridine derivativeTherapeutic class: Inotropic, vasodilatorPregnancy category: CIndications and Dosages To provide short-term treatment ofacute heart failureI.V. INFUSIONAdults. Loading: 50 mcg/kg over 10 min (atM

680Nursing Considerations• Make sure ECG equipment is available forcontinuous monitoring during milrinonetherapy.• Discard drug if it’s discolored or containsparticles.• For loading dose, infuse undiluted drugdirectly into I.V. line with compatibleinfusing solution. For continuous infumilrinonelactateMechanism of ActionAn inotropic drug, milrinone increasesthe force of myocardial contraction—andcardiac output—by blocking the enzymephosphodiesterase. Normally, thisenzyme is activated by hormones bindingto cell membrane receptors. As shownbelow left, phosphodiesterase normallydegrades intracellular cAMP, whichrestricts calcium movement into myocardialcells. By inhibiting phosphodiesterase,as shown below right, milrinoneslows the rate of cAMP degradation,increasing the intracellular cAMP leveland the amount of calcium that entersmyocardial cells. In blood vessels,increased cAMP causes smooth-musclerelaxation, which improves cardiac outputby reducing preload and afterload.Cell exteriorHormonereceptorBlockedcalciummovementMyocardial cellmembraneCell exteriorCell interiorPhosphodiesteraseDegradedcAMPPhosphodiesteraseinhibited byMilrinonemilrinonecAMPCell interiorCalciummovementinto cellcAMPleast 0.375 mcg/kg/min). Usual: 0.375 to0.75 mcg/kg/min. Maximum: 1.13 mg/kgdaily.DOSAGE ADJUSTMENT Dosage adjustedaccording to cardiac output, pulmonaryartery wedge pressure (PAWP), and clinicalresponse. If creatinine clearance is 30 to39 ml/min/1.73 m 2 , infusion rate reducedto 0.33 mcg/kg/min; if 20 to 29 ml/min/1.73 m 2 , to 0.28 mcg/kg/min; if 10 to19 ml/min/1.73 m 2 , to 0.23 mcg/kg/min;and if less than 9 ml/min/1.73 m 2 ,to0.2 mcg/kg/min.Route Onset Peak DurationI.V. 5–15 min Unknown 3–6 hrIncompatibilitiesDon’t administer milrinone through sameI.V. line as furosemide because precipitatewill form. Don’t add other drugs to premixedmilrinone flexible containers.ContraindicationsHypersensitivity to milrinone or its componentsInteractionsDRUGSantihypertensives: Possibly hypotensionAdverse ReactionsCNS: Headache, tremorCV: Angina, hypotension, supraventriculararrhythmias, ventricular ectopic activity,ventricular fibrillation, ventricular tachycardia,torsades de pointesGI: Liver function test abnormalitiesHEME: ThrombocytopeniaRESP: BronchospasmSKIN: RashOther: Anaphylactic shock, hypokalemia,infusion site reactions (pain, swelling, redness)

sion, dilute drug with half-normal (0.45)saline solution, normal saline solution, orD 5 W. Dilution isn’t needed when usingpremixed milrinone flexible containers.• Check platelet count before and periodicallyduring infusion, as ordered. Expect todiscontinue drug if platelet count fallsbelow 150,000/mm 3 .• Give loading dose using a controlled-rateinfusion device. For continuous infusion,use a calibrated electronic infusion device.• Monitor cardiac output, pulmonary arterywedge pressure, blood pressure, heart rate,weight, and fluid status during therapy todetermine drug effectiveness.• Monitor renal and liver function testresults and serum electrolyte levels. Notifyprescriber of abnormalities.• If severe hypotension develops, notify prescriberat once and expect to stop drug.• Expect patient to receive digoxin beforestarting milrinone, which can increaseventricular response rate.PATIENT TEACHING• Reassure patient that you will be presentand that he will be monitored constantlyduring therapy.minocyclineMinocinminocyclinehydrochlorideAlti-Minocycline (CAN), Apo-Minocycline (CAN), Dynacin, Gen-Minocycline (CAN), Minocin, Novo-Minocycline (CAN), Solodyn, VectrinClass and CategoryChemical class: TetracyclineTherapeutic class: Antibiotic, antiprotozoalPregnancy category: Dminocycline 681Indications and Dosages To treat bartonellosis, brucellosis, chancroid,granuloma inguinale, inclusionconjunctivitis, lymphogranuloma venereum,nongonococcal urethritis,plague, psittacosis, Q fever, relapsingfever, respiratory tract infections(including pneumonia), rickettsial pox,Rocky Mountain spotted fever, tularemia,typhus, and UTI caused by gramnegativeorganisms (including Bartonellabacilliformis, Brucella species,Haemophilus ducreyi, Haemophilusinfluenzae, Vibrio cholerae, andYersinia pestis), susceptible gram-positiveorganisms (including certain strainsof Streptococcus pneumoniae), andother organisms (including Actinomycesspecies, Bacillus anthracis, Borreliarecurrentis, Chlamydia species, Mycoplasmapneumoniae, and Rickettsiae);as adjunct to treat intestinal amebiasisand as alternative to treat listeriosiscaused by Listeria monocytogenes,syphilis caused by Treponema pallidum,and yaws caused by Treponema pertenuefor nonpregnant patients allergicto penicillinCAPSULES, ORAL SUSPENSIONAdults and adolescents. Initial: 200 mg.Maintenance: 100 mg every 12 hr. Or 100 to200 mg initially followed by 50 mg every6hr.Children over age 8. Initial: 4 mg/kg.Maintenance: 2 mg/kg every 12 hr.I.V. INJECTIONAdults and adolescents. Initial: 200 mg.Maintenance: 100 mg every 12 hr.Maximum: 400 mg daily.Children over age 8. Initial: 4 mg/kg.Maintenance: 2 mg/kg every 12 hr.DOSAGE ADJUSTMENT If patient has renalimpairment, don’t exceed 200 mg daily. As adjunct to treat inflammatory acnevulgaris that’s unresponsive to oral tetracyclineor erythromycinCAPSULES, ORAL SUSPENSIONAdults and adolescents. 50 mg once dailyto t.i.d. To treat inflammatory lesions of nonnodularmoderate to severe acne vulgarisE.R. TABLETSAdults and adolescents. 1 mg/kg once dailyfor 12 weeks.DOSAGE ADJUSTMENT For patient with renalimpairment, dosage reduced or time intervalbetween doses extended. To treat uncomplicated gonorrhea fromNeisseria gonorrhoeae in nonpregnantpatients allergic to penicillinCAPSULES, ORAL SUSPENSIONAdults and adolescents. Initial: 200 mg.M

682minocyclineMaintenance: 100 mg every 12 hr for atleast 4 days. To treat uncomplicated gonococcal urethritisin menCAPSULES, ORAL SUSPENSIONAdults and adolescents. 100 mg b.i.d. for5 days. To treat asymptomatic meningococcalcarriers with Neisseria meningitidis innasopharynxCAPSULES, ORAL SUSPENSIONAdults and adolescents. 100 mg every 12 hrfor 5 days.Children over age 8. Initial: 4 mg/kg.Maintenance: 2 mg/kg every 12 hr for 5 days. To treat infections caused byMycobacterium marinumCAPSULES, ORAL SUSPENSIONAdults. 100 mg every 12 hr for 6 to 8 wk.Route Onset Peak DurationP.O. Unknown 2–4 hr 6–12 hrI.V. Unknown Unknown 6–12 hrMechanism of ActionInhibits bacterial protein synthesis by competitivelybinding to the 30S ribosomal subunitof the mRNA-ribosome complex ofcertain organisms.IncompatibilitiesDon’t mix minocycline in same syringewith solution that contains calcium becauseprecipitate will form.ContraindicationsHypersensitivity to minocycline, othertetracyclines, or their componentsInteractionsDRUGSaluminum-, calcium-, or magnesiumcontainingantacids; calcium supplements;choline and magnesium salicylates; ironcontainingpreparations; magnesiumcontaininglaxatives; sodium bicarbonate:Possibly formation of nonabsorbable complex,impaired minocycline absorptioncholestyramine, colestipol: Possibly impairedcholestyramine or colestipol absorptioncimetidine: Possibly decreased GI absorptionand effectiveness of minocyclinedigoxin: Possibly increased blood digoxinlevel and risk of digitalis toxicityinsulin: Possibly decreased need for insuliniron salts: Possibly decreased GI absorptionand antimicrobial effect of minocyclinelithium: Possibly increased or decreasedblood lithium levelmethoxyflurane: Increased risk of nephrotoxicityoral anticoagulants: Possibly potentiatedanticoagulant effectsoral contraceptives containing estrogen:Decreased contraceptive effectiveness,increased risk of breakthrough bleedingpenicillin: Interference with bactericidalaction of penicillinvitamin A: Possibly benign intracranialhypertensionAdverse ReactionsCNS: Dizziness, fever, headache, lightheadedness,unsteadiness, vertigoCV: PericarditisEENT: Blurred vision, darkened or discoloredtongue, glossitis, papilledema, toothdiscoloration, vision changesGI: Abdominal cramps or pain, anorexia,diarrhea, dysphagia, enterocolitis, esophagealirritation and ulceration, hepatitis,hepatotoxicity, indigestion, nausea, pancreatitis,pseudomembranous colitis, vomitingGU: Genital candidiasis, nephrotoxicityHEME: Eosinophilia, hemolytic anemia,neutropenia, thrombocytopenia,thrombocytopenic purpuraMS: Arthralgia, myopathy (transient)RESP: Pulmonary infiltrates (witheosinophilia)SKIN: Erythema multiforme, exfoliativedermatitis, brown pigmentation of skin andmucous membranes, erythematous andmaculopapular rash, jaundice, onycholysis,photosensitivity, pruritus, purpura (anaphylactoid),Stevens-Johnson syndrome,urticariaOther: Anaphylaxis, angioedema, serumsicknesslike reaction, systemic lupuserythematosus exacerbationNursing Considerations• Use minocycline cautiously in patientswith renal or hepatic dysfunction and inthose taking other hepatotoxic drugsbecause drug may cause nephrotoxicity orhepatotoxicity.WARNING Notify prescriber if patient isbreast-feeding because drug appears inbreast milk and may have toxic effects.

• Monitor blood, renal, and hepatic testsbefore and during long-term therapy.• Shake oral suspension well before use.• To prepare drug for I.V. use, reconstituteeach 100-mg vial with 5 to 10 ml sterilewater for injection. Further dilute in500 to 1,000 ml normal saline solution,D 5 W, dextrose 5% in normal saline solution,or Ringer’s or lactated Ringer’s solution.Administer final dilution immediately,but avoid rapid administration.• Store reconstituted drug at room temperatureand use within 24 hours.• Assess patient for signs of superinfection;if they appear, notify prescriber, discontinueminocycline, and start appropriatetherapy, as ordered.• Monitor patient for development of foulsmelling diarrhea, which suggests Clostridiumdifficile. If present, notify prescriber,obtain stool culture, and expect towithhold minocycline and provide supportivecare, as indicated and ordered.• Monitor PT in patient who also takes ananticoagulant during minocycline therapy.PATIENT TEACHING• Instruct patient to shake oral suspensionwell and to use calibrated measuringdevice.• Advise patient to take minocycline with afull glass of water, with food or milk, andin an upright position to minimizeesophageal and GI irritation.• Direct patient to take a missed dose assoon as he remembers unless it’s nearlytime for the next dose. Caution againstdouble-dosing.• Instruct patient not to take minocyclinewithin 2 hours of an antacid or 3 hours ofan iron preparation.• Urge patient to complete full course oftreatment even if he feels better before finishing.• Instruct patient to notify prescriber if noimprovement occurs in a few days.• Advise patient to avoid prolonged exposureto sun or sunlamps during therapy.• Counsel female patient to avoid becomingpregnant because minocycline should beavoided, if possible, during tooth development(last half of gestation up to age 8).Drug may permanently turn teeth yellow,gray, or brown and cause enamel hypoplasia.It also may slow skeletal growth andcause congenital anomalies, includinglimb reduction.• Encourage patient who uses an oral contraceptiveto use additional contraceptivemethod during minocycline therapy.• Instruct patient to notify prescriber immediatelyabout blurred vision, dizziness,headache, known or suspected pregnancy,and unsteadiness.• Explain that diarrhea may occur up to2 months after completing therapy; urgepatient to notify prescriber if it occurs.minoxidil (oral)minoxidil 683Lonitenminoxidil (topical)Apo-Gain (CAN), Gen-Minoxidil (CAN),Minox (CAN), Minoxigaine (CAN),Rogaine (CAN), Rogaine ES for Men,Rogaine for Men, Rogaine for WomenClass and CategoryChemical class: PiperidinopyrimidinederivativeTherapeutic class: Antihypertensive (oral),hair-growth stimulant (topical)Pregnancy category: CIndications and Dosages To manage severe symptomatic hypertensionor hypertension with targetorgan damage that’s unresponsive toother treatmentTABLETSAdults and adolescents. Initial: 5 mg as asingle dose or divided doses b.i.d.Increased, as directed, after at least 3 days.Maintenance: 10 to 40 mg daily. Maximum:100 mg daily.Children. Initial: 0.2 mg/kg daily.Increased, as directed, after at least 3 days.Maintenance: 0.25 to 1 mg/kg daily as a singledose or in divided doses b.i.d.Maximum: 50-mg starting dose, 50 mgdaily.DOSAGE ADJUSTMENT Dosage possiblyreduced for elderly patients and those whohave renal failure or are having dialysis. To treat alopeciaTOPICAL 2%Adults up to age 65. 1 ml applied b.i.d. toM

684minoxidilarea of desired hair growth.TOPICAL 5%Adult men up to age 65. 1 ml applied b.i.d.to area of desired hair growth.Route Onset Peak DurationP.O. 30 min 2–3 hr 24–48 hrTopical 2% 4 mo 1 yr UnknownTopical 5% 2 mo 1 yr UnknownMechanism of ActionReduces blood pressure by inhibiting intracellularphosphodiesterase, an enzyme thatfacilitates hydrolysis of cAMP and cGMP.This action decreases the intracellularcAMP level, relaxes arterial smooth muscles,and lowers blood pressure. Oralminoxidil produces greater dilation inarteries than in veins. It also reducesperipheral resistance and increases heartrate, cardiac output, and stroke volume.Topical minoxidil may cause hairregrowth by increasing cutaneous bloodflow and stimulating resting hair follicles.ContraindicationsAcute MI; dissecting aortic aneurysm;hypersensitivity to minoxidil or its components,including propylene glycol; pheochromocytoma;skin irritation or abrasions(topical)InteractionsDRUGSguanethidine: Possibly severe hypotension,increased risk of orthostatic hypotension(oral)nitrates, other hypotension-producing drugs,potent parenteral antihypertensives: Possiblysevere hypotensionNSAIDs, sympathomimetics: Decreased antihypertensiveeffectstopical petrolatum, topical steroids: Increasedabsorption of topical minoxidil if used onsame areatopical retinoids: Increased absorption oftopical minoxidil and, possibly, formationof granulation tissueAdverse ReactionsCNS: Fatigue, paresthesia (oral); light-headedness,neuritis (topical); headache (both)CV: ECG changes, heart failure, pericardialtamponade, pericarditis, rebound hypertension(oral); cardiac tamponade, hypotension,palpitations, reflex hypertension (topical);angina, edema, fast or irregular heartbeat,pericardial effusion (both)EENT: Vision changes (topical)ENDO: Breast tenderness (oral)GI: Abdominal distention, ascites, nausea,vomiting (oral)GU: Elevated BUN and serum creatininelevels (oral); sexual dysfunction (topical)HEME: Leukopenia; thrombocytopenia;transient decrease in hematocrit, hemoglobin,and erythrocyte counts (oral)RESP: Dyspnea, pulmonary hypertension(oral)SKIN: Flushing, hyperpigmentation,Stevens-Johnson syndrome (oral); allergiccontact dermatitis, alopecia, dry or flakyskin, eczema, erythema, folliculitis, scalpburning (topical); hypertrichosis, rash(both)Other: Facial edema (topical); sodium andwater retention, weight gain (both)Nursing ConsiderationsWARNING Be aware that patient whoreceives guanethidine should be hospitalizedbefore starting oral minoxidil therapyso that his blood pressure can be monitored.• Be aware that drug isn’t usually prescribedfor mild hypertension.• For rapid management of hypertension,expect to adjust dosage up to every6 hours and to monitor patient as prescribed.Also expect to give a beta blockerand diuretic.• Monitor progress by measuring bloodpressure often and weight daily. Evaluatefor signs of fluid and sodium retentionand for other systemic adverse reactions.• Watch for signs of pericardial effusion. Beprepared to stop oral minoxidil, ifordered.• Expect to discontinue oral minoxidil graduallybecause abrupt discontinuation maylead to rebound hypertension.• Apply topical drug only on healthy scalp.Avoid sunburned or abraded scalp.• Use gloves when applying solution.• Avoid inhaling mist from spray applicator.• Expect minoxidil to be least effective inmen with mainly frontal hair loss.• Expect topical form to have little effect onblood pressure in patients who don’t havehypertension.

PATIENT TEACHING• Inform patient that oral minoxidil controlsbut doesn’t cure hypertension.• Advise him to take tablets at the same timeevery day.• Teach patient to take his radial pulse, andadvise him to take it daily. Instruct him tonotify prescriber if it exceeds normal rateby 20 beats/minute or more.• Stress the importance of daily blood pressureand weight measurements.• Instruct patient to notify prescriber immediatelyabout bloating, breathing problems,a fast or irregular heartbeat, flushedor red skin, swelling of feet or lower legs,or weight gain of more than 5 lb (2.3 kg)in 1 day.• Advise patient to have regular checkupswith prescriber to monitor progress.• Urge patient to consult prescriber beforetaking other prescription or OTC drugs.• Reassure patient that body hair thickeningand darkening reverses after oral minoxidilis discontinued.• For patient using topical minoxidil, teachproper application technique and providemanufacturer’s written instructions.Advise him to wear gloves when applyingdrug and to make sure hair and scalp aredry first.• Instruct patient to start applying drug atcenter of balding area, to let dry for 2 to4 hours, and not to use hairdryer to help itdry faster.• Warn patient to avoid applying drug toabraded, irritated, or sunburned areas ofscalp; to avoid inhaling mist when using aspray applicator; and to avoid getting drugin his eyes, nose, or mouth. If accidentalcontact does occur, advise him to flush thearea with large amounts of cool tap water.• Instruct patient not to shampoo his hairfor at least 4 hours after application and toavoid using other skin products on treatedskin. Direct him to avoid using minoxidilfor 24 hours before and after chemical hairproducts, such as dyes and relaxers.• Caution patient not to use more drug orapply it more often than prescribed andnot to apply it to other body areas. Explainthe risk of adverse systemic reactions withexcessive topical use.• Tell patient to keep topical minoxidil awayfrom heat or flame because it’s flammable.• Inform patient that minoxidil may stainclothing, hats, or bed linens before it’s dry.• Instruct patient to notify prescriber ifburning, itching, or redness develops afterapplication. For severe reactions, advisepatient to wash drug off and consult prescriberbefore applying it again.• Urge patient to consult prescriber if hairloss continues after 2 weeks or if growthfails to increase in 4 months.• Inform patient that new hair growth maybe lost 3 to 4 months after stopping topicalminoxidil and that progressive hair losswill resume.mirtazapineRemeron, Remeron SolTabClass and CategoryChemical class: PiperazinoazepineTherapeutic class: AntidepressantPregnancy category: Cmirtazapine 685Indications and Dosages To treat major depressionDISINTEGRATING TABLETS, TABLETSAdults. Initial: 15 mg daily, preferably atbedtime. Increased as needed and toleratedat 1- to 2-wk intervals. Maximum: 45 mgdaily.Route Onset Peak DurationP.O. 1–2 wk 6 wk or UnknownlongerMechanism of ActionMay inhibit neuronal reuptake of norepinephrineand serotonin. By doing so, thistetracyclic antidepressant increases theaction of these neurotransmitters in nervecells. Increased neuronal serotonin and norepinephrinelevels may elevate mood.ContraindicationsHypersensitivity to mirtazapine or its components,use within 14 days of an MAOinhibitorInteractionsDRUGSantihypertensives: Increased hypotensiveeffects of these drugs or enhanced mirtazapineeffectsM

686misoprostolanxiolytics, hypnotics, other CNS depressants(including sedatives): Increased CNS depressionMAO inhibitors: Possibly hyperpyrexia,hypertension, seizuresACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Agitation, amnesia, anxiety, apathy,asthenia, ataxia, cerebral ischemia, chills,confusion, delirium, delusions, depersonalization,depression, dizziness, dream disturbances,drowsiness, dyskinesia, dystonia,emotional lability, euphoria, extrapyramidalreactions, fever, hallucinations, hostility,hyperkinesia, hyperreflexia, hypoesthesia,hypokinesia, lack of coordination, malaise,mania, migraine headache, neurosis, paranoia,paresthesia, seizures, somnolence, syncope,tremor, vertigoCV: Angina, bradycardia, edema, hypercholesterolemia,hypertension, hypertriglyceridemia,hypotension, MI, orthostatichypotension, peripheral edema, PVCs,vasodilationEENT: Accommodation disturbances, conjunctivitis,dry mouth, earache, epistaxis,eye pain, glaucoma, gingival bleeding, glossitis,hearing loss, hyperacusis, keratoconjunctivitis,lacrimation, pharyngitis, sinusitis,stomatitisENDO: Breast painGI: Abdominal distention and pain, anorexia,cholecystitis, colitis, constipation, elevatedALT level, eructation, increased appetite,nausea, thirst, vomitingGU: Amenorrhea, cystitis, dysmenorrhea,dysuria, hematuria, impotence, increasedlibido, leukorrhea, renal calculi, urinary frequencyand incontinence, urine retention,UTI, vaginitisHEME: Agranulocytosis, neutropeniaMS: Arthralgia, back pain, dysarthria, muscletwitching, myalgia, myasthenia, neckpain and rigidityRESP: Asthma, bronchitis, cough, dyspnea,pneumoniaSKIN: Acne, alopecia, dry skin, exfoliativedermatitis, photosensitivity, pruritus, rashOther: Dehydration, facial edema, flulikesymptoms, herpes simplex, weight changeNursing Considerations• Administer mirtazapine before bedtime.• Expect disintegrating tablet to dissolve onpatient’s tongue within 30 seconds.WARNING Don’t give drug within 14 days ofan MAO inhibitor to avoid serious, possiblyfatal, reaction.• If patient takes drug for depression, watchclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes,because depression may briefly worsen.• Monitor patient closely for infection(fever, pharyngitis, stomatitis), which maybe linked to a low WBC count. If thesesigns occur, notify prescriber and expect tostop drug.• Expect mirtazapine therapy to last6 months or longer for acute depression.PATIENT TEACHING• Instruct patient not to swallow disintegratingtablet. Tell him to hold tablet ontongue and let it dissolve. Inform him thattablet will dissolve within 30 seconds.• Inform phenylketonuric patient that mirtazapinedisintegrating tablets containphenlyalanine 2.6 mg per 15-mg tablet,5.2 mg per 30-mg tablet, and 7.8 mg per45-mg tablet.• Instruct patient to avoid alcohol and otherCNS depressants during therapy and forup to 7 days after drug is discontinued.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Direct patient to change position slowly tominimize the effects of orthostatichypotension.• Instruct patient to notify prescriber atonce about chills, fever, mouth irritation,sore throat, and other signs of infection.• Encourage patient to visit prescriber regularlyduring therapy to monitor progress.misoprostolCytotecClass and CategoryChemical class: Prostaglandin E 1 analogueTherapeutic class: Antiulcer, gastric antisecretoryPregnancy category: XIndications and Dosages To prevent NSAID-induced gastric ulcersTABLETSAdults. 200 mcg q.i.d. or 400 mcg b.i.d.

with food, with last dose at bedtime everyday.DOSAGE ADJUSTMENT Dosage reduced to100 mcg q.i.d. if patient can’t tolerate200-mcg dose.Route Onset Peak DurationP.O. 30 min 60–90 min 3–6 hrMechanism of ActionMay protect the stomach from NSAIDinducedmucosal damage by increasing gastricmucus production and mucosal bicarbonatesecretion. Misoprostol also inhibitsgastric acid secretion caused by such stimulias food, coffee, and histamine.ContraindicationsHypersensitivity to prostaglandins or theiranalogues, pregnancyInteractionsDRUGSmagnesium-containing antacids: Increasedmisoprostol-induced diarrheaAdverse ReactionsCNS: Anxiety, asthenia, chills, confusion,depression, drowsiness, dizziness, fatigue,fever, headache, neuropathy, neurosis, rigors,stroke, syncope, thirstCV: Arrhythmias, chest pain, edema, hypertension,hypotension, increased cardiacenzyme levels, MI, phlebitis, thromboembolismEENT: Abnormal taste or vision, conjunctivitis,deafness, earache, epistaxis, gingivitis,tinnitusENDO: HyperglycemiaGI: Abdominal pain, constipation, diarrhea,dysphagia, flatulence, GI bleeding orinflammation, hepatobiliary dysfunction,indigestion, nausea, reflux, vomitingGU: Dysmenorrhea, dysuria, hematuria,hypermenorrhea, impotence, loss of libido,menstrual irregularities, polyuria, urinarytract infection, vaginal bleedingHEME: Anemia, abnormal differentialthrombocytopenia purpura, increased erythrocytesedimentation rateMS: Arthralgia, back pain, myalgia, musclecramps or stiffnessRESP: Bronchitis, bronchospasm, dyspnea,pneumonia, pulmonary embolism, upperrespiratory tract infectionIndications and Dosages To reduce neurologic disability and frequencyof relapses in patients with secmitoxantronehydrochloride 687SKIN: Alopecia, diaphoresis, dermatitis,pallor, rashOther: Anaphylaxis, gout, weight changesNursing ConsiderationsWARNING Ask female patient if she is ormay be pregnant. If so, notify prescriberbecause misoprostol may cause uterinebleeding, contractions, spontaneous abortion,and teratogenic effects in the fetus.• Use drug cautiously in patients with cerebrovasculardisease, coronary artery disease,or uncontrolled epilepsy because ofthe risk of severe complications.• Also use misoprostol cautiously in patientswith inflammatory bowel disease becausedrug may worsen intestinal inflammationand cause diarrhea. If diarrhea causessevere dehydration, misoprostol may bediscontinued.PATIENT TEACHING• Caution female patient about risk of takingmisoprostol during pregnancy, andurge her to use reliable contraception duringtherapy. Urge her to notify prescriberat once if she is or might be pregnant.• Instruct patient to take misoprostol withmeals and at bedtime.• Advise patient that he may take NSAIDs, ifprescribed, during misoprostol therapy.• Explain that diarrhea is dose related andusually resolves after 8 days. Tell patient toavoid magnesium-containing antacidsbecause they may worsen diarrhea and tocall prescriber if diarrhea lasts more than8 days.• Urge female patient to notify prescriberimmediately about postmenopausal bleeding;she may need diagnostic tests.mitoxantronehydrochlorideNovantroneClass and CategoryChemical class: AnthracenedioneTherapeutic class: AntineoplasticPregnancy category: DM

688mitoxantrone hydrochlorideondary (chronic) progressive, progressiverelapsing, or worsening relapsingremittingmultiple sclerosis (patientswhose neurologic status is significantlyabnormal between relapses)I.V. INFUSIONAdults. 12 mg/m 2 over 5 to 15 min every3mo.Maximum: Cumulative dose of140 mg/m 2 . As adjunct to treat pain related toadvanced hormone-refractory prostatecancerI.V. INFUSIONAdults. 12 to 14 mg/m2 over 5 to 15 minevery 21 days. As adjunct to treat acute nonlymphocyticleukemia (ANLL)I.V. INFUSIONAdults. Initial: 12 mg/m 2 over at least3 min on days 1 to 3 with 100 mg/m 2 ofcytarabine as a continuous 24-hr infusionon days 1 to 7. If patient’s antileukemicresponse is inadequate or incomplete, secondinduction course is given at samedosage. Maintenance: 6 wk after induction,12 mg/m 2 over at least 3 min on days 1 and2 with 100 mg/m 2 of cytarabine as a continuous24-hr infusion on days 1 to 5. Asecond maintenance course is given 4 wkafter the first if needed and tolerated.Mechanism of ActionBinds to DNA, causing cross-linkage andstrand breakage, interfering with RNA synthesis,and inhibiting topoisomerase II, anenzyme that uncoils and repairs damagedDNA. Mitoxantrone produces a cytocidaleffect on proliferating and nonproliferatingcells and doesn’t appear to be cell-cycle specific.It’s known to inhibit B-cell, T-cell, andmacrophage proliferation and impair antigenfunction.IncompatibilitiesDon’t mix mitoxantrone in the same infusionas heparin (because a precipitate mayform); don’t mix with any other drugs.ContraindicationsHypersensitivity to mitoxantrone or itscomponentsInteractionsDRUGSallopurinol, colchicine, probenecid, sulfinpyrazone:Possibly interference with antihyperuricemicaction of these drugsblood-dyscrasia–causing drugs (such ascephalosporins and sulfasalazine): Increasedrisk of leukopenia and thrombocytopeniabone marrow depressants, such as carboplatinand lomustine: Possibly additive bone marrowdepressiondaunorubicin, doxorubicin: Increased risk ofcardiotoxicitymethotrexate and other antineoplastics: Riskof developing leukemiavaccines, killed virus: Decreased antibodyresponse to vaccinevaccines, live virus: Increased risk of replicationof and adverse effects of vaccine virus,decreased antibody response to vaccineAdverse ReactionsCNS: Headache, seizuresCV: Arrhythmias, cardiotoxicity, chest pain,congestive heart failure, decreased left ventricularejection fraction, ECG changesEENT: Blue-colored cornea, conjunctivitis,mucositis, stomatitisGI: Abdominal pain, diarrhea, GI bleeding,nausea, vomitingGU: Blue-green urine, renal failureHEME: Acute myelogenous leukemia,leukopenia, other leukemias, thrombocytopeniaMS: MyelodysplasiaRESP: Cough, dyspneaSKIN: Alopecia, extravasation, jaundiceOther: Allergic reaction, anaphylaxis, hyperuricemia,infection, infusion site pain orrednessNursing Considerations• Before mitoxantrone therapy and beforeeach dose, expect patient to have an ECGand evaluation of left ventricular ejectionfraction. Expect to obtain hematocrit,hemoglobin level, and CBC with plateletcount. If patient’s left ventricular ejectionfraction drops below normal, expect drugto be discontinued.• Be aware that drug shouldn’t be given topatient with multiple sclerosis whose neutrophilcount is less than 1,500/mm 3 orwho has a below-normal left ventricularejection fraction.• Check liver function test results, as ordered,before each course of therapy. Expect thatdrug won’t be given to multiple sclerosispatient with abnormal liver function.

• Assess patient for cardiac dysfunctionthroughout therapy. Watch for evidence ofcardiotoxicity, such as arrhythmias andchest pain, in patient with heart disease.Risk increases when cumulative dosereaches 140 mg/m 2 in cancer or 100 mg/m 2 in multiple sclerosis. Notify prescriberof any significant changes, and expectdrug to be discontinued. Be aware thatcongestive heart failure may occur monthsor years after drug has been discontinued.• Anticipate obtaining pregnancy test beforeeach course of therapy for women ofchildbearing age with multiple sclerosis.• Follow facility policy for handling antineoplastics.Be aware that manufacturerrecommends goggles, gloves, and a gownduring drug preparation and delivery.• Before infusing drug, dilute it in at least50 ml of normal saline solution or D 5 W.WARNING Drug shouldn’t be given intrathecallybecause paralysis may occur.• If mitoxantrone solution contacts yourskin or mucosa, wash thoroughly withwarm water. If it contacts your eyes, irrigatethem thoroughly with water or normalsaline solution.• Discard unused diluted solution because itcontains no preservatives. After penetrationof stopper, store undiluted drug forup to 7 days at room temperature or14 days refrigerated. Avoid freezing drug.• If extravasation occurs, stop infusionimmediately and notify prescriber.Reinsert I.V. line in another vein andresume infusion. Although mitoxantroneis a nonvesicant, observe the extravasationsite for signs of necrosis or phlebitis.• Monitor patients with chickenpox orrecent exposure and patients with herpeszoster for severe, generalized disease.• Monitor blood uric acid level for hyperuricemiain patients with a history of goutor renal calculi. Expect to give allopurinol,as prescribed, to patients with leukemia orlymphoma and elevated blood uric acidlevel to prevent uric acid nephropathy.WARNING If severe or life-threatening nonhematologicor hematologic toxicityoccurs during first induction course,expect to withhold the second course untilit resolves.• If patient develops thrombocytopenia,take precautions per facility policy.mitoxantrone hydrochloride 689• Assess patient for evidence of infection,such as fever, if leukopenia occurs. Expectto obtain appropriate specimens for cultureand sensitivity testing.• Be aware that patients receiving mitoxantronein combination with other antineoplasticsor radiation therapy are at riskfor developing secondary leukemia,including acute myelogenous leukemia.PATIENT TEACHING• Advise patient to complete dental work, ifpossible, before treatment begins or deferit until blood counts return to normal;drug may delay healing and cause gingivalbleeding. Teach patient proper oralhygiene, and advise use of a toothbrushwith soft bristles.• Urge patient to drink plenty of fluid toincrease urine output and uric acid excretion.• Advise patient to contact prescriber immediatelyif GI upset occurs, but to continuetaking drug unless otherwise directed.• Stress the importance of complying withthe dosage regimen and keeping follow-upmedical and laboratory appointments.• Explain that urine may appear blue-greenfor 24 hours after treatment and that thewhites of the eyes may appear blue. Stressthat these effects are temporary and harmless.Explain that hair loss is possible, butthat hair should return after therapy ends.• Caution patient not to receive immunizationsunless approved by prescriber. Also,advise persons who live in same householdas patient to avoid receiving immunizationwith oral polio vaccine. Tell patient toavoid persons who recently received theoral polio vaccine or to wear a mask overhis nose and mouth.• Instruct patient to avoid persons withinfections if bone marrow depressionoccurs. Advise patient to contact prescriberif fever, chills, cough, hoarseness,lower back or side pain, or painful or difficulturination occurs; these changes maysignal an infection.• Tell patient to contact prescriber immediatelyif he has unusual bleeding or bruising,black or tarry stools, blood in urine orstool, or pinpoint red spots on his skin.• Urge patient not to touch his eyes or theinside of his nose unless he has justwashed his hands.M

690modafinil• Stress the need to avoid accidental cuts, asfrom a razor or fingernail clippers, becauseof possible excessive bleeding or infection.• Caution patient to avoid contact sports oractivities that may cause bruising or injury.• Urge patient to comply with yearly examinationsafter therapy ends to check forlate-occurring drug-induced heart problems.Tell patient to report trouble breathing,swelling in legs or ankles, or anuneven or fast heartbeat even after drughas been discontinued.modafinilProvigilClass, Category, and ScheduleChemical class: Benzhydryl sulfinylacetamidederivativeTherapeutic class: CNS stimulantPregnancy category: CControlled substance schedule: IVIndications and Dosages To improve daytime wakefulness inpatients with narcolepsy, obstructivesleep apnea hypopnea syndrome, andshift work sleep disorderTABLETSAdults and adolescents age 16 and over.200 mg daily in the morning or 1 hr beforestarting work shift Maximum: 400 mg daily.DOSAGE ADJUSTMENT For patients withsevere hepatic impairment, dosage shouldbe reduced by 50%.Mechanism of ActionMay inhibit the release of gamma-aminobutyricacid (GABA), the most commoninhibitory neurotransmitter, or CNSdepressant, in the brain. Modafinil alsoincreases the release of glutamate, an excitatoryneurotransmitter, or CNS stimulant, inthe thalamus and hippocampus. These twoactions may improve wakefulness.ContraindicationsHypersensitivity to modafinil or its componentsInteractionsDRUGSamitriptyline, citalopram, clomipramine,diazepam, imipramine, propranolol, tolbutamide,topiramate: Possibly prolonged eliminationtime and increased blood levels ofthese drugscarbamazepine: Possibly decreased modafinileffectiveness and decreased bloodcarbamazepine levelcimetidine, clarithromycin, erythromycin,fluconazole, fluoxetine, fluvoxamine, itraconazole,ketoconazole, nefazodone, sertraline:Possibly inhibited metabolism,decreased clearance, and increased bloodlevel of modafinilcontraceptive-containing implants or devices,oral contraceptives: Possibly contraceptivefailurecyclosporine: Possibly decreased bloodcyclosporine level and increased risk oforgan transplant rejectiondexamethasone, phenobarbital and otherbarbiturates, primidone, rifabutin, rifampin:Possibly decreased blood level and effectivenessof modafinildextroamphetamine, methylphenidate:Possibly 1-hour delay in modafinil absorptionwhen these drugs are given togetherfosphenytoin, mephenytoin, phenytoin:Possibly decreased effectiveness of modafinil,increased blood phenytoin level, andincreased risk of phenytoin toxicitytheophylline: Possibly decreased blood leveland effectiveness of theophyllinetriazolam: Possibly decreased effectivenessof triazolamwarfarin: Possibly decreased warfarinmetabolism and increased risk of bleedingFOODSall foods: 1-hour delay in modafinil absorptionand possibly delayed onset of actioncaffeine: Increased CNS stimulationgrapefruit juice: Possibly decreased modafinilmetabolismAdverse ReactionsCNS: Aggressiveness, agitation, anxiety,confusion, delusions, depression, hallucinations,headache, insomnia, mania, nervousness,psychosis, suicidal ideationGI: NauseaHEME: AgranulocytosisSKIN: Drug rash with eosinophilia and systemicsymptoms (DRESS), rash, Stevens-Johnson syndrome, toxic epidermal necrolysisOther: Anaphylaxis, angioedema, infection,multi-organ hypersensitivity

Nursing Considerations• Modafinil shouldn’t be given to patientswith mitral valve prolapse syndrome or ahistory of left ventricular hypertrophybecause drug may cause ischemic changes.• Use cautiously in patients with recent MIor unstable angina because effect of drugis unknown in these disorders.• Use cautiously in patients with a history ofpsychosis, depression, or mania becausethese conditions may worsen during therapyand may require modafinil to bestopped.WARNING Monitor patient with a history ofalcoholism, stimulant abuse, or other substanceabuse for compliance withmodafinil therapy. Observe for signs ofmisuse or abuse, including frequent prescriptionrefill requests, increased frequencyof dosing, or drug-seeking behavior.Also watch for evidence of excessivemodafinil dosage, including aggressiveness,anxiety, confusion, decreased prothrombintime, diarrhea, irritability, nausea,nervousness, palpitations, sleep disturbances,and tremor.• Be aware that modafinil, like other CNSstimulants, may alter mood, perception,thinking, judgment, feelings, motor skills,and signs that patient needs sleep.• If giving drug to patient with a history ofpsychosis, emotional instability, or psychologicalillness with psychotic features, beprepared to perform baseline behavioralassessments or frequent clinical observation.• Stop drug at first sign of rash, and notifyprescriber. Although rare, rash may indicatea potentially life-threatening event.• Monitor patient for signs and symptomsof multisystem organ hypersensitivity,such as fever, rash, myocarditis, hepatitis,hematologic abnormalities, pruritus,asthenia, or any other serious abnormalitybecause multi-organ hypersensitivity mayvary in its presentation. Notify prescriberif suspected, and expect to discontinuedrug and provide supportive care, asordered.• Watch closely for suicidal tendencies, especiallyin patients with a psychiatric history.PATIENT TEACHING• Inform patient that modafinil can help,but not cure, narcolepsy and that drug’smoexipril hydrochloride 691full effects may not be seen right away.• Advise patient to avoid taking modafinilwithin 1 hour of eating because food maydelay drug’s absorption and onset ofaction. If he drinks grapefruit juice,encourage him to drink a consistentamount daily.• Instruct patient to stop taking modafiniland to notify precriber if he develops arash, fever, or other serious effect.• Urge patient to report chest pain, depression,anxiety, or evidence of psychosis ormania to prescriber.• Inform patient that drug can affect concentrationand function and can hidesigns of fatigue. Urge him not to drive orperform activities that require mentalalertness until full CNS effects are known.• Because alcohol may decrease alertness,advise patient to avoid it while takingmodafinil.• Encourage a regular sleeping pattern.• Caution patient to avoid excessive intakeof foods, beverages, and OTC drugs thatcontain caffeine because caffeine may leadto increased CNS stimulation.• Inform female patient that modafinil candecrease the effectiveness of certain contraceptives,including birth control pillsand implantable hormonal contraceptives.If she uses such contraceptives, urge her touse an alternate birth control method duringmodafinil therapy and for up to 1month after she stops taking the drug.• Advise patient to keep follow-up appointmentswith prescriber so that her progresscan be monitored.• Urge family or caregiver to watch patientclosely for abnormal behaviors, includingsuicidal tendencies, especially if patienthas a psychiatric history.moexiprilhydrochlorideUnivascClass and CategoryChemical class: Prodrug of moexiprilatTherapeutic class: AntihypertensivePregnancy category: C (first trimester), D(later trimesters)M

692moexipril hydrochlorideIndications and Dosages To manage hypertension without diuretictherapyTABLETSAdults. Initial: 7.5 mg daily 1 hr before ameal. Maintenance: 7.5 to 30 mg as a singledose or in divided doses b.i.d. 1 hr beforemeals. Maximum: 30 mg/day.DOSAGE ADJUSTMENT For patients with creatinineclearance of less than 40 ml/min/1.73 m 2 , initial dosage reduced to 3.75 mgdaily and increased, as ordered, to maximumof 15 mg daily. To manage hypertension with diuretictherapyTABLETSAdults. Initial: 3.75 mg daily 1 hr before ameal. Increased gradually, as ordered, untilblood pressure is controlled.Route Onset Peak DurationP.O. 1 hr 3–6 hr 24 hrMechanism of ActionIs converted to the active metabolite moexiprilat,which reduces blood pressure byinhibiting ACE activity. ACE normally catalyzesconversion of angiotensin I to angiotensinII—a vasoconstrictor that stimulatesaldosterone secretion by adrenal cortex anddirectly suppresses renin release. InhibitedACE activity results in decreased peripheralarterial resistance, increased plasma reninactivity, and decreased aldosterone secretion.Decreased aldosterone secretion causeswater and sodium excretion.ContraindicationsHistory of angioedema with previous ACEinhibitor use, hypersensitivity to moexiprilor its componentsInteractionsDRUGSallopurinol, bone marrow depressants, corticosteroids(systemic), cytostatic drugs, procainamide:Increased risk of possibly fatalneutropenia or agranulocytosisantacids: Possibly decreased moexipril bioavailabilitycyclosporine, heparin, potassium-containingdrugs, potassium-sparing diuretics, potassiumsupplements: Increased risk of hyperkalemiadigoxin: Possibly increased digoxin leveldiuretics, other hypotension-producing drugs:Hypotension, risk of renal failure (fromsodium or volume depletion), possiblydecreased secondary aldosteronism andhypokalemia caused by diureticslithium: Increased blood lithium level andrisk of lithium toxicityNSAIDs (especially indomethacin), sympathomimetics:Decreased antihypertensiveeffect of moexiprilphenothiazines: Increased pharmacologiceffects of moexiprilFOODSall foods: Decreased moexipril absorptionlow-salt milk, salt substitutes: PossiblyhyperkalemiaACTIVITIESalcohol use: Possibly hypotensionAdverse ReactionsCNS: Anxiety, chills, confusion, dizziness,drowsiness, fatigue, fever, headache,malaise, mood changes, nervousness, sleepdisturbance, stroke, syncopeCV: Angina, arrhythmias, chest pain, hypotension,MI, orthostatic hypotension, palpitations,peripheral edemaEENT: Dry mouth, hoarseness, laryngealedema, mouth or tongue swelling, pharyngitis,rhinitis, sinusitis, taste perversion,tinnitusGI: Abdominal distention or pain, anorexia,constipation, diarrhea, dysphagia, elevatedliver function test results, hepatitis,increased appetite, nausea, pancreatitis,vomitingGU: Azotemia, elevated BUN and serumcreatinine and uric acid levels, interstitialnephritis, oliguria, proteinuria, renal insufficiency,urinary frequencyHEME: Agranulocytosis, bone marrowdepression, elevated erythrocyte sedimentationrate, hemolytic anemia, leukocytosis,leukopenia, neutropenia, thrombocytopeniaMS: Arthralgia, leg heaviness or weakness,myalgia, myositisRESP: Bronchospasm, cough, dyspnea,upper respiratory tract infectionSKIN: Alopecia, diaphoresis, flushing,onycholysis, pallor, pemphigus, photosensitivity,pruritus, rash, Stevens-Johnson syndrome,urticariaOther: Anaphylaxis, angioedema (of arms,face, larynx, legs, lips, mucous membranes,tongue), flulike symptoms, hyperkalemia,hyponatremia, positive ANA titer

molindone hydrochloride 693Nursing ConsiderationsWARNING Contact prescriber if patient is ormay be pregnant. Moexipril may causefetal or neonatal harm or death if usedduring second or third trimester.• Be aware that patient who already takes adiuretic should be medically supervisedfor several hours after first moexipril dose.• Administer drug 1 hour before meals.• Monitor blood pressure, leukocyte count,and liver and renal function test resultsduring moexipril therapy.• Be aware that black patients may be lessresponsive to antihypertensive effect ifmoexipril is used alone to control bloodpressure.PATIENT TEACHING• Urge female patient to notify prescriberimmediately if she is or may be pregnant.• Instruct patient to take moexipril at thesame time each day, 1 hour before meals.• Direct patient to take a missed dose assoon as he remembers unless it’s nearlytime for the next dose. Caution againstdoubling the dose.WARNING Instruct patient to stop drug andseek immediate medical attention forhoarseness; swelling of tongue, glottis, larynx,face, hands, or feet; or sudden difficultyswallowing or breathing.• Caution patient not to stop drug withoutconsulting prescriber, even if he feels better.• Inform patient about possible dizziness,especially after first dose and if he takes adiuretic.• Advise patient to change position slowly tominimize orthostatic hypotension.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to notify prescriber if hefaints or experiences persistent dizziness.• Instruct patient to report evidence ofinfection (such as chills, fever, and sorethroat), diarrhea, nausea, or vomiting,which may lead to dehydration-inducedhypotension.• Advise patient to avoid alcohol duringmoexipril therapy because it may causehypotension.• Instruct patient to check with prescriberbefore taking OTC drugs.• Urge patient to avoid potassium supplementsand potassium-containing salt substitutesunless prescriber allows them.• Advise patient to visit prescriber regularlyto monitor progress.• Discuss importance of weight control andlow-salt diet in managing hypertension.molindonehydrochlorideMoban ConcentrateClass and CategoryChemical class: Dihydroindolone derivativeTherapeutic class: Antipsychotic drugPregnancy category: Not ratedIndications and Dosages To manage symptoms of psychotic disordersORAL SOLUTIONAdults and children age 12 and over.Initial: 50 to 75 mg daily in divided dosest.i.d. or q.i.d. Dosage increased to 100 mgdaily in 3 to 4 days as needed. Maintenance:For mild psychosis, 5 to 15 mg t.i.d. orq.i.d.; for moderate psychosis, 10 to 25 mgt.i.d. or q.i.d.; for severe psychosis, 225 mgdaily in divided doses. Maximum: 225 mgdaily.DOSAGE ADJUSTMENT Initial dosage reducedfor elderly or debilitated patients.Route Onset Peak DurationP.O. Unknown Unknown 24–36 hrMechanism of ActionOccupies dopamine receptor sites in thereticular activating and limbic systems inthe CNS. By blocking dopamine activity inthese areas, molindone reduces the symptomsof psychosis, helping the patient tothink and behave more coherently.ContraindicationsHypersensitivity to molindone, its components,or other antipsychotic drugs, includinghaloperidol, loxapine, phenothiazines,and thioxanthenesInteractionsDRUGSamphetamines: Decreased amphetamineeffectiveness, decreased antipsychotic effec-M

694molindone hydrochloridetiveness of molindoneanesthetics, barbiturates, benzodiazepines,CNS depressants, opioid analgesics: Possiblyprolonged and intensified CNS depressanteffectsantacids, antidiarrheals: Decreased molindoneabsorptionanticholinergics, antidyskinetics, antihistamines:Possibly increased anticholinergiceffectsbeta blockers: Possibly increased effect ofbeta blockerbromocriptine: Possibly decreased therapeuticeffects of bromocriptine and increasedserum prolactin levelextrapyramidal reaction–causing drugs, suchas amoxapine, haloperidol, loxapine, metoclopramide,olanzapine, phenothiazines,pimozide, rauwolfia alkaloids, risperidone,tacrine, and thioxanthenes: Increased severityof extrapyramidal effectsinsulin, oral antidiabetic drugs: Possiblyincreased serum glucose levellevodopa: Inhibited antidyskinetic effects oflevodopa, possibly decreased antipsychoticeffects of molindonelithium: Increased risk of neurotoxicity,increased extrapyramidal effectsMAO inhibitors, maprotiline, trazodone, tricyclicantidepressants: Possibly prolongedand intensified sedative or anticholinergiceffects of all drugsphenytoin, tetracycline: Interference withabsorption of phenytoin and tetracyclineACTIVITIESalcohol use: Prolonged and intensified CNSdepressionAdverse ReactionsCNS: Depression, drowsiness, euphoria,extrapyramidal reactions (such as akathisia,dystonia, motor restlessness, pseudoparkinsonism,and tardive dyskinesia), headache,hyperactivity, lack of coordination, neurolepticmalignant syndrome, tirednessCV: Orthostatic hypotension, tachycardia,unstable blood pressureEENT: Blinking or eyelid spasm, blurredvision, dry mouth, inability to move eyes,nasal congestionENDO: Breast engorgement, lactationGI: Constipation, nauseaGU: Decreased libido, menstrual irregularities,urine retentionHEME: Agranulocytosis, leukopenia, neutropeniaMS: Muscle spasms of back, face, and neck;muscle twitching; twisting movements ofthe body; weakness or stiffness of limbsRESP: DyspneaSKIN: Diaphoresis, pallor, rashOther: HeatstrokeNursing Considerations• Molindone shouldn’t be used to treatdementia-related psychosis in the elderlybecause of an increased mortality risk.WARNING Assess patient for signs andsymptoms of neuroleptic malignant syndrome,such as diaphoresis, dyspnea,fatigue, fever, incontinence, pallor, severemuscle stiffness, tachycardia, and unstableblood pressure; notify prescriber immediatelyif they occur. Expect to discontinuedrug and begin intensive medical treatment.Monitor patient carefully for recurrenceif antipsychotic therapy resumes.• Molindone shouldn’t be given to patientswho have severe CNS depression or whoare comatose because of drug’s CNSdepressant effects.• Monitor elderly patients for orthostatichypotension and symptoms of tardivedyskinesia, including blinking or eyelidspasms, involuntary movements of thelimbs, and unusual facial expressions,because these patients may be sensitive todrug’s anticholinergic and extrapyramidaleffects. Expect to reduce dosage or discontinuedrug.• Give oral solution undiluted or mixedwith water, carbonated beverage, fruitjuice, or milk.• Monitor CBC often during first fewmonths of therapy, especially if patient haslow WBC count or history of druginducedleukopenia or neutropenia. IfWBC count drops, and especially if neutrophilcount drops below 1000/mm 3 ,expect molindone to be discontinued. Ifneutropenia is significant, also monitorpatient for fever or other evidence ofinfection and provide appropriate treatment,as prescribed.PATIENT TEACHING• Instruct patient to follow treatment regimenand to notify prescriber before discontinuingdrug because gradual dosagereduction may be needed.• Instruct patient not to take drug within

2 hours of taking an antacid. Advise himto take drug with food or a full glass ofmilk or water to reduce gastric irritation.• Instruct patient to take oral solution undilutedor mixed with water, carbonatedbeverage, fruit juice, or milk.• Urge patient to avoid alcohol consumptionbecause of possible additive effectsand hypotension.• Advise patient, especially an elderlypatient, to rise slowly from a supine orseated position to avoid feeling dizzy,light-headed, or faint.• Explain that drug may reduce body’sresponse to heat. Tell patient to avoid temperatureextremes, such as hot showers,tubs, or saunas. Urge caution during exercise.• Caution patient not to take OTC drugs forcolds or allergies during therapy becausethey can increase the risk of heatstrokeand increase anticholinergic effects, suchas blurred vision, constipation, dry mouth,and urine retention.• Inform patient and family members thatmaximum clinical improvement in symptomsmay take several weeks or months.mometasonefuroatemonohydrateNasonexClass and CategoryChemical class: GlucocorticoidTherapeutic class: Antiasthmatic, antiinflammatoryPregnancy category: CIndications and Dosages To manage symptoms of seasonal orperennial allergic rhinitisNASAL SPRAYAdults and children 12 years and over.100 mcg (2 sprays) in each nostril daily.Children ages 2 to 12. 50 mcg (1 spray) ineach nostril daily. To maintain asthma controlORAL INHALATIONAdults and children age 12 and over whohave been taking bronchodilators alone ormometasone furoate monohydrate 695inhaled corticosteroids. Initial: 220 mcg(1 inhalation) once daily in evening.Maximum: 440 mcg (2 inhalations) dailygiven as 220 mcg (1 inhalation) b.i.d. or440 mcg (1 inhalation) once daily.Adults and children age 12 and over whohave taken oral corticosteroids. 440 mcg(2 inhalations) b.i.d.Children ages 4 to 11. 110 mcg (1 inhalation)once daily in evening.Mechanism of ActionInhibits the activity of cells and mediatorsactive in the inflammatory response, possiblyby decreasing influx of inflammatorycells into nasal passages and therebydecreasing nasal inflammation.ContraindicationsHypersensitivity to mometasone or its components;recent septal ulcers, nasal surgery,or nasal trauma; status asthmaticus or otherasthma episodes that require emergencycareAdverse ReactionsCNS: HeadacheCV: Chest painEENT: Cataracts, conjunctivitis, dry mouth,earache, epistaxis, glaucoma, nasal irritation,oral and pharyngeal candidiasis, otitismedia, pharyngitis, rhinitis, sinusitis, throattightness, unpleasant tasteENDO: Adrenal insufficiency, growth suppressionGI: Diarrhea, dyspepsia, nausea, vomitingGU: DysmenorrheaMS: Arthralgia, decreased bone mineraldensity, myalgia, painRESP: Asthma, bronchitis, bronchospasm,increased cough, upper respiratory tractinfection, wheezingSKIN: UrticariaOther: Angioedema, flulike symptoms, viralinfectionNursing Considerations• Use mometasone cautiously if patient hastubercular infection; untreated fungal,bacterial, or systemic viral infection; orocular herpes simplex.• If patient takes an oral corticosteroid,expect to taper it slowly 1 week afterchanging to mometasone. If patient takesprednisone, expect to reduce it by no morethan 2.5 mg daily at weekly intervals,M

696montelukast sodiumbeginning at least 1 week after mometasonetherapy starts. Monitor patient forsymptoms of systemically active corticosteroidwithdrawal such as joint and musclepain, lassitude, and depression despitemaintenance or even improvement of respiratorysymptoms.WARNING Assess patient switched from systemiccorticosteroid to mometasone foradrenal insufficiency (fatigue, hypotension,lassitude, nausea, vomiting, weakness)during initial treatment and duringstress, trauma, surgery, infection or anelectrolyte-depleting condition. Notifyprescriber immediately if signs or symptomsarise because adrenal insufficiencymay be life-threatening. Hypothalamicpituitary-adrenalaxis function may takeseveral months to recover after systemiccorticosteroids are discontinued. Abruptwithdrawal of mometasone also may precipitateadrenal insufficiency.• Notify prescriber immediately if patienthas bronchospasm after mometasone oralinhalation, and expect to give a fast-actinginhaled bronchodilator, discontinuemometasone, and use an alternate drug.• Closely monitor a child’s growth pattern;drug may stunt growth.• Report oropharyngeal candidiasis, andexpect patient to receive appropriate antifungaltherapy while remaining onmometasone therapy. If candidiasis issevere, however, mometasone therapy mayneed to be temporarily halted.PATIENT TEACHING• For nasal spray, instruct patient to shakecontainer before each use. Instruct her toblow her nose, tilt her head slightly forward,and insert tube into a nostril, pointingtoward inner corner of eye, away fromnasal septum. Tell her to hold the othernostril closed and spray while inhalinggently. Then have her repeat the procedurein the other nostril.• For oral inhalation, give patient theseinstructions for using inhaler: Remove caponly after placing inhaler in an uprightposition. Twist cap in counterclockwisewhile holding colored base, making sureindented arrow (on white portion of theinhaler directly above the colored base) ispointing to the dose counter. Removingthe cap loads inhaler with drug, and thedose counter on the base will count downby one. Take a full breath in and out, andthen place mouthpiece in your mouth.Firmly close your lips around mouthpiece,taking care not to cover ventilation holeson the inhaler. Then take a fast, deepbreath. You may not taste, smell, or feelanything with the inhalation. After takingthe breath, remove inhaler from yourmouth and hold your breath for about10 seconds. Don’t exhale into the inhaler.Wipe the mouthpiece dry, if needed, andreplace the cap right away, turning itclockwise as you press down. You shouldhear a click when the cap is fully closed.Write down the date inhaler is opened,and discard it 45 days from that date orwhen dose counter reads 00, whichevercomes first.• Instruct patient to gargle or rinse aftereach use of oral inhaler to help preventmouth and throat dryness, relieve throatirritation, and prevent oropharyngealinfection.WARNING Caution patient not to usemometasone oral inhalation to relieveacute bronchospasm and to notify prescriberif rescue inhaler is required moreoften or doesn’t seem to be as effective.• If patient switches from an oral corticosteroidto mometasone, advise her to carryor wear medical identification indicatingthe need for supplemental systemic corticosteroidsduring stress or severe asthmaattack. Tell her to seek emergency care ifeither occurs.• Instruct patient to contact prescriber ifsymptoms persist or worsen after 3 weeks.•Caution patient to avoid exposure tochickenpox and measles and, if exposed, tocontact prescriber immediately.montelukastsodiumSingulairClass and CategoryChemical class: Leukotriene receptorantagonistTherapeutic class: AntiasthmaticPregnancy category: B

Indications and Dosages To prevent or treat asthmaORAL GRANULESChildren ages 12 to 23 mo. 4 mg daily inthe evening. Maximum: 4 mg daily.CHEWABLE TABLETSChildren ages 6 to 14. 5 mg daily in theevening. Maximum: 5 mg daily.Children ages 2 to 5. 4 mg daily in theevening. Maximum: 4 mg daily.TABLETSAdults and adolescents age 15 and over.10 mg daily in the evening. Maximum:10 mg daily. To treat seasonal allergic rhinitisORAL GRANULESChildren ages 2 to 5. 4 mg daily.CHEWABLE TABLETSChildren ages 6 to 14. 5 mg daily.Children ages 2 to 5. 4 mg daily.TABLETSAdults and adolescents age 15 and over.10 mg daily. To treat perennial allergic rhinitisORAL GRANULESChildren ages 6 months to 5 years. 4 mgdaily.CHEWABLE TABLETSChildren ages 6 to 14. 5 mg daily.Children ages 2 to 5. 4 mg daily.TABLETSAdults and adolescents age 15 and over.10 mg daily. To prevent exercise-induced bronchoconstrictionTABLETSAdults and adolescents age 15 and over.10 mg at least 2 hr before exercise.Maximum: 10 mg in 24 hr.Route Onset Peak DurationP.O. Unknown Unknown 24 hrMechanism of ActionAntagonizes receptors for cysteinyl leukotrienes,produced by arachidonic acidmetabolism and released from mast cells,eosinophils, and other cells. When cysteinylleukotrienes bind to receptors in bronchialairways, they increase endothelial membranepermeability, which leads to airway edema,smooth-muscle contraction, and alteredactivity of cells in asthma’s inflammatoryprocess. Montelukast blocks these effects.montelukast sodium 697InteractionsDRUGSphenobarbital: Decreased amount of circulatingmontelukastAdverse ReactionsCNS: Aggression, agitation, anxiousness,asthenia, depression, dizziness, dreamabnormalities, fatigue, fever, hallucinations,headache, hostility, hypoesthesia, insomnia,irritability, paresthesia, restlessness, sleepwalking, suicidal ideation, tremorCV: PalpitationsEENT: Dental pain, epistaxis, laryngitis,nasal congestion, otitis media, pharyngitis,sinusitisGI: Abdominal pain, cholestatic hepatitis,dyspepsia, elevated liver function testresults, hepatotoxicity, indigestion, infectiousgastroenteritis (in all patients); diarrhea,nausea (in children)GU: PyuriaRESP: Cough, upper respiratory tract infectionSKIN: Erythema nodosum, pruritus, rash,urticariaOther: Anaphylaxis, angioedema (in allpatients); flulike syndrome, viral infection(in children)Nursing ConsiderationsWARNING Montelukast isn’t for acute asthmaattack or status asthmaticus.• Montelukast shouldn’t be abruptly substitutedfor inhaled or oral corticosteroids;expect to taper corticosteroid dosage gradually,as directed.• Monitor patient for adverse reactions,such as cardiac and pulmonary symptoms,eosinophilia, and vasculitis, in patientundergoing corticosteroid withdrawal.Notify prescriber if such reactions occur.• Watch patient closely for suicidal tendenciesduring montelukast therapy, especiallywhen therapy starts or dosage changes.• Monitor patient for adverse neuropsychiatriceffects and notify prescriber if present.Drug may need to be discontinued.PATIENT TEACHING• Advise patient to take montelukast daily asprescribed, even when he feels well. Urgehim not to decrease dosage or stop takingother prescribed asthma drugs unlessinstructed by prescriber.• Caution patient not to use drug for acuteM

698morphine sulfateasthma attack or status asthmaticus; makesure he has appropriate short-acting rescuedrug available.• Tell parents administering oral granules topour contents directly into the child’smouth or mix with ice cream or cold orroom temperature applesauce, carrots, orrice—but not liquids or other foods—justbefore administration. Liquids may begiven after drug has been administered.Once packet is opened, the full dose mustbe administered within 15 minutes. Drugmust not be stored for future use if mixedwith food.• Instruct patient to notify prescriber if heneeds a short-acting inhaled bronchodilatormore often than usual, or more oftenthan prescribed, to control symptoms.• Teach patient to use a peak flowmeter todetermine his personal best expiratoryvolume.• Caution patient with aspirin sensitivity toavoid aspirin and NSAIDs during montelukasttherapy. Montelukast may not effectivelyreduce bronchospasm in such apatient.• Inform patient (or parents of child) withphenylketonuria that chewable tablet containsphenylalanine.• Instruct patient to notify prescriber if sheis or could be pregnant.• Urge family or caregiver to watch patientclosely for abnormal behaviors, includingsuicidal tendencies, during therapy, andurge them to notify prescriber if present.morphine sulfateAstramorph PF, Avinza, DepoDur,Duramorph, Epimorph (CAN), Kadian,M-Eslon (CAN), Morphine Extra-Forte(CAN), Morphine Forte (CAN), MorphineH.P. (CAN), Morphitec (CAN), MS Contin,MSIR, MS/L, MS/L Concentrate, MS/S,OMS Concentrate, Oramorph SR,Rescudose, RMS Uniserts, Roxanol,Roxanol 100, Roxanol UD, Statex (CAN)Class, Category, and ScheduleChemical class: Phenanthrene derivativeTherapeutic class: AnalgesicPregnancy category: CControlled substance schedule: IIIndications and Dosages To relieve acute or chronic moderate tosevere pain; as adjunct to treat pulmonaryedema caused by left-sided heartfailure; to supplement general, local, orregional anesthesiaCAPSULES, ORAL SOLUTION, SYRUP, TABLETSAdults. Initial: 10 to 30 mg every 4 hr, p.r.n.Children. Individualized dosage based onpatient’s age, size, and need.I.V. INFUSIONAdults. Initial: 15 mg (or more) followedby 0.8 to 10 mg/hr, increased as needed foreffectiveness. Maintenance: 0.8 to 80 mg/hr.Children. 0.01 to 0.04 mg/kg/hr postoperatively,0.025 to 2.6 mg/kg/hr for severechronic cancer pain, or 0.03 to 0.15 mg/kg/hr for sickle cell crisis.Neonates. Initial: 0.010 mg/kg/hr (10 mcg/kg/hr) postoperatively. Maintenance: 0.015 to0.02 mg/kg/hr (15 to 20 mcg/kg/hr).I.V. INJECTIONAdults. 2.5 to 15 mg injected slowly.Children. 0.5 to 0.1 mg/kg given slowly.I.M. OR SUBCUTANEOUS INJECTIONAdults. Initial: 10 mg (based on 70-kg[154-lb] adult) every 4 hr. Maintenance:5 to 20 mg.Children. Initial: 0.1 to 0.2 mg/kg every4hr.Maximum: 15 mg/dose.EPIDURAL INFUSION (PRESERVATIVE-FREE)Adults. Initial: 2 to 4 mg/24 hr, increasedby 1 to 2 mg/24 hr, as directed.EPIDURAL INJECTION (PRESERVATIVE-FREE)Adults. Initial: 5 mg into lumbar region. Ifpain isn’t relieved after 1 hr, 1- to 2-mgdoses given at appropriate intervals torelieve pain. Maximum: 10 mg/24 hr.INTRATHECAL INJECTION (PRESERVATIVE-FREE)Adults. 0.2 to 1 mg as a single dose.SUPPOSITORIESAdults. 10 to 30 mg every 4 hr, p.r.n.Children. Individualized dosage based onpatient’s age, size, and need. To relieve chronic moderate to severepain that requires opioids for more thana few daysE.R CAPSULESAdults. Individualized dosage given every12 to 24 hr.E.R. TABLETSAdults. 30 mg every 12 hr. Dosageincreased based on patient’s response. To relieve MI pain

I.V. INJECTIONAdults. 1 to 4 mg by slow I.V. injection.Repeated up to every 5 min, if needed.Maximum: 2 to 15 mg. To provide preoperative analgesiaI.M. OR SUBCUTANEOUS INJECTIONAdults. 5 to 20 mg given 45 to 60 minbefore surgery.Children. 0.05 to 0.1 mg/kg given 45 to60 min before surgery. Maximum: 10 mg. To provide analgesia during laborI.M. OR SUBCUTANEOUS INJECTIONAdults. 10 mg, with subsequent doses basedon patient’s response.Route Onset Peak DurationP.O. Unknown 1–2 hr 4–5 hrP.O. (E.R.) Unknown Unknown 8–12 hrI.V. Unknown 20 min 4–5 hrI.M. 10–30 min 30–60 min 4–5 hrSubQ 10–30 min 50–90 min 4–5 hrEpidural 15–60 min Unknown Up to 24 hrIntrathecal 15–60 min Unknown Up to 24 hrP.R. 20–60 min Unknown UnknownMechanism of ActionBinds with and activates opioid receptors(mainly mu receptors) in brain and spinalcord to produce analgesia and euphoria.morphine sulfate 699ContraindicationsFor all drug forms: Asthma, hypersensitivityto morphine or its components, labor (prematuredelivery), prematurity (in infants),respiratory depression, upper airwayobstructionFor oral solution: Acute abdominal disorders,acute alcoholism, alcohol withdrawalsyndrome, arrhythmias, brain tumor, headinjuries, heart failure caused by chroniclung disease, increased intracranial orcerebrospinal pressure, recent biliary tractsurgery, respiratory insufficiency, seizuredisorders, severe CNS depression, surgicalanastomosis, use within 14 days of an MAOinhibitorFor I.V., I.M., or subcutaneous injection:Acute alcoholism, alcohol withdrawal syndrome,arrhythmias, brain tumor, heartfailure caused by chronic lung disease,seizure disordersFor epidural or intrathecal injection: Anticoagulanttherapy, bleeding tendency, injectionsite infection, parenteral corticosteroidtreatment (or other treatment or conditionthat prohibits drug delivery by intrathecalor epidural route) within 2 weeksInteractionsDRUGSamitriptyline, clomipramine, nortriptyline:Increased CNS and respiratory depressionanticholinergics: Possibly severe constipationleading to ileus, urine retentionantidiarrheals (such as loperamide and paregoric):CNS depression, possibly severe constipationantihistamines, chloral hydrate, glutethimide,MAO inhibitors, methocarbamol: IncreasedCNS and respiratory depressant effectsantihypertensives, hypotension-producingdrugs: Increased hypotension, risk of orthostatichypotensionbupivacaine: Increased serum morphinelevel and possibly significant adverse effectsbuprenorphine: Decreased therapeuticeffects of morphine, increased respiratorydepression, possibly withdrawal symptomscimetidine: Increased analgesic and CNSand respiratory depressant effectsCNS depressants (antiemetics, general anesthetics,hypnotics, phenothiazines, sedatives,tranquilizers): Possibly coma, hypotension,respiratory depression, severe sedationdiuretics: Decreased diuretic efficacyhydroxyzine: Increased analgesic, CNSdepressant, and hypotensive effects of morphinemetoclopramide: Possibly antagonizedmetoclopramide effect on GI motilitymixed agonist-antagonist analgesics: Possiblywithdrawal symptomsnaloxone: Antagonized analgesic and CNSand respiratory depressant effects of morphine,possibly withdrawal symptomsnaltrexone: Possibly induction or worseningof withdrawal symptoms if morphine givenwithin 7 to 10 days before naltrexoneneuromuscular blockers: Increased or prolongedrespiratory depressionopioid analgesics (such as alfentanil and sufentanil):Increased CNS and respiratorydepression, increased hypotensionzidovudine: Decreased zidovudine clearanceACTIVITIESalcohol use: Increased CNS and respiratorydepression, increased hypotensionM

700release form and then switch to E.R. formif therapy must last longer than a few days.• Keep in mind that when morphine isgiven by epidural route, dosage must beindividualized according to patient’s age,body mass, physical status, previous experiencewith opioids, risk factors for respiratorydepression, and drugs to be coadministeredbefore or during surgery.• Give oral form with food or milk to minimizeadverse GI reactions, if needed.Solution can be mixed with fruit juice toimprove taste.• If needed, open E.R. capsules and sprinklecontents on applesauce (at room temperatureor cooler) just before giving topatient. Make sure patient doesn’t chew orcrush capsules or dissolve capsule’s pelletsin his mouth.• Be aware that E.R. forms of morphinearen’t interchangeable.• Discard injection solution that is discoloredor darker than pale yellow or thatcontains precipitates that don’t dissolvewith shaking.WARNING Don’t use highly concentratedsolutions (such as 10 to 25 mg/ml) for single-doseI.V., I.M., or subcutaneousadministration. These solutions areintended for use in continuous, controlledmicroinfusion devices.• For direct I.V. injection, dilute appropriatedose with 4 to 5 ml of sterile water forinjection. Inject 2.5 to 15 mg directly intotubing of free-flowing I.V. solution over 4to 5 minutes. Rapid I.V. injection mayincrease adverse reactions.• For continuous I.V. infusion, dilute drugin D 5 W and administer with infusioncontroldevice. Adjust dose and rate basedon patient response, as prescribed.• Avoid I.M. route for long-term therapybecause of injection site irritation.• During subcutaneous injection, take careto avoid injecting drug intradermally.• For intrathecal injection, expect prescriberto give no more than 2 ml of 0.5-mg/mlsolution or 1 ml of 1-mg/ml solution.Expect intrathecal dosage to be about onetenthof epidural dosage.• If rectal suppository is too soft to insert,refrigerate for 30 minutes or run wrappedsuppository under cold tap water.WARNING Monitor respiratory and cardiomorphinesulfateAdverse ReactionsCNS: Amnesia, anxiety, coma, confusion,decreased concentration, delirium, delusions,depression, dizziness, drowsiness,euphoria, fever, hallucinations, headache,insomnia, lethargy, light-headedness,malaise, psychosis, restlessness, sedation,seizures, syncope, tremor, unarousable,unresponsivenessCV: Bradycardia, cardiac arrest, hypotension,orthostatic hypotension, palpitations,shock, tachycardiaEENT: Blurred vision, diplopia, dry mouth,laryngeal edema or laryngospasm (allergic),miosis, nystagmus, rhinitisGI: Abdominal cramps or pain, anorexia,biliary tract spasm, constipation, diarrhea,dysphagia, elevated liver function testresults, gastroesophageal reflux, hiccups,ileus and toxic megacolon (in patients withinflammatory bowel disease), intestinalobstruction, indigestion, nausea, vomitingGU: Decreased ejaculate potency, decreasedlibido, difficult ejaculation, impotence,menstrual irregularities, oliguria, prolongedlabor, urinary hesitancy, urine retentionHEME: Anemia, leukopenia, thrombocytopeniaMS: ArthralgiaRESP: Apnea, asthma exacerbation, atelectasis,bronchospasm, depressed coughreflex, hypoventilation, pulmonary edema,respiratory arrest and depression, wheezingSKIN: Diaphoresis, flushing, pallor, pruritus,urticariaOther: Allergic reaction; anaphylaxis; facialedema; injection site edema, pain, rash, orredness; physical and psychological dependence;withdrawal symptomsNursing Considerations• Use cautiously in patients about to undergosurgery of the biliary tract and patientswith acute pancreatitis secondary to biliarytract disease because morphine maycause spasm of the sphincter of Oddi.• Store morphine at room temperature.• Before giving morphine, make sure opioidantagonist and equipment for oxygendelivery and respiration are available.• Before therapy, assess patient’s drug use,including all prescription and OTC drugs.• Expect prescriber to start patient who hasnever received opioids on immediate-

vascular status carefully and frequentlyduring morphine therapy. Be alert for respiratorydepression and hypotension.• Monitor patient with seizure disorder forincreased seizure activity because morphinemay worsen the disorder.• Monitor patient for excessive or persistentsedation; dosage may need to be adjusted.• If patient is receiving a continuous morphineinfusion, watch for and notify prescriberabout new neurologic signs orsymptoms. Inflammatory masses (such asgranulomas) have caused serious neurologicreactions, including paralysis.• Expect morphine to cause physical andpsychological dependence; watch for drugtolerance and withdrawal, such as bodyaches, diaphoresis, diarrhea, fever, piloerection,rhinorrhea, sneezing, and yawning.• If tolerance to morphine develops, expectprescriber to increase dosage.• Morphine may have a prolonged durationand cumulative effect in patients withimpaired hepatic or renal function. It alsomay prolong labor by reducing strength,duration, and frequency of uterine contractions.• When discontinuing morphine in patientsreceiving more than 30 mg daily, expectprescriber to reduce daily dose by aboutone-half for 2 days and then by 25% every2 days thereafter until total dose reachesinitial amount recommended for patientswho haven’t received opioids (15 to 30 mgdaily). This regimen minimizes the risk ofwithdrawal symptoms.PATIENT TEACHING• Instruct patient to take morphine exactlyas prescribed and not to change dosagewithout consulting prescriber.• Explain that patient may take tablets orcapsules with food or milk to relieve GIdistress and may mix oral solution withjuice to improve taste.• Urge patient not to break, chew, or crushE.R. capsules and tablets to avoid rapidrelease and, possibly, toxicity.• For patient who has difficulty swallowing,suggest that he open E.R. capsules andsprinkle contents on food or liquids. Urgehim to take drug immediately and not letcapsule contents dissolve in his mouth.• Instruct patient to moisten rectal suppositorybefore inserting it.moxifloxacin hydrochloride 701• Urge patient to avoid alcohol and otherCNS depressants during therapy.• Advise patient to avoid potentially hazardousactivities during morphine therapy.• Tell patient to change positions slowly tominimize the orthostatic hypotension.• Instruct patient to notify prescriber aboutworsening or breakthrough pain.• Explain that morphine may be habitforming.Urge him to notify prescriber ifhe experiences anxiety, decreased appetite,excessive tearing, irritability, muscle achesor twitching, rapid heart rate, or yawning.• Advise female patient to notify prescriberif she becomes pregnant. Regular morphineuse during pregnancy may causephysical dependence in fetus and withdrawalin neonate.moxifloxacinhydrochlorideAvelox, Avelox IVClass and CategoryChemical class: FluoroquinoloneTherapeutic class: AntibioticPregnancy category: CIndications and Dosages To treat acute sinusitis caused byHaemophilus influenzae, Moraxellacatarrhalis, or Streptococcus pneumoniae;to treat mild to moderate community-acquiredpneumonia caused byChlamydia pneumoniae, H. influenzae,M. catarrhalis, Mycoplasma pneumoniae,or S. pneumoniae (including penicillin-or multi-drug–resistant strains)TABLETS, I.V. INFUSIONAdults. 400 mg every 24 hr for 10 days. To treat acute exacerbation of chronicbronchitis caused by H. influenzae, H.parainfluenzae, Klebsiella pneumoniae,M. catarrhalis, S. pneumoniae, orStaphylococcus aureusTABLETS, I.V. INFUSIONAdults. 400 mg every 24 hr for 5 days. To treat uncomplicated skin and softtissueinfections caused by S. aureus orStreptococcus pyogenesTABLETS, I.V. INFUSIONAdults. 400 mg every 24 hr for 7 days.M

702Nursing Considerations• Use cautiously in patients with liver dysfunction,including cirrhosis, because drugmay adversely affect liver function.• Obtain a fluid or tissue specimen for cultureand sensitivity, as ordered. Expect tobegin therapy before results are available.WARNING Before starting moxifloxacin therapy,determine if patient takes a class IAantiarrhythmic, such as quinidine; a classIII antiarrhythmic, such as sotalol; orother drugs that prolong the QTc interval,such as antipsychotics, cisapride, erythromycin,or tricyclic antidepressants. Thesedrugs should be avoided in patients takingmoxifloxacin because they may prolongthe QTc interval and lead to life-threateningventricular tachycardia or torsades depointes. Monitor patient closely throughouttherapy, especially if he has significantbradycardia or acute myocardial ischemiabecause these conditions increase risk ofprolonging the QTc interval.• Infuse drug over 60 minutes with readymoxifloxacinhydrochloride To treat complicated skin and skin structureinfections caused by S. aureus, E.coli, K. pneumoniae, or EnterobactercloacaeTABLETS, I.V. INFUSIONAdults. 400 mg every 24 hr for 7 to 21 days. To treat complicated intra-abdominalinfections, including polymicrobial infectionssuch as abscesses caused by E.coli,Bacteroides fragilis, Streptococcusanginosus, Streptococcus constellatus,Enterococcus faecalis, Proteusmirabilis, Clostridium perfringens,Bacteroides thetaiotaomicron, orPeptostreptococcus speciesTABLETS, I.V. INFUSIONAdults. 400 mg every 24 hr for 5 to 14 dayswith initial dosage given as I.V. infusion.Mechanism of ActionInhibits synthesis of bacterial enzyme DNAgyrase by counteracting excessive supercoilingof DNA during replication or transcription.Inhibiting DNA gyrase causes rapidandslow-growing bacterial cells to die.IncompatibilitiesDon;t infuse I.V. moxifloxacin simultaneouslythrough the same I.V. line with otherI.V. substances, additives, or drugs.ContraindicationsHypersensitivity to moxifloxacin, other fluoroquinolones,or their componentsInteractionsDRUGSaluminum- or magnesium-containingantacids; drug formulations with divalent ortrivalent cations, such as didanosine chewablebuffered tablets or powder for oral solution;metal cations, such as iron; multivitaminscontaining iron or zinc; sucralfate:Possibly substantial interference with moxifloxacinabsorption, causing low bloodmoxifloxacin levelclass IA antiarrhythmics, such as quinidine;class III antiarrhythmics, such as sotalol;other drugs known to prolong QTc interval,such as disopyramide and pentamidine:Possibly prolonged QTc intervalcorticosteroids: Increased risk of Achilles andother tendon rupturesNSAIDs: Increased risk of CNS stimulationand seizureswarfarin: Possibly increased anticoagulationAdverse ReactionsCNS: Abnormal gait, altered coordination,dizziness, fever, headache, psychosis, psychoticreaction, seizures, syncopeCV: Hypertension, hypotension, palpitations,peripheral edema, prolonged QTcinterval, tachycardia, vasculitis, vasodilation,ventricular tachyarrhythmiasEENT: Altered taste, laryngeal edemaGI: Abdominal pain, abnormal liver functiontest results, acute hepatic necrosis orfailure, cholestatic hepatitis, diarrhea, dyspepsia,hepatitis, jaundice, nausea,pseudomembranous colitis, vomitingGU: Acute renal insufficiency or failure,interstitial nephritisHEME: Agranulocytosis, aplastic anemia,eosinophilia, hemolytic anemia, leukopenia,pancytopenia, prolonged PT, thrombocytopeniaMS: Arthralgia, myalgia, tendon inflammation,pain, or ruptureRESP: Allergic pneumonitisSKIN: Photosensitivity, rash, Stevens-Johnson syndrome, toxic epidermal necrolysisOther: Anaphylaxis, anaphylactic shock,angioedema, serum sickness, worsening ofmyasthenia gravis

to-use flexible bags with 400 mg of moxifloxacinin 250 ml of 0.8% saline. Don’tdilute further.• If giving through Y-type tubing or piggyback,stop other solutions during moxifloxacininfusion, and flush the line beforeand after infusion with a compatible solution,such as normal saline solution, 1Msodium chloride, 5% dextrose, sterilewater for injection, 10% dextrose, or lactatedRinger’s. Also flush line before andafter giving other drugs in same I.V. line.• Don’t refrigerate I.V. moxifloxacin readyto-usebags because precipitation willoccur. Discard any unused portion; premixedbags are for single-use only.• Expect to obtain a 12-lead ECG to assesspatient for prolonged QTc interval. Askpatient if he or a blood relative has a historyof prolonged QTc interval. Monitorelderly patients closely; they may haveincreased risk of prolonged QT interval.• If patient has hypokalemia, expect to correctit before beginning moxifloxacin therapyto prevent arrhythmias.• Determine if patient has a history of CNSdisorder, such as cerebral arteriosclerosisor epilepsy, because drug may lowerseizure threshold. Notify prescriber beforestarting drug, and take seizure precautions.• If profuse, watery diarrhea develops, contactprescriber and expect to obtain a stoolspecimen to rule out pseudomembranouscolitis caused by Clostridium difficile. Ifdiarrhea occurs, notify prescriber andexpect to withhold moxifloxacin and treatwith fluids, electrolytes, protein, and anantibiotic effective against C. difficile.• Monitor serum potassium level, as ordered,during therapy to assess for hypokalemia.• Keep emergency resuscitation equipmentreadily available, and observe for evidenceof hypersensitivity, such as angioedema,dyspnea, and urticaria. If you suspect anaphylaxis,prepare to give epinephrine,corticosteroids, and diphenhydramine, asprescribed.• Monitor patients who are prone to tendinitis,such as the elderly, athletes, andthose taking corticosteroids, for complaintsof tendon pain, inflammation, orrupture. If present, notify prescriber andexpect to discontinue moxifloxacin, placepatient on bedrest with no exercise ofmycophenolate mofetil 703affected limb, and obtain diagnostic teststo confirm rupture.PATIENT TEACHING• Urge patient to notify prescriber at onceabout palpitations or fainting because theymay indicate a serious arrhythmia.• Teach patient to take drug at least 4 hoursbefore and 8 hours after aluminum- ormagnesium-containing antacids, didanosinechewable buffered tablets or oral solutionprepared from powder, multivitaminscontaining iron or zinc, or sucralfate.• Urge patient to drink plenty of fluidswhile taking moxifloxacin.• Caution patient to stop drug and notifyprescriber if he has trouble breathing, arash, or other signs of an allergic reaction.• Urge patient to stop any exercise and contactprescriber immediately if he developstendon inflammation, pain, or rupture.• Caution patient to avoid hazardous activitiesuntil adverse CNS effects are known.• Urge patient to tell prescriber if diarrheadevelops, even more than 2 months aftermoxifloxacin therapy ends.• Caution patient to complete the prescribedcourse of therapy even if he feelsbetter before it’s completed.• Tell patient to avoid excessive exposure tosunlight or artificial ultraviolet lightbecause severe sunburn may result.Instruct patient to notify prescriber if sunburndevelops because moxifloxacin mayneed to be discontinued.mycophenolatemofetilCellCept, CellCept Oral SuspensionmycophenolatemofetilhydrochlorideCellCept Intravenousmycophenolic acidMyforticClass and CategoryChemical class: 2-morpholinoethyl ester ofM

704mycophenolate mofetilmycophenolic acidTherapeutic class: ImmunosuppressantPregnancy category: DIndications and Dosages To prevent organ rejection in patientsreceiving allogenic kidney transplantsCAPSULES, ORAL SUSPENSION, TABLETS,I.V. INFUSIONAdults. 1 g (over 2 hr for I.V. infusion) b.i.d.E.R. TABLETSAdults. 720 mg b.i.d.SUSPENSIONChildren with body surface area less than1.25 m 2 . 600 mg/m2 b.i.d. Maximum: 2 g(10 ml) daily.CAPSULESChildren with body surface area of1.25 m 2 to 1.5 m 2 . 750 mg b.i.d.CAPSULES, TABLETSChildren with body surface area greaterthan 1.5 m 2 . 1 g b.i.d. To prevent organ rejection in patientsreceiving allogenic heart transplantsCAPSULES, ORAL SUSPENSION, TABLETS,I.V. INFUSIONAdults. 1.5 g (over 2 hr for I.V. infusion)b.i.d. To prevent organ rejection in patientsreceiving allogenic liver transplantsI.V. INFUSIONAdults. 1 g infused over 2 hr b.i.d.CAPSULES, ORAL SUSPENSION, TABLETSAdults. 1.5 g b.i.d.Mechanism of ActionHydrolyzes to form mycophenolic acid(MPA), which inhibits guanosine nucleotidesynthesis and proliferation of T and Blymphocytes. MPA also suppresses antibodyformation by B lymphocytes and preventsglycosylation of lymphocyte and monocyteglycoproteins involved in adhesion toendothelial cells. MPA also may inhibitleukocytes from sites of inflammation andgraft rejection, which may explain howmycophenolate mofetil prolongs allogeneictransplant survival.IncompatibilitiesDon’t mix or give mycophenolate mofetilhydrochloride in same infusion catheterwith other I.V. drugs or admixtures.ContraindicationsHypersensitivity to mycophenolate mofetil,mycophenolic acid, or any of its components;hypersensitivity to polysorbate 80(I.V. form)InteractionsDRUGSacyclovir, ganciclovir, probenecid: Increasedplasma levels of both drugsamoxicillin plus clavulanic acid, cholestyramine,cyclosporine, metronidazole, norfloxacin,rifampin: Decreased plasma levelof mycophenolate mofetilantacids with magnesium and aluminumhydroxides, sevelamer: Decreased absorptionof oral mycophenolate mofetilazathioprine: Increased bone marrow suppressionlive vaccines: Decreased effectiveness of livevaccinesoral contraceptives: Possibly decreased effectivenessof oral contraceptivesAdverse ReactionsCNS: Agitation, anxiety, chills, confusion,delirium, depression, dizziness, emotionallability, fever, hallucinations, headache,hypertonia, hypesthesia, insomnia, malaise,meningitis, nervousness, neuropathy, paresthesia,progressive multifocal leukoencephalopathy,psychosis, seizure, somnolence,syncope, thinking abnormality,tremor, vertigoCV: Angina pectoris, arrhythmias, arterialthrombosis, atrial fibrillation or flutter,bradycardia, cardiac arrest, CV disorder,congestive heart failure, extrasystole, generalizededema, hemorrhage, hypercholesterolemia,hyperlipemia, hypertension,hypotension, increased lactic dehydrogenase,increased SGOT and SGPT,increased venous pressure, infectious endocarditis,orthostatic hypotension, palpitations,pericardial effusion, peripheraledema, peripheral vascular disorder, pulmonaryedema or hypertension, supraventriculartachycardia, thrombosis, vasodilation,vasospasm, ventricular extrasystole,ventricular tachycardiaEENT: Amblyopia, cataract, conjunctivitis,deafness, dry mouth, ear disorder or pain,epistaxis, eye hemorrhage, gingivitis, gumhyperplasia, lacrimation disorder, mouthulceration, oral candidiasis, pharyngitis,rhinitis, sinusitis, stomatitis, tinnitus, visionabnormality, voice alteration

ENDO: Cushing’s syndrome, diabetes mellitus,hypercalcemia, hypocalcemia, hypoglycemia,hypothyroidism, parathyroid disorderGI: Abdomen enlargement or pain, anorexia,ascites, cholangitis, cholestatic jaundice,colitis, constipation, diarrhea, dyspepsia,dysphagia, esophagitis, flatulence, gastritis,gastroenteritis, GI hemorrhage, GI infection,GI candidiasis, hepatitis, hernia, ileus,jaundice, liver damage, liver function testabnormalities, melena, nausea, pancreatitis,peritonitis, rectal disorder, stomach ulcer,vomitingGU: Albuminuria; bilirubinemia; BK virus–related nephropathy; dysuria; hematuria;hydronephrosis; impotence; increased BUNor creatinine levels; kidney tubular necrosis;nocturia; oliguria; pain; prostatic disorder;pyelonephritis; renal failure; scrotal edema,urinary tract disorder or infection; urineabnormality, frequency, incontinence, orretentionHEME: Anemia, coagulation disorder,hypochromic anemia, increased prothrombintime or thromboplastin time, leukocytosis,leukopenia, polyhemia, pure red cellaplasia, thrombocytopeniaMS: Arthralgia; back, neck or pelvic pain;joint disorder; leg cramps; myalgia; myasthenia;osteoporosisRESP: Apnea; asthma; atelectasis; bronchitis;cough; dyspnea; hemoptysis; hyperventilation;hypoxia; lung edema; pleural effusion;pneumonia; pneumothorax; pulmonaryfibrosis; respiratory acidosis, candidiasis,neoplasm, or pain; sputumincreaseSKIN: Abscess; acne; cellulite; ecchymosis;fungal dermatitis; pallor; petechia; pruritus;rash; benign neoplasm, carcinoma, hypertrophy,or ulcer; sweating; vesiculobullousrashOther: Abnormal healing, accidental injury,acidosis, activation of latent infections(such as tuberculosis), alkalosis, alopecia,cyst, dehydration, facial edema, flulike syndrome,gout, hiccup, hirsutism, hyperkalemia,hyperuricemia, hypervolemia,hypochloremia, hypokalemia, hypomagnesemia,hyponatremia, hypoproteinemia,hypophosphatemia, increased alkalinephosphatase, increased gamma glutamyltranspeptidase, infection, lymphoma,mycophenolate mofetil 705malignancies, sepsis, thirst, weight gain orlossNursing Considerations• Before starting mycophentolate therapy ina woman of childbearing potential, makesure she has a negative pregnancy testwithin 1 week of starting therapy, using atest with a sensitivity of at least 25 mIU/ml. Therapy shouldn’t start until resultsare confirmed.• Expect to give I.V. form within 24 hours oftransplantation and for no longer than14 days. Expect to switch patient to oralform as soon as possible, as ordered.• Expect to administer oral form of drug assoon as possible following transplantation.• When preparing oral suspension or I.V.form, avoid inhalation or direct contactwith skin or mucous membranes. If contactoccurs, wash area thoroughly withsoap and water and rinse eyes with water.• To prepare oral suspension, tap closedbottle several times to loosen powder andthen measure 94 ml of water in a graduatedcylinder. Add half of the water to thebottle and shake for about 1 minute. Thenadd reminder of water and shake again for1 minute. Remove child-resistant cap andpush bottle adapter into neck of bottle.Close bottle tightly with child-resistantcap. Be aware that the suspension bottlemay become cold immediately after reconstitution.• Know that oral suspension can be administeredby 8F or larger nasogastric tube.• When giving oral suspension, don’t mixwith any other drugs. Ask patient abouthistory of phenylketonuria before initialadministration because oral suspensioncontains aspartame.• Don’t open or crush capsules. If necessary,use the oral suspension.• Handle I.V. form similarly to a chemotherapeuticdrug because mycophenolatemofetil is genotoxic and embryotoxic andmay have mutagenic properties.• Know that I.V. form must be reconstitutedand diluted to 6 mg/ml using 5% dextroseinjection USP. Inject 14 ml 5% dextroseinjection USP into each vial (2 vials willbe needed for each 1-g dose; 3 vials foreach 1.5-g dose), then shake gently.Further dilute a 1-g dose by addingM

706mycophenolate mofetil2 reconstituted vials to 140 ml of 5% dextroseinjection USP; dilute a 1.5-g dose byadding 3 reconstituted vials to 210 ml of5% dextrose injection USP.• Be aware that I.V. form should be administeredwithin 4 hours of constitution asan infusion and over no less than 2 hours.Never administer by rapid or bolus I.V.injection.• Know that cyclosporine and corticosteroidsshould be used with mycophenolatemofetil therapy.• Obtain CBC weekly during first month oftherapy, twice monthly for the second andthird months of therapy, and then monthlythrough the first year, as ordered.• Monitor patient closely for adverse reactionsbecause drug has many adverseeffects, some of which can be serious orsevere.• Expect to stop drug or reduce the doseand provide supportive care, as ordered, ifneutropenia develops.WARNING Mycophenolate mofetil therapyhas been associated with progressive multifocalleukoencephalopathy that can belife-threatening. Monitor patient for hemiparesis,apathy, confusion, cognitive deficiencies,and ataxia. Report suspicions ofdisorder immediately to prescriber.PATIENT TEACHING• Advise women of childbearing age thattwo forms of contraceptives should beused simultaneously before beginningmycophenolate mofetil therapy and for 6weeks following discontinuation of therapybecause of potential for fetal harm.Inform women who use oral contraceptivesthat drug may decrease effectivenessof oral contraceptives. Urge patient tonotify prescriber immediately if pregnancyoccurs.• Before therapy starts, tell patient aboutincreased risk of lymphomas or othermalignancies. Tell patient to report anyunusual signs or symptoms to prescriber.• Tell patient to take oral form of drug onan empty stomach.• Inform patient prescribed oral suspensionthat it contains aspartame, which is asource of phenylalanine.• Instruct patient not to crush tablets orcapsules or open capsules.• Inform patient not to receive live vaccinesduring therapy. Urge him to avoid peoplewho have received such vaccines or towear a protective mask when he’s aroundthem.• Tell patient to report any serious or ongoingadverse reactions, especially neurologicabnormalities, to prescriber immediately.• Caution patient to avoid contact with peoplewho have infections because drugcauses immunosuppression.• Urge patient to report any signs of infection,unexpected bruising or bleeding, orany other sign of bone marrow depressionimmediately.• Tell patient that frequent laboratory testsmay be needed during therapy. Stress thathaving these tests done is essential to continuingtherapy.• Advise patient to avoid exposure to directsunlight and UV light and to wear sunscreenwhen outdoors because ofincreased risk for skin cancer.• Advise patient not to take antacids at thesame time as oral mycophenolate mofetilbecause some antacids can decrease drug’sabsorption.• Tell patient to report unusual tiredness,lack of energy, paleness, dizziness, or faintingbecause dosage may need to bereduced or drug discontinued.• Stress importance of follow-up care tomonitor the drug’s effectiveness and possibleadverse effects because of the increasedrisk for cancer and infections as a result ofimmunosuppression. Inform patient ofthe need for periodic laboratory tests.

N OnabumetoneRelafenClass and CategoryChemical class: Naphthylalkanone derivativeTherapeutic class: Anti-inflammatory,antirheumaticPregnancy category: C (first trimester), Notrated (later trimesters)Indications and Dosages To relieve symptoms of acute and chronicosteoarthritis and rheumatoid arthritisTABLETSAdults. Initial: 1 g daily as a single dose orin divided doses b.i.d., increased to 1.5 to2 g daily in divided doses b.i.d.Maintenance: Adjusted according to clinicalresponse. Maximum: 2 g daily.Mechanism of ActionBlocks activity of cyclooxygenase, theenzyme needed to synthesize prostaglandins,which mediate the inflammatoryresponse and cause local vasodilation,swelling, and pain. Prostaglandins also promotepain transmission from periphery tospinal cord. By blocking cyclooxygenaseand inhibiting prostaglandins, the NSAIDnabumetone reduces inflammatory symptomsand relieves pain.ContraindicationsAngioedema, asthma, bronchospasm, nasalpolyps, rhinitis, or urticaria induced byaspirin, iodides, or other NSAIDsInteractionsDRUGSacetaminophen (long-term use): Increasedrisk of adverse renal effectsanticoagulants, thrombolytics: Increased riskof GI bleedingantihypertensives: Decreased antihypertensiveeffectivenessbeta blockers: Decreased antihypertensiveeffects of beta blockersbone marrow depressants, such as aldesleukinand cisplatin: Increased risk of leukopeniaand thrombocytopenianabumetone 707cefamandole, cefoperazone, cefotetan, plicamycin,valproic acid: Increased risk of hypoprothrombinemiaand bleedingcolchicine, other NSAIDs, salicylates:Increased GI irritability and bleedingcyclosporine, gold compounds, nephrotoxicdrugs: Increased risk of nephrotoxicitydigoxin: Increased blood digoxin level andrisk of digitalis toxicitydiuretics: Decreased diuretic effectivenessglucocorticoids, potassium supplements:Increased GI irritability and bleedinginsulin, oral antidiabetic drugs: Increasedeffects of these drugs; risk of hypoglycemialithium: Increased risk of lithium toxicitymethotrexate: Increased risk of methotrexatetoxicityprobenecid: Increased risk of nabumetonetoxicityACTIVITIESalcohol use: Increased GI irritability andbleedingAdverse ReactionsCNS: Drowsiness, fatigue, fever, headache,nervousness, seizures, stroke, vertigoCV: Edema, hypertension, MI, tachycardiaEENT: Dry mouth, pharyngitis, stomatitis,tinnitusGI: Abdominal pain, anorexia, constipation,diarrhea, diverticulitis, dyspepsia, dysphagia,esophagitis, flatulence, gastritis, gastroenteritis,gastroesophageal reflux disease,GI bleeding and ulceration, hepatic dysfunction,indigestion, jaundice, melena,nausea, perforation of stomach or intestines,stomatitis, vomitingGU: Albuminuria, azotemia, interstitial nephritis,nephrotic syndromeHEME: Agranulocytosis, anemia,eosinophilia, granulocytopenia, hemolyticanemia, leukopenia, neutropenia, pancytopenia,thrombocytopeniaMS: Muscle spasms, myalgiaRESP: Asthma, pneumonitis, respiratorydepressionSKIN: Alopecia, erythema multiforme,photosensitivity, pruritus, rash, Stevens-Johnson syndrome, toxic epidermal necrolysisOther: Anaphylaxis, angioedemaNursing Considerations• Use nabumetone with extreme caution inpatients with a history of ulcer disease orNO

708nadololGI bleeding because NSAIDs such asnabumetone increase risk of GI bleedingand ulceration. Expect to use nabumetonefor shortest time possible in these patients.• Be aware that serious GI tract ulceration,bleeding, and perforation may occur withoutwarning symptoms. Elderly patientsare at greater risk. To minimize risk, givedrug with food. If GI distress occurs, withholddrug and notify prescriber immediately.• Use nabumetone cautiously in patientswith hypertension, and monitor bloodpressure closely throughout therapy. Drugmay cause hypertension or worsen it.WARNING Monitor patient closely forthrombotic events, including MI andstroke, because NSAIDs increase the risk.• Monitor patient—especially if elderly orreceiving long-term nabumetone therapy—forless common but serious adverseGI reactions, including anorexia, constipation,diverticulitis, dysphagia, esophagitis,gastritis, gastroenteritis, gastroesophagealreflux disease, hemorrhoids, hiatal hernia,melena, stomatitis, and vomiting.• Monitor liver function test results because,rarely, elevations may progress to severehepatic reactions, including fatal hepatitis,liver necrosis, and hepatic failure.• Monitor BUN and serum creatinine levelsin elderly patients, patients taking diureticsor ACE inhibitors, and patients withheart failure, impaired renal function, orhepatic dysfunction; nabumetone maycause renal failure.• Monitor CBC for decreased hemoglobinand hematocrit; drug may worsen anemia.WARNING If patient has bone marrow suppressionor is receiving treatment with anantineoplastic, monitor laboratory results(including WBC count), and watch forevidence of infection because antiinflammatoryand antipyretic actions ofnabumetone may mask signs and symptoms,such as fever and pain.• Assess patient’s skin regularly for signs ofrash or other hypersensitivity reactionbecause nabumetone is an NSAID andmay cause serious skin reactions withoutwarning, even in patients with no historyof NSAID sensivitity. At first sign of reaction,stop drug and notify prescriber.• Assess patient for severe hepatic reactions,including jaundice. Stop drug, as prescribed,if symptoms persist.PATIENT TEACHING• Instruct patient to take nabumetone withfood to reduce GI distress.• Advise patient to take drug with a fullglass of water and to remain upright for15 to 30 minutes afterward to preventdrug from lodging in esophagus and causingirritation.• Tell patient not to increase dose or frequencywithout consulting prescriber.• Urge patient to avoid alcohol to reducerisk of GI bleeding.• Inform patient that regular laboratorytests are needed to check for drug toxicityduring long-term therapy.• Caution pregnant patient not to takeNSAIDs such as nabumetone during thelast trimester because they may cause prematureclosure of the ductus arteriosus.• Explain that nabumetone may increase therisk of serious adverse cardiovascular reactions;urge patient to seek immediatemedical attention if signs or symptomsarise, such as chest pain, shortness ofbreath, weakness, and slurring of speech.• Explain that nabumetone may increase therisk of serious adverse GI reactions; stressthe importance of seeking immediatemedical attention for such signs andsymptoms as epigastric or abdominalpain, indigestion, black or tarry stools, orvomiting blood or material that looks likecoffee grounds.• Alert patient to rare but serious skin reactions.Urge her to seek immediate medicalattention for rash, blisters, itching, fever,or other indications of hypersensitivity.nadololCorgard, Syn-Nadolol (CAN)Class and CategoryChemical class: Nonselective beta blockerTherapeutic class: Antianginal, antihypertensivePregnancy category: CIndications and Dosages To manage hypertension, alone or withother antihypertensives

TABLETSAdults. Initial: 40 mg daily, increased by40 to 80 mg daily every 7 days, as prescribed.Maintenance: 40 to 80 mg daily.Maximum: 320 mg daily. To manage angina pectoris as long-termtherapyTABLETSAdults. Initial: 40 mg daily, increased by40 to 80 mg daily every 3 to 7 days, as prescribed.Maintenance: 40 to 80 mg daily.Maximum: 240 mg daily.DOSAGE ADJUSTMENT Interval possiblyincreased to every 24 to 36 hr if creatinineclearance is 31 to 50 ml/min/1.73 m 2 ;toevery 24 to 48 hr if it’s 10 to 30 ml/min/1.73 m 2 ; or to every 40 to 60 hr if it’s lessthan 10 ml/min/1.73 m 2 .Route Onset Peak DurationP.O. Up to 5 days 4 hr 24 hrMechanism of ActionSelectively blocks alpha 1 and beta 2 receptorsin vascular smooth muscle and beta 1 receptorsin the heart, thereby reducing peripheralvascular resistance and blood pressure.Potent beta blockade decreases cardiacexcitability, cardiac output, and myocardialoxygen demand, thus reducing angina. Italso prevents reflex tachycardia, which typicallyoccurs with most alpha blockers.ContraindicationsAsthma; bronchospasm; cardiogenic shock;heart failure; hypersensitivity to nadolol,other beta blockers, or their components;second- or third-degree AV block; severeCOPD; sinus bradycardiaInteractionsDRUGSallergen immunotherapy, allergenic extractsfor skin testing: Increased risk of serious systemicreactions or anaphylaxisamiodarone: Increased risk of conductionabnormalities and negative inotropic effectsbeta blockers, digoxin: Increased risk ofbradycardiacalcium channel blockers: Increased risk ofbradycardiacimetidine: Possibly increased effects ofnadololclonidine, guanabenz: Impaired blood pressurecontrolnadolol 709diazoxide, nitroglycerin: Increased risk ofhypotensionestrogens, NSAIDs: Possibly reduced antihypertensiveeffect of nadololgeneral anesthetics: Increased risk of hypotensionand myocardial depressioninsulin, oral antidiabetic drugs: Possiblyincreased risk of hyperglycemia andimpaired recovery from hypoglycemia,masking of signs of hypoglycemialidocaine: Increased risk of lidocaine toxicityneuromuscular blockers: Possibly prolongedaction of these drugsphenothiazines: Possibly increased bloodlevels of both drugsreserpine: Increased risk of bradycardia andhypotensionsympathomimetics with alpha- and betaadrenergiceffects, such as pseudoephedrine:Possibly hypertension, excessive bradycardia,and heart blockxanthines, such as theophyllines: Possiblydecreased therapeutic effects of both drugsAdverse ReactionsCNS: Anxiety, depression, dizziness, drowsiness,fatigue, headache, paresthesia, syncope,vertigo, weakness, yawningCV: Bradycardia, chest pain, edema, heartblock, heart failure, hypotension, orthostatichypotension, ventricular arrhythmiasEENT: Nasal congestion, taste perversionGI: Dyspepsia, elevated liver function testresults, hepatic necrosis, hepatitis, nausea,vomitingGU: Ejaculation failure, impotenceRESP: Cough, dyspnea, wheezingSKIN: Jaundice, pruritus, scalp tinglingNursing Complications• Use nadolol cautiously in patients withdiabetes mellitus because it may prolongor worsen hypoglycemia by interferingwith glycogenolysis.• Anticipate that drug may worsen psoriasisand, in patients with myasthenia gravis,muscle weakness and diplopia.WARNING Withdraw drug gradually over2 weeks, or as ordered, to avoid MI causedby unopposed beta stimulation or thyroidstorm caused by underlying hyperthyroidism.Expect drug to mask tachycardiacaused by hyperthyroidism.PATIENT TEACHING• Teach patient how to take her radial pulse,NO

710Nursing Considerations• Be aware that pregnancy must be ruledout before nafarelin therapy starts andthat drug isn’t recommended for use bybreastfeeding women.• Expect to start treatment for endometriosisbetween days 2 and 4 of menstrualcycle. Menses should cease after 6 weeks oftreatment. Continued menses may indinafarelinacetateand direct her to do so before each dose ofnadolol.• Instruct patient to notify prescriber ifpulse rate falls below 60 beats/minute.• Caution patient not to stop taking nadololabruptly or change dosage. Tell her to takea missed dose as soon as possible unlessit’s within 8 hours of the next scheduleddose.• Advise patient with diabetes to checkblood glucose level often because nadololmay mask signs of hypoglycemia, such astachycardia.• Review signs of impending heart failure,and urge patient to notify prescriberimmediately if they occur.nafarelin acetateSynarelClass and CategoryChemical class: Decapeptide, gonadotropinreleasinghormone analogueTherapeutic class: Antiendometriotic,gonadal hormone inhibitorPregnancy category: XIndications and Dosages To treat endometriosisNASAL INHALATIONAdults. 1 spray (200 mcg) into a nostrilevery morning and 1 spray into other nostrilevery evening for up to 6 mo. If amenorrheadoesn’t occur in 2 mo, dosageincreased, as prescribed, to 800 mcg daily individed doses. To treat gonadotropin-dependent precociouspubertyNASAL INHALATIONChildren at puberty. 2 sprays (400 mcg)into each nostril every morning andevening. Maximum: 1,800 mcg daily individed doses t.i.d.Mechanism of ActionStimulates release of the gonadotropinsluteinizing hormone (LH) and folliclestimulatinghormone (FSH), which temporarilyincrease ovarian steroidogenesis.Within 1 month, however, repeated administrationof nafarelin halts pituitary glandstimulation and decreases LH and FSHsecretion. This action decreases estrogenlevel, which improves symptoms ofendometriosis. In children, repeated nafarelinadministration returns LH and FSH toprepubescent levels, stopping developmentof secondary sex characteristics and slowingbone growth.Route Onset Peak DurationNasal 60–120 20 days† 3–6 mo†days*ContraindicationsBreast-feeding; hypersensitivity to gonadotropin-releasinghormones, gonadotropinreleasinghormone analogues, nafarelin, ortheir components; pregnancy; undiagnosedvaginal bleedingInteractionsDRUGSnasal decongestants: Possibly impaired nafarelinabsorptionAdverse ReactionsCNS: Asthenia, depression, fever, headache,mood changes, paresthesiaCV: Chest pain, edema, hot flashes, palpitationsEENT: Eye pain, rhinitisENDO: Galactorrhea, gynecomastia, transientincrease in pubic hair growthGU: Hypermenorrhea, hypertrophy offemale genitalia, impotence, libido changes,menstrual irregularities, ovarian cysts, uterinebleeding, vaginal dryness, vaginal spottingbetween mensesMS: Arthralgia, decreased bone density,myalgiaRESP: DyspneaSKIN: Acne, hirsutism, rash, seborrhea,skin discoloration (brown)Other: Body odor* For gonadal hormone inhibitor effects,4 wk.† For antiendometriotic effects.

cate lack of compliance.• Be aware that bone loss may increase ifendometriosis treatment lasts longer than6 months. Safety of retreatment after6 months is unknown.• Avoid giving nasal decongestant within2 hours after nafarelin because it mayimpair nafarelin absorption.• Be aware that prescriber will regularlymonitor serum hormone levels in patientwith gonadotropin-dependent precociouspuberty, especially during first 6 to8 weeks of therapy, to ensure rapid suppressionof pituitary function.PATIENT TEACHING• Instruct patient to comply with prescriber’sinstructions for administeringnafarelin to obtain desired drug effects.• Instruct patient to tilt her head back whileadministering nafarelin to enhanceabsorption; urge her to try not to sneezeafterward.• Caution patient not to change dosagewithout consulting prescriber.• Counsel patient to use nonhormonal contraceptionand to notify prescriber if she isor could be pregnant.• Direct patient not to use nasal decongestantwithin 2 hours after using nafarelin. Ifrhinitis occurs, urge her to contact prescriberfor instructions.• Teach patient how to cope with adversereactions to help maximize compliance.• Inform patient with endometriosis thatdrug should cause menses to stop. Urgeher to notify prescriber if periods fail tostop even though she’s taking drug exactlyas prescribed.• Advise patient with endometriosis to avoidalcohol and tobacco during therapybecause they increase bone loss.• Inform patient with gonadotropin-dependentprecocious puberty that signs ofpuberty will persist during first month oftreatment. If they don’t resolve within2 months, advise patient or parents tonotify prescriber.• Tell patient with gonadotropin-dependentprecocious puberty that prescriber willassess bone growth velocity and bone ageduring first 3 to 6 months of therapy.• Reassure parents of child with precociouspuberty that child will resume growingwhen treatment stops.nafcillin sodiumNafcil, Nallpen, UnipenClass and CategoryChemical class: PenicillinTherapeutic class: AntibioticPregnancy category: Bnafcillin sodium 711Indications and Dosages To treat infections caused by penicillinase-producingStaphylococcus aureusCAPSULES, TABLETSAdults and adolescents. 250 to 1,000 mgevery 4 to 6 hr. Maximum: 6,000 mg daily.Children over age 1 month. 6.25 to12.5 mg/kg every 6 hr.Neonates. 10 mg/kg every 6 to 8 hr.I.V. INFUSIONAdults and adolescents. 500 to 1,500 mgevery 4 hr. Maximum: 20,000 mg daily.Children from birth to age 12. 10 to 20 mg/kg every 4 hr, or 20 to 40 mg/kg every 8 hr.I.M. INJECTIONAdults and adolescents. 500 mg every 4 to6hr.Maximum: 12,000 mg daily.Children over age 1 month. 25 mg/kg every12 hr.Neonates. 10 mg/kg every 12 hr. To treat streptococcal pharyngitisCAPSULES, TABLETSChildren. 250 mg every 8 hr. To treat bone and joint infections, endocarditis,meningitis, and pericarditiscaused by susceptible organismsI.V. INFUSIONAdults and adolescents. 1,500 to 2,000 mgevery 4 to 6 hr. Maximum: 20,000 mg daily.I.V. INFUSION, I.M. INJECTIONChildren from birth to age 12. 10 to 20 mg/kg every 4 hr or 20 to 40 mg/kg every 8 hr.For meningitis in neonates weighing up to2 kg (4.4 lb), 25 to 50 mg/kg every 12 hr forfirst week after birth and then 50 mg/kgevery 8 hr. For neonates weighing 2 kg ormore, 50 mg/kg every 8 hr during first weekafter birth and then 50 mg/kg every 6 hr.Mechanism of ActionBinds to certain penicillin-binding proteinsin bacterial cell walls, thereby inhibiting thefinal stage of bacterial cell wall synthesis.The result is cell lysis. Nafcillin’s action isbolstered by its chemical composition; itsNO

712nalbuphine hydrochlorideunique side chain resists destruction bybeta-lactamases.IncompatibilitiesDon’t mix nafcillin in same I.V. bag as aminoglycosides;they’re chemically incompatible.ContraindicationsHypersensitivity to nafcillin, other penicillins,or their componentsInteractionsDRUGSaminoglycosides: Substantial mutual inactivationchloramphenicol, erythromycins, sulfonamides,tetracyclines: Possibly decreasedtherapeutic effects of nafcillinhepatotoxic drugs: Increased risk of hepatotoxicitymethotrexate: Increased risk of methotrexatetoxicityprobenecid: Increased blood nafcillin levelFOODSall foods: Decreased nafcillin absorptionAdverse ReactionsCNS: Depression, headache, seizuresEENT: Oral candidiasisGI: Abdominal pain, diarrhea, nausea,pseudomembranous colitis, vomitingGU: VaginitisHEME: Leukopenia, neutropeniaSKIN: Exfoliative dermatitis, pruritus, rash,urticariaOther: Anaphylaxis; hypokalemia; injectionsite pain, redness, and swelling; serum sicknesslikereactionNursing Considerations• Obtain body fluid or tissue samples forculture and sensitivity testing, as prescribed,and obtain test results, if possible,before giving nafcillin, as ordered.• Give capsules or tablets at least 1 hourbefore meals or 2 hours afterward.• For I.M. injection, use only reconstitutedsolutions from vials. Inject deep into largemuscle, preferably upper outer quadrantof gluteus maximus or lateral thigh.• For intermittent I.V. infusion, infuse over30 to 60 minutes.• Give nafcillin at least 1 hour before orafter aminoglycosides, especially if patienthas renal disease.• When giving nafcillin to patient at risk forhypertension or fluid overload, be awarethat each gram contains 2.5 mEq sodium.WARNING Avoid giving nafcillin to prematureneonate if drug was reconstitutedwith bacteriostatic water that containsbenzyl alcohol. Doing so can cause potentiallyfatal metabolic acidosis and circulatory,CNS, renal, and respiratory dysfunction.• Monitor serum nafcillin level closely inchildren, as ordered, because liver and biliarytract, the main routes of nafcillinelimination, function immaturely in children.• Watch for evidence of superinfection, suchas oral candidiasis and pseudomembranouscolitis, especially in elderly, immunocompromised,or debilitated patients whoreceive large doses of nafcillin. If profuse,watery diarrhea develops, contact prescriberand expect to obtain a stool specimento rule out pseudomembranous colitiscaused by Clostridium difficile. If diarrheaoccurs, notify prescriber and expectto withhold nafcillin and treat with fluids,electrolytes, protein, and an antibioticeffective against C. difficile.PATIENT TEACHING• Instruct patient to take nafcillin capsulesor tablets on an empty stomach.• Urge patient to complete entire prescription,even if she feels better.• Advise patient to notify prescriber if sheexperiences chills, fever, GI distress, orrash.• Urge patient to tell prescriber if diarrheadevelops, even 2 or ore months after nafcillintherapy ends.nalbuphinehydrochlorideNubainClass and CategoryChemical class: Phenanthrene derivativeTherapeutic class: Analgesic, anesthesiaadjunctPregnancy category: BIndications and Dosages To relieve moderate to severe pain

I.V., I.M., OR SUBCUTANEOUS INJECTIONAdults weighing 70 kg (154 lb). 10 mgevery 3 to 6 hr, p.r.n. Dosage adjusted forpatients weighing more or less. As adjunct to anesthesiaI.V. INJECTIONAdults. 0.3 to 3 mg/kg over 10 to 15 minfollowed by 0.25 to 0.5 mg/kg, as needed.DOSAGE ADJUSTMENT For patients who haverepeatedly received an opioid agonist, initialdose possibly reduced to 25% of usual. Forpatients in whom tolerance to drug’s effectshasn’t developed, maximum usually is20 mg/dose or 160 mg daily.Route Onset Peak DurationI.V. 2–3 min 30 min 3–4 hrI.M. In 15 min 1 hr 3–6 hrSubQ In 15 min Unknown 3–6 hrMechanism of ActionBinds with and stimulates mu and kappaopiate receptors in the spinal cord andhigher levels in the CNS. In this way, nalbuphinealters the perception of and emotionalresponse to pain.IncompatibilitiesDon’t give nalbuphine with diazepam orpentobarbital. Use separate I.V. line or flushline well before and after administration.ContraindicationsHypersensitivity to nalbuphine or its componentsInteractionsDRUGSalfentanil, CNS depressants, fentanyl, sufentanil:Increased risk of hypotension andCNS and respiratory depressionanticholinergics: Increased risk of severeconstipation and urine retentionantidiarrheals, such as difenoxin and atropine,loperamide, and paregoric: Increasedrisk of severe constipation and increasedCNS depressionantihypertensives: Increased risk ofhypotensionbuprenorphine: Possibly decreased therapeuticeffects of nalbuphine and increasedrisk of respiratory depressionhydroxyzine: Increased risk of CNS depressionand hypotensionMAO inhibitors: Risk of possibly fatalnalbuphine hydrochloride 713increased CNS excitation or depressionmetoclopramide: Possibly antagonizedeffects of metoclopramidenaloxone, naltrexone: Decreased pharmacologiceffects of nalbuphineneuromuscular blockers: Increased risk ofprolonged CNS and respiratory depressionACTIVITIESalcohol use: Increased risk of coma, hypotension,profound sedation, and respiratorydepressionAdverse ReactionsCNS: Confusion, depression, dizziness,euphoria, fatigue, hallucinations, headache,nervousness, restlessness, seizures, syncope,tiredness, weaknessCV: Hypertension, hypotension, tachycardiaEENT: Blurred vision, diplopia, dry mouthGI: Abdominal cramps, anorexia, constipation,nausea, vomitingGU: Decreased urine output, ureteralspasmRESP: Dyspnea, pulmonary edema, respiratorydepression, wheezingSKIN: Diaphoresis, flushing, pruritus, rash,sensation of warmth, urticariaOther: Injection site burning, pain, redness,swelling, and warmthNursing Considerations• Use nalbuphine cautiously in patients takingother drugs that can cause respiratorydepression.• Keep resuscitation equipment andnaloxone readily available to reverse nalbuphine’seffects, if needed.• For direct I.V. injection through an I.V.line with a compatible infusing solution,give drug slowly—no more than 10 mgover 3 to 5 minutes. Inject into free-flowingnormal saline solution, D 5 W, or lactatedRinger’s solution.• During prolonged use, expect to give astool softener to minimize constipation.• If patient is opioid-dependent, expectdrug to cause withdrawal symptoms, suchas abdominal cramps, anorexia, anxiety,backache, bone or joint pain, confusion,depression, diaphoresis, dysphoria, erythema,fear, fever, irritability, labile bloodpressure and pulse, lacrimation, musclespasms, myalgia, mydriasis, nasal congestion,nausea, opioid craving, piloerection,restlessness, rhinorrhea, sensation ofNO

714nalidixic acidcrawling skin, sleep disturbances, tremor,uneasiness, vomiting, and yawning.WARNING Be aware that drug may obscureneurologic assessment findings if patienthas a cerebral aneurysm, head injury, orincreased intracranial pressure.PATIENT TEACHING• Advise patient to avoid hazardous activitiesuntil nalbuphine’s CNS effects areknown.• Counsel patient against making importantdecisions while receiving drug because itmay cloud her judgment.nalidixic acidNegGramClass and CategoryChemical class: Naphthyridine derivativequinoloneTherapeutic class: AntibioticPregnancy category: Not rated (first trimester),B (later trimesters)Indications and Dosages To treat UTI caused by gram-negativebacteria, such as most Enterobacterspecies, Escherichia coli, Klebsiellaspecies, Morganella morganii, Proteusmirabilis, Proteus vulgaris, andProvidencia rettgeriORAL SUSPENSION, TABLETSAdults and children age 12 and over.Initial: 1,000 mg every 6 hr for 1 to 2 wk.Maintenance: 500 mg every 6 hr. Maximum:4,000 mg daily.Children ages 3 months to 12 years. Initial:55 mg/kg daily in divided doses q.i.d. for1 to 2 wk. Maintenance: 33 mg/kg daily individed doses q.i.d.Mechanism of ActionInhibits the enzyme DNA gyrase, which isresponsible for unwinding and supercoilingof bacterial DNA before it replicates. Byinhibiting this enzyme, nalidixic acid causesbacterial cells to die.ContraindicationsHypersensitivity to nalidixic acid or itscomponents, porphyria, seizure disorder,use with melphalan or other relatedchemotherapeutic alkylating drugsInteractionsDRUGSaluminum-, calcium-, and magnesium-containingantacids; didanosine; multivitaminscontaining iron or zinc; sucralfate: Possiblyinterference with nalidixic acid absorptionchloramphenicol, nitrofurantoin, tetracycline:Decreased effects of nalidixic acidcyclosporine: Possibly increased blood cyclosporinelevelmelphalan: Possibly increased risk of seriousGI toxicityoral anticoagulants: Increased anticoagulanteffectsprobenecid: Decreased effects of nalidixicacid and increased risk of adverse reactionstheophylline: Possibly increased blood theophyllinelevelFOODScaffeine: Decreased clearance and prolongedhalf-life of caffeineAdverse ReactionsCNS: Confusion, drowsiness, hallucinations,headache, increased intracranial pressurewith bulging fontanels (infants andchildren), light-headedness, malaise, paresthesia,peripheral neuropathy, psychosis,restlessness, seizures, tremor, weaknessEENT: Altered color perception, blurredvision, diplopia, halo vision, photophobiaGI: Abdominal pain, diarrhea, nausea,pseudomembranous colitis, vomitingHEME: Eosinophilia, hemolytic anemia,leukopenia, thrombocytopeniaMS: Tendon ruptureSKIN: Jaundice, photosensitivity, pruritus,rash, Stevens-Johnson syndrome, urticariaOther: Anaphylaxis, metabolic acidosisNursing Considerations• Be aware that nalidixic acid shouldn’t begiven to patient with creatinine clearancebelow 10 ml/min/1.73 m 2 because of theincreased risk of drug toxicity and shouldbe used cautiously in patients with liverdisease, epilepsy, glucose-6-phosphatedehydrogenase deficiency, or severe cerebralarteriosclerosis or renal failure.• Avoid giving drug within 2 hours ofdidanosine; multivitamins that containiron or zinc; sucralfate; or antacid thatcontains aluminum, calcium, or magnesium.• If nalidixic acid therapy exceeds 2 weeks,

monitor patient’s blood counts and renaland liver function test results periodically,as ordered.WARNING Stop nalidixic acid at first sign ofhypersensitivity, including rash, because itmay indicate anaphylaxis. Reaction mayoccur with first dose. Expect to give epinephrineand supportive care.• If patient also takes cyclosporine or theophylline,monitor blood level of thesedrugs and adjust dosage, as prescribed.• If patient has a history of seizures or cerebralarteriosclerosis, monitor for seizuresduring nalidixic acid therapy.• Notify prescriber if patient has symptomsof peripheral neuropathy (pain, burning,tingling, numbness, weakness, or alteredsensations of light touch, pain, temperature,position sense, or vibration sense),which could be permanent; or tendonrupture, which requires immediate rest. Ineach case, expect to stop nalidixic acid.PATIENT TEACHING• Encourage patient to drink plenty of fluidsduring therapy unless directed otherwiseby prescriber.• Urge patient to complete entire course oftherapy, even if she feels better before it’sfinished.• Advise patient to protect skin from sunlight.• Urge patient to notify prescriber immediatelyabout vision changes or such adverseCNS reactions as confusion, drowsiness,hallucinations, psychosis, and seizures.• Urge patient to stop drug and notify prescriberif rash or other evidence of hypersensitivitydevelops.• Tell patient to take drug at least 2 hoursbefore or after aluminum-, calcium-, ormagnesium-containing antacids; didanosinechewable buffered tablets or oral solutionprepared from powder; multivitaminsthat contain iron or zinc; or sucralfate.• Caution patient to avoid hazardous tasksuntil CNS effects of drug are known.• Instruct patient to limit caffeine intakewhile taking nalidixic acid.• Tell patient to stop drug and notify prescriberif she develops tendon pain orinflammation or abnormal changes inmotor or sensory function.• Urge patient to notify prescriber if diarrheadevelops, even up to 2 months afternalidixic acid therapy stops.naloxone hydrochloride 715naloxonehydrochlorideNarcanClass and CategoryChemical class: Thebaine derivativeTherapeutic class: Opioid antagonistPregnancy category: BIndications and Dosages To treat known or suspected opioidoverdoseI.V. INJECTIONAdults and children age 5 and over weighingmore than 20 kg (44 lb). 0.4 to 2 mgrepeated every 2 to 3 min, p.r.n. If noresponse after 10 mg, patient may not haveopioid-induced respiratory depression.Infants and children under age 5.0.01 mg/kg as a single dose; if no improvement,another 0.1 mg/kg, as prescribed. Or,0.1 mg/kg repeated every 2 to 3 min, asneededI.V., I.M., OR SUBCUTANEOUS INJECTIONNeonates. 0.01 mg/kg repeated I.V. every2 to 3 min, as prescribed, until desiredresponse occurs. Or, initial I.V. dose of0.1 mg/kg. To treat postoperative opioid-inducedrespiratory depressionI.V. INJECTIONAdults and adolescents. Initial: 0.1 to0.2 mg every 2 to 3 min until desiredresponse occurs. Additional doses givenevery 1 to 2 hr, if needed, based on patientresponse.Children. Initial: 0.005 to 0.01 mg every2 to 3 min until desired response occurs.Additional doses given every 1 to 2 hr, ifneeded, based on patient response. To reverse opioid-induced asphyxiaI.V.,I.M., OR SUBCUTANEOUS INJECTIONNeonates. Initial: 0.01 mg/kg every 2 to3 min until desired response occurs.Additional doses given every 1 to 2 hr, ifneeded, based on patient response. As adjunct to treat hypotension causedby septic shockI.V. INFUSION OR INJECTIONAdults. 0.03 to 0.2 mg/kg over 5 min followedby continuous infusion of 0.03 to0.3 mg/kg/hr for 1 to 24 hr, as needed,NO

716naltrexone hydrochloridebased on patient response.Route Onset Peak DurationI.V. 1–2 min 5–15 min 45 min orlongerI.M., 2–5 min 5–15 min 45 min orSubQlongerMechanism of ActionBriefly and competitively antagonizes mu,kappa, and sigma receptors in the CNS,thus reversing analgesia, hypotension, respiratorydepression, and sedation caused bymost opioids. Mu receptors are responsiblefor analgesia, euphoria, miosis, and respiratorydepression. Kappa receptors areresponsible for analgesia and sedation.Sigma receptors control dysphoria andother delusional states.IncompatibilitiesDon’t mix naloxone with any other solutionunless you verify the drugs are compatible;drug is incompatible with alkaline, bisulfite,and metabisulfite solutions.ContraindicationsHypersensitivity to naloxone or its componentsInteractionsDRUGSbutorphanol, nalbuphine, pentazocine:Reversal of these drugs’ analgesic andadverse effectsopioid analgesics: Reversal of these drugs’analgesic and adverse effects, possibly withdrawalsymptoms in opioid-dependentpatientsAdverse ReactionsCNS: Excitement, irritability, nervousness,restlessness, seizures, tremor, violent behaviorCV: Hypertension (severe), hypotension,ventricular fibrillation, ventricular tachycardiaGI: Nausea, vomitingRESP: Pulmonary edemaSKIN: DiaphoresisOther: Withdrawal symptomsNursing Considerations• Keep resuscitation equipment readilyavailable during naloxone administration.• Administer drug by I.V. route wheneverpossible.• Give repeat doses as prescribed, dependingon patient’s response.• Anticipate that rapid reversal of opioideffects can cause diaphoresis, nausea, andvomiting.WARNING Watch for withdrawal symptoms,especially when giving naloxone to opioiddependentpatient. Symptoms may includeabdominal cramps, anorexia, anxiety,backache, bone or joint pain, confusion,depression, diaphoresis, dysphoria, erythema,fear, fever, irritability, labile bloodpressure and pulse, lacrimation, musclespasms, myalgia, mydriasis, nasal congestion,nausea, opioid craving, piloerection,restlessness, rhinorrhea, sensation ofcrawling skin, sleep disturbances, tremor,uneasiness, vomiting, and yawning.• Expect patient with hepatic or renal dysfunctionto have increased circulatingblood naloxone level.PATIENT TEACHING• Inform patient or family that naloxonewill reverse opioid-induced adverse reactions.• Urge opioid-dependent patient to seekdrug rehabilitation.naltrexonehydrochlorideReVia, VivitrolClass and CategoryChemical class: Thebaine derivativeTherapeutic class: Opioid antagonistPregnancy category: CIndications and Dosages To treat opioid dependenceTABLETSAdults. Initial: 25 mg, repeated within 1 hr,if needed and if no withdrawal symptomsoccur. Maintenance: 50 to 150 mg daily or350 mg/wk by intermittent dosing regimen. As adjunct to treat alcoholismTABLETSAdults. 50 mg daily (up to 100 mg daily forsome patients) for 12 wk.I.M. INJECTIONAdults. 380 mg every 4 wk or once monthly.

Mechanism of ActionDisplaces opioid agonists from—or blocksthem from binding with—mu, kappa, anddelta receptors. Opioid receptor blockadereverses the euphoric effect of opioids.Naltrexone also inhibits the effects ofendogenous opioids, thus reducing alcoholcraving.Route Onset Peak DurationP.O. 15–30 min In 12 hr 24 hr*I.M. Unknown 2 hr UnknownContraindicationsAcute hepatitis, acute opioid withdrawal,concurrent use of opioid analgesics (includingopioid agonists, such as methadone orlevo-alpha-acetyl-methadol [LAAM]), failureof naloxone challenge test, hepatic failure,hypersensitivity to naltrexone or itscomponents, opioid dependence, positiveurine screen for opioidsInteractionsDRUGSopioid analgesics: Reversal of analgesic andadverse effects of these drugs, possiblywithdrawal symptoms in opioid-dependentpatientsthioridazine: Increased somnolence andlethargy* For 50 mg; 48 hr for 100 mg; 72 hr for150 mg.naltrexone hydrochloride 717Adverse ReactionsCNS: Anxiety, chills, confusion, depression,dizziness, fatigue, fever, hallucinations,headache, insomnia, irritability, nervousness,restlessness, somnolence, suicidalideation, syncopeCV: Chest pain, edema, hypertension,tachycardiaEENT: Blurred vision, burning eyes, conjunctivitis,dry mouth, eyelid swelling,hoarseness, pharyngitis, rhinitis, sneezing,tinnitusGI: Abdominal cramps, anorexia, constipation,diarrhea, GI ulceration, hepatotoxicitywith excessive doses, nausea, thirst, vomitingGU: Difficult ejaculation, urinary frequencyMS: Arthralgia, back pain or stiffness, jointsitffness, muscle cramps, myalgiaRESP: Cough, dyspnea, eosinophilic pneumonia,upper respiratory tract infectionSKIN: Pruritus, rashOther: Injection site reactions, such as pain,tenderness, induration, swelling, erythema,pruritusNursing Considerations• Use naltrexone cautiously in patients withsevere renal impairment, thrombocytopenia,hemophilia, or severe hepatic failure.• To avoid withdrawal symptoms, wait 7 to10 days after last opioid dose, as prescribed,before starting naltrexone.Because urine testing isn’t always conclusive,prepare patient for naloxone challengetest if there are any doubts aboutpatient’s abstinence.• Give oral drug with food or antacids todecrease adverse GI reactions.• Dilute parenteral form using only diluentsupplied in carton. Inject in gluteal muscleusing only needle supplied in carton.Don’t substitute any components for componentsin carton. Store entire dose packin refrigerator; unrefrigerated drug can bestored at room temperature for no morethan 7 days.• Inspect injection site for reactions, such astenderness, induration, swelling, or redness.Ask if patient feels pain or itching atthe site. Report any such findings to prescriberbecause abscesses and site necrosismay occur and require surgical intervention.WARNING Never give parenteral form intravenously.• Patients who receive naltrexone and needpain management are more likely to havelonger, deeper respiratory depression andhistamine-release reactions (such as facialswelling, itching, generalized erythema,and bronchoconstriction) if given an opioidanalgesic. Expect alternative analgesicsto be used, such as regional analgesia, conscioussedation with a benzodiazepine,nonopioid analgesics, or general anesthesia.If an opioid analgesic must be used,monitor patient closely.• Watch patient closely for suicidal tendenciesthroughout naltrexone therapy.• Anticipate that some patients may needtreatment for up to 1 year.PATIENT TEACHINGWARNING Caution patient against takingNO

718naproxenopioids during naltrexone therapy or inthe future because she’ll be more sensitiveto them. In fact, strongly warn patient thattaking large doses of heroin or any otheropioid (including methadone or LAAM)while taking naltrexone could lead tocoma, serious injury, or death.• Explain that patient may have nausea afterfirst injection but that it is usually mildand subsides within a few days. Mostpatients don’t have nausea with repeatdoses.• Tell patient to report adverse reactionspromptly, especially dyspnea, coughing,wheezing, abdominal pain, and jaundice.• Urge family or caregiver to watch patientclosely for abnormal behaviors, includingsuicidal tendencies, even after patientstops taking naltrexone.• Inform patient that naltrexone doesn’teliminate or diminish alcohol withdrawalsymptoms.• Urge patient to have comprehensive rehabilitationin addition to receiving naltrexone.• Inform patient about nonopioid treatmentsfor cough, diarrhea, and pain.• Instruct patient to carry medical identificationthat lists naltrexone therapy.• Instruct women of childbearing age tonotify prescriber if pregnancy is suspected.naproxenApo-Naproxen (CAN), EC-Naprosyn,Naprosyn, Naprosyn-E (CAN), Naxen(CAN), Novo-Naprox (CAN), Nu-Naprox(CAN)naproxen sodiumAleve, Anaprox, Anaprox DS, Apo-Napro-Na (CAN), Naprelan, Naprosyn-SR (CAN), Novo-Naprox Sodium (CAN)Class and CategoryChemical class: Propionic acid derivativeTherapeutic class: Analgesic, antiinflammatory,antipyreticPregnancy category: CIndications and Dosages To relieve mild to moderate musculoskeletalinflammation, including ankylosingspondylitis, osteoarthritis, andrheumatoid arthritisDELAYED-RELEASE TABLETS, ORAL SUSPENSION,TABLETS (NAPROXEN)Adults. 250 to 500 mg b.i.d. Maximum:1,500 mg daily for limited periods, as prescribed.E.R. TABLETS (NAPROXEN SODIUM)Adults. 750 to 1,000 mg daily. Maximum:1,500 mg daily.TABLETS (NAPROXEN SODIUM)Adults. 275 to 550 mg b.i.d. Maximum:1,650 mg daily for limited periods, as prescribed.SUPPOSITORIES (NAPROXEN SODIUM)Adults. 500 mg at bedtime in addition todaytime P.O. administration. Maximum:1,500 mg daily (P.O. and suppository combined). To relieve symptoms of juvenile rheumatoidarthritis and other inflammatoryconditions in childrenORAL SUSPENSION, TABLETS (NAPROXEN)Children. 10 mg/kg daily in divided dosesb.i.d. To relieve symptoms of acute goutyarthritisDELAYED-RELEASE TABLETS, ORAL SUSPENSION,TABLETS (NAPROXEN)Adults. Initial: 750 mg, then 250 mg every8 hr until symptoms subside.E.R. TABLETS (NAPROXEN SODIUM)Adults. Initial: 1,000 to 1,500 mg on day 1;then 1,000 mg daily until symptoms subside.Maximum: 1,500 mg daily.TABLETS (NAPROXEN SODIUM)Adults. Initial: 825 mg, then 275 mg every8 hr until symptoms subside. To relieve mild to moderate pain,including acute tendinitis and bursitis,arthralgia, dysmenorrhea, and myalgiaDELAYED-RELEASE TABLETS (NAPROXEN)Adults. Initial: 1,000 mg daily. Maximum:1,500 mg daily.E.R. TABLETS (NAPROXEN SODIUM)Adults. Initial: 1,100 mg daily, increased asprescribed. Maximum: 1,500 mg daily.ORAL SUSPENSION, TABLETS (NAPROXEN)Adults. Initial: 500 mg, then 250 mg every6 to 8 hr, p.r.n. Maximum: 1,250 mg daily.TABLETS (NAPROXEN SODIUM)Adults. Initial: 550 mg, then 275 mg every6 to 8 hr, p.r.n. Maximum: 1,375 mg daily. To relieve fever and mild to moderate

musculoskeletal inflammation or painTABLETS (OTC NAPROXEN SODIUM)Adults. 220 mg every 8 to 12 hr; or 440 mgand 220 mg 12 hr later. Maximum: 660 mgdaily for 10 days unless directed otherwise.DOSAGE ADJUSTMENT For patients over age65, 220 mg every 12 hr. Maximum: 440 mgfor 10 days unless directed otherwise.Route Onset Peak DurationP.O. 1 hr† 2–4 hr†‡ 7–12 hr†(naproxen)*P.O. 30 min† 1 hr†‡ 7–12 hr†(naproxensodium)*Mechanism of ActionBlocks cyclooxygenase, the enzyme neededto synthesize prostaglandins, which mediatethe inflammatory response and cause localvasodilation, swelling, and pain. Thus,naproxen, an NSAID, reduces symptoms ofinflammation and relieves pain. Antipyreticaction probably stems from effects on thehypothalamus, which increases peripheralblood flow, causing vasodilation and heatdissipation.ContraindicationsAngioedema, asthma, bronchospasm, nasalpolyps, rhinitis, or urticaria induced byaspirin, iodides, or other NSAIDs; hypersensitivityto naproxen or its componentsInteractionsDRUGSACE inhibitors: Decreased antihypertensiveeffects; increased risk of renal dysfunctionacetaminophen: Increased risk of adverserenal effects with combined long-term usealuminum hydroxide or magnesium oxideantacids, cholestyramine, sucralfate: Possiblydelayed absorption of naproxenanticoagulants, thrombolytics: Prolonged PT,increased risk of bleedingantihypertensives: Decreased effectiveness ofantihypertensiveaspirin: Decreased aspirin effectiveness fromlowered plasma and peak aspirin levels* For antirheumatism, onset is in 14 days,peak is unknown, and duration is 2 to4wk.† For analgesia.‡ For gout, 1 to 2 days.naproxen 719beta blockers: Decreased antihypertensiveeffects of these drugsbone marrow depressants, such as aldesleukinand cisplatin: Increased risk of leukopeniaand thrombocytopeniacefamandole, cefoperazone, cefotetan, plicamycin,valproic acid: Increased risk ofhypoprothrombinemia and bleedingcimetidine: Altered blood naproxen levelcolchicine, glucocorticoids, other NSAIDs,potassium supplements, salicylates: IncreasedGI irritability and bleedingcyclosporine, gold compounds, nephrotoxicdrugs: Increased risk of nephrotoxicitydigoxin: Increased blood digoxin level andrisk of digitalis toxicitydiuretics: Decreased diuretic effectivenessfurosemide: Decreased natriuretic effectinsulin, oral antidiabetic drugs: Increasedeffectiveness of these drugs; risk of hypoglycemialithium: Increased risk of lithium toxicitymethotrexate: Increased risk of methotrexatetoxicitynaproxen-containing products: Increased riskof toxicityphenytoin: Increased blood phenytoin levelprobenecid: Increased risk of naproxen toxicityACTIVITIESalcohol use, smoking: Increased risk ofnaproxen-induced GI ulcerationAdverse ReactionsCNS: Aseptic meningitis, chills, cognitiveimpairment, decreased concentration,depression, dizziness, dream disturbances,drowsiness, fever, headache, insomnia,light-headedness, malaise, seizures, stroke,vertigoCV: Edema, heart failure, hypertension, MI,palpitations, tachycardia, vasculitisEENT: Papilledema, papillitis, retrobulbaroptic neuritis, stomatitis, tinnitus, vision orhearing changesENDO: Hyperglycemia, hypoglycemiaGI: Abdominal pain, anorexia, colitis, constipation,diarrhea, diverticulitis, dyspepsia,dysphagia, elevated liver function test results,esophagitis, flatulence, gastritis, gastroenteritis,gastroesophageal reflux disease, GI bleedingand ulceration, heartburn, hematemesis,hepatitis, indigestion, melena, nausea, pancreatitis,peptic ulceration, perforation ofstomach or intestines, stomatitis, vomitingNO

720tion, diverticulitis, dysphagia, esophagitis,gastritis, gastroenteritis, gastroesophagealreflux disease, hemorrhoids, hiatal hernia,melena, stomatitis, and vomiting.• Monitor liver function test results because,in rare cases, elevations may progress tosevere hepatic reactions, including fatalhepatitis, liver necrosis, and hepatic failure.• Monitor BUN and serum creatinine levelsin elderly patients, patients taking diureticsor ACE inhibitors, and patients withheart failure, impaired renal function, orhepatic dysfunction; naproxen may causerenal failure.• Monitor CBC for decreased hemoglobinand hematocrit because drug may worsenanemia.WARNING If patient has bone marrow suppressionor is receiving treatment with anantineoplastic drug, monitor laboratoryresults (including WBC count), and watchfor evidence of infection because antiinflammatoryand antipyretic actions ofnaproxen may mask signs and symptoms,such as fever and pain.• Assess patient’s skin regularly for signs ofrash or other hypersensitivity reactionbecause naproxen is an NSAID and maycause serious skin reactions without warning,even in patients with no history ofNSAID sensivitity. At first sign of reaction,stop drug and notify prescriber.• Assess drug effectiveness in ankylosingspondylitis, as evidenced by decreasednight pain, morning stiffness, and pain atrest; in osteoarthritis: decreased joint painor tenderness and increased mobility,range of motion, and ability to performdaily activities; in rheumatoid arthritis:increased mobility and decreased jointswelling and morning stiffness; in acutegouty arthritis: decreased heat, pain,swelling, and tenderness in affected joints.• Tell prescriber if patient complains ofvision changes; patient may need ophthalmicexam.PATIENT TEACHING• Caution patient not to exceed recommendeddosage, take for longer thandirected, or take for more than 10 dayswithout consulting prescriber becauseserious adverse reactions may occur.• Tell patient to swallow delayed-release tabnaproxenGU: Elevated serum creatinine level,glomerulonephritis, hematuria, infertility(in women), interstitial nephritis, menstrualirregularities, nephrotic syndrome, renalfailure, renal papillary necrosisHEME: Agranulocytosis, anemia, aplasticanemia, eosinophilia, granulocytopenia,hemolytic anemia, leukopenia, neutropenia,pancytopenia, thrombocytopeniaMS: Muscle weakness, myalgiaRESP: Asthma, dyspnea, eosinophilic pneumonitis,respiratory depressionSKIN: Alopecia, diaphoresis, ecchymosis,erythema multiforme, photosensitivity,pruritus, pseudoporphyria, purpura, rash,Stevens-Johnson syndrome, systemic lupuserythematosus, toxic epidermal necrolysis,urticariaOther: Anaphylaxis, angioedema, hyperkalemiaNursing Considerations• Use naproxen with extreme caution inpatients with a history of ulcer disease orGI bleeding because NSAIDs such asnaproxen increase risk of GI bleeding andulceration. Expect to use naproxen for theshortest time possible in these patients.• Serious GI tract ulceration, bleeding, andperforation may occur without warningsymptoms. Elderly patients are at greaterrisk. To minimize risk, give drug withfood. If GI distress occurs, withhold drugand notify prescriber immediately.• Use naproxen cautiously in patients withhypertension, and monitor blood pressureclosely. Drug may cause hypertension orworsen it. Because of naproxen’s sodiumcontent, watch for fluid retention.• Rehydrate a dehydrated patient before givingdrug. If patient has renal disease, monitorrenal function closely during therapy.• Naproxen isn’t recommended for patientswith advanced renal disease.WARNING Monitor patient closely forthrombotic events, including MI andstroke, because NSAIDs increase the risk,especially if used in higher doses than recommendedor for extended periods oftime.• Monitor patient—especially if elderly orreceiving long-term naproxen therapy—for less common but serious adverse GIreactions, including anorexia, constipa-

lets whole and not to break, crush, orchew them.• Advise patient to take drug with food toreduce GI distress.• Tell patient to take drug with a full glass ofwater and to remain upright for 15 to30 minutes after taking it to prevent drugfrom lodging in esophagus and causingirritation.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Urge patient to keep scheduled appointmentswith prescriber to monitor progress.• Tell pregnant patient to avoid takingnaproxen-containing products late inpregnancy.• Explain that naproxen may increase risk ofserious adverse cardiovascular reactions;urge patient to seek immediate medicalattention if signs or symptoms arise, suchas chest pain, shortness of breath, weakness,and slurring of speech.• Inform patient that naproxen may increaserisk of serious adverse GI reactions; stressthe importance of seeking immediatemedical attention for such signs andsymptoms as epigastric or abdominalpain, indigestion, black or tarry stools, orvomiting blood or material that looks likecoffee grounds.• Alert patient to rare but serious skin reactions.Urge her to seek immediate medicalattention for rash, blisters, itching, fever,or other indications of hypersensitivity.• Advise patient to consult prescriber beforetaking naproxen-containing OTC productsif he has asthma, ulcers, bleeding problems,high blood pressure, heart or kidneydisease, a need for diuretic therapy, seriousadverse effects from previous use of feverreducers or pain relievers, or persistentstomach problems, such as heartburn,upset stomach, or stomach pain.naratriptanhydrochlorideAmergeClass and CategoryChemical class: Selective serotonin 5-HTnaratriptan hydrochloride 721receptor agonistTherapeutic class: AntimigrainePregnancy category: CIndications and Dosages To relieve acute migraine with or withoutauraTABLETSAdults. 1 to 2.5 mg as a single dose, repeatedin 4 hr p.r.n. if only partial reliefobtained. Maximum: 5 mg daily.DOSAGE ADJUSTMENT For patients withmild to moderate renal or hepatic impairment,maximum dosage reduced to 2.5 mgdaily.Mechanism of ActionBinds to receptors on intracranial bloodvessels and sensory nerves in trigeminalvascularsystem to stimulate negative feedback,which halts serotonin release. Thus,naratriptan selectively constricts inflamedand dilated cranial vessels in the carotid circulationand inhibits production of proinflammatoryneuropeptides.ContraindicationsBasilar or hemiplegic migraine; cerebrovascular,peripheral vascular, or coronaryartery disease (ischemic or vasospastic);hypersensitivity to naratriptan or its components;hypertension (uncontrolled);severe hepatic or renal dysfunction; usewithin 24 hours of another 5-HT agonist oran ergotamine-containing or ergot-typedrug, such as dihydroergotamine or methysergideInteractionsDRUGSergot-containing drugs: Possibly prolongedor additive vasospastic reactionsfluoxetine, fluvoxamine, paroxetine, sertraline:Possibly weakness, hyperreflexia, andincoordinationoral contraceptives: Possibly reduced clearanceand increased blood level of naratriptanother selective serotonin 5-HT receptor agonists(including rizatriptan, sumatriptan,and zolmitriptan): Possibly additive effectsAdverse ReactionsCNS: Dizziness, drowsiness, fatigue,malaise, paresthesiaCV: Chest pain, pressure, or heavinessNO

722natalizumabEENT: Decreased salivation, otitis media,pharyngitis, photophobia, rhinitis, throattightnessGI: Nausea, vomitingNursing ConsiderationsWARNING Because naratriptan therapy cancause coronary artery vasospasm, monitorpatient with coronary artery disease forsigns or symptoms of angina while takingdrug. Because naratriptan may also causeperipheral vasospastic reactions, such asischemic bowel disease, monitor patientfor abdominal pain and bloody diarrhea.• Monitor patient for hypertension duringnaratriptan therapy. It may increase systolicblood pressure by up to 32 mm Hg.• Be prepared to perform complete neurovascularassessment in any patient whoreports an unusual headache or who failsto respond to first dose of naratriptan.PATIENT TEACHING• Inform patient that naratriptan is used totreat acute migraine attacks and that itwon’t prevent or reduce the number ofmigraines.• Advise patient not to take more than maximumprescribed amount during any24-hour period.• If patient has no relief from initial dose ofnaratriptan, instruct her to notify prescriberrather than taking another dose in4 hours because she may need a differentdrug.• Advise patient to seek reevaluation by prescriberif she has more than fourheadaches during any 30-day period whiletaking naratriptan.natalizumabTysabriClass and CategoryChemical class: Recombinant humanizedIgG4K monoclonal antibodyTherapeutic class: Anti-multiple scleroticPregnancy category: CIndications and Dosages To delay physical disability and reducefrequency of clinical exacerbations inrelapsing forms of multiple sclerosis; toinduce and maintain remission in moderatelyto severely active Crohn’s diseasewith evidence of inflammation inpatients who had inadequate response toor are unable to tolerate conventionaltherapy and inhibitors of tumor necrosisfactor alphaI.V. INFUSIONAdults. 300 mg infused over 1 hr every4wk.Route Onset Peak DurationI.V. Unknown 24 wk UnknownMechanism of ActionInhibits migration of leukocytes from vascularspace, increasing the number of circulatingleukocytes. It does this by binding tointegrins on the surface of leukocytes(except neutrophils) and inhibiting adhesionof leukocytes to their counter receptors.In multiple sclerosis, lesions probablyoccur when activated inflammatory cells,including T-lymphocytes, cross the bloodbrainbarrier.ContraindicationsHistory of or presence of progressive multifocalleukoencephalopathy, hypersensitivityto natalizumab or its componentsInteractionsDRUGSantineoplastics, immunosuppresants,immunomodulating agents: Increased risk oflife-threatening infectionAdverse ReactionsCNS: Depression, dizziness, fatigue,headache, progressive multifocal leukoencephalopathy(PML), rigors, somnolence,suicidal ideation, vertigoCV: Chest discomfort, peripheral edemaEENT: Sinusutis, tonsillitis, tooth infectionGI: Abdominal discomfort, abnormal liverfunction test results, cholelithiasis, diarrhea,gastroenteritis, hepatotoxicity, jaindice,nauseaGU: Amenorrhea; dysmenorrhea; irregularmenstruation; ovarian cysts; UTI; urinaryincontinence, frequency, or urgency; vaginitisMS: Arthralgia, back or limb pain, jointswelling, muscle crampRESP: Cough, pneumonia or other respiratorytract infection

SKIN: Dermatitis, night sweats, pruritus,rash, urticariaOther: Acute hypersensitivity reaction, anaphylaxis,antibody formation, flulike illness,herpes, serious infection, weight gain orlossNursing Considerations• Make sure patient has enrolled in theTOUCH prescribing program before givingnatalizumab. Once patient has signedand initialed the TOUCH program enrollmentform, place original signed form inthe patient’s medical record, send a copyto Biogen Idec, and give a copy to patient.• Be aware that all serious opportunistic andatypical infections must be reported toBiogen Idec at 1-800-456-2255 and theFDA’s MedWatch Program at 1-800-FDA-1088.• Make sure patient with multiple sclerosishas had an MRI of the brain before startingnatalizumab therapy. It will help distinguishevidence of multiple sclerosisfrom PML symptoms if they occur aftertherapy starts.• Dilute natalizumab concentrate 300 mg/15 ml in 100 ml of normal saline injection.Gently invert solution to mix completely.Do not shake.• Following dilution, infuse drug immediatelyover 1 hour. After infusion, flush linewith normal saline injection.• Do not give natalizumab by I.V. push orbolus injection.• If not infused right away, refrigerate drugand use within 8 hours.• Observe patient during and for 1 hourafter infusion for hypersensitivity reaction,evidenced by urticaria, dizziness, fever,rash, rigors, pruritus, nausea, flushing,hypotension, dyspnea, and chest pain.Reaction is more likely to occur if natalizumabtherapy was interrupted. If hypersensitivityreaction occurs, notify prescriber;expect to withhold drug and providesupportive care.WARNING Monitor patient closely for evidenceof PML, a viral brain infection thatmay be disabling or fatal, because natalizumabincreases the risk. If patient hasunexplained neurologic changes, notifyprescriber, withhold natalizumab, and preparepatient for a gadolinium-enhancednatalizumab 723brain MRI and possible cerebrospinal fluidanalysis, as ordered.• Expect that patient will be reevaluated3 months after first infusion, 6 monthsafter first infusion, and every 6 monthsthereafter.• Assess patient for evidence of infectionbecause natalizumab may adversely affectimmune system, increasing risk of infection.If infection occurs, expect to obtainappropriate specimens for culture andsensitivity and to treat accordingly.• Be aware that if patient with Crohn’s diseasehas no therapeutic response after12 weeks, natalizumab should be discontinued.If patient is on chronic oral corticosteroidtherapy, expect tapering of oralcorticosteroid dose to begin. If patientcan’t be tapered off oral corticosteroidswithin 6 months of starting natalizumabtherapy, expect natalizumab to be discontinued.Likewise, if patient needs additionalsteroid use that extends beyond3 months in a calendar year to controlsigns and symptoms of Crohn’s disease,expect natalizumab to be discontinued.• Assess patient’s liver function regularly, asordered, because natalizumab may causesignificant liver damage. Expect drug to bediscontinued if patient becomes jaundicedor liver enzymes become elevated.PATIENT TEACHING• Instruct patient on benefits and risks ofnatalizumab therapy, and provide medicationguide for patient to read.• Encourage patient to ask questions beforesigning the enrollment form.• Emphasize need to report any worseningsymptoms that persist over several days.• Tell patient to inform all health careproviders that he is receiving natalizumabtherapy.• Stress the need to have follow-up visits3 months after first infusion, 6 monthsafter first infusion, and at least every6 months thereafter.• Instruct patient to report evidence ofallergic reaction such as urticaria, dizziness,fever, rash, rigors, pruritus, nausea,flushing, hypotension, dyspnea, and chestpain.• Instruct patient to avoid people who haveinfections. Advise him to report fever,cough, lower-back or side pain, or otherNO

724nateglinideunexplained signs and symptoms becausethey may indicate infection.nateglinideStarlixClass and CategoryChemical class: Amino acid derivativeTherapeutic class: AntidiabeticPregnancy category: CIndications and Dosages To control blood glucose level in type 2diabetes mellitus, either as monotherapyor with metformin or a thiazolidinedioneTABLETSAdults. 120 mg t.i.d. 1 to 30 min beforemeals.DOSAGE ADJUSTMENT Dosage reduced to60 mg t.i.d. in patients with near-goal glycosylatedhemoglobin (HbA 1c ) level.ContraindicationsDiabetic ketoacidosis, hypersensitivity toMechanism of ActionNateglinide stimulates the release ofinsulin from functioning beta cells of thepancreas. In patients with type 2 diabetesmellitus, a lack of functioning beta cellsdiminishes blood levels of insulin andcauses glucose intolerance. By interactingwith the adenosine triphosphatase(ATP)–potassium channel on the beta cellmembrane, nateglinide prevents potassium(K + ) from leaving the cell. This causesnateglinide or its components, type 1 diabetesmellitusRoute Onset Peak DurationP.O. 20 min 1 hr 4 hrInteractionsDRUGScorticosteroids, sympathomimetics, thiazidediuretics, thyroid products: Possibly reducedhypoglycemic effects of nateglinideMAO inhibitors, nonselective beta-adrenergicblockers, NSAIDs, salicylates: Possibly additivehypoglycemic effects of nateglinideAdverse ReactionsCNS: DizzinessENDO: HypoglycemiaGI: Cholestatic hepatitis, diarrhea, elevatedliver enzyme levels, jaundiceMS: Accidental trauma, arthropathy, backpainRESP: Bronchitis, cough, upper respiratorytract infectionSKIN: Pruritus, rash, urticariaOther: Flulike symptomsthe beta cell to depolarize and the cellmembrane’s calcium channel to open.Consequently, calcium (Ca ++ ) moves intothe cell and insulin moves out of it. Theextent of insulin release is glucosedependent; the lower the glucose level,the less insulin is secreted from the cell.By promoting insulin secretion inpatients with type 2 diabetes mellitus,nateglinide improves glucose tolerance.Outside beta cellNateglinideATP-potassiumchannelCa ++ Ca ++Calcium channelATPCa ++InsulinsecretionK +K +Inside beta cellInsulin

Nursing Considerations• Give nateglinide 1 to 30 minutes beforemeals to reduce the risk of hypoglycemia.• Monitor fasting glucose and HbA 1c levelsperiodically, as ordered, to evaluate treatmenteffectiveness.• Monitor patient often in event of fever,infection, trauma, or surgery because transientloss of glucose control may occur,requiring an alteration in therapy.PATIENT TEACHING• Instruct patient to take nateglinide 1 to30 minutes before meals. Advise her toskip scheduled dose if she skips a meal toreduce the risk of hypoglycemia.• Teach patient to measure blood glucoselevel and recognize hyperglycemia andhypoglycemia. Advise her to notify prescriberif blood glucose level is abnormal.• Inform patient that strenuous exercise,insufficient calorie intake, and consumptionof alcohol increase risk of hypoglycemia.• Advise patient to monitor blood glucoselevel as prescribed and to keep follow-upappointments to monitor HbA 1c levelbecause drug may become less effectiveover time.nebivololhydrochlorideBystolicClass and CategoryChemical class: Beta-adrenergic blockerTherapeutic class: AntihypertensivePregnancy category: CIndications and Dosages To treat hypertensionTABLETSAdults. Initial: 5 mg once daily, increased at2-wk intervals, as needed. Maximum: 40 mgonce daily.DOSAGE ADJUSTMENT For patients withmoderate renal impairment (creatinineclearance less than 30 ml/min/1.73 m 2 ) ormoderate hepatic impairment (Child-PughClass B), initial dose reduced to 2.5 mg.Mechanism of ActionMay prevent arterial dilation and inhibitnebivolol hydrochloride 725renin secretion, although precise mechanismof action isn’t known. Negativechronotropic effects may slow resting heartrate, and negative inotropic effects mayreduce cardiac output, myocardial contractility,and myocardial oxygen consumptionduring stress or exercise. All of these actionsmay work together to lower systolic anddiastolic blood pressure.Route Onset Peak DurationP.O. Unknown 1.5–4 hr UnknownContraindicationsAdvanced AV block, cardiogenic shock,decompensated cardiac failure, hypersensitivityto nebivolol or its components, sicksinus syndrome (unless permanent pacemakeris in place), severe bradycardia,severe hepatic impairmentInteractionsDRUGSantiarrhythmias such as disopyramide, betablockers, digoxin, diltiazem: Increased effecton AV conduction and myocardial depression;increased risk of bradycardiafluoxetine, paroxetine, propafenone, quinidine:Increased hypertensive effect ofnebivololguanethidine, reserpine: Possibly excessivereduction of sympathetic activityAdverse ReactionsCNS: Asthenia, dizziness, fatigue, headache,insomnia, paresthesia, somnolence, syncope,vertigoCV: Allergic vasculitis, AV block, bradycardia,chest pain, hypercholesterolemia,hyperuricemia, MI, peripheral edema,peripheral ischemia, Raynaud’s phenomenonGI: Abdominal pain, diarrhea, elevated liverenzymes, nausea, vomitingGU: Acute renal failure, elevated BUN level,erectile dysfunctionHEME: Decreased platelet count, thrombocytopeniaRESP: Acute pulmonary edema, bronchospasm,dyspneaSKIN: Pruritus, psoriasis, rash, urticariaOther: AngioedemaNursing Considerations• Know that patients with bronchospasticNO

726nefazodone hydrochloridedisease usually shouldn’t be treated withbeta blocker therapy such as nebivolol.• Use nebivolol cautiously in patients withimpaired hepatic or renal function.• Expect to administer an alpha blocker, asordered, before starting nebivolol therapyin patients with pheochromocytoma.• Monitor blood pressure and pulse rateoften, especially at start of nebivolol therapyand during dosage adjustments. Alsomonitor fluid intake and output and dailyweight, and watch for evidence of heartfailure, such as dyspnea, edema, fatigue,and jugular vein distention. If heart failureoccurs or worsens, expect drug to be discontinued.• Be aware that drug shouldn’t be stoppedabruptly because MI, myocardial ischemia,severe hypertension, or ventriculararrhythmias may result.• Expect to temporarily withhold nebivololbefore surgery. If drug will be continuedduring perioperative period, monitorpatient closely for protracted severehypotension and difficulty restarting andkeeping a heartbeat.• Assess distal circulation and peripheralpulses in patient with peripheral vasculardisease because drug can worsen it.• Be aware that nebivolol may mask tachycardiafrom hyperthyroidism and thatabrupt withdrawal can cause thyroidstorm. Drug also can decrease blood glucoselevel, prolong or mask symptoms ofhypoglycemia, and promote hyperglycemiain patient with diabetes mellitus;or worsen psoriasis.• Monitor patient closely for hypersensitivityreactions that may occur with betablockers, especially patients with a historyof severe anaphylactic reactions who maynot be responsive to usual doses of epinephrineused to treat allergic reactions.PATIENT TEACHING• Instruct patient to take nebivolol exactlyas prescribed and not to stop abruptly.• Tell patient to weigh herself daily duringnebivolol therapy and to notify prescriberif she gains more than 2 lb (0.9 kg) in1 day or 5 lb. (2.3 kg) in 1 week.• Advise patient to rise slowly from a seatedor lying position to minimize effects oforthostatic hypotension.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to contact prescriberabout bleeding or bruising, cough atnight, dizziness, edema, rash, shortness ofbreath, or slow pulse rate.• Advise diabetic patient to monitor herblood glucose level more often duringnebivolol therapy because drug may masksymptoms of hypoglycemia.• Inform patient with psoriasis that drugmay aggravate this condition.nefazodonehydrochlorideSerzoneClass and CategoryChemical class: Phenylpiperazine derivativeTherapeutic class: AntidepressantPregnancy category: CIndications and Dosages To treat major depressionTABLETSAdults. Initial: 100 mg b.i.d., increased by100 to 200 mg daily every wk, as prescribed.Maintenance: 150 to 300 mg b.i.d.Maximum: 600 mg daily.DOSAGE ADJUSTMENT Initial dosage possiblyreduced to 50 mg b.i.d. for elderly or debilitatedpatients; then dosage adjusted asordered, based on patient response.Route Onset Peak DurationP.O. Several wk Unknown UnknownMechanism of ActionMay inhibit serotonin reuptake at presynapticneurons, which may increase neuronallevel of serotonin, an inhibitory neurotransmitterthought to regulate mood.Nefazodone also may act as a postsynapticserotonin receptor antagonist, furtherincreasing the amount of synaptic serotoninthat’s available.ContraindicationsConcurrent use of astemizole, cisapride, orterfenadine; hypersensitivity to nefazodone,other phenylpiperazine antidepressants, ortheir components; restarting nefazodonetherapy that was discontinued because of

liver injury; use within 14 days of MAOinhibitor therapyInteractionsDRUGSalprazolam, buspirone, carbamazepine,cyclosporine, modafinil, triazolam: Increasedblood levels of these drugsantihypertensives: Increased risk ofhypotensionastemizole, cisapride, terfenadine: Increasedblood levels of these drugs, prolonged QTinterval, and, possibly, serious cardiovasculareffects, including death from ventriculartachycardiacilostazol: Decreased cilostazol clearance,increased adverse effects of cilostazol, suchas headachedextromethorphan, sibutramine, tramadol,trazodone: Increased risk of serotonin syndromedigoxin: Increased blood digoxin level,increased risk of digitalis toxicityhaloperidol: Decreased haloperidol clearanceindinavir: Inhibited indinavir metabolismlevobupivacaine: Increased blood levobupivacainelevel, possibly toxicitylovastatin, simvastatin: Increased risk ofrhabdomyolysis and myositisMAO inhibitors: Possibly fatal reactions,including autonomic instability (with rapidlyfluctuating vital signs), hyperthermia,mental status changes (such as severe agitationprogressing to delirium and coma),muscle rigidity, and myoclonusmethadone: Increased blood level andadverse effects of methadone, additive CNSeffectsnevirapine: Increased nefazodone metabolism,inhibited nevirapine metabolismritonavir: Inhibited nefazodone and ritonavirmetabolismsildenafil: Decreased sildenafil clearancetacrolimus: Decreased tacrolimus clearanceand increased adverse effects, includingdelirium and renal failureACTIVITIESalcohol use: Increased risk of CNS depressionNursing ConsiderationsWARNING Be aware that nefazodone shouldnot be given with astemizole, cisapride,MAO inhibitors, or terfenadine; serious,even fatal, reactions may occur.WARNING Be aware that life-threateninghepatic failure has occurred during nefazodonetherapy, resulting in need fortransplant or even death. Monitor patientfor signs of hepatic failure, such as jaunnefazodonehydrochloride 727Adverse ReactionsCNS: Abnormal gait, apathy, asthenia, ataxia,chills, confusion, decreased concentration,delusions, depersonalization, dizziness,dream disturbances, euphoria, fever,hallucinations, headache, hostility, hypotonia,insomnia, light-headedness, malaise,memory loss, myoclonic jerks, neuralgia,paranoia, paresthesia, somnolence, suicidalideation, syncope, tremor, vertigoCV: Angina, hypertension, hypotension,peripheral edema, orthostatic hypotension,tachycardia, vasodilation, ventriculararrhythmiasEENT: Abnormal vision, blurred vision,conjunctivitis, diplopia, dry eyes andmouth, earache, epistaxis, eye pain, gingivitis,halitosis, hyperacusis, laryngitis, mydriasis,neck rigidity, periodontal abscess,pharyngitis, photophobia, stomatitis, tasteperversion, tinnitus, visual field defectsENDO: Breast pain, gynecomastia, lymphadenopathyGI: Abdominal distention, colitis, constipation,diarrhea, elevated liver function testresults, eructation, esophagitis, gastritis,gastroenteritis, hernia, hepatotoxicity, hiccups,increased appetite, indigestion, lifethreateninghepatic failure, nausea, pepticulcer, rectal bleeding, thirst, vomitingGU: Abnormal ejaculation; amenorrhea;cystitis; hematuria; hypermenorrhea; impotence;libido changes; nocturia; pelvic pain;polyuria; renal calculi; urinary frequency,incontinence, or urgency; urine retention;UTI; vaginal bleeding; vaginitisHEME: Anemia, leukopeniaMS: Arthralgia, arthritis, bursitis,dysarthria, gout, muscle stiffness, tenosynovitisRESP: Asthma, bronchitis, cough, dyspnea,pneumoniaSKIN: Acne, alopecia, dry skin, ecchymosis,eczema, maculopapular rash, photosensitivity,pruritus, rash, urticariaOther: Allergic reaction, dehydration, infection,serotonin syndrome, weight lossNO

728Nursing Considerations• Monitor patient’s BUN and serum creatineomycinsulfatedice, malaise, and elevated liver functiontest results.• Assess for evidence of serotonin syndrome,such as abdominal cramps, aggression,agitation, chills, diarrhea, headache,insomnia, lack of coordination, nausea,palpitations, paresthesia, poor concentration,and worsening of obsessive thoughts.• Monitor patient closely for suicidal tendencies,especially when therapy starts ordosage changes, because depression mayworsen temporarily. Follow facility policy.PATIENT TEACHING• Instruct patient to take nefazodone exactlyas prescribed and not to alter dosage.• Urge patient to immediately report evidenceof hepatic failure, such as jaundice,dark urine, lack of appetite, nausea, orabdominal pain.• Inform patient that antidepressant effectsmay not occur for several weeks and thattreatment may last 6 months or longer.• Caution patient to avoid alcohol duringnefazodone therapy.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Suggest that patient try sugarless gum orhard candy for dry mouth. Urge her tonotify prescriber if dry mouth persists.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes.neomycin sulfateMycifradin, Neo-FradinClass and CategoryChemical class: AminoglycosideTherapeutic class: AntibioticPregnancy category: DIndications and Dosages To suppress intestinal bacterial growthin preoperative bowel preparationTABLETS (24-HR REGIMEN)Adults. 1 g every hr for 4 doses and then1 g every 4 hr for remainder of 24 hr beforesurgery. Or, for 8 a.m. surgery, 1 g of neomycinwith erythromycin at 1 p.m., 2 p.m.,and 11 p.m. the day before surgery.Children. 25 mg/kg at 1 p.m., 2 p.m., and11 p.m. the day before surgery.TABLETS (2- TO 3-DAY REGIMEN)Adults and children. 88 mg/kg every 4 hrin 6 equally divided doses for 2 to 3 daysbefore surgery. As adjunct in hepatic encephalopathyTABLETSAdults. 4 to 12 g daily in divided dosesevery 6 hr for 5 to 6 days.Children. 50 to 100 mg/kg daily in divideddoses every 6 hr for 5 to 6 days. To treat infectious diarrhea caused byenteropathic Escherichia coliTABLETSAdults and children. 50 mg/kg daily individed doses q.i.d. for 2 to 3 days.Mechanism of ActionIs transported into bacterial cells, where itcompetes with messenger RNA to bind witha specific receptor protein on the 30S ribosomalsubunit of DNA. This action causesabnormal, nonfunctioning proteins toform. A lack of functional proteins causesbacterial cell death.ContraindicationsHypersensitivity or serious reaction to neomycin,other aminoglycosides, or theircomponents; inflammatory or ulcerative GIdisease; intestinal obstructionInteractionsDRUGSdigoxin, spironolactone: Possibly reducedabsorption rate of these drugsdimenhydrinate: Possibly masked symptomsof neomycin-induced ototoxicitymethotrexate: Possibly decreased absorptionand bioavailability of methotrexateneuromuscular blockers: Potentiated neuromuscularblockade, increased risk of prolongedrespiratory depressionoral anticoagulants: Possibly potentiatedanticoagulant effectsAdverse ReactionsEENT: OtotoxicityGI: Diarrhea, malabsorption syndrome(decreased serum carotene level and xyloseabsorption, increased fecal fat and flatulence),nausea, pseudomembranous colitis,vomitingGU: Nephrotoxicity

nine levels to assess renal function beforeand during neomycin therapy. Expect todecrease dosage or stop drug if nephrotoxicitydevelops.• Monitor blood neomycin level, as directed,to assess for therapeutic range of 5 to10 mcg/ml.WARNING Neomycin is highly ototoxic andmay cause hearing loss and tinnitus.• Watch for evidence of pseudomembranouscolitis, such as severe abdominalcramps and severe, watery diarrhea.• Anticipate that neomycin’s curare-likeeffect may worsen muscle weakness inpatients with neuromuscular disorders,such as myasthenia gravis and parkinsonism.PATIENT TEACHING• Urge patient to complete full course ofneomycin therapy.• Unless contraindicated, urge patient todrink plenty of fluids to prevent nephrotoxicity.• Urge patient undergoing bowel preparationto comply with recommended regimen,including low-residue diet, bisacodylenema administration, and neomycin use.• Advise patient to notify prescriber abouthearing loss or ringing in ears.neostigminebromideProstigminneostigminemethylsulfateProstigminClass and CategoryChemical class: Quaternary ammoniumcompoundTherapeutic class: Anticholinesterase, curareantidotePregnancy category: CIndications and Dosages To treat symptoms of myasthenia gravisTABLETS (NEOSTIGMINE BROMIDE)Adults. Initial: 15 mg every 3 to 4 hr.Dosage adjusted based on clinical response.Maintenance: 150 mg daily in divided dosesneostigmine 729based on clinical response.Children. 2 mg/kg daily in 6 to 8 divideddoses.I.M. OR SUBCUTANEOUS INJECTION (NEOSTIGMINEMETHYLSULFATE)Adults. Initial: 0.5 mg. Dosage adjustedbased on clinical response.Children. 0.01 to 0.04 mg/kg every 2 to 3 hr. To reverse nondepolarizing neuromuscularblockadeI.V. INJECTION (NEOSTIGMINE METHYLSULFATE)Adults. 0.5 to 2 mg by slow push, repeatedas needed up to 5 mg; 0.6 to 1.2 mg ofatropine or 0.2 to 0.6 mg of glycopyrrolategiven with or a few minutes before neostigmine,as ordered.Children. 0.04 mg/kg by slow push; 0.02 mgof atropine/kg is given I.M. or subcutaneouslywith each dose or alternate doses. To prevent postoperative, nonobstructiveurine retention and abdominal distention(adynamic ileus)I.M. OR SUBCUTANEOUS INJECTION (NEOSTIGMINEMETHYLSULFATE)Adults. 0.25 mg immediately after surgeryand repeated every 4 to 6 hr for 2 to 3 days. To treat postoperative, nonobstructiveurine retention and abdominal distention(adynamic ileus)I.M. OR SUBCUTANEOUS INJECTION (NEOSTIGMINEMETHYLSULFATE)Adults. 0.5 mg; injections repeated every3 hr for at least 5 doses if patient has voidedor bladder has emptied within 1 hr.Route Onset Peak DurationP.O. 45 –75 min* Unknown 3–6 hrI.V. 4 –8 min† 30 min 2–4 hrI.M. 20–30 min† 30 min 2–4 hrMechanism of ActionInhibits action of cholinesterase, an enzymethat destroys acetylcholine at myoneuronaljunctions, thereby increasing acetylcholineaccumulation at myoneuronal junctionsand facilitating nerve impulse transmissionacross the junctions. This action:• helps prevent or relieve urine retention byincreasing detrusor muscle tone in thebladder and causing bladder contractionsstrong enough to induce urination* For adynamic ileus, 2 to 4 hr.† For adynamic ileus, 10 to 30 min.NO

730Mechanism of ActionBinds to guanylate cyclase receptor of vasnesiritide• prevents or treats postoperative abdominaldistention by increasing gastric motilityand tone• improves muscle strength and increasesmuscle response to repetitive nerve stimulationin myasthenia gravis.ContraindicationsHypersensitivity to neostigmine, other anticholinesterases,bromides, or their components;mechanical obstruction of intestinalor urinary tract; peritonitisInteractionsDRUGSaminoglycosides, anesthetics, capreomycin,colistimethate, colistin, lidocaine, lincomycins,polymyxin B, quinine: Increased risk ofneuromuscular blockadeanticholinergics: Possibly masked signs ofcholinergic crisisguanadrel, guanethidine, mecamylamine, trimethaphan:Possibly antagonized effects ofneostigmine, possibly decreased antihypertensiveeffectsneuromuscular blockers: Possibly prolongedaction of depolarizing—and antagonizedaction of nondepolarizing—neuromuscularblockersprocainamide, quinidine: Possibly antagonizedeffects of neostigminequinine: Decreased neostigmine effectivenessAdverse ReactionsCNS: Dizziness, drowsiness, headache, seizures,syncope, weaknessCV: Arrhythmias (AV block, bradycardia,nodal rhythm, tachycardia), cardiac arrest,ECG changes, hypotensionEENT: Increased salivation, lacrimation,miosis, vision changesGI: Abdominal cramps, diarrhea, flatulence,increased peristalsis, nausea, vomitingGU: Urinary frequencyMS: Arthralgia, dysarthria, muscle spasmsRESP: Bronchospasm, dyspnea, increasedbronchial secretions, respiratory arrest ordepressionSKIN: Flushing, diaphoresis, rash, urticariaNursing Considerations• Be aware that 15 mg oral neostigmine bromideis equivalent to 0.5 mg parenteralneostigmine methylsulfate.• If also giving atropine, be sure to administerit before neostigmine, as prescribed.• When giving neostigmine I.V., make surepatient is well ventilated and airwayremains patent until normal respiration isassured.• If patient has myasthenia gravis, give drugnight and day, as ordered, with larger portionsof daily dose during periods ofincreased fatigue. If patient’s conditionbecomes refractory to neostigmine, expectto reduce dosage or discontinue drug, asprescribed, for a few days.WARNING Monitor patient for evidence ofneostigmine overdose, which can causepossibly fatal cholinergic crisis (increasedmuscle weakness, including respiratorymuscles). Expect to stop neostigmine andatropine, as ordered.PATIENT TEACHING• Instruct patient to take neostigmine exactlyas prescribed.• Advise patient to take drug with food ormilk to reduce adverse GI reactions.• Suggest that patient with myastheniagravis keep a daily record of doses andadverse reactions during therapy.• Instruct patient to schedule activities tominimize fatigue.nesiritideNatrecorClass and CategoryChemical class: Human B-type natriureticpeptideTherapeutic class: Arterial and venoussmooth muscle cell relaxantPregnancy category: CIndications and Dosages To reduce dyspnea at rest or with minimalactivity in patients with acutedecompensated congestive heart failureI.V. INFUSION, I.V. INJECTIONAdults. 2-mcg/kg bolus and then continuousinfusion of 0.01 mcg/kg/min for up to48 hr.Route Onset Peak DurationI.V. In 15 min 1 hr 3 hr

cular smooth muscle and endothelial cells.This action increases intracellular levels ofcyclic guanosine monophosphate, whichleads to arterial and venous smooth musclecell relaxation. Ultimately, nesiritidereduces pulmonary capillary wedge pressureand systemic arterial pressure inpatients with congestive heart failure, whichdecreases the heart’s workload and subsequentlyrelieves dyspnea.IncompatibilitiesDon’t infuse nesiritide through same I.V.line as bumetanide, enalaprilat, ethacrynatesodium, furosemide, heparin, hydralazine,or insulin because these drugs are chemicallyand physically incompatible with nesiritide.Don’t infuse drugs that contain thepreservative sodium metabisulfite throughsame I.V. line as nesiritide.ContraindicationsHypersensitivity to nesiritide or its components;primary therapy for cardiogenicshock; systolic blood pressure less of than90 mm HgInteractionsDRUGSACE inhibitors: Increased risk of symptomatichypotensionAdverse ReactionsCNS: Anxiety, dizziness, headache, insomniaCV: Angina, bradycardia, hypotension,PVCs, ventricular tachycardiaGI: Abdominal pain, nausea, vomitingGU: Elevated serum creatinine levelMS: Back painNursing ConsiderationsWARNING Be aware that nesiritide isn’t recommendedfor patients suspected to havelow cardiac filling pressures or patients forwhom vasodilating drugs aren’t appropriate,such as those with constrictive pericarditis,pericardial tamponade, restrictiveor obstructive cardiomyopathy, significantvalvular stenosis, or other conditions inwhich cardiac output depends on venousreturn.• Reconstitute 1.5-mg vial by adding 5 mldiluent removed from a 250-ml plastic I.V.bag containing preservative-free D 5 W,normal saline solution, dextrose 5% innesiritide 731half-normal (0.45) saline solution, or dextrose5% in quarter-normal (0.2) salinesolution.• Don’t shake vial. Rock it gently so all surfaces,including the stopper, are in contactwith diluent to ensure complete reconstitution.Inspect drug for particulate matterand discoloration; if present, discard drug.• Withdraw entire contents of reconstitutedsolution and add it to 250-ml plastic I.V.bag used to withdraw diluent to yield asolution of about 6 mcg/ml. Invert I.V. bagseveral times to ensure complete mixing.• After preparing infusion bag, withdrawbolus volume from infusion bag and giveit over about 60 seconds. Immediatelyafter bolus, infuse drug at 0.1 ml/kg/hr,which will deliver 0.01 mcg/kg/min.• Prime I.V. tubing with 25 ml of solutionbefore connecting to the I.V. line andbefore administering the bolus dose orstarting the infusion.• Flush the I.V. line between doses of nesiritideand incompatible drugs.• Because nesiritide binds to heparin andtherefore could bind to the heparin liningof a heparin-coated catheter, don’t give itthrough a central heparin-coated catheter.• Store reconstituted vials at room temperature(20° to 25° C [68° to 77° F]) or refrigerate(2° to 8° C [36° to 46° F]) for up to24 hours.• Because nesiritide contains no antimicrobialpreservatives, discard the reconstitutedsolution after 24 hours.• Monitor blood pressure and heart rate andrhythm frequently during therapy.• If hypotension occurs, notify prescriberand expect to reduce dosage or discontinuedthe drug. Implement measures to supportblood pressure as prescribed.• Assess patient’s breath sounds and respiratoryrate, rhythm, depth, and quality frequentlyduring drug therapy.• Monitor serum creatinine level duringdrug therapy and notify prescriber ofabnormal results.• Store unopened drug at controlled roomtemperature or refrigerate. Keep in cartonuntil time of use.PATIENT TEACHING• Instruct patient to notify you or anothernurse if she becomes dizzy because thismay indicate hypotension.NO

732netilmicin sulfate• Reassure patient that her blood pressure,heart rate, and breathing will be monitoredfrequently.netilmicin sulfateNetromycinClass and CategoryChemical class: AminoglycosideTherapeutic class: AntibioticPregnancy category: DIndications and Dosages To treat serious systemic infections, suchas intra-abdominal infections, lower respiratorytract infections, septicemia,and skin and soft-tissue infections,caused by Enterobacter aerogenes,Escherichia coli, Klebsiella pneumoniae,Proteus mirabilis, Pseudomonasaeruginosa, Serratia species, and StaphylococcusaureusI.V. INFUSION, I.M. INJECTIONAdults and children age 12 and over. 1.3 to2.2 mg/kg every 8 hr or 2 to 3.25 mg/kgevery 12 hr for 7 to 14 days. Maximum:7.5 mg/kg daily.Children ages 6 weeks to 12 years. 1.8 to2.7 mg/kg every 8 hr or 2.7 to 4 mg/kgevery 12 hr for 7 to 14 days.Infants up to age 6 weeks. 2 to 3.25 mg/kgevery 12 hr for 7 to 14 days. To treat complicated UTI caused byCitrobacter species, Enterobacterspecies, E. coli, K. pneumoniae, P.mirabilis, P. aeruginosa, Serratiaspecies, and Staphylococcus speciesI.V. INFUSION, I.M. INJECTIONAdults and adolescents. 1.5 to 2 mg/kgevery 12 hr for 7 to 14 days. Maximum:7.5 mg/kg daily.Mechanism of ActionIs transported into bacterial cells, where itcompetes with messenger RNA to bind witha specific receptor protein on the 30S ribosomalsubunit of DNA. This action causesabnormal, nonfunctioning proteins toform. A lack of functional proteins causesbacterial cell death.IncompatibilitiesDon’t mix netilmicin with beta-lactamantibiotics (penicillins and cephalosporins)because substantial mutual inactivationmay result. If prescribed concurrently,administer these drugs at separate sites.ContraindicationsHypersensitivity to netilmicin, otheraminoglycosides, or their componentsInteractionsDRUGScapreomycin, other aminoglycosides:Increased risk of nephrotoxicity, neuromuscularblockade, and ototoxicitycephalosporins, nephrotoxic drugs: Increasedrisk of nephrotoxicityloop diuretics, ototoxic drugs: Increased riskof ototoxicitymethoxyflurane, polymyxins (parenteral):Increased risk of nephrotoxicity and neuromuscularblockadeneuromuscular blockers: Increased neuromuscularblockadeAdverse ReactionsCNS: Disorientation, dizziness,encephalopathy, headache, myastheniagravis–like syndrome, neuromuscularblockade (acute muscle paralysis andapnea), paresthesia, peripheral neuropathy,seizures, vertigo, weaknessCV: Hypotension, palpitationsEENT: Blurred vision, hearing loss, nystagmus,tinnitusGI: Diarrhea, elevated liver function testsresults, nausea, vomitingGU: Elevated BUN and serum creatininelevels, nephrotoxicity, oliguria, proteinuriaHEME: Anemia, eosinophilia, leukopenia,prolonged PT, thrombocytopenia, thrombocytosisMS: Muscle twitchingRESP: ApneaSKIN: Allergic dermatitis, erythema, pruritus,rashOther: Angioedema; hyperkalemia; injectionsite hematoma, induration, and painNursing Considerations• To prepare netilmicin for I.V. use, diluteeach dose in 50 to 200 ml of suitable diluent,such as normal saline solution, D 5 W,or lactated Ringer’s solution, and giveslowly over 30 to 60 minutes.• Ensure adequate hydration during therapyto maintain adequate renal function.

• Monitor blood netilmicin level; optimumpeak level is 6 to 10 mcg/ml and troughlevel is 0.5 to 2 mcg/ml.• Check patient’s BUN and serum creatininelevels, urine specific gravity, and creatinineclearance during netilmicin therapy, asordered.• Anticipate higher risk of nephrotoxicity inelderly patients, those with impaired renalfunction, and those who receive highdoses or prolonged netilmicin therapy.• Reduce dosage or discontinue drug, asordered, if signs of drug-induced auditoryor vestibular toxicity develop; the damagemay be permanent.PATIENT TEACHING• Encourage patient to drink plenty of fluidsduring netilmicin therapy.• Instruct patient to notify prescriber immediatelyabout dizziness, hearing loss, muscletwitching, nausea, numbness and tingling,ringing or buzzing in ears, seizures,significant changes in amount of urine orfrequency of urination, and vomiting.• Urge patient to keep follow-up appointmentsto monitor progress.nicardipinehydrochlorideCardene, Cardene IV, Cardene SRClass and CategoryChemical class: Dihydropyridine derivativeTherapeutic class: Antianginal, antihypertensivePregnancy category: CIndications and Dosages To manage angina pectoris and Prinzmetal’sangina, to manage hypertensionCAPSULESAdults and adolescents. 20 to 40 mg t.i.d.,increased every 3 days, as prescribed.E.R. CAPSULESAdults. 30 mg b.i.d.I.V. INFUSIONAdults. 0.5 to 2.2 mg/hr by continuousinfusion. To control acute hypertensionI.V. INFUSIONAdults. Initial: 5 mg/hr by continuous infusion;increased by 2.5 mg/hr every 5 tonicardipine hydrochloride 73315 min, as prescribed. Maximum: 15 mg/hr.Route Onset Peak DurationP.O. 20 min 1–2 hr UnknownP.O. (E.R.) 20 min 1–2 hr 12 hrI.V. Immediate Unknown UnknownMechanism of ActionMay slow extracellular calcium movementinto myocardial and vascular smoothmusclecells by deforming calcium channelsin cell membranes, inhibiting ioncontrolledgating mechanisms, and interferingwith calcium release from the sarcoplasmicreticulum. By decreasing the intracellularcalcium level, nicardipine inhibitssmooth-muscle cell contraction and dilatescoronary and systemic arteries. As withother calcium channel blockers, theseactions lead to decreased myocardial oxygenrequirements and reduced peripheralresistance, blood pressure, and afterload.IncompatibilitiesDon’t mix nicardipine with sodiumbicarbonate or LR solution, and don’tadminister through same I.V. line.ContraindicationsAdvanced aortic stenosis, hypersensitivityto any calcium channel blocker, second- orthird-degree AV block in patient withoutartificial pacemakerInteractionsDRUGSanesthetics (hydrocarbon inhalation):Possibly hypotensionbeta blockers, other antihypertensives, prazocin:Increased risk of hypotensioncalcium supplements: Possibly impairedaction of nicardipinecimetidine: Increased nicardipine bioavailabilitydigoxin: Transiently increased blood digoxinlevel, increased risk of digitalis toxicitydisopyramide, flecainide: Increased risk ofbradycardia, conduction defects, and heartfailureestrogens: Possibly increased fluid retentionand decreased therapeutic effects ofnicardipinelithium: Increased risk of neurotoxicityNSAIDs, sympathomimetics: Possiblydecreased therapeutic effects of nicardipineNO

734nicardipine hydrochlorideprocainamide, quinidine: Possibly prolongedQT intervalFOODSgrapefruit, grapefruit juice: Possiblyincreased bioavailability of nicardipinehigh-fat meals: Decreased blood nicardipinelevelACTIVITIESalcohol use: Increased hypotensive effectAdverse ReactionsCNS: Anxiety, asthenia, ataxia, confusion,dizziness, drowsiness, headache, nervousness,paresthesia, psychiatric disturbance,syncope, tremor, weaknessCV: Arrhythmias (bradycardia, tachycardia),chest pain, heart failure, hypotension,orthostatic hypotension, palpitations,peripheral edemaEENT: Altered taste, blurred vision, drymouth, epistaxis, gingival hyperplasia,pharyngitis, rhinitis, tinnitusENDO: Gynecomastia, hyperglycemiaGI: Anorexia, constipation, diarrhea, elevatedliver function test results, indigestion,nausea, thirst, vomitingGU: Dysuria, nocturia, polyuria, sexual dysfunction,urinary frequencyHEME: Anemia, leukopenia, thrombocytopeniaMS: Joint stiffness, muscle spasmsRESP: Bronchitis, cough, upper respiratorytract infectionSKIN: Dermatitis, diaphoresis, erythemamultiforme, flushing, photosensitivity, pruritus,rash, Stevens-Johnson syndrome,urticariaOther: Hypokalemia, injection site irritation,weight gainNursing Considerations• Check blood pressure and pulse ratebefore nicardipine therapy begins, duringdosage changes, and periodically throughouttherapy. During prolonged therapy,periodically assess ECG tracings forarrhythmias and other changes.• Dilute each 25-mg ampule of nicardipinewith 240 ml of solution to yield 0.1 mg/ml. Mixture is stable at room temperaturefor 24 hours.• If using premixed nicardipine for intravenousinfusion, check strength carefullybecause drug comes as single strength(20 mg nicardipine in 200 ml of solution,providing 0.1 mg/ml) or double strength(40 mg nicardipine in 200 ml of solution,providing 0.2 mg/ml).• Administer continuous infusion by I.V.pump or controller, and adjust accordingto patient’s blood pressure, as prescribed.• Change peripheral I.V. site every 12 hours,if feasible, to minimize peripheral venousirritation.• Give first dose of oral nicardipine 1 hourbefore stopping I.V. infusion, as ordered.• Monitor fluid intake and output and dailyweight for signs of fluid retention, whichmay precipitate heart failure. Also assessfor signs of heart failure, such as crackles,dyspnea, jugular vein distention, peripheraledema, and weight gain.• During prolonged therapy, periodicallymonitor liver and renal function testresults. Expect elevated liver function testresults to return to normal after drug isdiscontinued.• Monitor serum potassium level duringprolonged therapy. Hypokalemia increasesthe risk of arrhythmias.• Because of drug’s negative inotropic effecton some patients, closely monitor patientswho take a beta blocker or have heart failureor significant left ventricular dysfunction.WARNING Expect to taper dosage graduallybefore discontinuing drug. Otherwise,angina or dangerously high blood pressurecould result.PATIENT TEACHING• Urge patient to take nicardipine as prescribed,even if she feels well.• Instruct patient to swallow E.R. capsuleswhole, not to chew, crush, cut, or openthem.• Advise patient not to take drug within1 hour of eating a high-fat meal or grapefruitproduct. Urge her not to alter theamount of grapefruit products in her dietwithout consulting prescriber.WARNING Caution patient against stoppingnicardipine abruptly because angina ordangerously high blood pressure couldresult.• Teach patient how to take her pulse, andurge her to notify prescriber immediatelyif it falls below 50 beats/minute.• Teach patient how to measure blood pressure,and urge her to do so weekly if drug

was prescribed for hypertension. Suggestthat she keep a log of blood pressure readingsand take it to follow-up visits.• Advise patient to change position slowly tominimize orthostatic hypotension.• Urge patient to avoid potentially hazardousactivities until drug’s CNS effectsare known.• Advise patient to notify prescriber immediatelyabout chest pain that’s not relievedby rest or nitroglycerin, constipation,irregular heartbeats, nausea, pronounceddizziness, severe or persistent headache,and swelling of hands or feet.• Encourage patient to comply with suggestedlifestyle changes, such as alcohol moderation,low-sodium or low-fat diet, regularexercise, smoking cessation, stress management,and weight reduction.• Inform patient that saunas, hot tubs, andprolonged hot showers may cause dizzinessor fainting.• Instruct patient to avoid prolonged sunexposure and to use sunscreen when goingoutdoors.niclosamideNiclocideClass and CategoryChemical class: Salicylanilide derivativeTherapeutic class: AnthelminticPregnancy category: BIndications and Dosages To treat beef (Taenia saginata), fish(Diphyllobothrium latum), or pork(Taenia solium) tapeworm infestationsCHEWABLE TABLETSAdults. 2 g as a single dose; repeated in7 days, if needed. Maximum: 2 g daily.Children weighing more than 34 kg(75 lb). 1.5 g as a single dose; repeated in7 days, if needed. Maximum: 2 g daily.Children weighing 11 (24 lb) to 34 kg. 1 gas a single dose; repeated in 7 days, if needed.Maximum: 2 g daily. To treat dwarf tapeworm(Hymenolepsis nana) infestationsCHEWABLE TABLETSAdults. 2 g daily for 7 days; repeated in 7 to14 days, if needed.niclosamide 735Children weighing more than 34 kg. 1.5 gon day 1 and then 1 g daily for next 6 days;repeated in 7 to 14 days, if needed.Maximum: 2 g daily.Children weighing 11 to 34 kg. 1 g on day1 and then 500 mg daily for the next 6 days;repeated in 7 to 14 days, if needed.Maximum: 2 g daily.Mechanism of ActionMay alter anaerobic energy production intapeworms by inhibiting oxidative phosphorylationin their mitochondria, whichdecreases synthesis of ATP. Niclosamidecauses the scolex (headlike segment) andproximal segment of tapeworm to detachfrom intestinal wall, which leads to parasiteevacuation from intestine through normalperistalsis.ContraindicationsAge under 2 years; hypersensitivity to niclosamide,other anthelmintics, or their componentsInteractionsACTIVITIESalcohol use: Decreased niclosamide effectsAdverse ReactionsCNS: Dizziness, drowsiness, headache,light-headednessEENT: Taste perversionGI: Abdominal distress, anorexia, constipation,diarrhea, nausea, vomitingSKIN: Anal pruritus, rashNursing Considerations• To identify infestation, collect several stoolspecimens before starting niclosamidetherapy, as ordered, because eggs and parasitesegments are released irregularly.• If patient can’t chew tablets thoroughly,crush and give them with small amount ofwater.• For young child, crush tablets to fine powderand mix with small amount of waterto make paste.• Be aware that treatment isn’t consideredsuccessful until stools have shown no eggsor parasites for at least 3 months.PATIENT TEACHING• Instruct patient to take niclosamide after alight meal.• For young child, instruct parent to crushtablets to fine powder and mix with smallNO

736nicotineamount of water to make paste.• Urge patient to complete entire course ofniclosamide therapy.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to store niclosamide in acool, dry, dark place. Caution against storingin bathroom, near kitchen sink, or inother damp places because heat and moisturebreak down drug.• Inform patient that stool may need to beexamined on day 7 of treatment and again1 and 3 months after treatment.• Instruct patient to wash hands thoroughly,to wash all bedding, and to use meticulouspersonal and environmental hygiene todecrease the risk of autoinfection.• Caution patient against eating undercookedfish, pork, or beef.nicotine forinhalationNicotrol Inhalernicotine nasalsolutionNicotrol NSnicotine polacrilexNicorette, Nicorette Plus (CAN), Thrivenicotinetransdermal systemHabitrol, Nicoderm, NicoDerm CQ,Nicotrol, ProStepClass and CategoryChemical class: Pyridine alkaloidTherapeutic class: Smoking cessationadjunctPregnancy category: C (nicotine polacrilex),D (other forms of nicotine)Indications and Dosages To relieve nicotine withdrawal symptoms,including cravingCHEWING GUMAdults. Initial: 2 or 4 mg p.r.n. or every 1 to2 hr, adjusted to complete withdrawal by4 to 6 mo. Maximum: 30 pieces of 2-mggum daily or 20 pieces of 4-mg gum daily.NASAL SOLUTIONAdults. 1 to 2 sprays (1 to 2 mg) in eachnostril/hr. Maximum: 5 mg/hr or 40 mgdaily for up to 3 mo.ORAL INHALATIONAdults and adolescents. 6 to 16 cartridges(24 to 64 mg) daily for up to 12 wk; thendosage gradually reduced over 12 wk orless. Maximum: 16 cartridges (64 mg) dailyfor 6 mo.TRANSDERMAL SYSTEMAdults. Initial: 14 to 22 mg daily, adjustedto lower-dose systems over 2 to 5 mo.DOSAGE ADJUSTMENT For adolescents andfor adults weighing less than 45 kg (100 lb)and who smoke less than 10 cigarettes dailyor have heart disease, initial dosage reducedto 11 to 14 mg daily and adjusted to lowerdosesystems over 2 to 5 mo.Mechanism of ActionBinds selectively to nicotinic-cholinergicreceptors at autonomic ganglia, in the adrenalmedulla, at neuromuscular junctions,and in the brain. By providing a lower doseof nicotine than cigarettes, this drugreduces nicotine craving and withdrawalsymptoms.ContraindicationsHypersensitivity to nicotine, its components,or components of transdermal system;life-threatening arrhythmias; nonsmokers;recovery from acute MI; severeangina pectoris; skin disorders (transdermal);temporomandibular joint disease(chewing gum)InteractionsDRUGSacetaminophen, beta blockers, imipramine,insulin, oxazepam, pentazocine, theophylline:Possibly increased therapeutic effects ofthese drugs (chewing gum, nasal spray,transdermal system)alpha blockers, bronchodilators: Possiblyincreased therapeutic effects of these drugs(chewing gum, transdermal system)bupropion: Potentiated therapeutic effectsof nicotine, possibly increased risk ofhypertensionsympathomimetics: Possibly decreased therapeuticeffects of these drugs (chewinggum, transdermal system)

theophylline, tricyclic antidepressants:Possibly altered pharmacologic actions ofthese drugs (oral inhalation)FOODSacidic beverages (citrus juices, coffee, softdrinks, tea, wine): Decreased nicotineabsorption from gum if beverages consumedwithin 15 minutes before or whilechewing gumcaffeine: Increased effects of caffeine (chewinggum, nasal spray, transdermal system)Adverse ReactionsCNS: Dizziness, dream disturbances,drowsiness, headache, irritability, lightheadedness,nervousness (chewing gum,transdermal system); amnesia, confusion,difficulty speaking, headache, migraineheadache, paresthesia (nasal spray); chills,fever, headache, paresthesia (oral inhalation)CV: Arrhythmias (all forms); hypertension(chewing gum, transdermal system);peripheral edema (nasal spray)EENT: Increased salivation, injury to teethor dental work, mouth injury, pharyngitis,stomatitis (chewing gum); altered taste, drymouth (chewing gum, transdermal system);altered smell and taste, burning eyes, drymouth, earache, epistaxis, gum disorders,hoarseness, lacrimation, mouth and tongueswelling, nasal blisters, nasal irritation orulceration, pharyngitis, rhinitis, sinus problems,sneezing, vision changes (nasal spray);altered taste, lacrimation, pharyngitis,rhinitis, sinusitis, stomatitis (oral inhalation)GI: Eructation (chewing gum); abdominalpain, constipation, diarrhea, flatulence,increased appetite, indigestion, nausea,vomiting (chewing gum, transdermal system);abdominal pain, constipation, diarrhea,flatulence, hiccups, indigestion, nausea(nasal spray); diarrhea, flatulence, hiccups,indigestion, nausea, vomiting (oralinhalation)GU: Dysmenorrhea (chewing gum, transdermalsystem); menstrual irregularities(nasal spray)MS: Jaw and neck pain (chewing gum); arthralgia,myalgia (chewing gum, transdermalsystem); arthralgia, back pain, myalgia(nasal spray); back pain (oral inhalation)RESP: Cough (chewing gum, transdermalnicotine 737system); bronchitis, bronchospasm, chesttightness, cough, dyspnea, increased sputumproduction (nasal spray); chest tightness,cough, dyspnea, wheezing (oralinhalation)SKIN: Diaphoresis, erythema, pruritus,rash, urticaria (chewing gum, transdermalsystem); acne, flushing of face, pruritus,purpura, rash (nasal spray); pruritus, rash,urticaria (oral inhalation)Other: Allergic reaction (chewing gum,transdermal system); physical dependence(nasal spray); flulike symptoms, generalizedpain, withdrawal symptoms (oral inhalation)Nursing Considerations• When administering nicotine by oral inhalation,expect optimal effect to result fromcontinuous puffing for 20 minutes.• To avoid possible burns, remove patchbefore patient has an MRI.PATIENT TEACHING• Instruct patient to read and follow packageinstructions to obtain best results withnicotine product.• Advise patient to notify prescriber aboutother drugs she takes.• Stress that patient must stop smoking assoon as nicotine treatment starts to avoidtoxicity.• For chewing gum therapy, instruct patientto wait at least 15 minutes after drinkingcoffee, juice, soft drink, tea, or wine.Advise her to chew gum until she detects atingling sensation or peppery taste andthen to place gum between her cheek andgum until tingling or peppery taste subsides.Then direct her to move gum to adifferent site until tingling or taste subsides,repeating until she no longer feelsthe sensation—usually about 30 minutes.Caution against swallowing the gum.• For nasal spray, tell patient to tilt her headback and spray into a nostril. Cautionagainst sniffing, swallowing, or inhalingspray because nicotine is absorbedthrough nasal mucosa.• Warn patient that prolonged use of nasalform may cause dependence.• For oral inhalation, tell patient to use 6 to16 cartridges daily to prevent or relievewithdrawal symptoms and craving.Starting with 1 or 2 cartridges daily yieldsNO

738nifedipinepoor success. Direct patient to inhalethrough device like a cigarette, puffingoften for 20 minutes.• For transdermal system, tell patient not toopen package until just before use becausenicotine is lost in the air. Advise her toapply system to clean, hairless, dry site onupper outer arm or upper body. Instructher to change systems and rotate sitesevery 24 hours and not to use the samesite for 7 days. To avoid possible burns,advise patient to remove patch beforeundergoing any MRI procedure.WARNING Urge patient to keep all unusednicotine forms safely away from childrenand pets and to discard used forms carefully.(Enough nicotine may remain inused systems to poison children and pets.)Instruct her to contact a poison controlcenter immediately if she suspects that achild has ingested nicotine.• Explain to patient with asthma or COPDthat nicotine may cause bronchospasm.• Inform patient that it may take severalattempts to stop smoking. Urge her to joina smoking cessation program.nifedipineAdalat, Adalat CC, Adalat PA (CAN),Adalat XL (CAN), Apo-Nifed (CAN), Novo-Nifedin (CAN), Nu-Nifed (CAN),Procardia, Procardia XLClass and CategoryChemical class: Dihydropyridine derivativeTherapeutic class: Antianginal, antihypertensivePregnancy category: CIndications and Dosages To manage anginaCAPSULES (ADALAT, APO-NIFED, NOVO-NIFEDIN,NU-NIFED, PROCARDIA)Adults. Initial: 10 mg t.i.d., increased over1 to 2 wk as needed. Maintenance: 10 to20 mg t.i.d. Maximum: 180 mg daily, 30mg/dose.E.R. TABLETS (ADALAT XL, PROCARDIA XL)Adults. Initial: 30 to 60 mg daily, increasedor decreased over 7 to 14 days based onpatient response. Maximum: 90 mg daily. To manage hypertensionE.R. TABLETS (ADALAT CC)Adults. Initial: 30 mg daily. Maintenance:30 to 60 mg daily, increased or decreasedover 7 to 14 days based on patient response.Maximum: 90 mg daily.E.R. TABLETS (ADALAT PA)Adults. Initial: 10 to 20 mg b.i.d., increasedevery 3 wk based on patient response.Maintenance: 20 mg b.i.d. Maximum: 80 mgdaily.E.R. TABLETS (ADALAT XL)Adults. Initial: 30 to 60 mg daily, increasedor decreased over 7 to 14 days based onpatient response. Maintenance: 60 to 90 mgdaily. Maximum: 120 mg daily.E.R. TABLETS (PROCARDIA XL)Adults. 30 to 60 mg daily, increased ordecreased over 7 to 14 days based onpatient response. Maximum: 120 mg daily.DOSAGE ADJUSTMENT Dosage may bereduced for elderly patients and those withheart failure or impaired hepatic or renalfunction.Route Onset Peak DurationP.O. (caps) 20 min Unknown UnknownMechanism of ActionMay slow movement of calcium intomyocardial and vascular smooth-musclecells by deforming calcium channels in cellmembranes, inhibiting ion-controlled gatingmechanisms, and disrupting calciumrelease from sarcoplasmic reticulum.Decreasing intracellular calcium levelinhibits smooth-muscle cell contractionand dilates arteries, which decreasesmyocardial oxygen demand, peripheralresistance, blood pressure, and afterload.ContraindicationsHypersensitivity to a calcium channelblocker, second- or third-degree AV blockwithout artificial pacemaker, sick sinus syndromeInteractionsDRUGSanesthetics (hydrocarbon inhalation):Possibly hypotensionantiviral drugs, cimetidine, dalfopristin, diltiazem,erythromycin, fluconazole, itraconazole,ketoconazole, nefazodone, other antihypertensives,prazocin, quinupristin, timolol,valproic acid, verapamil: Increased risk ofhypotension

enazepril: Possibly increased heart rate andhypotensive effectbeta blockers: Increased risk of profoundhypotension, heart failure, and worseningof anginacalcium supplements: Possibly interferencewith action of nifedipinecarbamazepine, NSAIDs, phenobarbitone,phenytoin, rifampin, rifapentine, St. John’swort, sympathomimetics: Possibly decreasedtherapeutic effects of nifedipinedigoxin: Transiently increased blood digoxinlevel, increased risk of digitalis toxicitydisopyramide, flecainide: Increased risk ofbradycardia, conduction defects, and heartfailuredoxazocin: Decreased doxazocin effectiveness;increased nifedipine effectivenessestrogens: Possibly increased fluid retentionand decreased nifedipine effectslithium: Increased risk of neurotoxicitymetformin: Increased metformin absorptionand plasma leveltacrolimus: Decreased tacrolimus metabolismFOODSgrapefruit, grapefruit juice: Possiblyincreased bioavailability of nifedipinehigh-fat meals: Possibly delayed nifedipineabsorptionACTIVITIESalcohol use: Additive hypotensive effectAdverse ReactionsCNS: Anxiety, ataxia, confusion, dizziness,drowsiness, headache, nervousness (possiblyextreme), nightmares, paresthesia, psychiatricdisturbance, syncope, tremor, weaknessCV: Arrhythmias (bradycardia, tachycardia),chest pain, heart failure, hypotension,palpitations, peripheral edemaEENT: Altered taste, blurred vision, drymouth, epistaxis, gingival hyperplasia, nasalcongestion, pharyngitis, sinusitis, tinnitusENDO: Gynecomastia, hyperglycemiaGI: Anorexia, constipation, diarrhea, dyspepsia,elevated liver function test results,hepatitis, nausea, vomitingGU: Dysuria, nocturia, polyuria, sexual dysfunction,urinary frequencyHEME: Anemia, leukopenia, positiveCoombs’ test, thrombocytopeniaMS: Joint stiffness, muscle crampsRESP: Chest congestion, cough, dyspnea,nifedipine 739respiratory tract infection, wheezingSKIN: Dermatitis, diaphoresis, erythemamultiforme, flushing, photosensitivity, pruritus,rash, urticariaNursing Considerations• When starting and stopping nifedipinetherapy, taper it, as prescribed, over 7 to14 days.• For closely monitored hospitalized patientwith angina, dosage may be increased 10 mgevery 4 to 6 hours to control chest pain.• Because of drug’s negative inotropic effecton some patients, frequently monitorheart rate and rhythm and blood pressurein patients who take a beta blocker or haveheart failure or significant left ventriculardysfunction.• Monitor fluid intake and output and dailyweight; fluid retention may lead to heartfailure. Also assess for signs of heart failure,such as crackles, dyspnea, jugular veindistention, peripheral edema, and weightgain.PATIENT TEACHING• Instruct patient to swallow E.R. tabletswhole, not to crush, chew, or break them.Inform her that their empty shells mayappear in stool.• Urge patient to take nifedipine exactly asprescribed, even when she’s feeling well.Advise her to notify prescriber if she missestwo or more doses.• Urge patient not to take drug within 1hour of a high-fat meal or grapefruit. Urgeher not to alter the amount of grapefruitin her diet without consulting prescriber.WARNING Caution patient against stoppingnifedipine abruptly because angina ordangerously high blood pressure couldresult.• Teach patient to measure pulse rate andblood pressure, and advise her to call prescriberif they drop below accepted levels.Suggest keeping a log of weekly measurementsand taking it to follow-up visits.• Instruct patient to notify prescriber immediatelyabout chest pain, difficulty breathing,ringing in ears, and swollen gums.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Urge patient to avoid alcoholic beveragesbecause they may worsen dizziness,drowsiness, and hypotension.• Teach patient to minimize constipation byNO

740nisoldipineincreasing her intake of fluids, if allowed,and dietary fiber.• Emphasize the need to comply with prescribedlifestyle changes, such as alcoholmoderation, low-fat or low-sodium diet,regular exercise, smoking cessation, stressreduction, and weight reduction.• Stress the need for good oral hygiene andregular dental visits.• Caution patient that hot tubs, saunas, andprolonged hot showers may cause dizzinessand fainting.• Advise patient to avoid prolonged sunexposure and to wear sunscreen outdoors.nisoldipineSularClass and CategoryChemical class: Dihydropyridine derivativeTherapeutic class: AntihypertensivePregnancy category: CIndications and Dosages To manage hypertensionE.R. TABLETSAdults. 20 mg daily, increased by 10 mgevery 7 days, as prescribed. Maintenance:20 to 40 mg daily. Maximum: 60 mg daily.DOSAGE ADJUSTMENT For patients over age65 and patients with hepatic impairment,initial dosage reduced to 10 mg daily.Mechanism of ActionMay slow extracellular calcium movementinto myocardial and vascular smoothmusclecells by deforming calcium channelsin cell membranes, inhibiting ioncontrolledgating mechanisms, and interferingwith calcium release from the sarcoplasmicreticulum. By decreasing the intracellularcalcium level, nisoldipine inhibitssmooth-muscle cell contraction and dilatescoronary and systemic arteries. As withother calcium channel blockers, theseactions lead to decreased myocardial oxygenrequirements and reduced peripheralresistance, blood pressure, and afterload.ContraindicationsHypersensitivity to calcium channel blocker,second- or third-degree AV block withno artificial pacemaker, sick sinus syndromeInteractionsDRUGSbeta blockers: Possibly increased risk ofhypotensionCYP3A4 inducers such as carbamazepine,phenytoin: Decreased nisoldipine levels andeffectivenessCYP3A4 inhibitors such as azole antifungals,cimetidine, quinidine: Increased bloodnisoldipine level; increased risk of adversereactionsNSAIDs: Decreased antihypertensive effectof nisoldipineFOODSgrapefruit, grapefruit juice: Possiblyincreased bioavailability of nisoldipinehigh-fat meals: Possibly delayed nisoldipineabsorptionACTIVITIESalcohol use: Additive hypotensive effectAdverse ReactionsCNS: Dizziness, headacheCV: Angina, hypotension, palpitations,peripheral edema, vasodilationEENT: Pharyngitis, sinusitisGI: Constipation, nauseaRESP: Bronchospasm, dyspneaSKIN: RasOther: Allergic-type reactionNursing Considerations• Monitor pulse rate and rhythm and bloodpressure before starting nisoldipine therapy,during dosage adjustments, and periodicallythroughout therapy.• Don’t break or crush E.R. tablets.• For optimal absorption, give drug 1 hourbefore or 2 hours after meals.• Monitor fluid intake and output and dailyweight to assess for signs of fluid retention,which may lead to heart failure. Alsoassess for signs of heart failure, such ascrackles, dyspnea, jugular vein distention,peripheral edema, and weight gain.• Monitor patient for allergic-type reactionthat may include bronchospasm, especiallyif patient has aspirin sensitivity, becausedrug contains FD&C yellow no. 5 dye.PATIENT TEACHING• Instruct patient to swallow E.R. nisoldipinetablets whole, not to break, crush, orchew them.• Advise patient to take drug 1 hour beforeor 2 hours after meals. Urge her not to

alter amount of grapefruit products in herdiet without consulting prescriber.• Urge patient to continue taking drug asprescribed, even if she feels well.WARNING Caution patient against stoppingdrug abruptly because blood pressurecould rise dangerously high.• Instruct patient to notify prescriber aboutconstipation, difficulty breathing, dizziness,irregular heartbeat, nausea, severeheadache, and swelling of hands or feet.• Teach patient and family how to measureblood pressure, and instruct them to notifyprescriber if systolic blood pressure fallsbelow 90 mm Hg. Suggest that patientkeep a log of weekly measurements andtake it to follow-up visits.• Advise patient to change positions slowlyto minimize the effects of orthostatichypotension. Inform her that hot tubs,saunas, and prolonged hot showers mayworsen this adverse reaction.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Urge patient to avoid alcohol and OTCalcohol-containing drugs without consultingprescriber. Many OTC preparationscan raise blood pressure.• Emphasize the need to adhere to prescribedlifestyle changes, such as alcoholmoderation, low-fat and low-sodium diet,regular exercise, smoking cessation, stressreduction, and weight reduction.nitazoxanideAliniaClass and CategoryChemical class: BenzamideTherapeutic class: AntiprotozoalPregnancy category: BIndications and Dosages To treat diarrhea caused byCryptosporidium parvumORAL SUSPENSION, TABLETSAdults and children age 12 and over.500 mg every 12 hr with meals for 3 days.ORAL SUSPENSIONChildren ages 4 to 11. 200 mg (10 ml)every 12 hr with meals for 3 days.Children ages 12 months to 47 months.nitazoxanide 741100 mg (5 ml) every 12 hr with meals for3 days. To treat diarrhea caused by GiardialambliaORAL SUSPENSION, TABLETSChildren age 12 and over. 500 mg every12 hr with meals for 3 daysORAL SUSPENSIONChildren ages 4 to 11. 200 mg (10 ml)every 12 hr with meals for 3 days.Children ages 12 months to 47 months.100 mg (5 ml) every 12 hr with meals for3 days.Route Onset Peak DurationP.O. 1–4 hr Unknown UnknownMechanism of ActionMay destroy Cryptosporidium parvum andGiardia lamblia by interfering with enzymedependentelectron transfer required fortheir anaerobic energy metabolism. Otherunidentified mechanisms may also beinvolved. With loss of protozoal activity inthe intestines, diarrhea ceases.ContraindicationsHypersensitivity to nitazoxanide or its componentsInteractionsDRUGSother highly plasma protein–bound drugswith narrow therapeutic indices (such aswarfarin and phenytoins): Possibly increasedrisk of toxicity of these drugsAdverse ReactionsCNS: HeadacheGI: Abdominal pain, anorexia, diarrhea,nausea, vomitingNursing Considerations• Use nitazoxanide cautiously in childrenwith impaired hepatic function, biliarydisease, or renal insufficiency.• Prepare suspension by first tapping bottleuntil powder flows freely. Add 24 ml of tapwater to powder and shake vigorously tosuspend powder. Add another 24 ml waterand shake vigorously again. Keep bottle ofreconstituted suspension tightly capped.• Use oral suspension for children age11 and under because tablets contain morenitazoxanide than is recommended forchildren under age 12.NO

742nitrofurantoinPATIENT TEACHING• Tell parents of patient to give nitazoxanidewith meals.• Advise parents to keep reconstituted nitazoxanidebottle tightly closed and to shakethe bottle well before each use.• Instruct parents to discard any unuseddrug after 7 days from first opening bottle.• Inform parents of diabetic patient thatoral nitazoxanide suspension contains1.48 grams of sucrose/5 ml. Tell them thatthey should make sure to monitorpatient’s blood glucose level closely.• Tell parents that discoloration of eyes orurine, although uncommon, may occurand is harmless.nitrofurantoinApo-Nitrofurantoin (CAN), Furadantin,Macrobid, Macrodantin, Novo-Furantoin (CAN)Class and CategoryChemical class: Nitrofuran derivativeTherapeutic class: AntibioticPregnancy category: B (except near term)Indications and Dosages To treat acute cystitisCAPSULES, ORAL SUSPENSION, TABLETSAdults. 50 to 100 mg every 6 hr. Maximum:600 mg daily or 10 mg/kg daily.Children over age 1 month. 0.75 to1.75 mg/kg every 6 hr.E.R. CAPSULESAdults and children age 12 and over.100 mg every 12 hr for 7 days. To suppress chronic cystitisCAPSULES, ORAL SUSPENSION, TABLETSAdults. 50 to 100 mg at bedtime.Maximum: 600 mg daily or 10 mg/kg daily.Children over age 1 month. 1 mg/kg dailyat bedtime.Mechanism of ActionInactivates or alters bacterial ribosomalproteins and other macromolecules. Thisaction of nitrofurantoin inhibits bacterialprotein synthesis, aerobic energy metabolism,DNA synthesis, RNA synthesis, andcell wall synthesis. Nitrofurantoin is bacteriostaticat low doses and bactericidal athigher doses.ContraindicationsAge under 1 month, anuria, creatinineclearance less than 60 ml/min/1.73 m 2 , historyof cholestatic jaundice or hepatic dysfunctionwith previous nitrofurantoin therapy,hypersensitivity to nitrofurantoin orparabens, oliguria, pregnancy near termInteractionsDRUGShepatotoxic drugs: Increased risk of hepatotoxicitymagnesium trisilicate: Decreased nitrofurantoinabsorptionmethyldopa, procainamide, hemolytics:Increased risk of toxic effects from nitrofurantoinnalidixic acid: Possibly impaired therapeuticeffects of this drugneurotoxic drugs: Increased risk of neurotoxicityprobenecid, sulfinpyrazone: Increased bloodnitrofurantoin level and increased risk oftoxicityAdverse ReactionsCNS: Chills, confusion, depression,headache, neurotoxicity, peripheral neuropathyEENT: Optic neuritis, parotitis, tooth discolorationGI: Abdominal pain, anorexia, cholestaticjaundice, diarrhea, hepatic necrosis, hepatitis,nausea, pancreatitis, pseudomembranouscolitis, vomitingGU: Rust-colored to brown urineHEME: Aplastic anemia, granulocytopenia,hemolytic anemia, leukopenia, megaloblasticanemia, methemoglobinemia, thrombocytopeniaMS: Arthralgia, myalgiaRESP: Asthma (in asthmatic patients),cyanosis, interstitial pneumonitis (acute),pulmonary fibrosisSKIN: Alopecia, erythema multiforme,exfoliative dermatitis, jaundice, pruritus,rash, urticariaOther: Anaphylaxis, angioedema, druginducedfeverNursing Considerations• Obtain a specimen of patient’s urine forculture and sensitivity tests, as ordered;review test results if possible before givingnitrofurantoin.

• Give drug with food or milk to avoidstaining teeth.• Don’t crush or break capsules.• Shake oral nitrofurantoin suspensionbefore pouring dose, and mix with food ormilk, as needed.• Monitor patient for evidence of superinfection,such as abdominal pain, diarrhea,and fever. If patient develops diarrhea, itmay indicate pseudomembranous colitiscaused by Clostridium difficile. Notify prescriberand expect to withhold nitrofurantoinand treat with fluids, electrolytes, protein,and an antibiotic effective against C.difficile.• Monitor patient for pulmonary and hepaticabnormalities because rare but severereactions have occurred with nitrofurantoinuse, especially in the elderly.• Observe patient for changes in nervousfunction because peripheral neuropathy,although uncommon, may become severeor irreversible. Patients with renal impairment,anemia, diabetes mellitus, electrolyteimbalance, vitamin B deficiency, ordebilitating disease are at higher risk forperipheral neuropathy.PATIENT TEACHING• Instruct patient to shake nitrofurantoinoral suspension before measuring doseand to take drug with food or milk.• Caution patient against taking any preparationsthat contain magnesium trisilicateduring therapy.• Explain that urine may turn brown,orange, or rust-colored during therapy.• Instruct patient to complete prescribedcourse of therapy even if symptoms subsidebefore course is completed.• Urge patient to tell prescriber about diarrheathat’s severe or lasts longer than3 days. Explain that watery or bloodystools can occur 2 or more months afternitrofurantoin therapy and can be serious,requiring prompt treatment.nitroglycerin(glyceryl trinitrate)Deponit, Minitran, Nitro-Bid, Nitrocot,Nitro-Dur, Nitrogard, Nitroglyn E-R,Nitroject, Nitrol, Nitrolingual,nitroglycerin 743NitroMist, Nitrong SR, Nitro-par,Nitrostat, Nitro-time, Transderm-Nitro,TridilClass and CategoryChemical class: NitrateTherapeutic class: Antianginal, antihypertensive,vasodilatorPregnancy category: CIndications and Dosages To prevent or treat anginaE.R. BUCCAL TABLETSAdults. 1 mg every 5 hr while awake.E.R. CAPSULESAdults. 2.5, 6.5, or 9 mg every 12 hr.Frequency of doses increased to every 8 hrbased on patient’s response.E.R. TABLETSAdults. 2.6 or 6.5 mg every 12 hr.Frequency of doses increased to every 8 hrbased on patient’s response.S.L. TABLETSAdults. 0.3 to 0.6 mg, repeated every 5 min.Maximum: 3 tabs in 15 min or 10 mg daily.TRANSDERMAL OINTMENTAdults. 1" to 2" (15 to 30 mg) every 8 hr.Frequency of doses increased to every 6 hrif angina occurs between doses. Maximum:5" (75 mg)/application.TRANSDERMAL PATCHAdults. 0.1 to 0.8 mg/hr, worn 12 to 14 hr.TRANSLINGUAL SPRAYAdults. For treatment, 1 or 2 metered doses(0.4 or 0.8 mg) onto or under tongue,repeated every 5 min as needed. For prevention,1 or 2 metered doses (0.4 or0.8 mg) onto or under tongue 5 to 10 minutesbefore activities that could lead toacute attack. To prevent or treat angina, to managehypertension or heart failureI.V. INFUSIONAdults. 5 mcg/min, increased by 5 mcg/minevery 3 to 5 min to 20 mcg/min, as prescribed,and then by 10 to 20 mcg/minevery 3 to 5 min until desired effect occurs.Mechanism of ActionMay interact with nitrate receptors in vascularsmooth-muscle cell membranes. Thisinteraction reduces nitroglycerin to nitricoxide, which activates the enzyme guanylatecyclase, increasing intracellular formationNO

744nitroglycerinof cGMP. Increased cGMP level may relaxvascular smooth muscle by forcing calciumout of muscle cells, causing vasodilation.Venous dilation decreases venous return tothe heart, reducing left ventricular enddiastolicpressure and pulmonary arterywedge pressure. Arterial dilation decreasessystemic vascular resistance, systolic arterialpressure, and mean arterial pressure. Thus,nitroglycerin reduces preload and afterload,decreasing myocardial workload and oxygendemand. It also dilates coronary arteries,increasing blood flow to ischemicmyocardial tissue.Route Onset Peak DurationP.O. * 3 min Unknown 5 hrP.O.† 20–45 min Unknown 8–12 hrI.V. 1–2 min Unknown 3–5 minS.L. 1–3 min Unknown 30–60 minTrans- In 30 min Unknown 4–8 hrdermal‡Trans- In 30 min Unknown 8–24 hrdermal§Trans- 2 to 4 min Unknown 30–60 minlingualIncompatibilitiesDon’t administer I.V. nitroglycerin throughI.V. bags or tubing made of polyvinyl chloride.Don’t mix drug with other solutions.ContraindicationsAcute MI (S.L.), angle-closure glaucoma,cerebral hemorrhage, concurrent use ofphosphodiesterase inhibitors, constrictivepericarditis (I.V.), head trauma, hypersensitivityto adhesive in transdermal form,hypersensitivity to nitrates, hypotension(I.V.), hypovolemia (I.V.), inadequate cerebralcirculation (I.V.), increased intracranialpressure, orthostatic hypotension, pericardialtamponade, severe anemiaInteractionsDRUGSacetylcholine, norepinephrine: Possiblydecreased therapeutic effects of these drugsheparin: Possibly decreased anticoagulant* Buccal.† E.R.‡ Ointment.§ Patch.effect of heparin (I.V. nitroglycerin)opioid analgesics, other antihypertensives,vasodilators: Possibly increased orthostatichypotensionphosphodiesterase inhibitors, such as sildenafil:Possibly severe hypotensive effect ofnitroglycerinsympathomimetics: Possibly decreased antianginaleffect of nitroglycerin and increasedrisk of hypotensionACTIVITIESalcohol use: Possibly increased orthostatichypotensionAdverse ReactionsCNS: Agitation, anxiety, dizziness,headache, insomnia, restlessness, syncope,weaknessCV: Arrhythmias (including tachycardia),edema, hypotension, orthostatic hypotension,palpitationsEENT: Blurred vision, burning or tinglingin mouth (buccal, S.L. forms), dry mouthGI: Abdominal pain, diarrhea, indigestion,nausea, vomitingGU: Dysuria, impotence, urinary frequencyHEME: MethemoglobinemiaMS: ArthralgiaRESP: Bronchitis, pneumoniaSKIN: Contact dermatitis (transdermalforms), flushing of face and neck, rashNursing Considerations• Use nitroglycerin cautiously in elderlypatients, especially those who are volumedepleted or taking several medications,because of the increased risk of hypotensionand falls. Hypotension may beaccompanied by angina and paradoxicalslowing of the heart rate. Notify prescriberif these occur, and provide appropriatetreatment, as ordered.• Plan a nitroglycerin-free period of about10 hours each day, as prescribed, to maintaintherapeutic effects and avoid tolerance.• Place E.R. buccal tablets in buccal pouchwith patient in sitting or lying position.• Don’t break or crush E.R. tablets or capsules.Have patient swallow them wholewith a full glass of water.• Place S.L. tablet under patient’s tongueand make sure it dissolves completely.• Be sure to remove cotton from S.L. tabletcontainer to allow quick access to drug.

nitroglycerin 745• When applying transdermal ointment,apply correct amount on dose-measuringpaper. Then place paper on hairless area ofbody and spread in a thin, even layer overan area at least 2 inches by 3 inches. Don’tplace on cuts or irritated areas. Wash yourhands after application. Rotate sites. Storeat room temperature.• Open transdermal patch package immediatelybefore use. Apply patch to hairlessarea, and press edges to seal. Rotate sites.Store at room temperature. If patientneeds cardioversion or defibrillation,remove transdermal patch.• Don’t shake translingual spray containerbefore administering. Have patient inhaleand hold her breath, and then spray drugunder or on her tongue.• Be aware that I.V. nitroglycerin should bediluted only in D 5 W or normal salinesolution and shouldn’t be mixed withother infusions. The pharmacist shouldadd drug to a glass bottle, not a containermade of polyvinyl chloride. Don’t use afilter because plastic absorbs drug.Administer with infusion pump.• Check vital signs before every dosageadjustment and often during therapy.• Frequently monitor heart and breathsounds, level of consciousness, fluid intakeand output, and pulmonary artery wedgepressure, if possible.• Store premixed containers in the dark;don’t freeze them.WARNING Assess patient for evidence ofoverdose, such as confusion, diaphoresis,dyspnea, flushing, headache, hypotension,nausea, palpitations, tachycardia, vertigo,vision changes, and vomiting. Treat as prescribedby removing nitroglycerin source,if possible; elevating legs above heart level;and administering an alpha-adrenergicagonist, such as phenylephrine, as prescribed,to treat severe hypotension.PATIENT TEACHING• Teach patient to recognize signs andsymptoms of angina pectoris, includingchest fullness, pain, and pressure, possiblywith sweating and nausea. Pain may radiatedown left arm or into neck or jaw.Inform women and those with diabetesmellitus or hypertension that they mayfeel only fatigue and shortness of breath.• Instruct patient to read and follow packageinstructions to obtain full benefits ofdrug.• To prevent drug tolerance, inform patientthat prescriber may order a 10- to 12-hourdrug-free period at night (or at anothertime if she has chest pain at night or in themorning).• Instruct patient to swallow E.R. tablets orcapsules whole—not to break, crush, orchew them—with a full glass of water.• For sublingual or buccal use, advisepatient to place tablet under her tongue orin buccal pouch when angina starts andthen to sit or lie down. Instruct her not toswallow drug, but to let it dissolve. Explainthat moisture in her mouth helps drugabsorption. If angina doesn’t subside,instruct patient to place another tabletunder her tongue or in buccal pouch after5 minutes and to repeat, if needed, forthree doses total. If pain doesn’t subsideafter 20 minutes, urge patient to call 911or another emergency service.• Advise patient to carry S.L. tablets in theiroriginal brown bottle in a purse or jacketpocket, but not one that will be affected bybody heat. Instruct her to store drug in adry place at room temperature and to discardcotton from container. Advise her todiscard and replace S.L. tablets after6 months.• Advise patient using transdermal ointmentor patch to rotate sites to avoid skinsensitization.• Inform patient that swimming or bathingdoesn’t affect transdermal forms but thathot tubs, saunas, prolonged hot showers,electric blankets, and magnetic therapyover the site may increase drug absorptionand cause dizziness and hypotension.• Caution against inhaling translingualspray. Before first use, tell patient to pressactuator button 10 times to prime containerand then hold container uprightwith forefinger on top of actuator button.Tell her to open her mouth, bring containeras close as possible, press actuator buttonfirmly to release spray onto or undertongue, and release button and immediatelyclose her mouth. Remind her toreplace plastic cover on container and tonot spit out the drug or rinse her mouthfor 5 to 10 minutes. Tell her to reprimecontainer by pressing actuator buttonNO

746nitroprusside sodiumtwice if container hasn’t been used formore than 6 weeks. Remind patient toperiodically check level of fluid in container.If it reaches the top or middle hole onside of container, more should beobtained. Caution patient not to let levelof liquid get to bottom of hole.• Inform patient that nitroglycerin commonlycauses headache, which typicallyresolves after a few days of continuoustherapy. Suggest taking acetaminophen, asneeded.• Advise patient to notify prescriber immediatelyabout blurred vision, dizziness, andsevere headache.• Suggest that patient change positionsslowly to minimize orthostatic hypotension.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Urge patient to avoid alcohol and erectiledysfunction drugs during therapy.nitroprussidesodiumNipride, NitropressClass and CategoryChemical class: CyanonitrosylferrateTherapeutic class: Antihypertensive,vasodilatorPregnancy category: CIndications and Dosages To treat hypertensive crisis and managesevere heart failureI.V. INFUSIONAdults and children. Initial: 0.25 to0.3 mcg/kg/min, increased gradually everyfew minutes until blood pressure reachesdesired level. Maintenance: 3 mcg/kg/min(range, 0.25 to 10 mcg/kg/min). Maximum:10 mcg/kg/min for 10 min.Route Onset Peak DurationI.V. 1–2 min Immediate 1–10 minMechanism of ActionMay interact with nitrate receptors in vascularsmooth-muscle cell membranes. Thisaction reduces nitroprusside to nitric oxideand then activates intracellular guanylatecyclase, which increases the cGMP level.Increased cGMP level may relax vascularsmooth muscle by forcing calcium out ofmuscle cells. Smooth-muscle relaxationcauses arteries and veins to dilate, whichreduces peripheral vascular resistance andblood pressure.IncompatibilitiesDon’t mix nitroprusside with any otherdrug.ContraindicationsAcute heart failure with decreased peripheralvascular resistance, congenital optic atrophy,decreased cerebral perfusion, hypersensitivityto nitroprusside or its components,hypertension from aortic coarctationor AV shunting, tobacco-induced amblyopiaInteractionsDRUGSdobutamine: Increased cardiac output,decreased pulmonary artery wedge pressureganglionic blockers, general anesthetics,hypotension-producing drugs: Increasedhypotensive effectsympathomimetics: Decreased antihypertensiveeffect of nitroprussideAdverse ReactionsCNS: Anxiety, dizziness, headache,increased intracranial pressure, nervousness,restlessnessCV: Hypotension, tachycardiaENDO: HypothyroidismGI: Abdominal pain, ileus, nausea, vomitingHEME: MethemoglobinemiaMS: Muscle twitchingSKIN: Diaphoresis, flushing, rashOther: Infusion site phlebitisNursing Considerations• Obtain baseline vital signs before administeringnitroprusside.WARNING Don’t give drug undiluted.Reconstitute with 2 ml D 5 W, and addsolution to 250 to 500 ml D 5 W to produce200 mcg/ml or 100 mcg/ml, respectively.• Be aware that solution is stable at roomtemperature for 24 hours when protectedfrom light. Don’t use reconstituted solutionif it contains particles or is blue,green, red, or darker than faint brown.• Use an infusion pump. Place opaque cover

over infusion container because drug ismetabolized by light. I.V. tubing doesn’tneed to be covered.• Keep patient supine when starting drug ortitrating dose up or down.• Monitor blood pressure continuously withintra-arterial pressure monitor. Recordblood pressure every 5 minutes at start ofinfusion and every 15 minutes thereafter.• If patient has severe heart failure, expect toadminister an inotropic drug, such asdopamine or dobutamine, as prescribed.WARNING For patient who receives prolongednitroprusside therapy or shorttermhigh-dose therapy, watch for evidenceof thiocyanate toxicity (ataxia,blurred vision, delirium, dizziness, dyspnea,headache, hyperreflexia, loss of consciousness,nausea, tinnitus, vomiting).Toxicity can cause arrhythmias, metabolicacidosis, severe hypotension, and death.• Monitor serum thiocyanate level at leastevery 72 hours; levels above 100 mcg/mlare associated with toxicity.WARNING Assess patient for evidence ofcyanide toxicity (absence of reflexes, coma,distant heart sounds, hypotension, metabolicacidosis, mydriasis, pink skin, shallowrespirations, and weak pulse). If youdetect such evidence, discontinue nitroprusside,as ordered, and give 4 to 6 mg/kgsodium nitrite over 2 to 4 minutes to converthemoglobin to methemoglobin.Follow with 150 to 200 mg/kg sodiumthiosulfate. Repeat this regimen at half theoriginal doses after 2 hours, as ordered.PATIENT TEACHING• Advise patient to change position slowly tominimize dizziness from sudden, severehypotension.nizatidineApo-Nizatidine (CAN), Axid, Axid ARClass and CategoryChemical class: Ethenediamine derivativeTherapeutic class: AntiulcerPregnancy category: BIndications and Dosages To manage active duodenal ulcerCAPSULESAdults and adolescents. 300 mg at bedtimenizatidine 747or 150 mg b.i.d. for 8 wk.DOSAGE ADJUSTMENT Dosage reduced to150 mg daily if creatinine clearance is 20 to50 ml/min/1.73 m 2 ; to 150 mg every otherday if creatinine clearance is less than20 ml/min/1.73 m 2 . To prevent recurrence of duodenalulcerCAPSULESAdults and adolescents. 150 mg at bedtime.DOSAGE ADJUSTMENT Dosage reduced to150 mg every other day for patients withcreatinine clearance of 20 to 50 ml/min/1.73 m 2 ; to 150 mg every 3 days for thosewith creatinine clearance less than 20 ml/min/1.73 m 2 . To manage acute benign gastric ulcerCAPSULESAdults and adolescents. 300 mg at bedtimeor 150 mg b.i.d. To manage gastroesophageal refluxdiseaseCAPSULESAdults and adolescents. 150 mg b.i.d. To prevent or relieve acid indigestion orheartburnTABLETSAdults and adolescents. 75 mg 30 min to1 hr before meals.Route Onset Peak DurationP.O. Unknown Unknown 10–12 hr*Mechanism of ActionInhibits basal and nocturnal secretion ofgastric acid by reversibly and competitivelyblocking H 2 receptors, especially those ingastric parietal cells. Nizatidine also inhibitsgastric acid secretion in response to stimuli,including food and caffeine.ContraindicationsHypersensitivity to nizatidine or other H 2 -receptor antagonistsInteractionsDRUGSantacids: Decreased nizatidine bioavailabilityitraconazole, ketoconazole: Decreasedabsorption of these drugssalicylates: Increased blood level of these* For nocturnal acid secretion; up to 4 hrfor food-stimulated acid secretion.NO

748norepinephrine bitartratedrugssucralfate: Possibly decreased nizatidineabsorptionAdverse ReactionsCNS: Agitation, anxiety, confusion, depression,dizziness, fatigue, fever, hallucinations,headache, insomnia, somnolenceCV: Arrhythmias, chest pain, vasculitisEENT: Amblyopia, dry mouth, laryngealedema, pharyngitis, rhinitis, sinusitisENDO: GynecomastiaGI: Abdominal pain, constipation, diarrhea,hepatitis, nausea, vomitingGU: Decreased libido, hyperuricemia notassociated with gout or nephrolithiasis,impotenceHEME: Anemia, aplastic anemia,eosinophilia, hemolytic anemia, leukopenia,neutropenia, pancytopenia, thrombocytopeniaMS: Back pain, myalgiaRESP: Bronchospasm, coughSKIN: Alopecia, diaphoresis, erythemamultiforme, exfoliative dermatitis, jaundice,pruritus, rash, Stevens-Johnson syndrome,toxic epidermal necrolysis, urticariaOther: Anaphylaxis, angioedema, serumsicknesslike reactionNursing Considerations• Monitor CBC, BUN and serum creatininelevels, and liver function test results beforeand periodically during nizatidine therapy.• Don’t give within 1 hour of an antacid.PATIENT TEACHING• Instruct patient not to take nizatidinewithin 1 hour of an antacid.• Urge patient to take nizatidine exactly asprescribed, even if she feels better beforeprescription is finished. Inform her thatulcer may take up to 8 weeks to heal.• If patient smokes, urge her to stop becausesmoking increases gastric acid production.• Teach patient to minimize constipation bydrinking plenty of fluids (if allowed), eatinghigh-fiber foods, and exercising regularly.• Instruct patient to notify prescriber immediatelyabout abdominal pain, easy bruising,extreme fatigue, yellow skin or sclera,trouble swallowing food, bloody vomitus,or bloody or tarry stools.• Urge patient not to take nizatidine withother acid reducers.norepinephrinebitartrate(levarterenol bitartrate)LevophedClass and CategoryChemical class: CatecholamineTherapeutic class: Cardiac stimulant, vasopressorPregnancy category: CIndications and Dosages To treat acute hypotension, cardiogenicshock, and septic shockI.V. INFUSIONAdults. Initial: 0.5 to 1 mcg/min. Increased,as ordered, until systolic blood pressurereaches desired level. Maintenance: 2 to12 mcg/min.Children. 0.1 mcg/kg/min. Maximum:1 mcg/kg/min. To treat refractory shockI.V. INFUSIONAdults. Up to 30 mcg/min.Route Onset Peak DurationI.V. Rapid Unknown 1–2 minMechanism of ActionAt more than 4 mcg/min, directly stimulatesalpha-adrenergic receptors andinhibits adenyl cyclase, which inhibitscAMP production. Inhibition of cAMPcontricts arteries and veins and increasesperipheral vascular resistance and systolicblood pressure. At less than 2 mcg/min,norepinephrine directly stimulates betaadrenergicreceptors in the myocardiumand increases adenyl cyclase activity, producingpositive inotropic and chronotropiceffects.ContraindicationsConcurrent use of hydrocarbon inhalationanesthetics, hypersensitivity to norepinephrineor its components, hypovolemia, mesentericor peripheral vascular thrombosisInteractionsDRUGSalpha blockers: Decreased vasopressoreffects of norepinephrine

eta blockers: Decreased cardiac-stimulatingeffect of norepinephrine, possibly decreasedtherapeutic effects of both drugsdigoxin: Increased risk of arrhythmias, possiblypotentiated inotropic effectdoxapram: Possibly increased vasopressoreffects of both drugsergonovine, ergotamine, methylergonovine,methysergide, oxytocin: Possibly increasedvasoconstrictiongeneral anesthetics: Risk of arrhythmiasguanadrel, guanethidine: Increased vasopressorresponse to norepinephrine, possiblysevere hypertensionMAO inhibitors: Possibly life-threateningarrhythmias, hyperpyrexia, severe headache,severe hypertension, and vomitingmaprotiline, tricyclic antidepressants:Possibly potentiated cardiovascular andpressor effects of norepinephrine, includingarrhythmias, severe hypertension, andhyperpyrexiamethylphenidate: Possibly potentiated vasopressoreffect of norepinephrinenitrates: Possibly decreased therapeuticeffects of both drugsphenoxybenzamine: Possibly arrhythmias orhypotensionsympathomimetics: Increased risk of adversecardiovascular effectsthyroid hormones: Increased risk of coronaryinsufficiencyAdverse ReactionsCNS: Anxiety, dizziness, headache, insomnia,nervousness, tremor, weaknessCV: Angina, bradycardia, ECG changes,edema, hypertension, hypotension, palpitations,peripheral vascular insufficiency(including gangrene), PVCs, sinus tachycardiaGI: Nausea, vomitingGU: Decreased renal perfusionRESP: Apnea, dyspneaSKIN: PallorOther: Infusion site sloughing and tissuenecrosis, metabolic acidosisNursing Considerations• Dilute norepinephrine concentrate forinfusion in D 5 W, dextrose 5% in normalsaline solution, or normal saline solution.Dilutions typically range from 16 to32 mcg/ml.• Make sure solution contains no particlesand isn’t discolored before administering.• Give drug with a flow-control device.• Check blood pressure every 2 to 3 minutes,preferably by direct intra-arterialmonitoring, until stabilized and then every5 minutes.WARNING Because extravasation can causesevere tissue damage and necrosis, expectprescriber to give multiple subcutaneousinjections of phentolamine (5 to 10 mgdiluted in 10 to 15 ml normal saline solution)around extravasated infusion site.• If blanching occurs along vein, changeinfusion site and notify prescriber at once.• Monitor continuous ECG during therapy.PATIENT TEACHING• Urge patient to immediately report burning,leaking, or tingling around I.V. site.norfloxacinNoroxinClass and CategoryChemical class: FluoroquinoloneTherapeutic class: AntibioticPregnancy category: Cnorfloxacin 749Indications and Dosages To treat uncomplicated UTI caused byEscherichia coli, Klebsiella pneumoniae,or Proteus mirabilisTABLETSAdults. 400 mg every 12 hr for 3 days. To treat uncomplicated UTI caused byCitrobacter freundii, Enterobacteraerogenes, Enterobacter cloacae,Enterococcus faecalis, Proteus species,Pseudomonas aeruginosa, Staphylococcusaureus, Staphylococcus epidermidis,Staphylococcus saprophyticus,or Streptococcus agalactiaeTABLETSAdults. 400 mg every 12 hr for 7 to 10 days. To treat complicated UTI caused by E.coli, E. faecalis, K. pneumoniae, P.aeruginosa, P. mirabilis, or SerratiamarcescensTABLETSAdults. 400 mg every 12 hr for 10 to21 days. Maximum: 800 mg daily. To treat uncomplicated gonorrheaTABLETSAdults. 800 mg as a single dose.NO

750Nursing Considerations• Obtain urine specimen for culture andsensitivity tests before starting drug, ifpossible.• Determine if patient has a history of CNSdisorder because drug may lower seizurethreshold. Notify prescriber before startingdrug, and institute seizure precautions.WARNING Before starting therapy, determineif patient takes a class IA antiarrhythmic,such as quinidine; a class IIIantiarrhythmic, such as sotalol; or otherdrugs that prolong the QTc interval. Alsofind out if patient has hypokalemia or anunderlying QT-interval prolonging condition.These drugs and conditions, especiallyin the elderly, may prolong the QTcinterval and lead to life-threatening ventriculartachycardia or torsades de pointesin a patient taking norfloxacin.• Give drug on an empty stomach 2 hoursbefore or after antacids, didanosine,sucralfate, or vitamins that contain iron orzinc.• Keep emergency resuscitation equipmentreadily available, and watch for signs ofhypersensitivity, such as angioedema, dysnorfloxacin To treat prostatitis caused by E. coliTABLETSAdults. 400 mg every 12 hr for 28 days.DOSAGE ADJUSTMENT Dosage reduced to400 mg daily for patients with creatinineclearance of 30 ml/min/1.73 m 2 or less.Mechanism of ActionInhibits the enzyme DNA gyrase, whichunwinds and supercoils bacterial DNAbefore it replicates. By inhibiting thisenzyme, norfloxacin interferes with bacterialcell replication and causes cell death.ContraindicationsHypersensitivity to norfloxacin, other fluoroquinolones,or their componentsInteractionsDRUGSaluminum-, calcium-, or magnesiumcontainingantacids; ferrous sulfate;magnesium-containing laxatives; sucralfate;zinc: Possibly decreased absorption andblood level of norfloxacincaffeine, clozapine, ropinirole, tacrine, theophylline,tizanidine: Possibly increasedblood level of these drugsclass IA antiarrhythmics, such as quinidine;class III antiarrhythmics, such as sotalol;other drugs known to prolong QTc interval,such as disopyramide and pentamidine:Possibly prolonged QTc intervalcyclosporine: Possibly increased serum creatinineand blood cyclosporine levelsdidanosine: Possibly decreased norfloxacinabsorptionglyburide: Risk of severe hypoglycemianitrofurantoin: Possibly decreased norfloxacineffectivenessNSAIDs: Possibly increased risk of CNSstimulation and seizuresprobenecid: Decreased norfloxacin excretionand risk of toxicitywarfarin: Possibly increased anticoagulanteffect and risk of bleedingFOODScaffeine: Reduced clearance of caffeine leadingto accumulation of caffeine in bloodAdverse ReactionsCNS: Ataxia, confusion, dizziness, drowsiness,fever, Guillian-Barré syndrome,headache, hypoesthesia, insomnia, paresthesia,peripheral neuropathy, psychosis,seizures, tremorsCV: Prolonged QT interval, torsades depointes, vasculitisEENT: Decreased taste sensation, diplopia,hearing loss, stomatitis, taste perversion,tinnitus, visual changesGI: Abdominal cramps or pain, acutehepatic necrosis or failure, diarrhea, elevatedliver function test results, hepatitis, jaundice,nausea, pancreatitis, pseudomembranouscolitis, vomitingGU: Interstitial nephritis, renal failure, vaginalcandidiasisHEME: Agranulocytosis, aplastic anemia,hemolytic anemia, leukopenia, neutropenia,pancytopenia, thrombocytopeniaMS: Arthralgia; myasthenia gravis exacerbation;myalgia; tendinitis; tendon inflammation,pain, or ruptureRESP: Allergic pneumonitis, dyspneaSKIN: Blisters, diaphoresis, erythema, erythemamultiforme, exfoliative dermatitis,photosensitivity, pruritus, rash, Stevens-Johnson syndrome, toxic epidermal necrolysis,urticariaOther: Anaphylaxis, angioedema, serumsickness

pnea, jaundice, rash, and urticaria. If yoususpect anaphylaxis, prepare to give epinephrine,corticosteroids, and diphenhydramine,as prescribed.• If patient has myasthenia gravis, assess heroften for a change in respiratory statusbecause drug may lead to life-threateningweakness of respiratory muscles.• Notify prescriber if patient has symptomsof peripheral neuropathy (pain, burning,tingling, numbness, weakness, or alteredsensations of light touch, pain, temperature,position sense, or vibration sense),which could be permanent. Expect to stopnofloxacin.• Monitor patients prone to tendinitis, suchas the elderly, athletes, and those takingcorticosteroids, for complaints of tendonpain, inflammation, or rupture. If present,notify prescriber and expect to discontinuenorfloxacin, place patient on bedrestwith no exercise of affected limb, andobtain diagnostic tests to confirm rupture.• Monitor patient for diarrhea, which mayindicate pseudomembranous colitiscaused by Clostridium difficile. If diarrheaoccurs, notify prescriber and expect towithhold norfloxacin and treat with fluids,electrolytes, protein, and an antibioticeffective against C. difficile.PATIENT TEACHING• Instruct patient to take drug on an emptystomach with a large glass of water to preventcrystalluria. Urge her to drink severalglasses of water daily during therapy.• Instruct patient to take norfloxacin at least2 hours before or after eating, drinkingmilk, or taking antacids, didanosine, sucralfate,or vitamins that contain iron or zinc.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Tell patient to stop drug and report tendonpain or inflammation or abnormalchanges in motor or sensory function.• Urge patient to protect skin from sunlightand to report photosensitivity at once.• Tell patient to take drug exactly as prescribed,even if symptoms subside.• Urge patient to tell prescriber about diarrheathat’s severe or lasts longer than3 days. Remind patient that watery orbloody stools can occur 2 or more monthsafter antibiotic therapy and can be serious,requiring prompt treatment.nortriptyline hydrochloride 751nortriptylinehydrochlorideAventyl, PamelorClass and CategoryChemical class: DibenzocycloheptenederivativeTherapeutic class: AntidepressantPregnancy category: DIndications and Dosages To treat depressionCAPSULES, ORAL SOLUTIONAdults. Initial: 25 mg t.i.d. or q.i.d.Maximum: 150 mg daily.Adolescents. 25 to 50 mg daily or 1 to3 mg/kg daily in divided doses.Children ages 6 to 12. 10 to 20 mg daily or1 to 3 mg/kg daily in divided doses.DOSAGE ADJUSTMENT Dosage possiblyreduced to 30 to 50 mg daily (in divideddoses or at bedtime) for elderly patients.Route Onset Peak DurationP.O. 2–3 wk Unknown UnknownMechanism of ActionMay interfere with reuptake of serotonin(and possibly other neurotransmitters) atpresynaptic neurons, thus enhancing serotonin’seffects at postsynaptic receptors. Byrestoring normal neurotransmitter levels atnerve synapses, this tricyclic antidepressantmay elevate mood.ContraindicationsAcute recovery phase of stroke or MI; hypersensitivityto nortriptyline, other tricyclicantidepressants, or their components; usewithin 14 days of MAO inhibitor therapyInteractionsDRUGSamantadine, anticholinergics, antidyskinetics,antihistamines: Possibly increased anticholinergiceffects, confusion, hallucinations,nightmares; increased CNS depressionanticonvulsants: Possibly increased CNSdepression and risk of seizures, possiblydecreased anticonvulsant effectivenessantithyroid drugs: Possibly agranulocytosisNO

752nystatinbarbiturates, carbamazepine: Possiblydecreased level and effects of nortriptylinebupropion, clozapine, cyclobenzaprine, haloperidol,loxapine, maprotiline, molindone,phenothiazines, thioxanthenes: Possiblyincreased sedative and anticholinergiceffects, possibly increased risk of seizurescimetidine, fluoxetine: Possibly increasedblood nortriptyline level and risk of toxicityclonidine: Possibly decreased antihypertensiveeffect and increased CNS depressiondisulfiram: Possibly deliriumethchlorvynol: Possibly delirium, increasedCNS depressionguanadrel, guanethidine: Possibly decreasedantihypertensive effect of these drugsMAO inhibitors: Increased risk of hypertensivecrisis, severe seizures, and deathoral anticoagulants: Possibly increased anticoagulantactivitypimozide, probucol: Possibly arrhythmiassympathomimetics, including ophthalmicepinephrine and vasoconstrictive local anesthetics:Increased risk of arrhythmias,hyperpyrexia, hypertension, tachycardiathyroid hormones: Possibly increased therapeuticand toxic effects of both drugsACTIVITIESalcohol use: Increased CNS and respiratorydepression, hypertension, alcohol effectsAdverse ReactionsCNS: Ataxia, confusion, delirium, dizziness,drowsiness, excitation, hallucinations, headache,insomnia, nervousness, nightmares,parkinsonism, stroke, suicidal ideation,tremorCV: Arrhythmias, orthostatic hypotensionEENT: Blurred vision, dry mouth, increasedintraocular pressure, taste perversionGI: Constipation, diarrhea, heartburn, ileus,increased appetite, nausea, vomitingGU: Sexual dysfunction, urine retentionHEME: Bone marrow depressionRESP: WheezingSKIN: Diaphoresis, urticariaOther: Weight gainNursing Considerations• Expect to stop MAO inhibitor therapy10 to 14 days before starting nortriptyline.• Watch patient closely (especially children,adolescents, and young adults), for suicidaltendencies, particularly when therapystarts and dosage changes because depressionmay worsen temporarily during thesetimes, possibly leading to suicidal ideation.• Oral solution (10 mg/5 ml) is 4% alcohol.• Give nortriptyline with food to reduce GIreactions.• Monitor blood nortriptyline level; therapeuticrange is 50 to 150 ng/ml.• Monitor ECG tracing to detect arrhythmias.PATIENT TEACHING• Explain that oral solution contains alcohol.• Discourage alcohol consumption duringtherapy.• Explain that improvement may takeweeks.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes andparticularly if patient is a child, teenager,or young adult.• Instruct patient to change position slowlyto minimize orthostatic hypotension.• Suggest that patient minimize constipationby drinking plenty of fluids (ifallowed), eating high-fiber foods, andexercising regularly.nystatinMycostatin, Nadostine (CAN), Nilstat,Nystex, Nystop, Pedi-DriClass and CategoryChemical class: Amphoteric polyenemacrolideTherapeutic class: AntifungalPregnancy category: Not rated (lozenges,oral suspension, tablets, topical), A (vaginal)Indications and Dosages To treat oropharyngeal candidiasis(thrush)LOZENGES (PASTILLES)Adults and children over age 5. 200,000 to400,000 units dissolved in mouth 4 or5 times daily for up to 14 days.ORAL SUSPENSIONAdults and children. 400,000 to600,000 units swished and swallowed q.i.d.until at least 48 hr after symptoms subside.

Infants. 200,000 units to each side ofmouth q.i.d. until at least 48 hr after symptomssubside.Neonates. 100,000 units applied to eachside of mouth q.i.d. until at least 48 hr aftersymptoms subside.TABLETSAdults and adolescents. 500,000 to1,000,000 units t.i.d. until at least 48 hrafter symptoms subside.Children age 5 and over. 500,000 units q.i.d.until at least 48 hr after symptoms subside. To treat cutaneous and mucocutaneouscandidiasisCREAM, OINTMENT, POWDERAdults and children. 100,000 units (1 g) onaffected area b.i.d. or t.i.d. for at least 2 wk. To treat vulvovaginal candidiasisVAGINAL TABLETSAdults and adolescents. 100,000 units(1 tab) once or twice daily for 14 days.Mechanism of ActionBinds to sterols in fungal cell membranes,impairing membrane integrity. Cells loseintracellular potassium and other cellularcontents and, eventually, die.ContraindicationsHypersensitivity to nystatin or its componentsAdverse ReactionsENDO: Hyperglycemia (lozenge, oral suspension)GI: Abdominal pain, diarrhea, nausea,vomiting (oral forms)GU: Vaginal burning or itching (vaginalform)SKIN: Irritation (topical forms)Nursing Considerations• Prepare nystatin powder for oral suspensionfor each dose; it has no preservatives.• Gently rub nystatin cream or ointmentinto skin at affected area. Keep area dryand avoid occlusive dressings.• Don’t get topical form in patient’s eyes.• When treating candidal infection of feet,dust patient’s shoes, socks, and feet.• For vaginal form, use applicator suppliedby manufacturer.PATIENT TEACHING• Instruct patient to let nystatin lozengesdissolve slowly in her mouth, not to chewor swallow them.octreotide acetate 753• Tell patient to swish oral suspension in hermouth as long as possible before swallowing.• Advise patient to gently rub ointment orcream into skin at affected area, to keeparea dry, and to avoid occlusive dressings.• Caution patient to keep topical form awayfrom her eyes.• Advise patient with candidal infection offeet to dust her shoes, socks, and feet withnystatin.• For vaginal form, tell patient to insert withapplicator supplied by manufacturer.octreotide acetateSandostatin, Sandostatin LAR DepotClass and CategoryChemical class: Cyclic octapeptide, somatostatinanalogueTherapeutic class: Antidiarrheal, hormonesuppressantPregnancy category: BIndications and Dosages To control symptoms associated withvasoactive intestinal peptide tumors(watery diarrhea) and metastatic carcinoidtumors (diarrhea and flushing)I.M. INJECTIONAdults currently receiving subcutaneousinjections. 20 mg every 4 wk for 2 mo, withsubcutaneous doses continued for 2 to 4 wkafter I.M. injections start. If patient haspositive response to initial 2-mo regimen,dosage reduced to 10 mg every 4 wk. Ifsymptoms persist or increase after initial2-mo regimen, dosage increased to 30 mgevery 4 wk, as prescribed.SUBCUTANEOUS INJECTIONAdults. Initial: 200 to 300 mcg daily individed doses b.i.d. to q.i.d. for first 2 wk.Maintenance: Individualized. Maximum:450 mcg daily. To treat symptoms of acromegaly, tosuppress the release of growth hormonefrom pituitary tumorsI.V. OR SUBCUTANEOUS INJECTIONAdults. Initial: 50 mcg t.i.d. Usual: 100 mcgt.i.d. Maximum: 1,500 mcg daily.I.M. INJECTIONAdults currently receiving subcutaneousinjections. 20 mg every 4 wk for 3 mo; thenNO

754octreotide acetateadjusted as prescribed in response to serumgrowth hormone level. Maximum: 40 mgevery 4 wk.Route Onset Peak DurationSubQ Unknown Unknown Up to 12 hrMechanism of ActionControls many types of secretory diarrheaby inhibiting secretion of serotonin andpituitary and GI hormones (includinginsulin, glucagon, growth hormone, thyrotropin,and, possibly, thyroid-stimulatinghormone) as well as vasoactive intestinalpeptides and pancreatic polypeptides(including gastrin, secretin, and motilin).Inhibiting serotonin and peptides increasesintestinal absorption of water and electrolytes,decreases pancreatic and gastricacid secretions, and increases intestinaltransit time by slowing gastric motility.By inhibiting hormones involved invasodilation, octreotide increases splanchnicarterial resistance and decreases GIblood flow, hepatic vein wedge pressure,hepatic blood flow, portal vein pressure,and intravariceal pressure, thus raising seatedand standing blood pressures. Byinhibiting serotonin secretion, octreotideeases symptoms of acromegaly, includingdiarrhea, flushing, wheezing, and urinaryexcretion of 5-hydroxyindoleacetic acid.IncompatibilitiesDon’t mix octreotide in same syringe withfat emulsions or total parenteral nutritionsolutions.ContraindicationsHypersensitivity to octreotide or its componentsInteractionsDRUGSbeta blockers, calcium channel blockers:Additive cardiovascular effects of thesedrugsbromocriptine: Increased blood bromocriptinelevelcisapride: Decreased effectiveness of bothdrugscyclosporine: Decreased cyclosporine leveldiuretics: Increased risk of fluid and electrolyteimbalancesinsulin, oral antidiabetic drugs: Increasedrisk of hypoglycemiaquinidine, terfenadine: Decreased clearanceand increased blood levels of these drugsvitamin B 12 : Decreased vitamin B 12 levelAdverse ReactionsCNS: Dizziness, drowsiness, fatigue, headache,intracranial hemorrhage, migraine,paranoia, seizures, suicidal ideationCV: Arrhythmias (including conductionabnormalities), edema, hypertension,hypotension, MI, orthostatic hypotension,Raynaud’s syndromeEENT: Deafness, epistaxis, glaucoma, retinalvein thrombosis, sinusitis, visionchangesENDO: Hyperglycemia, hypoglycemia,hypothyroidism, pituitary apoplexyGI: Abdominal pain, acute cholecystitis,ascending cholangitis, biliary obstruction,cholelithiasis, cholestatic hepatitis, constipation,diarrhea, elevated liver enzymes,flatulence, gastric or peptic ulcer, GI hemorrhage,intestinal obstruction, nausea,pancreatitis, vomitingGU: Decreased libido, hematuria, increasedurine output, renal failureHEME: Anemia, pancytopenia, thrombocytopeniaMS: Arthropathy, back pain, myalgiaRESP: Status asthmaticus, pulmonaryhypertension, upper respiratory tract infectionSKIN: Alopecia, petechiae, pruritus, rash,urticariaOther: Anaphylaxis, angioedema, dehydration,electrolyte imbalances, flulike symptoms,injection site irritation or painNursing Considerations• Give octreotide by I.V. injection only in anemergency, as prescribed.• To prepare depot injection (long-actingsuspension form), let powder and diluentwarm to room temperature and thenreconstitute according to manufacturer’sinstructions. Gently inject 2 ml of supplieddiluent down side of vial withoutdisturbing depot powder. Let diluent saturatepowder. After 2 to 5 minutes, checksides and bottom of vial without invertingit. Once powder is completely saturated,swirl—don’t shake—vial for 30 to 60 secondsto form suspension. Use immediatelyafter reconstituting.

• Don’t give depot injection by subcutaneousroute; give only by I.M. route andonly to patients who respond to and toleratesubcutaneous drug, as prescribed.• To minimize pain, use smallest injectionvolume to deliver dose, and rotate injectionsites.• Avoid deltoid site for I.M. use becauseinjection site reaction and pain may result.Intragluteal injection is recommended.WARNING To avoid worsening symptoms,expect to continue subcutaneous injectionswhen switching to I.M. injections, asprescribed.• Be aware that octreotide increases risk ofacute cholecystitis, ascending cholangitis,biliary obstruction, cholestatic hepatitis,and pancreatitis.• Monitor vital signs, bowels sounds, andstool consistency. Assess for abdominalpain and signs of gallbladder disease.• Monitor serum liver enzyme levels, asappropriate.• Monitor patient for signs of electrolyteimbalances and dehydration.• Carefully monitor diabetic patient foraltered glucose control.• Monitor patient’s thyroid function, asordered, because octreotide suppressessecretion of thyroid-stimulating hormone,which may cause hypothyroidism.• If patient has periodic symptom flare-ups,expect to give additional subcutaneousoctreotide temporarily, as prescribed.PATIENT TEACHING• Advise patient to change position slowly tominimize orthostatic hypotension.• Instruct patient to notify prescriber aboutadverse reactions, especially abdominalpain, which may indicate pancreatitis.• Urge diabetic patient to check blood glucoselevel often.• Caution female patient of childbearing agethat drug may restore fertility and, if pregnancyisn’t desired, that contraceptionshould be used during octreotide therapy.ofloxacinFloxinClass and CategoryChemical class: FluoroquinoloneTherapeutic class: AntibioticPregnancy category: Cofloxacin 755Indications and Dosages To treat acute, uncomplicated cystitiscaused by Escherichia coli or KlebsiellapneumoniaeTABLETS, I.V. INFUSIONAdults. 200 mg every 12 hr for 3 days. To treat uncomplicated cystitis caused byCitrobacter diversus, Enterobacteraerogenes, Proteus mirabilis, orPseudomonas aeruginosaTABLETS, I.V. INFUSIONAdults. 200 mg every 12 hr for 7 days. To treat complicated UTI caused by C.diversus, E. coli, K. pneumoniae, P.mirabilis, or P. aeruginosaAdults. 200 mg every 12 hr for 10 days. To treat uncomplicated gonorrheaTABLETS, I.V. INFUSIONAdults and adolescents. 400 mg as singledose. To treat urethritis or cervicitis caused byChlamydia trachomatis or NeisseriagonorrhoeaeTABLETS, I.V. INFUSIONAdults and adolescents. 300 mg b.i.d. for7 days as an alternative to doxycycline orazithromycin. To treat pelvic inflammatory diseasecaused by susceptible organismsTABLETSAdults and adolescents. 400 mg b.i.d. withmetronidazole P.O. for 10 to 14 days.I.V. INFUSIONAdults and adolescents. 400 mg every12 hr with metronidazole I.V.; thenswitched to oral therapy, as prescribed, after24 hr. Full course of therapy lasts 14 days. To treat prostatitis caused by E. coliTABLETS, I.V. INFUSIONAdults. 300 mg every 12 hr for 6 wk. To treat lower respiratory tract infectionscaused by Haemophilus influenzaeor Streptococcus pneumoniae andskin and soft-tissue infections caused byStaphylococcus aureus or StreptococcuspyogenesTABLETS, I.V. INFUSIONAdults. 400 mg every 12 hr for 10 days.DOSAGE ADJUSTMENT If creatinine clearanceis 20 to 50 ml/min/1.73 m 2 , dosing intervalpossibly reduced to every 24 hr; if clearanceNO

756ofloxacinis less than 10 ml/min/1.73 m 2 , dosage possiblyreduced by 50% and given every 24 hr.Mechanism of ActionInhibits synthesis of the bacterial enzymeDNA gyrase by counteracting excessivesupercoiling of DNA during replication ortranscription. Inhibition of DNA gyrasecauses rapid- and slow-growing bacterialcells to die.IncompatibilitiesDon’t mix ofloxacin with other I.V. drugsor additives.ContraindicationsHypersensitivity to ofloxacin, other fluoroquinolones,or their componentsInteractionsDRUGSaluminum-, calcium-, or magnesiumcontainingantacids; didanosine; ferrous sulfate;magnesium-containing laxatives; multivitamins;sevelamer; sucralfate; zinc:Decreased absorption of oral ofloxacinprobenecid: Decreased ofloxacin excretion,increased risk of toxicityprocainamide: Decreased renal clearance ofprocainamidewarfarin: Possibly increased anticoagulantactivity and risk of bleedingAdverse ReactionsCNS: Aggressiveness, agitation, ataxia,dizziness, drowsiness, emotional lability,exacerbation of extrapyramidal disordersand myasthenia gravis, fever, headache,incoordination, insomnia, light-headedness,mania, peripheral neuropathy, psychoticreactions, restlessness, stroke, suicidalideation, syncopeCV: Arrhythmias, prolonged QT interval,severe hypotension, torsades de pointes,vasculitisEENT: Blurred vision; diplopia; disturbancesin taste, smell, hearing, and equilibriumENDO: Hyperglycemia, hypoglycemiaGI: Abdominal cramps or pain, acutehepatic necrosis or failure, diarrhea, hepatitis,jaundice, nausea, pseudomembranouscolitis, vomitingGU: Acute renal insufficiency or failure,interstitial nephritis, renal calculi, vaginalcandidiasisHEME: Agranulocytosis, aplastic orhemolytic anemia, leukopenia, pancytopenia,thrombocytopeniaMS: Arthralgia; myalgia; rhabdomyolysis;tendinitis; tendon inflammation, pain, orruptureRESP: Allergic pneumonitis, pulmonaryedemaSKIN: Blisters, diaphoresis, erythema, erythemamultiforme, exfoliative dermatitis,photosensitivity, pruritus, rash, Stevens-Johnson syndrome, toxic epidermal necrolysis,urticariaOther: Acidosis, anaphylaxis, infusion sitephlebitis, serum sicknessNursing Considerations• Because of increased risk of prolonged QTinterval, ofloxacin shouldn’t be used ifpatient has had a prolonged QT interval,has an uncorrected electrolyte disorder, ortakes a Class IA or III antiarrhythmic.Monitor elderly patients closely becauserisk of prolonged QT interval may beincreased in this group.• For I.V. infusion, dilute drug in normalsaline solution or D 5 W to at least 4 mg/ml, and infuse over 60 minutes to minimizethe risk of hypotension. Discardunused portion.• Monitor patient closely for hypersensitivity,which may occur as early as first dose.Reaction may include angioedema, bronchospasm,dyspnea, itching, rash, jaundice,shortness of breath, and urticaria. If thesesigns or symptoms appear, notify prescriberimmediately and expect to discontinuedrug.• Notify prescriber if patient has symptomsof peripheral neuropathy (pain, burning,tingling, numbness, weakness, or alteredsensations of light touch, pain, temperature,position sense, or vibration sense),which could be permanent; tendon rupture(pain and inflammation), which mayoccur more often in patients (especiallyelderly ones) taking corticosteroids andrequires immediate rest; or a severe photosensitivityreaction. In each case, expect tostop ofloxacin.• Maintain adequate hydration to preventdevelopment of highly concentrated urineand crystalluria.• Expect an increased risk of toxicity in

severe hepatic disease, including cirrhosis.• Be aware that ofloxacin may stimulate theCNS and aggravate seizure disorders.• If diarrhea develops, notify prescriberbecause it may indicate pseudomembranouscolitis. Ofloxacin may need to be discontinuedand additional therapy started.• Be alert for secondary fungal infection.PATIENT TEACHING• Encourage patient to take each oral dosewith a full glass of water.• Tell patient to complete full course ofofloxacin therapy exactly as prescribed,even if he feels better before it’s complete.• Urge patient not to take antacids, iron orzinc preparations, or other drugs (such assucralfate and didanosine), within 2 hoursof ofloxacin to prevent decreased ordelayed drug absorption.• Advise patient to avoid hazardous activitiesuntil CNS effects of drug are known.• Tell patient to limit exposure to sun andultraviolet light to prevent phototoxicity.• Advise patient to notify prescriber immediatelyabout burning skin, hives, itching,rash, rapid heart rate, abnormal motor orsensory function, and tendon pain.• Urge patient to seek medical care immediatelyfor trouble breathing or swallowing,which may signal an allergic reaction.• Instruct diabetic patient who takes insulinor an antidiabetic to notify prescriberimmediately if he develops a hypoglycemicreaction; ofloxacin will have to be stopped.• Advise patient to notify prescriber if diarrheadevelops, even up to 2 months afterofloxacin therapy ends. Additional therapymay be needed.olanzapineZydis, ZyprexaClass and CategoryChemical class: ThienobenzodiazepinederivativeTherapeutic class: AntipsychoticPregnancy category: CIndications and Dosages To treat psychosisORALLY DISINTEGRATING TABLETS, TABLETSAdults. Initial: 5 to 10 mg daily. Usual:10 mg daily. Maximum: 20 mg daily.olanzapine 757 To treat manic phase of acute bipolardisorderORALLY DISINTEGRATING TABLETS, TABLETSAdults. Initial: 10 to 15 mg daily; may beincreased or decreased by 5 mg every 24 hras needed and prescribed. Usual: 5 to 20 mgdaily for 3 to 4 wk. Maximum: 20 mg daily. As adjunct to treat acute bipolardisorderORALLY DISINTEGRATING TABLETS, TABLETSAdults. Initial: 10 mg daily with lithium orvalproate sodium; may be increased ordecreased by 5 mg every 24 hr, as neededand prescribed. Usual: 5 to 20 mg/day for6wk.Maximum: 20 mg daily.DOSAGE ADJUSTMENT Initial dosage possiblyreduced to 5 mg for debilitated patients,those prone to hypotension, and femalenonsmokers over age 65. To treat agitation associated withschizophrenia and bipolar I maniaI.M. INJECTIONAdults. 5 to10 mg p.r.n. Repeat as neededevery 2 to 4 hr.DOSAGE ADJUSTMENT Dosage decreased to5 mg for elderly patients and 2.5 mg fordebilitated patients, those prone tohypotension, and female nonsmokers overage 65.Route Onset Peak DurationP.O. 1 wk Unknown UnknownI.M. Unknown Unknown UnknownMechanism of ActionMay achieve antipsychotic effects by antagonizingdopamine and serotonin receptors.Anticholinergic effects may result fromcompetitive binding to and antago-nism ofthe muscarinic receptors M 1 through M 5 .ContraindicationsBlood dyscrasias, bone marrow depression,cerebral arteriosclerosis, coma, coronaryartery disease, hepatic dysfunction, highdoseCNS depressants, hypersensitivity toolanzapine or its components, hypertension,hypotension, myeloproliferative disorders,severe CNS depression, subcorticalbrain damageInteractionsDRUGSanticholinergics: Increased anticholinergiceffects, altered thermoregulationNO

758olanzapineantihypertensives: Increased effects of bothdrugs, increased risk of hypotensionbenzodiazepines (parenteral): Increased riskof excessive sedation and cardiorespiratorydepressioncarbamazepine, omeprazole, rifampin:Increased olanzapine clearanceCNS depressants: Additive CNS depression,potentiated orthostatic hypotensiondiazepam: Increased CNS depressant effectsfluvoxamine: Decreased olanzapine clearancelevodopa: Decreased levodopa efficacylorazepam (parenteral): Possibly increasedsomnolence with I.M. olanzapine injectionACTIVITIESalcohol use: Additive CNS depression,potentiated orthostatic hypotensionsmoking: Decreased blood olanzapine levelAdverse ReactionsCNS: Abnormal gait, agitation, akathisia,altered thermoregulation, amnesia, anxiety,asthenia, dizziness, euphoria, fatigue, fever,headache, hypertonia, insomnia, nervousness,neuroleptic malignant syndrome, restlessness,somnolence, stuttering, suicidalideation, tardive dyskinesia, tremorCV: Chest pain, hyperlipidemia, hypertension,hypotension, orthostatic hypotension,peripheral edema, tachycardiaEENT: Amblyopia, dry mouth, increasedsalivation, pharyngitis, rhinitisENDO: Hyperglycemia, prolactin elevationGI: Abdominal pain, constipation, dysphagia,hepatitis, increased appetite, nausea,thirst, vomitingGU: Urinary incontinence, UTIHEME: Agranulocytosis, leukopenia, neutropeniaMS: Arthralgia; back, joint, or limb pain;muscle spasms and twitchingRESP: CoughSKIN: Ecchymosis, photosensitivity, pruritus,urticariaOther: Anaphylaxis, angioedema, flulikesymptoms, weight gainNursing ConsiderationsWARNING Olanzapine shouldn’t be used forelderly patients with dementia-related psychosisbecause drug increases risk of deathin these patients.• Reconstitute parenteral olanzapine by dissolvingcontents of vial in 2.1 ml sterilewater to yield 5 mg/ml. Solution should beclear yellow. Use within 1 hour.• Inject I.M. olanzapine slowly, deep intomuscle mass.• Keep patient recumbent after I.M. injectionof olanzapine if drowsiness, dizziness,bradycardia, or hypoventialtion occurs.Don’t let patient sit or stand up untilblood pressure and heart rate havereturned to baseline.• Monitor patient’s blood pressure routinelyduring therapy because olanzapine maycause orthostatic hypotension.• Olanzapine may worsen such conditionsas angle-closure glaucoma, benign prostatichyperplasia, and seizures.• Assess daily weight to detect fluid retention.• Notify prescriber if patient develops tardivedyskinesia or urinary incontinence.• Be alert for and immediately report signsof neuroleptic malignant syndrome.• Watch patient closely (especially children,adolescents, and young adults), for suicidaltendencies, particularly when therapystarts and dosage changes, because depressionmay worsen temporarily during thesetimes, possibly leading to suicidal ideation.• Monitor patient’s lipid levels throughouttherapy, as ordered, because olanzapinemay cause significant elevations.• Monitor patient’s blood glucose level routinelybecause olanzapine may increaserisk of hyperglycemia.• Monitor CBC often during first fewmonths of therapy, especially if patient haslow WBC count or history of druginducedleukopenia or neutropenia. IfWBC count declines, and especially if neutrophilcount drops below 1,000/mm 3 ,expect olanzapine to be discontinued. Ifneutropenia is significant, also monitorpatient for fever or other evidence ofinfection and provide appropriate treatment,as prescribed.PATIENT TEACHING• Advise patient to avoid alcohol and smokingduring olanzapine therapy.• Teach patient to open orally disintegratingtablet sachet by peeling back foil on theblister and not by pushing tablet throughthe foil. Immediately after opening blister,tell him to use dry hands to remove tabletand place it in his mouth. Explain that

tablet will disintegrate rapidly in saliva sohe can easily swallow it without liquid.• Caution patient with phenylketonuria thatdisintegrating olanzapine tablets containphenylalanine.• Urge patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to change position slowlyto minimize effects of orthostatichypotension.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes andparticularly if patient is a child, teenager,or young adult.olmesartanmedoxomilBenicarClass and CategoryChemical class: Angiotensin II receptorantagonistTherapeutic class: AntihypertensivePregnancy category: C (first trimester), D(later trimesters)Indications and Dosages To manage or as adjunct to managehypertensionTABLETSAdults. Initial: 20 mg daily, increased in2 wk to 40 mg daily, if needed.DOSAGE ADJUSTMENT Lower starting dosageis recommended for patients with possibledepletion of intravascular volume, such asolmesartan medoxomil 759those treated with diuretics, especially ifimpaired renal function is present.ContraindicationsHypersensitivity to olmesartan medoxomilor its componentsAdverse ReactionsCNS: Ashenia, dizziness, fatigue, headache,insomnia, vertigoCV: Chest pain, hypercholesterolemia,hyperlipidemia, hypertriglyceridemia,peripheral edema, tachycardiaEENT: Pharyngitis, rhinitis, sinusitisENDO: Hyperglycemia, hyperuricemiaGI: Abdominal pain, diarrhea, gastroenteritis,indigestion, nausea, vomitingGU: Acute renal failure, elevated BUN andserum creatinine levels, hematuria, UTIMS: Arthralgia, arthritis, back pain, myalgia,rhabdomyolysis, skeletal painRESP: Bronchitis, cough, upper respiratorytract infectionSKIN: Alopecia, pruritus, rash, urticariaOther: Angioedema, hyperkalemia,increased CK level, flulike symptoms, painNursing Considerations• Expect to provide treatment such as normalsaline solution I.V., as prescribed, tocorrect known or suspected hypovolemiabefore beginning olmesartan therapy.• Monitor patient for increased BUN andserum creatinine levels, especially in apatient with impaired renal function,because drug may cause acute renal failure.If increased levels are significant orpersist, notify prescriber immediately.• Monitor blood pressure frequently toassess effectiveness of therapy. If bloodNOMechanism of ActionOlmesartan medoxomil blocksangiotensin II from binding toreceptor sites in many tissues,including vascular smoothmuscle and adrenal glands.Angiotensin II, a potent vasoconstrictor,is then free tostimulate the adrenal cortex tosecrete aldosterone, and theinhibiting effects of angiotensinII reduce blood pressure.Angiotensin I ACEAngiotensin IIOlmesartanCell exteriorAT 1Cell interiorAngiotensin IIOlmesartanAT1Angiotensin IISmooth musclecell membrane

760olsalazine sodiumpressure isn’t controlled with olmesartanalone, expect to administer a diuretic, suchas hydrochlorothiazide, as prescribed.WARNING Monitor patient’s blood pressurefrequently if he receives a diuretic or otherantihypertensive during olmesartan therapybecause of an increased risk ofhypotension.• Expect to discontinue drug temporarily ifpatient experiences hypotension. Placepatient in supine position immediatelyand prepare to administer normal salinesolution I.V., as prescribed. Expect toresume drug therapy after blood pressurestabilizes.• If patient also receives a diuretic, provideadequate hydration, as appropriate, to helpprevent hypovolemia. Watch for evidenceof hypovolemia, such as hypotension withdizziness and fainting.PATIENT TEACHING• Advise patient to avoid exercise in hotweather and excessive alcohol use toreduce the risk of dehydration andhypotension. Also instruct him to notifyprescriber if he has prolonged diarrhea,nausea, or vomiting.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Explain the importance of regular exercise,proper diet, and other lifestyle changes incontrolling hypertension.• Advise female patient to notify prescriberimmediately about known or suspectedpregnancy. Explain that if she becomespregnant, prescriber may replace olmesartanwith another antihypertensive that’ssafe to use during pregnancy.olsalazine sodiumDipentumClass and CategoryChemical class: Salicylate derivativeTherapeutic class: Bowel disease suppressantPregnancy category: CIndications and Dosages To maintain remission of ulcerativecolitisCAPSULES, TABLETSAdults and adolescents. 500 mg b.i.d.Mechanism of ActionExerts anti-inflammatory action in GI tractafter being converted by colonic bacteria tomesalamine (5-aminosalicylic acid), whichinhibits cyclooxygenase. Inhibition ofcyclooxygenase reduces prostaglandin productionin intestinal mucosa. This in turnreduces production of arachidonic acidmetabolites, which may be increased inpatients with inflammatory bowel disease.Olsalazine also exerts an anti-inflammatoryeffect by indirectly inhibiting leukotrienesynthesis, which normally catalyzes productionof arachidonic acid.ContraindicationsHypersensitivity to olsalazine, salicylates, ortheir componentsInteractionsDRUGS6-mercaptopurine, thioguanine: Increasedrisk of myelosuppressionlow-molecular-weight heparins or heparinoids:Increased risk of bleeding after neuraxialanesthesiaoral anticoagulants: Possibly prolonged PTvaricella vaccine: Increased risk of Reye’ssyndromeAdverse ReactionsCNS: Anxiety, depression, dizziness, drowsiness,fatigue, fever, headache, insomnia,lethargy, paresthesia, peripheral neuropathy,vertigoCV: Myocarditis, pericarditis, seconddegreeAV blockENDO: Hot flashesEENT: Dry eyes and mouth, lacrimation,stomatitis, tinnitusGI: Abdominal pain, anorexia, cholestaticjaundice, cirrhosis, diarrhea, dyspepsia, elevatedliver enzymes, hepatic failure ornecrosis, hepatitis, hepatotoxicity, nausea,vomitingGU: Dysuria, hematuria, interstitial nephritis,nephrotic syndrome, urinary frequencyHEME: Aplastic or hemolytic anemia, lymphopenia,neutropenia, pancytopeniaMS: Arthralgia, joint pain, muscle spasms,myalgiaRESP: Dyspnea, interstitial lung diseaseSKIN: Acne, alopecia, erythema nodosum,photosensitivity, pruritus, rashOther: Angioedema, dehydration

Nursing Considerations• Assess patient for aspirin allergy beforegiving olsalazine.• If patient has severe allergies or asthma,watch closely for worsening symptomsduring olsalazine therapy, and notify prescriberimmediately if they occur.• Assess quantity and consistency of stoolsand frequency of bowel movementsbefore, during, and after therapy.• Give drug with food to decrease adverseGI reactions.• Monitor skin for adequate hydration.• Assess patient for abdominal pain andhyperactive bowel sounds.• Monitor renal and hepatic status inpatient with underlying renal or hepaticdysfunction because drug may furtherimpair these functions.PATIENT TEACHING• Instruct patient to take olsalazine withfood.• Urge patient to continue taking drug asprescribed, even if symptoms improve.• Advise patient to watch for signs of dehydration.• Tell patient to report unusual, persistent,or severe adverse effects to prescriber.omalizumabXolairClass and CategoryChemical class: Recombinant IgG1K anti-IgE monoclonal antibodyTherapeutic class: AntiallergenicPregnancy category: BIndications and Dosages To treat moderate to severe persistentasthma in patients with positive skin testor in vitro reactivity to a perennialaeroallergen whose symptoms have beeninadequately controlled with inhaledcorticosteroidsSUBCUTANEOUS INJECTIONAdults and adolescents age 12 and over.150 to 375 mg every 2 or 4 wk. Dose andfrequency determined by body weight andblood IgE levels.DOSAGE ADJUSTMENT Dosage adjusted forsignificant changes in body weight.Nursing Considerations• Record patient’s weight, and obtain bloodIgE levels, as ordered, before starting omalizumab;dosage and dosing frequency arebased on these factors.• Reconstitute using sterile water for injection,and allow 15 to 20 minutes (on average)for lyophilized product to dissolve.Draw 1.4 ml sterile water for injection intoa 3-ml syringe with a 1" 18G needle. Placeomalizumab vial upright, and inject sterilewater into vial using aseptic technique.Gently swirl upright vial for about1 minute to evenly wet powder. Don’tshake. Every 5 minutes, gently swirl for5 to 10 seconds until solution contains nogel-like particles. Discard if powder takeslonger than 40 minutes to dissolve, andstart with a new vial. Once reconstituted,solution should be clear or slightly opalescentand may have a few small bubbles orfoam around edge of vial. Use omalizumabwithin 8 hours if refrigerated or4 hours if stored at room temperature.• To remove reconstituted omalizumabfrom vial, invert vial for 15 seconds to letsolution drain toward stopper. Using anew 3-ml syringe with a 1" 18G needle,insert needle into inverted vial and posiomalizumab761Mechanism of ActionHelps reduce inflammation by binding tocirculating IgE and keeping it from bindingto mast cells. This action inhibits degranulationand blocks release of histamine andother chemical mediators. In asthma,inflammation results when antigen reexposurecauses mast cells to degranulate andrelease histamine and chemical mediators.ContraindicationsHypersensitivity to omalizumab or its componentsAdverse ReactionsCNS: Dizziness, fatigue, headache, vertigoEENT: Earache, pharyngitis, sinusitisMS: Arm or leg pain, arthralgia, fracturesRESP: Upper respiratory tract infectionSKIN: Dermatitis, pruritus, urticariaOther: Anaphylaxis; generalized pain; injectionsite bruising, burning, hive or massformation, induration, inflammation, itching,pain, redness, stinging, and warmth;malignancies; viral infectionNO

762omega-3-acid ethyl esterstion needle tip at the very bottom of solutionin the vial stopper. Then pull plungerall the way back to end of syringe barrel toremove all solution from inverted vial. Toobtain full 150-mg dose (1 vial containing1.2 ml of reconstituted omalizumab), youmust withdraw all product from vialbefore expelling any air or excess solutionfrom syringe.• Don’t give more than 150 mg of omalizumabper injection site.• Be prepared to inject omalizumab over5 to 10 seconds because solution is slightlyviscous.WARNING Monitor patient closely forhypersensitivity reactions, particularly forfirst 2 hours after delivery. Although rare,anaphylaxis has occurred as early as firstdose and more than 1 year after startingregular treatment. Keep emergency medicationand equipment readily available.WARNING Monitor patient closely for signsof cancer. Report any abnormal findingsto prescriber.PATIENT TEACHING• Instruct patient to notify prescriber immediatelyabout possible hypersensitivity,such as rash, hives, or difficulty breathing.• Caution patient that any improvement inhis asthma may take time.• Encourage patient to comply with regularlyscheduled prescriber visits.• Inform patient of risk of malignancy andsuggest routine cancer screening.• Explain that omalizumab isn’t used to treatacute bronchospasm or status asthmaticus.• Tell patient not to abruptly stop any prescribedsystemic or inhaled corticosteroidwhen starting omalizumab therapybecause steroid dosage must be taperedgradually under prescriber’s supervision.• If female patient becomes pregnant within8 weeks before or during omalizumabtherapy, urge her to enroll in the XolairPregnancy Exposure Registry at 1-866-496-5247. Also, tell her to notify prescriberbecause drug may need to be changed.omega-3-acid ethylestersLovazaClass and CategoryChemical class: Ethyl esters of omega-3 fattyacidsTherapeutic class: Lipid regulatorPregnancy category: CIndications and Dosages As adjunct to diet to reduce triglyceridelevel that exceeds 500 mg/dlCAPSULESAdults. 4 g once daily or 2 g b.i.d.Mechanism of ActionOmega-3-acid ethyl esters are essential fattyacids that may inhibit very-low-densitylipoprotein and triglyceride synthesis in theliver. With less triglyceride synthesis, plasmatriglyceride levels decrease.ContraindicationsHypersensitivity to omega-3-acid ethylesters or their componentsInteractionsDRUGSanticogulants: Possibly increased bleedingtimeAdverse ReactionsCV: Angina pectorisEENT: Halitosis, nosebleeds, taste perversionGI: Diarrhea, dyspepsia, eructation, nausea,vomitingHEME: Prolonged bleeding timeMS: Back painSKIN: Bruising, rashOther: Anaphylaxis, flulike symptomsNursing Considerations• Be aware that drugs known to increasetriglyceride levels—such as beta blockers,thiazide diuretics, and estrogens—shouldbe discontinued or changed, if possible,before omega-3 ethyl ester therapy starts.• Expect to check patient’s triglyceride levelbefore starting and periodically throughoutomega-3-acid ethyl ester therapy todetermine effectiveness.• Administer drug with meals.• Expect to stop omega-3-acid ethyl estertherapy after 2 months if patient’s trigylceridelevel doesn’t decrease as expected.PATIENT TEACHING• Explain to patient the importance ofdietary measures, an exercise program,and controlling other factors—such as

lood glucose level—that may contributeto elevated triclyceride levels.• Advise patient to take drug with meals.• Explain that patient will need periodiclaboratory tests to evaluate therapy.• Instruct patient to seek immediate medicalattention if chest pain occurs.omeprazoleLosec (CAN), Prilosec, ZegeridClass and CategoryChemical class: Substituted benzimidazoleTherapeutic class: AntiulcerPregnancy category: CIndications and Dosages To treat gastroesophageal reflux disease(GERD) without esophageal lesions, toprevent erosive esophagitisDELAYED-RELEASE CAPSULES, DELAYED-RELEASETABLETS, ORAL SUSPENSIONAdults. 20 mg daily for 4 wk. To treat GERD with erosive esophagitisDELAYED-RELEASE CAPSULES, DELAYED-RELEASETABLETS, ORAL SUSPENSIONAdults. 20 mg daily for 4 to 8 wk. To treat pediatric GERD and other acidrelateddisordersDELAYED-RELEASE CAPSULESChildren age 2 and over weighing morethan 20 kg. 20 mg daily.Children age 2 and over weighing 20 kg(44 lb) or less. 10 mg daily. To provide short-term treatment ofactive benign gastric ulcerDELAYED-RELEASE CAPSULESAdults. 40 mg daily for 4 to 8 wk.DELAYED-RELEASE TABLETSAdults. 20 mg daily for 4 to 8 wk, increasedto 40 mg daily, p.r.n. To treat duodenal or gastric ulcer associatedwith Helicobacter pyloriDELAYED-RELEASE CAPSULES, ORAL SUSPENSIONAdults. 40 mg daily with clarithromycin for14 days, followed by 20 mg daily alone foranother 14 days. Or, 20 mg b.i.d. withamoxicillin for 14 days. Or, 20 mg b.i.d.with amoxicillin and clarithromycin for10 days.DELAYED-RELEASE TABLETSAdults. 20 mg b.i.d. with clarithromycinand amoxicillin or metronidazole foromeprazole 7637 days, followed by 20 mg daily for up to3 wk (for duodenal ulcer) or 20 to 40 mgdaily for up to 12 wk (for gastric ulcer). To provide long-term treatment of gastrichypersecretory conditions, such asmultiple endocrine adenoma syndrome,systemic mastocytosis, and Zollinger-Ellison syndromeDELAYED-RELEASE CAPSULES, DELAYED-RELEASETABLETSAdults. 60 mg daily or in divided doses, asprescribed. Maximum: 120 mg t.i.d.Route Onset Peak DurationP.O. 1 hr In 2 hr 72–96 hrContraindicationsHypersensitivity to omeprazole, other protonpump inhibitors, or their componentsInteractionsDRUGSalprazolam, astemizole, carbamazepine, cisapride,cyclosporine, diazepam, diltiazem,erythromycin, felodipine, lidocaine, lovastatin,midazolam, quinidine, simvastatin,terfenadine, triazolam, verapamil, voriconazole:Decreased clearance and increasedblood levels of these drugsampicillin, iron salts, itraconazole, ketoconazole,vitamin B 12 : Impaired absorption ofthese drugsatazanavir, nelfinavir: Decreased plasmaatazanavir or nelfinavir levelcilostazol: Increased blood cilostazol levelclarithromycin: Increased blood levels ofomeprazole and clarithromycinldigoxin: Increased digoxin bioavailability,possibly digitalis toxicitylevobupivacaine: Increased risk of levobupivacainetoxicitymethotrexate: Possibly delayed methotrexateeliminationnifedipine: Decreased nifedipine clearance,increased risk of hypotensionphenytoin: Decreased phenytoin clearance,increased risk of phenytoin toxicitysaquinavir: Increased plasma saquinavirlevelsucralfate: Decreased omeprazole absorptiontacrolimus: Possibly increased tacrolimuslevelwarfarin: Possibly increased risk of abnormalbleedingNO

764omeprazoleMechanism of ActionOmeprazole interferes with gastric acidsecretion by inhibiting the hydrogenpotassium-adenosinetriphosphatase(H + K + -ATPase) enzyme system, or protonpump, in gastric parietal cells. Normally,the proton pump uses energy fromhydrolysis of adenosine triphosphate todrive hydrogen (H + ) and chloride (Cl - )out of parietal cells and into the stomachlumen in exchange for potassium (K + ),which leaves the stomach lumen andenters parietal cells. After this exchange,H + and Cl - combine in the stomach toform hydrochloric acid (HCl), as shownbelow left. Omeprazole irreversiblyblocks the exchange of intracellular H +and extracellular K + , as shown belowright. By preventing H + from enteringthe stomach lumen, omeprazole keepsadditional HCl from forming.K + ParietalProtonHParietal+cellpumpcellmembraneOmeprazoleStomachCl - Cl -H + lumenK + BlockedprotonpumpHClAdverse ReactionsCNS: Agitation, asthenia, dizziness, drowsiness,fatigue, headache, psychic disturbance,somnolenceCV: Chest pain, hypertension, peripheraledemaEENT: Anterior ischemic optic neuropathy,optic atrophy or neuritis, stomatitisENDO: HypoglycemiaGI: Abdominal pain, constipation, diarrhea,dyspepsia, elevated liver function tests, flatulence,hepatic dysfunction or failure, indigestion,nausea, pancreatitis, vomitingGU: Interstitial nephritisHEME: Agranulocytosis, anemia, hemolyticanemia, leukopenia, leukocytosis, neutropenia,pancytopenia, thrombocytopeniaMS: Back painRESP: CoughSKIN: Erythema multiforme, photosensitivity,pruritus, rash, Stevens-Johnson syndrome,toxic epidermal necrolysis, urticariaOther: Anaphylaxis, angioedema, hyponatremiaNursing Considerations• Give omeprazole before meals, preferablyin the morning for once-daily dosing. Ifneeded, also give an antacid, as prescribed.• If needed, open capsule and sprinkleenteric-coated granules on applesauce oryogurt or mix with water or acidic fruitjuice, such as apple or cranberry juice.Give immediately.• To give drug via NG tube, mix granules inacidic juice because enteric coating dissolvesin alkaline pH.• Because drug can interfere with absorptionof vitamin B 12 , monitor patient formacrocytic anemia.• Be aware that long-term use of omeprazolemay increase the risk of gastric carcinoma.PATIENT TEACHING• Tell patient to take drug before eating—usually before breakfast—and to swallowdelayed-release capsules or tablets whole.If needed, patient may sprinkle contents ofcapsule onto 1 tablespoon of applesauceand swallow immediately without chewingpellets. Tell him to follow with a glass ofcool water and not to keep any leftovermixture.• If patient takes the oral suspension, tell

him to empty package into a small cupcontaining 2 tablespoons of water (noother beverage should be used), stir themixture well, drink it immediately, refillthe cup with water, and drink again.• Encourage patient to avoid alcohol, aspirinproducts, ibuprofen, and foods that mayincrease gastric secretions during therapy.Tell him to notify all prescribers aboutprescription drug use.• Advise patient to notify prescriber immediatelyabout abdominal pain or diarrhea.• Urge female patient of childbearing age touse effective contraception during therapyand to inform prescriber immediately ifshe is or suspects she may be pregnant.ondansetronhydrochlorideZofran, Zofran ODTClass and CategoryChemical class: CarbazoleTherapeutic class: AntiemeticPregnancy category: BIndications and Dosages To prevent chemotherapy-induced nauseaand vomitingDISINTEGRATING TABLETS, ORAL SOLUTION,TABLETSAdults and children age 12 and over.Initial: 8 mg given 30 min before chemotherapy.After chemotherapy: 8 mg given 8hr after initial dose; then 8 mg every 12 hrfor 1 to 2 days.Children ages 4 to 12. Initial: 4 mg given30 min before chemotherapy. Afterchemotherapy: 4 mg given 4 and 8 hr afterinitial dose; then 4 mg every 8 hr for 1 to2 days.I.V. INFUSIONAdults. 32 mg infused over 15 min starting30 min before chemotherapy; or three 0.15-mg/kg doses, each infused over 15 min,starting with first dose given 30 min beforechemotherapy and second and third dosesgiven 4 and 8 hours after first dose.Children ages 6 months to 18 years. Three0.15-mg/kg doses, each infused over 15 min,starting with first dose given 30 min beforechemotherapy and second and third dosesondansetron hydrochloride 765given 4 and 8 hours after first dose. To prevent postoperative nausea andvomitingDISINTEGRATING TABLETS, ORAL SOLUTION,TABLETSAdults. 16 mg as a single dose 1 hr beforeanesthesia induction.I.V. INJECTIONAdults and children age 12 and over. 4 mgas a single dose over 2 to 5 min just beforeanesthesia induction or if nausea or vomitingdevelops shortly after surgery.Children ages 2 to 12 weighing more than40 kg (88 lb). 4 mg as a single dose over2 to 5 min just before anesthesia inductionor if nausea or vomiting develops shortlyafter surgery.Children ages 1 month to 12 years weighingless than 40 kg. 0.1 mg/kg as a singledose over 2 to 5 min just before or immediatelyafter anesthesia induction or if nauseaor vomiting develops shortly after surgery.I.M. INJECTIONAdults and children age 12 and over. 4 mgas a single dose just before anesthesiainduction or if nausea or vomiting developsshortly after surgery. To prevent nausea and vomiting afterradiation therapyDISINTEGRATING TABLETS, ORAL SOLUTION,TABLETSAdults and children age 12 and over.Initial: 8 mg as a single dose given 1 to 2 hrbefore radiation therapy. Posttherapy: 8 mgevery 8 hr, as needed and tolerated.DOSAGE ADJUSTMENT For patients withhepatic impairment, maximum dosage limitedto 8 mg daily I.V. or P.O.Mechanism of ActionBlocks serotonin receptors centrally in thechemoreceptor trigger zone and peripherallyat vagal nerve terminals in the intestine.This action reduces nausea and vomiting bypreventing serotonin release in the smallintestine (probable cause of chemotherapyandradiation-induced nausea and vomiting)and by blocking signals to the CNS.Ondansetron may also bind to other serotoninreceptors and to mu-opioid receptors.IncompatibilitiesDon’t give ondansetron in same I.V. line asacyclovir, allopurinol, aminophylline,amphotericin B, ampicillin, ampicillin andNO

766orlistatsulbactam, amsacrine, cefepime, cefoperazone,furosemide, ganciclovir, lorazepam,methylprednisolone, mezlocillin, piperacillin,or sargramostim. Alkaline solutionsand highly concentrated fluorouracil solutionsare physically incompatible.ContraindicationsHypersensitivity to ondansetron or its componentsInteractionsDRUGScisplatin, cyclophosphamide: Possibly alteredblood levels of these drugsACTIVITIESalcohol use: Increased stimulant and sedativeeffects, including mood and physicalsensationsAdverse ReactionsCNS: Agitation, akathisia, anxiety, ataxia,dizziness, drowsiness, fever, headache,hypotension, restlessness, seizures, syncope,somnolence, weaknessCV: Arrythmias, chest pain, hypotension,pulmonary embolism, shock, tachycardia,transient prolonged QT intervalEENT: Accommodation disturbances,altered taste, blurred vision, dry mouth,laryngeal edema, laryngospasm, transientblindnessGI: Abdominal pain, anorexia, constipation,diarrhea, elevated liver function test results,flatulence, indigestion, intestinal obstruction,thirstRESP: Bronchospasm, shortness of breathSKIN: Flushing, hyperpigmentation,maculopapular rash, pruritusOther: Anaphylaxis, angioedema, injectionsite burning, pain, and rednessNursing ConsiderationsWARNING Be aware that oral disintegratingtablets may contain aspartame, which ismetabolized to phenylalanine and must beused cautiously in patients with phenylketonuria.• Place disintegrating tablet on patient’stongue immediately after opening package.It dissolves in seconds.• Use calibrated container or oral syringe tomeasure dose of oral solution.• Give up to 4 mg I.V. diluted in 50 ml ofD 5 W or normal saline solution.WARNING Be aware that ondansetron maymask symptoms of adynamic ileus or gastricdistention after abdominal surgery.PATIENT TEACHING• Advise patient to use calibrated containeror oral syringe to measure oral solution.• Instruct patient to place ondansetron disintegratingtablet on his tongue immediatelyafter opening package and to let itdissolve on his tongue before swallowing.• Advise patient to immediately report signsof hypersensitivity, such as rash.• Reassure patient with transient blindnessthat it will resolve within a few minutes to48 hours.orlistatAlli, XenicalClass and CategoryChemical class: Lipase inhibitorTherapeutic class: AntiobesityPregnancy category: BIndications and Dosages To promote weight loss in patients withbody mass index above 30 kg (66 lb)/m 2(27 kg [59.4 lb]/m 2 in those with diabetesmellitus, hyperlipidemia, or hypertension)and to reduce the risk of weightregainGELCAPSAdults. 120 mg t.i.d. with fat-containingmeals.ContraindicationsCholestasis, chronic malabsorption syndrome,hypersensitivity to orlistat or itscomponentsInteractionsDRUGScyclosporine: Altered cyclosporine absorptionfat-soluble vitamins: Decreased vitaminabsorption, especially vitamin E and betacarotenelevothyroxine: Possibly decreased levothyroxineeffectiveness, resulting in hypothyroidismpravastatin: Potentiated lipid-loweringeffectAdverse ReactionsCNS: Anxiety, depression, dizziness, fatigue,

orphenadrine 767Mechanism of ActionIn the GI tract, orlistat binds with andinactivates gastric and pancreaticenzymes known as lipases, as shown.Normally, lipase enzymes convert ingestedtriglycerides into absorbable free fattyacids and monoglycerides. By inactivatinglipase, orlistat allows undigestedtriglycerides to pass through the GI tractand exit the body in feces. Blocking theabsorption of some of these fats lowersthe number of calories received fromfood, which promotes weight loss.Intestinal lumenTriglycerideLipaseMonoglycerideLipaseTriglycerideFreefatty acidOrlistatheadache, sleep disturbanceCV: Pedal edemaEENT: Gingival or tooth disorder, otitisGI: Abdominal discomfort or pain,cholelithiasis, diarrhea (infectious), elevatedliver enzyme levels, fatty or oily stool, fecalincontinence or urgency, flatulence withdischarge, hepatitis, increased frequency ofbowel movements, nausea, pancreatitis, rectalpain, vomitingGU: Menstrual irregularities, UTI, vaginitisMS: Arthralgia, arthritis, back pain, legpain, myalgia, tendinitisRESP: Respiratory tract infectionSKIN: Dry skin, pruritus, rash, urticariaOther: Anaphylaxis, angioedema, flulikesymptomsNursing Considerations• Give orlistat with or up to 1 hour aftermeals that contain fat.• Give levothyroxine and orlistat at least4 hours apart because orlistat maydecrease levothyroxine effectiveness,resulting in hypothyroidism.• Consult prescriber if you think patient hasan eating disorder, such as anorexia nervosaor bulimia.PATIENT TEACHING• Instruct patient to take orlistat with orshortly after meals that contain fat.• Advise patient to take a multivitamin thatcontains fat-soluble vitamins and betacaroteneat least 2 hours before or afterorlistat, if indicated.• If patient takes levothyroxine, tell him toseparate it from orlistat by at least 4 hours.• Explain orlistat’s adverse GI effects andthat reducing dietary fat may decreasethem. Instruct him to notify prescriber ifthey become too unpleasant.• Help patient plan a reduced-fat diet (lessthan 30% of daily calories) and an exerciseprogram to promote weight loss.• Advise patient to weigh himself daily, atthe same time and wearing similar clothes,to check his progress in losing weight.orphenadrinecitrateAniflex, Banflex, Flexoject, Miolin,Mio-Rel, Myotrol, Norflex, Orfro,OrphenateorphenadrinehydrochlorideDisipal (CAN)NO

768oxacillin sodiumClass and CategoryChemical class: Tertiary amineTherapeutic class: Skeletal muscle relaxantPregnancy category: CIndications and Dosages To relieve muscle spasms in painfulmusculoskeletal conditionsE.R. TABLETS (ORPHENADRINE CITRATE)Adults and adolescents. 100 mg b.i.d. inthe morning and evening.TABLETS (ORPHENADRINE HYDROCHLORIDE)Adults and adolescents. 50 mg t.i.d.Maximum: 250 mg daily.I.V. OR I.M. INJECTION (ORPHENADRINE CITRATE)Adults and adolescents. 60 mg every 12 hr,p.r.n.DOSAGE ADJUSTMENT Dosage reduced to25 to 50 mg t.i.d. or q.i.d. if patient alsoreceives aspirin and caffeine.Route Onset Peak DurationP.O. In 1 hr Unknown 4–6 hr*I.V. Immediate Unknown 4–6 hrI.M. 30 min Unknown 4–6 hrMechanism of ActionMay reduce muscle spasms by acting oncerebral motor centers or medulla. Postganglionicanticholinergic effects and someantihistaminic and local anesthetic actioncontribute to skeletal muscle relaxation.ContraindicationsAngle-closure glaucoma; hypersensitivity toorphenadrine or its components; myastheniagravis; obstruction of bladder neck,duodenum, or pylorus; prostatic hypertrophy;stenosing peptic ulcersInteractionsDRUGSamantadine, amitriptyline, amoxapine, antimuscarinics,atropine, bupropion, carbinoxamine,chlorpromazine, clemastine, clomipramine,clozapine, cyclobenzaprine, diphenhydramine,disopyramide, doxepin,imipramine, maprotiline, mesoridazine,methdilazine, nortriptyline, phenothiazines,procainamide, promazine, promethazine,protriptyline, thioridazine, triflupromazine,trimeprazine, trimipramine: Possibly additiveanticholinergic effects* 12 hr for extended-release.CNS depressants: Increased CNS depressionhaloperidol: Increased schizophrenic symptoms,possibly tardive dyskinesiapropoxyphene: Increased risk of anxiety,confusion, and tremorACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Agitation, confusion, dizziness,drowsiness, light-headedness, syncope,tremorCV: Palpitations, tachycardiaEENT: Blurred vision, dry eyes and mouth,increased contact lens awarenessGI: Abdominal distention, constipation,nausea, vomitingGU: Urine retentionNursing Considerations• Be aware that orphenadrine shouldn’t begiven to patients with tachycardia or cardiacinsufficiency.• Give I.V. form over 5 minutes with patientin supine position. Have patient stay inthis position for 5 to 10 minutes to minimizeadverse reactions. Then help him tositting position.• Be aware that drug can aggravate myastheniagravis and cause tachycardia.• Anticipate that drug’s anticholinergiceffects may cause blurred vision, dry eyes,and increased contact lens awareness.PATIENT TEACHING• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Explain that dry mouth may occur, andsuggest increased fluid intake, ice chips,and sugarless candy or gum.• Suggest that patient (especially one whowears contact lenses) use artificial tears toavoid discomfort from dry eyes.oxacillin sodiumBactocill, ProstaphlinClass and CategoryChemical class: PenicillinTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat bacteremia, bone and joint

oxacillin sodium 769infections (such as osteomyelitis andinfectious arthritis), CNS infections(such as ventriculitis and meningitis),endocarditis, septicemia, skin and softtissueinfections, upper and lower respiratorytract infections, and UTI causedby penicillinase-producing strains ofStaphylococcus or other susceptibleorganismsCAPSULES, ORAL SOLUTIONAdults and children weighing 40 kg (88 lb)or more. 500 to 1,000 mg every 4 to 6 hr.Maximum: 6 g daily.Children weighing less than 40 kg. 50 to100 mg/kg daily in divided doses every 4 to6hr. To treat mild to moderate infectionscaused by penicillinase-producingstrains of Staphylococcus or other susceptibleorganismsI.V. INFUSION, I.M. INJECTIONAdults and children weighing 40 kg ormore. 250 to 500 mg every 4 to 6 hr.Infants and children weighing less than40 kg. 50 mg/kg daily in divided dosesevery 4 to 6 hr.Neonates over age 7 days weighing morethan 2,000 g. 25 to 50 mg/kg every 6 hr.Neonates over age 7 days weighing lessthan 2,000 g. 25 to 50 mg/kg every 8 hr.Neonates age 7 days and under weighingmore than 2,000 g. 25 to 50 mg/kg every8hr.Neonates age 7 days and under weighing2,000 g or less. 25 to 50 mg/kg every 12 hr. To treat severe infections caused by penicillinase-producingstrains of Staphylococcusor other susceptible organismsI.V. INFUSION, I.M. INJECTIONAdults and children weighing 40 kg ormore. 1,000 mg every 4 to 6 hr.Infants and children weighing less than40 kg. 100 to 200 mg/kg daily in divideddoses every 4 to 6 hr.Neonates over age 7 days weighing morethan 2,000 g. 25 to 50 mg/kg every 6 hr.Neonates over age 7 days weighing lessthan 2,000 g. 25 to 50 mg/kg every 8 hr.Neonates age 7 days and under weighingmore than 2,000 g. 25 to 50 mg/kg every8 hr.Neonates age 7 days and under weighing2,000 g or less. 25 to 50 mg/kg every 12 hr. To treat endocarditis caused by methicillin-susceptibleStaphylococcus aureusin patients without a prosthetic valveI.V. INFUSIONAdults. 2 g every 4 hr for 4 to 6 wk. To treat endocarditis caused by methicillin-susceptibleS. aureus in patientswith a prosthetic valveI.V. INFUSIONAdults. 2 g every 4 hr for at least 6 wk.Mechanism of ActionInhibits bacterial cell wall synthesis. In susceptiblebacteria, the rigid, cross-linked cellwall is assembled in several steps. Oxacillinaffects final stage of cross-linking processby binding with and inactivating penicillinbindingproteins (enzymes responsible forlinking the cell wall strands). This actioncauses bacterial cell lysis and death.IncompatibilitiesDon’t give oxacillin at same time or in sameadmixture as aminoglycosides because theyare chemically and physically incompatibleand will inactivate each other.ContraindicationsHypersensitivity to oxacillin, penicillins, ortheir componentsInteractionsDRUGSaminoglycosides: Inactivation of both drugschloramphenicol, erythromycins, sulfonamides,tetracyclines: Decreased therapeuticeffects of oxacillinoral contraceptives: Decreased contraceptiveefficacyprobenecid: Increased blood oxacillin levelFOODSall foods: Altered absorption of oxacillinAdverse ReactionsCNS: Anxiety, depression, fatigue, hallucinations,headache, seizuresEENT: Oral candidiasisGI: Diarrhea, nausea, pseudomembranouscolitis, vomitingGU: Interstitial nephritis, vaginal candidiasisHEME: Agranulocytosis, anemia, granulocytopenia,neutropeniaSKIN: Exfoliative dermatitis, pruritus, rash,urticariaOther: AnaphylaxisNursing Considerations• Administer oxacillin at least 1 hour beforeNO

770oxandroloneother antibiotics.• Give oral forms on an empty stomach,preferably 1 hour before or 2 hours after ameal, to prevent impaired absorption.• Before reconstitution, tap bottle severaltimes to loosen powder. For I.M. injection,reconstitute with sterile water for injection,half-normal (0.45) saline solution, ornormal saline solution. Shake until solutionis clear.• For I.V. infusion, reconstitute only withnormal saline solution or D 5 W.• When giving drug to patient at risk forhypertension or fluid overload, be awarethat each gram of oxacillin contains4.02 mEq of sodium.• Monitor patient closely for diarrhea,which may indicate pseudomembranouscolitis caused by Clostridium difficile. Ifdiarrhea occurs, notify prescriber andexpect to withhold oxacillin and treat withfluids, electrolytes, protein, and an antibioticeffective against C. difficile.PATIENT TEACHING• Advise patient to take oxacillin on anempty stomach.• Instruct patient to notify prescriber immediatelyshould a rash develop.• Advise female patient who uses an oralcontraceptive to use an additional contraceptivemethod during oxacillin therapy.• Urge patient to tell prescriber about diarrheathat’s severe or lasts longer than3 days. Remind patient that watery orbloody stools can occur 2 or more monthsafter antibiotic therapy and can be serious,requiring prompt treatment.oxandroloneOxandrinClass, Category, and ScheduleChemical class: Testosterone derivativeTherapeutic class: Appetite stimulantPregnancy category: XControlled susbstance schedule: IIIIndications and Dosages To promote weight gain after chronicinfection, extensive surgery, failure tomaintain weight despite no evidence ofpathology, or severe trauma; to offsetprotein catabolism from prolonged use ofcorticosteroidsTABLETSAdults. 2.5 to 20 mg in divided doses givenb.i.d. to q.i.d. for 2 to 4 wk; intermittenttherapy repeated as prescribed. Maximum:20 mg daily.Children. 0.1 mg/kg daily; intermittenttherapy repeated as prescribed.DOSAGE ADJUSTMENT Dosage shouldn’texceed 5 mg b.i.d. for elderly patients.Mechanism of ActionPromotes tissue-building processes andreverses catabolic or tissue-depletingprocesses by promoting protein anabolism.ContraindicationsBreast cancer (males); breast cancer withhypercalcemia (females); hypersensitivity tooxandrolone, anabolic steroids, or theircomponents; nephrosis; pregnancy; prostatecancerInteractionsDRUGScorticosteroids: Increased risk of edema andsevere acnehepatotoxic drugs: Increased risk of hepatotoxicityinsulin, oral antidiabetic drugs: PossiblyhypoglycemiaNSAIDs, oral anticoagulants, salicylates:Increased anticoagulant effectssodium-containing drugs: Increased risk ofedemasomatrem, somatropin: Possibly acceleratedepiphyseal closurewarfarin: Increased warfarin half-life andrisk of bleedingFOODShigh-sodium foods: Increased risk of edemaAdverse ReactionsCNS: Depression, excitement, insomniaCV: Decreased serum HDL level, edema,hyperlipidemia, hypertensionENDO: Feminization in postpubertal males(epididymitis, gynecomastia, impotence,oligospermia, priapism, testicular atrophy);glucose intolerance; virilism in females(acne, clitoral enlargement, decreased breastsize, deepened voice, diaphoresis, emotionallability, flushing, hirsutism, hoarseness,libido changes, male-pattern baldness, menstrualirregularities, nervousness, oily skin

or hair, vaginal bleeding, vaginitis, weightgain), virilism in prepubertal males (acne,decreased ejaculatory volume, penisenlargement, prepubertal closure of epiphysealplates, unnatural growth of body andfacial hair)GI: Diarrhea, elevated liver function testresults, hepatocellular carcinoma, nausea,vomitingGU: Benign prostatic hyperplasia, prostatecancer, urinary frequency, urine retention(elderly men)HEME: Iron deficiency anemia, leukemia,prolonged bleeding timeSKIN: JaundiceOther: Fluid retention, hypercalcemia(females), physical and psychologicaldependence, sodium retentionNursing Considerations• Use oxandrolone cautiously in patientswith heart disease because drug has hypercholesterolemiceffects.• Provide adequate calories and protein, asordered, to maintain a positive nitrogenbalance during oxandrolone therapy.• Anticipate an increased risk of fluid andsodium retention in patients with cardiac,hepatic, or renal dysfunction.• Weigh patient daily to detect fluid retention.If patient has fluid retention, expect asodium-restricted diet or diuretics.WARNING Be aware that oxandrolone maysuppress spermatogenesis in males andcause permanent virilization in females.• Monitor blood glucose level frequently inpatient with diabetes mellitus.• If patient takes an oral anticoagulant,check INR or PT as ordered.PATIENT TEACHING• Advise patient to consume a diet high inprotein and calories to achieve maximumtherapeutic effect of oxandrolone.• Urge patient to weigh himself daily duringtherapy and to report swelling or unexplainedweight gain at once.• Explain that drug may alter libido.• Inform woman that drug may cause permanentphysical changes, such as clitoralenlargement, deepened voice, and hairgrowth.• Advise female patient of childbearing agethat she must use contraception duringoxandrolone therapy and should notifyprescriber immediately about suspected orknown pregnancy.• Instruct diabetic patient to monitor bloodglucose level frequently.• If patient takes warfarin, advise bleedingprecautions (such as an electric shaver andsoft toothbrush). Tell patient to notify prescriberimmediately if bleeding occurs.oxaprozinDayprooxaprozin 771Class and CategoryChemical class: Proprionic acid derivativeTherapeutic class: Anti-inflammatory, antirheumaticPregnancy category: C (first trimester), Notrated (later trimesters)Indications and Dosages To treat rheumatoid arthritisTABLETSAdults. 1,200 mg daily. Dosage adjustedbased on response. Maximum: 1,800 mgdaily or 26 mg/kg daily (whichever is less)in divided doses b.i.d. or t.i.d. To treat osteoarthritisTABLETSAdults. 600 to 1,200 mg daily. Maximum:1,800 mg daily or 26 mg/kg (whichever isless) in divided doses b.i.d. or t.i.d.DOSAGE ADJUSTMENT Initial loading dose of1,200 to 1,800 mg possibly given to speedonset of action. Initial dose limited to600 mg daily for patients with renal impairment.Route Onset Peak DurationP.O. In 7 days Unknown UnknownMechanism of ActionBlocks cyclooxygenase, the enzyme neededto synthesize prostaglandins, which mediatethe inflammatory response and cause localvasodilation, swelling, and pain. By blockingcyclooxygenase and prostaglandins, theNSAID oxaprozin relieves pain.ContraindicationsAngioedema, asthma, bronchospasm, nasalpolyps, rhinitis, or urticaria induced byaspirin, iodides, or other NSAIDsNO

772oxaprozinInteractionsDRUGSACE inhibitors, antihypertensives: Decreasedantihypertensive response, possiblyimpaired renal functionacetaminophen: Increased risk of adverserenal effects with long-term use of bothdrugsanticoagulants, thrombolytics: Prolonged PT,increased risk of bleedingbeta blockers: Decreased antihypertensiveeffectbone marrow depressants: Increased risk ofleukopenia and thrombocytopeniacefamandole, cefoperazone, cefotetan, plicamycin,valproic acid: Increased risk of hypoprothrombinemiaand bleedingcimetidine: Decreased oxaprozin clearancecorticosteroids, potassium supplements:Increased risk of adverse GI effectsdigoxin: Increased blood digoxin level andrisk of digitalis toxicitydiuretics: Possibly decreased diuretic effectinsulin, oral antidiabetic drugs: Increasedeffects of these drugs; risk of hypoglycemialithium: Increased blood lithium levelmethotrexate: Increased blood methotrexatelevel and risk of methotrexate toxicityother NSAIDs, salicylates: Increased GI irritabilityand bleedingprobenecid: Increased risk of oxaprozin toxicityACTIVITIESalcohol use, smoking: Increased risk ofadverse GI effectsAdverse ReactionsCNS: Aseptic meningitis, cerebral hemorrhage,confusion, dizziness, drowsiness,fatigue, headache, insomnia, ischemicstroke, nervousness, sedation, transientischemic attacks, vertigo, weaknessCV: Deep vein thrombosis, hypertension,hypotension, MI, peripheral edemaEENT: TinnitusENDO: HypoglycemiaGI: Abdominal pain, constipation, diarrhea,dyspepsia, elevated liver function testresults, GI bleeding or ulceration, hepatitis,jaundice, liver failure, nausea, perforationof stomach or intestine, vomitingGU: Acute renal failure, dysuria, interstitialnephritis, urinary frequencyHEME: Agranulocytosis, anemia, aplasticanemia, leukopenia, pancytopenia, thrombocytopeniaSKIN: Alopecia, erythema multiforme,exfoliative dermatitis, maculopapular rash,photosensitivity, Stevens-Johnson syndrome,toxic epidermal necrolysisOther: Anaphylaxis, angioedemaNursing Considerations• Use oxaprozin with extreme caution inpatients with a history of ulcer disease orGI bleeding because NSAIDs such asoxaprozin increase risk of GI bleeding andulceration. Expect to use oxaprozin for theshortest time possible in these patients.• Be aware that serious GI tract ulceration,bleeding, and perforation may occur withoutwarning symptoms. Elderly patientsare at greater risk. To minimize risk, givedrug with food. If GI distress occurs, withholddrug and notify prescriber at once.• Use oxaprozin cautiously in patients withhypertension, and monitor blood pressureclosely throughout therapy. Drug maycause hypertension or worsen it.WARNING Monitor patient closely forthrombotic events, including MI andstroke, because NSAIDs increase the risk.WARNING If patient has bone marrow suppressionor is receiving antineoplastic drugtherapy, monitor laboratory results(including WBC count), and watch forevidence of infection because anti-inflammatoryand antipyretic actions ofoxaprozin may mask signs and symptoms,such as fever and pain.• Especially if patient is elderly or takingoxaprozin long-term, watch for less commonbut serious adverse GI reactions,including anorexia, constipation, diverticulitis,dysphagia, esophagitis, gastritis, gastroenteritis,gastroesophageal reflux disease,hemorrhoids, hiatal hernia, melena,stomatitis, and vomiting.• Monitor liver function test results because,in rare cases, elevated levels may progressto severe hepatic reactions, including fatalhepatitis, liver necrosis, and hepatic failure.• Monitor BUN and serum creatinine levelsin patients with heart failure, impairedrenal function, or hepatic dysfunction;those taking diuretics or ACE inhibitors;and elderly patients because drug maycause renal failure.• Monitor CBC for decreased hemoglobinlevel and hematocrit because drug may

worsen anemia.• Assess patient’s skin routinely for rash orother signs of hypersensitivity reactionbecause oxaprozin and other NSAIDs maycause serious skin reactions without warning,even in patients with no history ofNSAID hypersensitivity. Stop drug at firstsign of reaction, and notify prescriber.PATIENT TEACHING• Instruct patient to take oxaprozin exactlyas prescribed.• Advise patient to take drug with a fullglass of water and to stay upright for 15 to30 minutes afterward to keep drug fromlodging in esophagus and causing irritation.• Urge patient to avoid alcohol as well asaspirin and other NSAIDs duringoxaprozin therapy to avoid bleeding complications.• Advise patient to avoid excessive sun exposureto reduce the risk of photosensitivity.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Inform patient that risk of bleeding maycontinue up to 2 weeks after stoppingdrug.• Explain that oxaprozin may increase therisk of serious adverse cardiovascular reactions;urge patient to seek immediatemedical attention if signs or symptomsarise, such as chest pain, shortness ofbreath, weakness, and slurring of speech.• Inform patient that oxaprozin also mayincrease the risk of serious adverse GIreactions; stress need to seek immediatemedical attention for such signs andsymptoms as epigastric or abdominalpain, indigestion, black or tarry stools, orvomiting blood or material that looks likecoffee grounds.• Alert patient to rare but serious skin reactions.Urge him to seek immediate medicalattention for rash, blisters, itching, fever,or other indications of hypersensitivity.oxazepamApo-Oxazepam (CAN), Novoxapam(CAN), SeraxClass, Category, and ScheduleChemical class: Benzodiazepineoxazepam 773Therapeutic class: Antianxiety, sedative hypnoticPregnancy category: Not ratedControlled substance schedule: IVIndications and Dosages To treat anxietyCAPSULES, TABLETSAdults. 10 to 15 mg t.i.d. or q.i.d. for mildto moderate anxiety; up to 30 mg t.i.d. orq.i.d. for severe anxiety. To help manage acute alcoholwithdrawal symptomsCAPSULES, TABLETSAdults. 15 to 30 mg t.i.d. or q.i.d.DOSAGE ADJUSTMENT For elderly or debilitatedpatients, initial dose of 10 mg t.i.d.increased cautiously to 15 mg t.i.d. or q.i.d.Mechanism of ActionMay potentiate the effects of gammaaminobutyricacid (GABA) and otherinhibitory neurotransmitters by binding tospecific benzodiazepine receptors in limbicand cortical areas of the CNS. GABAinhibits excitatory stimulation, which helpscontrol emotional behavior. The limbic systemcontains highly dense areas of benzodiazepinereceptors, which may explainoxazepam’s antianxiety effects.ContraindicationsAcute angle-closure glaucoma; concurrentuse of itraconazole or ketoconazole; hypersensitivityto oxazepam, benzodiazepines,or their components; psychosesInteractionsDRUGScimetidine, oral contraceptives: Impairedmetabolism and elimination of oxazepamclozapine: Increased risk of respiratorydepression and arrestCNS depressants: Increased risk of apneaand CNS depressionlevodopa: Decreased therapeutic effects oflevodopaprobenecid: Increased therapeutic effects ofoxazepam and risk of oversedationACTIVITIESalcohol use: Increased risk of apnea andCNS depressionAdverse ReactionsCNS: Anxiety (in daytime), ataxia, confusion,depression, dizziness, drowsiness,NO

774oxcarbazepinefatigue, headache, insomnia, nightmares,sleep disturbance, slurred speech, syncope,talkativeness, tremor, vertigoGI: NauseaOther: Drug tolerance, physical and psychologicaldependence, withdrawal symptomsNursing ConsiderationsWARNING Oxazepam may cause physicaland psychological dependence.• Be aware that drug shouldn’t be stoppedabruptly after prolonged use; doing somay cause seizures or withdrawal symptoms,such as insomnia, irritability, andnervousness.• Be aware that withdrawal symptoms canoccur when therapy lasts only 1 or2 weeks.WARNING Monitor respiratory status inpatients with pulmonary disease (such assevere COPD), respiratory depression, orsleep apnea; drug may worsen ventilatoryfailure.• Expect an increased risk of falls amongelderly patients from impaired cognitionand motor function. Take safety precautions.• Be aware that drug may worsen acuteintermittent porphyria, myasthenia gravis,and severe renal impairment.• Expect patient with late-stage Parkinson’sdisease to experience decreased cognitionor coordination and, possibly, increasedpsychosis.PATIENT TEACHING• Instruct patient to take oxazepam exactlyas prescribed and not to stop taking itwithout consulting prescriber.• Caution patient about possible drowsinessand reduced coordination.• Urge patient to avoid alcohol, whichincreases oxazepam’s sedative effects.oxcarbazepineTrileptalClass and CategoryChemical class: Tricyclic iminostilbenederivativeTherapeutic class: AnticonvulsantPregnancy category: CIndications and Dosages As adjunct to treat partial seizuresORAL SUSPENSION, TABLETSAdults and adolescents over age 16. Initial:300 mg b.i.d. Dosage increased by 600 mg/day every wk. Usual: 1,200 mg daily.Maximum: 2,400 mg daily.Children ages 4 to 16. Initial: 4 to 5 mg/kgb.i.d. to maximum initial dose of 600 mgdaily. Usual: 900 mg daily for childrenweighing 20 to 29 kg (44 to 64 lb);1,200 mg daily for those weighing 29.1 to39 kg (65 to 86 lb); 1,800 mg daily for thoseweighing more than 39 kg. Maximum:1,800 mg daily.DOSAGE ADJUSTMENT For patients with creatinineclearance less than 30 ml/min/1.73 m 2 , usual initial dosage reduced by50%. As monotherapy to treat partial seizuresORAL SUSPENSION, TABLETSAdults and adolescents over age 16. Initial:300 mg b.i.d. Dosage increased by 300 mg/day every 3 days as needed. Usual: 1,200 mgdaily. Maximum: 2,400 mg daily.Children ages 4 to 16. Initial: 4 to 5 mg/kgb.i.d., increased by 5 mg/kg daily everythird day to maximum maintenancedosage, as needed. Maximum: 900 mg dailyfor children weighing 20 to 24.9 kg (44 to55 lb); 1,200 mg daily for those weighing25 to 34.9 kg (55 to 77 lb); 1,500 mg dailyfor those weighing 35 to 49.9 kg (77 to110 lb); 1,800 mg daily for those weighing50 to 59.9 kg (110 to 132 lb); 2,100 mgdaily for those weighing 60 to 70 kg (132 to154 lb). To convert to monotherapy in treatingpartial seizuresORAL SUSPENSION, TABLETSAdults and adolescents over age 16. Initial:300 mg b.i.d. Dosage increased by 600 mgdaily every wk over 2 to 4 wk, as needed,while dosage of other anticonvulsant isreduced. Usual: 1,200 mg daily. Maximum:2,400 mg daily.Children ages 4 to 16. Initial: 4 to 5 mg/kgb.i.d., increased by 10 mg/kg daily weekly asneeded to maximum maintenance dosagewhile dosage of other anticonvulsant isreduced over 3 to 6 wk. Maximum: 900 mgdaily for children weighing 20 to 24.9 kg(44 to 55 lb); 1,200 mg daily for thoseweighing 25 to 34.9 kg (55 to 77 lb);

1,500 mg daily for those weighing 35 to49.9 kg (77 to 110 lb); 1,800 mg daily forthose weighing 50 to 59.9 kg (110 to132 lb); 2,100 mg daily for those weighing60 to 70 kg (132 to 154 lb).Mechanism of ActionMay prevent or halt seizures by closing orblocking sodium channels in neuronal cellmembrane. By preventing sodium fromentering the cell, oxcarbazepine may slownerve impulse transmission, thus decreasingthe rate at which neurons fire.ContraindicationsHypersensitivity to carbamazepine, oxcarbazepine,or their componentsInteractionsDRUGScarbamazepine, phenobarbital, phenytoin,valproic acid: Decreased blood oxcarbazepinelevel, possibly increased blood levelsof phenobarbital and phenytoinfelodipine, verapamil: Decreased blood levelsof these drugsoral contraceptives: Decreased effectivenessACTIVITIESalcohol use: Possibly additive CNS depressanteffectsAdverse ReactionsCNS: Abnormal gait, ataxia, dizziness,fatigue, fever, headache, somnolence, suicidalideation, tremorEENT: Abnormal vision, diplopia, nystagmus,rhinitisGI: Abdominal pain, indigestion, nausea,vomitingSKIN: Rash, Stevens-Johnson syndrome,toxic epidermal necrolysisOther: Anaphylalxis, hyponatremiaNursing Considerations• Patient with allergic reaction to carbamazepinemay have hypersensitivity tooxcarbazepine.• Monitor serum sodium level for signs ofhyponatremia, especially during first3 months.• Monitor therapeutic oxcarbazepine levelsduring initiation and titration, and expectto adjust dosage accordingly.• Implement seizure precautions as needed.• Monitor patient’s skin closely. If a reactiondevelops, notify prescriber at once becauseoxcarbazepine 775skin reactions caused by oxcarbazepinemay be serious or life-threatening.WARNING Watch closely for evidence ofmulti-organ hypersensitivity, such as fever,rash, organ dysfunction, lymphadenopathy,hepatitis, liver function abnormalities,hematologic abnormalities, pruritus,nephritis, oliguria, hepato-renal syndrome,arthralgia, and asthenia. If suspected, notifyprescriber and expect to stop drug.Provide supportive care, as prescribed.• Monitor patient closely for evidence ofsuicidal thinking or behavior, especiallywhen therapy starts or dosage changes.PATIENT TEACHING• Teach patient to shake suspension well andprepare dose immediately afterward. Tellhim to then withdraw prescribed amountusing supplied oral dosing syringe.Instruct him to mix dose in a small glassof water just before taking it, or tell himthat he can swallow drug directly fromsyringe. Instruct him to close bottle andrinse syringe with warm water and let itdry thoroughly.• Inform patient that he may experiencedizziness, double vision, and unsteady gait.• Instruct patient not to drink alcohol duringoxcarbazepine therapy.• Alert patient to possibility of hypersensitivityor serious skin reactions and need toreport them to prescriber.• Warn patient to notify prescriber immediatelyif he develops a fever; rash; swellingof face, eyes, lips, tongue; difficulty swallowingor breathing; or other evidence ofhypersensitivity because drug may need tobe stopped and emergency medical caregiven.• Alert woman of childbearing age thatoxcarbazepine may render hormonal contraceptivesineffective. Urge patient to usean additional or a different contraceptiveduring oxcarbazepine therapy.• Urge caregivers to watch patient closely forevidence of suicidal tendencies, especiallywhen therapy starts or dosage changes,and to report concerns to prescriber atonce.• Urge female patient who becomes pregnantwhile taking oxcarbazepine to enrollin the North American antiepileptic drugpregnancy registry by calling 1-888-233-2334. Explain that the registry is collectingNO

776oxtriphyllineinformation about the safety of antiepilepticdrugs during pregnancy.oxtriphyllineApo-Oxtriphylline (CAN), Choledyl,Choledyl SAClass and CategoryChemical class: Xanthine derivativeTherapeutic class: BronchodilatorPregnancy category: CIndications and Dosages To treat acute asthma, bronchospasmdue to chronic bronchitis or COPDDELAYED-RELEASE TABLETSAdults and children age 6 and over. 300 mgdaily for 3 days; then increased to 400 mgdaily for 3 days. Maintenance: 600 mg dailyin divided doses every 6 to 8 hr.E.R. TABLETSAdults and children age 6 and over. 300 mgdaily for 3 days; then increased to 400 mgdaily for 3 days. Maintenance: 600 mg dailyin divided doses every 12 hr.Mechanism of ActionInhibits phosphodiesterase enzymes, causingbronchodilation. Normally, theseenzymes inactivate cAMP and cGMP, whichare responsible for bronchial smoothmusclerelaxation. Other mechanisms ofaction may include calcium translocation,prostaglandin antagonism, catecholaminestimulation, inhibition of cGMP metabolism,and adenosine receptor antagonism.ContraindicationsHypersensitivity to oxtriphylline, xanthines,or their components; peptic ulcer; seizuredisorder unless controlled by an anticonvulsantInteractionsDRUGSactivated charcoal, aminoglutethimide, barbiturates,ketoconazole, rifampin, sulfinpyrazone,sympathomimetics: Decreased bloodtheophylline levelallopurinol, beta blockers (nonselective), calciumchannel blockers, cimetidine, corticosteroids,disulfiram, ephedrine, influenzavirus vaccine, interferon, macrolides, mexiletine,oral contraceptives, quinolones, thiabendazole:Increased blood theophylline levelbenzodiazepines, propofol: Possibly antagonizedsedative effects of these drugscarbamazepine, isoniazid, loop diuretics:Possibly altered blood theophylline levelhalothane anesthetics: Increased risk of cardiotoxicityhydantoins: Possibly decreased bloodhydantoin levelketamine: Increased risk of seizureslithium: Decreased blood lithium levelneuromuscular blockers: Possibly reversal ofneuromuscular blockadetetracyclines: Possibly increased adverseeffects of theophyllineFOODSall foods: Altered bioavailability and absorptionof E.R. oxtriphyllinecharcoal broiled beef; low-carbohydrate, highproteindiet: Increased theophylline eliminationhigh-carbohydrate, low-protein diet:Decreased elimination and prolonged halflifeof theophyllineACTIVITIESalcohol use: Increased CNS effects, especiallywith elixirsmoking (1 or more packs daily): Decreasedeffects of oxtriphyllineAdverse ReactionsCNS: Anxiety, dizziness, headache, insomnia,restlessness, seizuresCV: Hypotension, palpitations, sinus tachycardiaEENT: Unpleasant tasteGI: Anorexia, diarrhea, nausea, vomitingRESP: TachypneaSKIN: Alopecia, flushing, rashNursing Considerations• Be aware that oxtriphylline contains 64%anhydrous theophylline, so dosage is basedon equivalent of 5 to 6 mg of anhydroustheophylline/kg.• Be aware that food delays absorption ofdelayed-release and E.R. forms and thatlarge volumes of fluid may increaseabsorption.• Know that delayed-release and E.R. preparationsvary in their absorption rate.• Monitor blood theophylline level becausetoxicity may develop at a level only slightlyabove therapeutic.PATIENT TEACHING

• If patient complains of GI discomfort,suggest taking drug with or just aftermeals.• Urge patient to stop smoking and to notifyprescriber about changes in smokinghabits. Also instruct him to avoid alcoholduring oxtriphylline therapy.• Encourage patient to keep follow-upappointments for laboratory studies.oxybutynin chlorideDitropan, Ditropan XL, Gelnique 10%Class and CategoryChemical class: Tertiary amineTherapeutic class: AntispasmodicPregnancy category: BIndications and Dosages To treat overactive bladder, includingneurogenic bladder, with urinary frequency,urgency, or incontinence frominvoluntary contraction of detrusormuscleE.R. TABLETSAdults. Initial: 5 mg daily, adjusted by 5 mg/wk, as prescribed. Maximum: 30 mg daily.SYRUP, TABLETSAdults. 5 mg b.i.d. or t.i.d. Maximum: 5 mgq.i.d. or 20 mg daily.Children age 5 and over. 5 mg b.i.d.Maximum: 15 mg t.i.d.TRANSDERMAL SYSTEMAdults. System supplying 3.9 mg daily,applied twice weekly.TOPICAL GELAdults. 1 sachet (containing 100 mg/g oxybutyninchloride gel) applied once daily todry, intact skin on the abdomen, upperarms, shoulders, or thighs.DOSAGE ADJUSTMENT For elderly patients,possibly 2.5 mg b.i.d. initially, increased tomaximum of 5 mg t.i.d., as prescribed.Route Onset Peak DurationP.O. 30–60 min 3–6 hr 6–10 hrTrans- Unknown 24–48 hr 96 hrdermaloxybutynin chloride 777Mechanism of ActionExerts antimuscarinic (atropine-like) andpotent direct antispasmodic (papaverinelike)actions on smooth muscle in the bladderand decreases detrusor muscle contractions.The result is increased bladder capacityand a decreased urge to void.ContraindicationsAcute hemorrhage, angle-closure glaucoma,gastric retention (gel form), GI obstruction,hypersensitivity to oxybutynin or its components,ileus, intestinal atony in elderly ordebilitated patients, myasthenia gravis,obstructive uropathy, toxic megacolon withulcerative colitis, urine retention (gel form)InteractionsDRUGSamantadine, amitriptyline, amoxapine,antimuscarinics, brompheniramine, bupropion,carbinoxamine, chlorpheniramine, chlorpromazine,clemastine, clomipramine, clozapine,cyclobenzaprine, dimenhydrinate,diphenhydramine, disopyramide, doxepin,doxylamine, imipramine, maprotiline,mesoridazine, methdilazine, nortriptyline,procainamide, promazine, promethazine,protriptyline, thioridazine, triflupromazine,trimeprazine, trimipramine: Increased anticholinergiceffectsCNS depressants: Increased sedationketoconazole: Possibly altered total absorptionrate and blood level of ketoconazoleopioid agonists: Increased depressive effectson GI motility and bladder functionparasympathomimetics: Decreased antimuscarinicaction of oxybutyninACTIVITIESalcohol use: Increased sedationAdverse ReactionsCNS: Agitation, asthenia, confusion, dizziness,drowsiness, fatigue, hallucinations,headache, insomnia, memory impairment,nervousness, psychosis, restlessness,seizures, somnolenceCV: Arrhythmias, hypertension, hypotension,palpitations, peripheral edema, QTintervalprolongation, tachycardia, vasodilationEENT: Blurred vision; cycloplegia; dry eyes,mouth, nose, and throat; keratoconjunctivitissicca; eye irritation; mydriasis; nasopharyngitis;rhinitis; sinusitisENDO: Hyperglycemia, suppression oflactationGI: Abdominal pain, constipation,NO

778oxycodone hydrochloridedecreased GI motility, diarrhea, dysphagia,esophagitis, flatulence, gastroesophagealreflux, indigestion, nausea, vomitingGU: Cystitis, dysuria, impotence, urinaryhesitancy, urine retention, UTIMS: Arthralgia, arthritis, back painRESP: Asthma, bronchitis, cough, upperrespiratory tract infectionSKIN: Decreased sweating, dry skin, flushing,pruritus, rash, urticariaOther: Application site reactions (anesthesia,dermatitis, erythema, irritation,papules, pruritus), flulike symptoms, fungalinfections, heatstrokeNursing Considerations• Use oxybutynin cautiously in patients withdiarrhea because it may signal incompleteGI obstruction, especially in patients withcolostomy or ileostomy. Also use cautiouslyin patients with dementia because drugmay aggravate symptoms.• Use cautiously in patients with myastheniagravis or GI disorders because drug mayadversely affect these conditions.• Assess urinary symptoms before and aftertreatment.• Make sure patient swallows E.R. tabletswhole and doesn’t crush, chew, or dividethem. Expect to see portions of drug instool.• Apply transdermal system to dry, intactskin of abdomen, hip, or buttock; avoidusing same site for at least 7 days by rotatingsites.• Apply gel form to dry, intact skin onpatient’s abdomen, upper arms, shoulders,or thighs. Rotate application sites.WARNING Watch for adverse cardiovascularreactions in patients with arrhythmias,coronary artery disease, heart failure, orhypertension because drug’s antimuscariniceffects may increase their risk.• Decreased GI motility can cause adynamicileus; assess for abdominal pain and ileus.• Be aware that drug may aggravate benignprostatic hyperplasia, gastroesophagealreflux disease, and hyperthyroidism.• Monitor patient for anticholinergic CNSeffects, such as hallucinations, agitation,confusion and somnolence, especially inthe first few months of therapy or whendosage is increased. If such effects occur,notify prescriber and expect dosage to bereduced or drug discontinued.PATIENT TEACHING• Instruct patient to take oxybutynin on anempty stomach. If adverse GI reactionsdevelop, suggest taking drug with food ormilk.• Advise patient to swallow tablets wholeand not to chew, crush, or break them.• Instruct patient how to apply transdermalsystem or gel. Tell her to apply to clean,dry skin, avoiding areas that have beenrecently shaved or have open sores orrashes. Remind patient to wash handsafter handling product.• Warn patient that gel is flammable andthat she should avoid open fire or smokinguntil gel has dried. Also tell patient toavoid bathing, swimming, showering,exercising, or immersing application sitein water for 1 hour after application andto cover site with clothing once gel hasdried.• Warn of possible decreased alertness, andadvise patient against performing hazardousactivities until drug’s CNS effectsare known.• Caution patient to avoid strenuous exerciseand excessive sun exposure because ofincreased risk of heatstroke.• Urge patient to avoid alcohol during therapy.oxycodonehydrochlorideOxyContin, Roxicodone,Supeudol (CAN)Class, Category, and ScheduleChemical class: Phenanthrene derivativeTherapeutic class: AnalgesicPregnancy category: Not ratedControlled substance schedule: IIIndications and Dosages To relieve moderate to severe painORAL SOLUTIONAdults. 5 mg every 3 to 6 hr, p.r.n., andincreased as needed.TABLETSAdults. 5 mg every 3 to 6 hr or 10 mg every6 to 8 hr, p.r.n. To manage pain for more than a fewdays

CONTROLLED-RELEASE TABLETS, E.R. TABLETSAdults who haven’t received opioidsbefore. Initial: 10 to 20 mg every 12 hr,adjusted every 1 to 2 days, as prescribed,based on total amount of oxycodone neededdaily to control pain.Adults who currently receive an opioidagonist or fixed-ratio combination drugs(opioid agonist plus acetaminophen,aspirin, or NSAID). Half the 24-hr oxycodonedose every 12 hr, as prescribed. Beprepared to manage breakthrough painwith immediate-release tablets, p.r.n., andadjust every 1 to 2 days, as prescribed.Adults who use fentanyl transdermalpatch. 10 mg oxycodone for each 25 mcg/hr of fentanyl patch dosage every 12 hr,beginning 12 to 18 hr after removing patch.DOSAGE ADJUSTMENT To provide supplementalanalgesia for adults receivingcontrolled-release oxycodone, one-fourth toone-third the 12-hr controlled-release dosegiven as tablet every 3 to 6 hr, p.r.n.Route Onset Peak DurationP.O. 10–15 min 1 hr 3–4 hrMechanism of ActionAlters perception of and emotionalresponse to pain at spinal cord and higherlevels of CNS by blocking release ofinhibitory neurotransmitters, such asgamma-aminobutyric acid and acetylcholine.ContraindicationsHypercapnia, hypersensitivity to oxycodoneor its components, ileus, use within 14 daysof MAO inhibitor therapyInteractionsDRUGSanticholinergics: Possibly severe constipationand ileusantidiarrheals: Possibly severe constipationand additive CNS depressionantihypertensives: Possibly exaggerated antihypertensiveeffects and risk of orthostatichypotensionbutorphanol, pentazocine: Possibly acutewithdrawal symptoms in opioid-dependentpatients, decreased analgesic effectscarbamazepine, phenytoin, primidone, rifampin:Possibly need for increased oxycodonedosage to achieve analgesia and preventoxycodone hydrochloride 779withdrawal symptoms in opioid-dependentpatientscimetidine: Possibly apnea, confusion, disorientation,and seizures from respiratorydepression and impaired CNS functionCNS depressants: Possibly increased CNSand respiratory depression and orthostatichypotensionMAO inhibitors: Possibly fatal reactions,including cardiac arrest, coma, respiratorydepression, seizures, and severe hypertensionnalbuphine, nalmefene, naloxone, naltrexone:Blocked oxycodone effects, withdrawalsymptoms in opioid-dependent patientsACTIVITIESalcohol use: Additive CNS effectsAdverse ReactionsCNS: Abnormal dreams, anxiety, asthenia,chills, dizziness, drowsiness, euphoria, excitation,headache, insomnia, nervousness,sedation, seizures, somnolence, syncope,twitchingCV: Bradycardia, chest pain, hypotension,orthostatic hypotension, palpitationsEENT: Blurred vision, dry eyes or mouth,lens opacities, miosisENDO: Syndrome of inappropriate antidiuretichormone secretionGI: Abdominal pain, anorexia, constipation,diarrhea, dyspepsia, elevated liver functiontest results, gastritis, hiccups, nausea, vomitingGU: Amenorrhea, decreased libido, erectiledysfunction, oliguria, urinary hesitancy,urine retentionRESP: Dyspnea, respiratory depressionSKIN: Diaphoresis, pruritus, rashOther: Anaphylaxis, drug tolerance,hyponatremia, physical and psychologicaldependence, withdrawal symptomsNursing ConsiderationsWARNING Be aware that oxycodone has ahigh potential for abuse.WARNING Be aware that abuse of crushedcontrolled-release tablets poses a hazard ofoverdose and death. If you suspect abuseand determine that patient also is abusingalcohol or illicit substances, notify prescriberimmediately because risk of overdoseand death is increased. If you suspectparenteral abuse, be aware that tabletexcipients, especially talc, may result inNO

780oxymetholonelocal tissue necrosis, infection, pulmonarygranulomas, endocarditis, and valvularheart injury.• Assess baseline neurologic status beforeeach dose in patient with head injurybecause oxycodone may obscure progressionof his condition.• Assess patient’s pain level regularly, andgive drug as prescribed before painbecomes severe.• Be prepared to adjust dosage for patientwho hasn’t previously received opioidsuntil he can tolerate drug’s effects.• Expect to give controlled-release tabletsonly to opioid-tolerant patients who needat least 160 mg daily.• Assess patient for possible respiratorydepression or paradoxical excitation duringdosage titration.• Assess patient for abdominal pain becauseoxycodone may mask underlying GI disorders.PATIENT TEACHINGWARNING Strongly warn patient to swallowoxycodone tablets whole and not to break,chew, or crush them because taking broken,chewed, or crushed tablets leads torapid release and absorption of a potentiallyfatal dose.• Instruct patient not to take oxycodonemore often than prescribed and not tostop abruptly after long-term use.• Instruct patient to avoid alcohol and hazardousactivities during therapy.• Tell patient to notify prescriber aboutsigns of possible toxicity or hypersensitivity,such as excessive light-headedness,extreme dizziness, itching, swelling, andtrouble breathing.oxymetholoneAnadrol-50, Anapolon-50 (CAN)Class, Category, and ScheduleChemical class: Testosterone derivativeTherapeutic class: Antianemic, antiangioedema(hereditary)Pregnancy category: XControlled substance schedule: IIIIndications and Dosages To treat acquired and congenital aplasticanemias, anemias caused by deficientRBC production, bone marrow failureanemias, hypoplastic anemias caused bymyelotoxic drugs, and myelofibrosis; toprevent or treat hereditary angioedemaTABLETSAdults and children. 1 to 2 mg/kg daily for3 to 6 mo. Maximum: 5 mg/kg daily.Mechanism of ActionCombats anemia by increasing productionof erythropoietin, a precursor of RBCs.Oxymetholone also increases hemoglobinlevel and RBC volume.ContraindicationsBreast or prostate cancer in men, hypercalcemiain women with breast cancer, hypersensitivityto oxymetholone or anabolicsteroids, nephrosis, nephrotic phase ofneph-ritis, pregnancy, severe hepatic dysfunctionInteractionsDRUGScorticosteroids: Increased risk of edema andsevere acnehepatotoxic drugs: Increased risk of hepatotoxicityinsulin, oral antidiabetic drugs: PossiblyhypoglycemiaNSAIDs, oral anticoagulants, salicylates:Increased anticoagulant effectssodium-containing drugs: Increased risk ofedemasomatrem, somatropin: Possibly acceleratedepiphyseal maturationFOODShigh-sodium foods: Increased risk of edemaAdverse ReactionsCNS: Depression, excitement, insomniaCV: Decreased serum HDL level, edema,hyperlipidemia, hypertensionENDO: Feminization in postpubertal males(epididymitis, gynecomastia, impotence,oligospermia, priapism, testicular atrophy),glucose intolerance, virilism in females(acne, clitoral enlargement, decreased breastsize, deepened voice, diaphoresis, emotionallability, flushing, hirsutism, hoarseness,libido changes, male-pattern baldness, menstrualirregularities, nervousness, oily hairor skin, vaginal bleeding, vaginitis, weightgain), virilism in prepubertal males (acne,decreased ejaculatory volume, penis

enlargement, prepubertal closure of epiphysealplates, unnatural growth of body andfacial hair)GI: Diarrhea, elevated liver function testresults, hepatocellular carcinoma, nausea,vomitingGU: Benign prostatic hyperplasia, prostatecancer, urinary frequency, urine retention(elderly men)HEME: Iron deficiency anemia, leukemia,prolonged bleeding timeSKIN: JaundiceOther: Fluid retention, hypercalcemia(females), physical and psychologicaldependence, sodium retentionNursing Considerations• Be aware that oxymetholone shouldn’t beused in patients with a history of hypercalcemiabecause drug may exacerbate thiscondition or in patients with prostateproblems because drug may promotebenign or cancerous tumor growth.• Anticipate increased risk of fluid and sodiumretention in patients with cardiac,hepatic, or renal dysfunction. Monitor forsigns and symptoms of fluid retention.• Monitor daily weight. Expect to placepatient with fluid retention on sodiumrestricteddiet or diuretics, as prescribed.WARNING Be aware that oxymetholone maysuppress spermatogenesis in males andcause permanent virilization in females.PATIENT TEACHING• Advise patient to consume a diet high inprotein and calories to achieve maximumtherapeutic effect of oxymetholone.• Instruct patient to check his weight dailyduring oxymetholone therapy and to notifyprescriber immediately about swellingor unexplained weight gain.• Inform patient that drug may alter libido.• Advise diabetic patient to monitor bloodglucose levels frequently because drug mayincrease hypoglycemic effect of antidiabeticdrugs.• Inform female patient that drug may causepermanent physical changes, such as clitoralenlargement, deepened voice, andunnatural hair growth.• Advise female patient of childbearing ageto use contraception during therapy andto notify prescriber immediately aboutsuspected or known pregnancy.oxymorphone hydrochloride 781oxymorphonehydrochlorideNumorphan, Opana, Opana ERClass, Category, and ScheduleChemical class: Phenanthrene derivativeTherapeutic class: AnalgesicPregnancy category: Not ratedControlled substance schedule: IIIndications and Dosages To relieve moderate to severe painTABLETSAdults. Initial: 5 to 20 mg every 4 to 6 hr,p.r.n. To relieve moderate to severe pain inpatients requiring continuous, aroundthe-clockopioid treatment for anextended timeE.R. TABLETSAdults. Initial: 5 mg every 12 hr, increasedas needed in 5- to 10-mg increments every3 to 7 days.DOSAGE ADJUSTMENT For patients with creatinineclearance less than 50 ml/min/1.73 m 2 or elderly patients, dosage startedat lowest level and titrated slowly. Forpatients receiving other CNS depressants,dosage started at one-third to one-half theusual starting dose. To relieve moderate to severe pain, torelieve anxiety in patients with dyspneafrom pulmonary edema caused by acuteleft ventricular dysfunctionI.V. INJECTIONAdults. Initial: 0.5 mg, repeated every 3 to6 hr, p.r.n.I.M. OR SUBCUTANEOUS INJECTIONAdults. Initial: 1 to 1.5 mg, repeated every3 to 6 hr, p.r.n.SUPPOSITORIESAdults. 5 mg every 4 to 6 hr, p.r.n. To relieve obstetric pain during laborI.M. INJECTIONAdults. 0.5 to 1 mg as a single dose.Mechanism of ActionAlters perception of and emotional responseto pain at spinal cord and higher levels ofCNS by blocking release of inhibitory neurotransmitters,such as gamma-aminobutyricacid and acetylcholine.NO

782oxymorphone hydrochlorideContraindicationsAcute or severe asthma; hypercarbia; hypersensitivityto oxymorphone, other morphineanalogues, or their components;ileus; moderate to severe hepatic impairment;pulmonary edema from a chemicalrespiratory irritant; severe respiratorydepression; upper airway obstructionRoute Onset Peak DurationI.V. 5–10 min 15–30 min 3–4 hrI.M. 10–15 min 30–90 min 3–6 hrSubQ 10–20 min 30–90 min 3–6 hrP.R. 15–30 min 2 hr 3–6 hrInteractionsDRUGSanticholingerics: Increased risk of urineretention, severe constipationantidiarrheals, antiperistaltics: Increased riskof severe constipation, CNS depressionantihypertensives, diuretics, hypotensionproducingdrugs: Increased hypotensiveeffectsbuprenorphine: Reduced oxymorphoneeffectiveness if buprenorphine is given first,possibly withdrawal symptoms in oxymorphone-dependentpatientsCNS depressants: Additive CNS depressanteffects, increased risk of habituationhydroxyzine, other opioid analgesics:Increased analgesia, CNS depression, andhypotensive effectsMAO inhibitors: Increased risk ofunpredictable, severe, sometimes fataladverse reactionsmetoclopramide: Antagonized effects ofmetoclopramide on GI motilitynaloxone: Antagonized analgesic, CNS, andrespiratory depressant effects of oxymorphonenaltrexone: Withdrawal symptoms inoxymorphone-dependent patientsneuromuscular blockers: Additive respiratorydepressionACTIVITIESalcohol use: Additive CNS depressanteffects, increased risk of habituationAdverse ReactionsCNS: Agitation, asthenia, CNS depression,confusion, delusions, depersonalization,dizziness, drowsiness, euphoria, fatigue, hallucinations,headache, insomnia, lightheadedness,nervousness, nightmares, restlessness,seizures, somnolence, tiredness,tremor, weaknessCV: Bradycardia, hypertension, hypotension,palpitations, tachycardiaEENT: Blurred vision, diplopia, dry mouth,laryngeal edema, laryngospasm, miosis, tinnitusGI: Abdominal cramps or pain, anorexia,bilary colic, constipation, hepatotoxicity,ileus, nausea, vomitingGU: Decreased urine output, dysuria, urinaryfrequency and hesitancy, urine retentionMS: Muscle rigidity (with large doses),uncontrolled muscle movementsRESP: Apnea, atelectasis, bradypnea,bronchospasm, dyspnea, irregular breathing,respiratory depression, wheezingSKIN: Dermatitis, diaphoresis, erythema,flushing of face, pruritus, urticariaOther: Angioedema, injection site burning,pain, redness, and swellingNursing Considerations• Use with extreme caution in patients withincreased intracranial pressure or headinjury because oxymorphone may obscureneurologic signs of increasing severity.• Use cautiously in patients with mildhepatic impairment because drug ismetabolized in liver; impaired renal functionbecause drug is excreted by kidneys;and biliary tract disease because drug maycause spasm of sphincter of Oddi.• Use cautiously in patients receiving mixedagonist-antagonist opioid analgesicsbecause these drugs may reduce analgesiceffect of oxymorphone or may cause withdrawalsymptoms.• Use cautiously in elderly patients becauseplasma oxymorphone levels are higher inelderly than in younger patients.• Oral hydromorphone shouldn’t be used“as needed” or for first 24 hours after surgeryin patients not already taking opioidsbecause of the risk of oversedation andrespiratory depression.• If patient is being converted from oneform of drug to another, watch closely foranalgesic effectiveness and adverse reactions.For conversion from immediatereleaseoral form to extended-release oralform, expect to give half the total daily

dose every 12 hours. For conversion fromparenteral to oral oxymorphone, expectthat you may give 10 times the total dailyparenteral dose as tablets, divided intoequal doses and given over 24 hours.• Taper dosage, as ordered, before stoppingtherapy to prevent withdrawal in physicallydependent patients.• Monitor vital signs during oxymorphonetherapy to detect respiratory depressionand hypotension, especially in elderlypatients, debilitated patients, and thosewith conditions accompanied by hypoxia,when even moderate doses may severelydecrease pulmonary ventilation.• Monitor urinary and bowel status; constipationmay be so severe it causes ileus.• Offer fluids to relieve dry mouth.PATIENT TEACHING• Instruct patient to take oxymorphoneexactly as prescribed and not to stopabruptly; warn that drug can cause physicaldependence.• Stress importance of taking drug beforepain becomes severe.• Instruct patient prescribed tablet form totake it on an empty stomach.• Tell patient prescribed extended-releasetablet form not to break, chew, dissolve, orcrush tablets before taking them becausegoing so will lead to a rapid drug releaseand increased risk of a potentially fataldose.• Instruct patient to store suppositories inrefrigerator.• Encourage patient to increase fluid andfiber intake during therapy to preventconstipation.• Stress need to avoid alcohol and CNSdepressants during therapy because of riskof severe life-threatening adverse reactions.• Caution patient to avoid potentially hazardousactivities until drug’s CNS effectsare known.• Advise female patient to stop drug andnotify prescriber about known or suspectedpregnancy.oxytetracyclineTerramycin I.M.oxytetracycline 783oxytetracyclinehydrochlorideTerramycinClass and CategoryChemical class: Tetracycline derived fromStreptomyces rimosusTherapeutic class: Antibiotic, antiprotozoalPregnancy category: DIndications and Dosages To treat systemic bacterial and protozoalinfections, such as bronchitis, chlamydialinfection, Lyme disease, nongonococcalurethritis, rickettsial infection, traveler’sdiarrhea, and UTICAPSULES (OXYTETRACYCLINE HYDROCHLORIDE)Adults and adolescents. 250 to 500 mgevery 6 hr. Maximum: 4,000 mg daily.Children ages 8 to 12. 6.25 to 12.5 mg/kgevery 6 hr.I.M. INJECTION (OXYTETRACYCLINE)Adults and adolescents. 100 mg every 8 hr,150 mg every 12 hr, or 250 mg daily.Maximum: 500 mg daily.Children ages 8 to 12. 5 to 8.3 mg/kg every8 hr or 7.5 to 12.5 mg/kg every 12 hr.Maximum: 250 mg daily.DOSAGE ADJUSTMENT Dosage possiblyreduced for patients with renal impairment. To treat brucellosisCAPSULES (OXYTETRACYCLINE HYDROCHLORIDE)Adults and adolescents. 500 mg every 6 hrfor 3 wk with 1,000 mg of streptomycinI.M. every 12 hr in wk 1 and daily in wk 2.Maximum: 4,000 mg daily. To treat uncomplicated gonorrheaCAPSULES (OXYTETRACYCLINE HYDROCHLORIDE)Adults and adolescents. Initial: 1,500 mg,then 500 mg every 6 hr to total of 9,000 mgfor full course of treatment. To treat syphilisCAPSULES (OXYTETRACYCLINE HYDROCHLORIDE)Adults and adolescents. 500 to 1,000 mgevery 6 hr for 10 to 15 days to total of 30 to40 g for full course of treatment.Mechanism of ActionBinds with ribosomal subunits of susceptiblebacteria and alters cytoplasmic membrane,inhibiting bacterial protein synthesisand rendering the organism ineffective.NO

784oxytetracyclineContraindicationsHypersensitivity to tetracyclines or theircomponentsInteractionsDRUGSantacids, calcium supplements, cholestyramine,choline salicylates, colestipol, iron supplements,magnesium salicylates: Possiblydecreased absorption of oxytetracyclinedigoxin: Increased blood digoxin levellithium: Altered blood lithium levelmethoxyflurane: Increased risk of nephrotoxicityoral anticoagulants: Increased anticoagulanteffectsoral contraceptives: Decreased contraceptiveeffectiveness, increased risk of breakthroughbleeding and pregnancypenicillins: Decreased bactericidal effects ofpenicillinssodium bicarbonate: Possibly decreasedabsorption of oral oxytetracyclinevitamin A: Increased risk of benignintracranial hypertensionFOODSall foods, especially dairy products: Possiblyinterference with oxytetracycline absorptionAdverse ReactionsCNS: Dizziness, light-headedness, tiredness,unsteadiness, weaknessEENT: Darkened, discolored, or soretongue; stomatitis, tooth discoloration (ininfants and children under age 8)GI: Abdominal cramps, diarrhea, indigestion,nausea, thirst, vomitingGU: Urinary frequencySKIN: PhotosensitivityOther: SuperinfectionNursing ConsiderationsWARNING Be aware that oxytetracyclineshouldn’t be given to premature infantsbecause it may impair skeletal growth orto children under age 8 because it maypermanently discolor teeth and causeenamel hypoplasia.• For an adult, give I.M. injection in upperouter quadrant of buttocks or mid-lateralthigh; deltoid muscle may be used butonly if well developed. In children, giveinjection only in mid-lateral thigh.• Be aware that patient should be switchedfrom parenteral to oral form as soon aspossible.PATIENT TEACHING• Instruct patient to take oxytetracyclinecapsules 1 hour before meals and 3 hoursbefore or after other drugs and dairyproducts.• Advise patient to take drug with a fullglass of water and in an upright positionto minimize adverse GI reactions.• Urge patient to complete entire course ofoxytetracycline therapy, even if he feelsbetter beforehand.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to avoid excessive sun exposureand to protect skin when outdoors.• Urge female patient who uses oral contraceptivesto use an additional form of birthcontrol during oxytetracycline therapy.• Advise patient to discard outdated capsulesbecause drug may become toxic.

PpaliperidoneInvegaClass and CategoryChemical class: Benzisoxazole derivativeTherapeutic class: Antipsychotic (Atypical)Pregnancy category: CIndications and Dosages To treat schizophreniaE.R. TABLETSAdults. Initial: 6 mg once daily in themorning; then increased or decreased inincrements of 3 mg daily every 6 or moredays, as needed. Maximum: 12 mg daily.DOSAGE ADJUSTMENT For patients withmild renal impairment (creatinine clearance50 to 79 ml/min/1.73 m 2 ), maximumdosage is 6 mg daily. For patients withmoderate to severe renal impairment (creatinineclearance less than 50 ml/min/1.73 m 2 ), maximum dosage is 3 mg daily.Route Onset Peak DurationP.O. Unknown 24 hr UnknownMechanism of ActionThe main active metabolite of risperidone,paliperidone selectively blocks serotoninand dopamine receptors in mesocorticaltract of CNS to suppress psychotic symptoms.ContraindicationsAV block, cardiac arrhythmias, congenitalheart disease, history of congenital long-QTsyndrome; hypersensitivity to paliperidone,risperidone, or its componentsInteractionsDRUGSantiarrhythmics of class IA (such as quinidine,procainamide) and class III (such asamiodarone, sotalol), antibiotics (such as gatifloxacin,moxifloxacin), antipsychotics (suchas chlorpromazine, thioridazine): Increasedrisk of QT-interval prolongationantihypertensives: Increased antihypertensiveeffectsbromocriptine, levodopa, pergolide: Possiblypaliperidone 785antagonized effects of these drugscarbamazepine: Decreased paliperidone levelCNS depressants: Additive CNS depressionparoxetine: Possible increased bloodpaliperidone levelACTIVITIESalcohol use: CNS depressionAdverse ReactionsCNS: Agitation, akathisia, anxiety, asthenia,dizziness, dyskinesia, dystonia, extrapyramidaldisorder, fatigue, fever, headache, hyperkinesia,hypertonia, neuroleptic malignantsyndrome, parkinsonism, somnolence, syncope,tardive dyskinesia, tremorCV: Bundle branch block, first-degree heartblock, hypertension, orthostatic hypotension,palpitations, prolonged QT interval,tachycardia, venous thrombosisEENT: Blurred vision, dry mouth, salivaryhypersecretion, swollen tongueENDO: HyperglycemiaGI: Dyspepsia, nausea, upper abdominal painGU: PriapismHEME: Agranulocytosis, leukopenia, neutropenia,thrombocytopeniaMS: Back or limb painRESP: Cough, dyspneaOther: Anaphylaxis, weight gainNursing Considerations• Paliperidone shouldn’t be used to treatdementia-related psychosis in the elderlybecause of an increased mortality risk.• Drug shouldn’t be given if patient has acondition that severely narrows GI tractbecause tablet doesn’t change shape as itpasses and could cause blockage.WARNING Immediately notify prescriberand expect to stop drug if patient showssigns of neuroleptic malignant syndrome(altered mental status, autonomic instability,hyperpyrexia, muscle rigidity).• Monitor patient for involuntary, dyskineticmovements. Notify prescriber if present,and expect to stop therapy. In some cases,therapy may need to continue despite tardivedyskinesia.• Monitor blood glucose level because drugincreases risk of hyperglycemia and possibleketoacidosis or hyperosmolar coma.• Dosage adjustments of paliperidone maybe needed when carbamazepine therapy isstarted or discontinued because of carbamazepine’sinteraction with paliperidone.P

786palonosetron hydrochloride• Check CBC often during first few monthsof therapy, especially if patient has lowWBC count or history of drug-inducedleukopenia or neutropenia. If WBC countdeclines, and especially if neutrophil countgoes 1,000/mm 3 , expect to stop drug. Ifneutropenia is significant, also watch forevidence of infection and provide appropriatetreatment, as prescribed.PATIENT TEACHING• Instruct patient to take tablet whole withliquid. Caution against chewing, splitting,or crushing it because it’s designed torelease drug at a controlled rate.• Explain that shell of tablet will be eliminatedin stool and that patient need notworry if he sees tablet in stool.• Urge patient to rise slowly from sitting orlying to minimize orthostatic hypotension.• Caution patient to avoid hazardous activitiesuntil CNS effects of drug are known.• Advise patient to avoid activities that maycause overheating, such as exercisingstrenuously, being exposed to extremeheat, or becoming dehydrated.palonosetronhydrochlorideAloxiClass and CategoryChemical class: Selective serotoninsubtype 3 (5-HT 3 ) receptor antagonistTherapeutic class: AntiemeticPregnancy category: BIndications and Dosages To prevent acute and delayed nauseaand vomiting from chemotherapyCAPSULESAdults. 0.5 mg 1 hr before chemotherapy.I.V. INJECTIONAdults. 0.25 mg over 30 sec about 30 minbefore start of chemotherapy. To prevent postoperative nausea andvomiting for up to 24 hr after surgeryI.V. INJECTIONAdults. 0.75 mg over 10 sec immediatelybefore induction of anesthesia.IncompatibilitiesPalonosetron shouldn’t be mixed with anyother drug.ContraindicationsHypersensitivity to palonosetron or itscomponentsAdverse ReactionsCNS: Anxiety, dizziness, drowsiness, fatigue,headache, insomnia, weaknessCV: Bradycardia, hypotension, prolongedQT interval, tachycardiaGI: Abdominal pain, constipation, diarrheaSKIN: Dermatitis, pruritus, rashOther: Hyperkalemia, hypersensitivity reaction,injection site reaction (burning,induration, discomfort, pain)Nursing Considerations• Use palonosetron cautiously in patientsMechanism of ActionChemotherapy may induce nauseaand vomiting by irritating the smallintestine’s mucosa, causing mucosalenterochromaffin cells to release serotonin(5-HT 3 ). The 5-HT 3 stimulatessympathetic receptors on afferentvagal nerve endings, and the vagusnerve causes the vomiting reflex.Palonosetron selectively blocksthese 5-HT 3 receptors. By keeping thevagus nerve from inducing the vomitingreflex, drug reduces or preventsnausea and vomiting. It also mayblock 5-HT 3 receptors centrally, inthe brain’s chemoreceptor trigger zone.IrritationEnterochromaffincellsSmallintestinemucosaPalonosetron5-HT 35-HT 35-HT 35-HT 3Vagus nerve5-HT 3Nerve impulse5-HT 3receptorsites

who have or may develop prolonged cardiacconduction intervals—especially QTinterval—such as those with congenitalQT syndrome, hypokalemia, or hypomagnesemia;those taking a diuretic known toinduce electrolyte abnormalities, anantiarrhythmic, or another drug that mayprolong QT interval; and those who havereceived cumulative high-dose anthracyclinetherapy. With these patients, obtain abaseline ECG before giving palonosetron;repeat the ECG 15 minutes or 24 hoursafter giving drug, as ordered. Notify prescriberof any delayed conduction.• Flush I.V. line with normal saline solutionbefore and after giving I.V. palonosetron.• Closely monitor any patient hypersensitiveto other selective serotonin receptor antagonistsfor a similar reaction. If a reactionoccurs, notify prescriber immediately.PATIENT TEACHING• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to notify prescriber of anyhypersensitivity reaction, such as rash orallergic dermatitis.pamidronatedisodiumArediaClass and CategoryChemical class: BisphosphonateTherapeutic class: Antihypercalcemic, boneresorption inhibitorPregnancy category: DIndications and Dosages To treat cancer-induced hypercalcemiathat’s inadequately managed by oralhydration aloneI.V. INFUSIONAdults. 60 to 90 mg over 2 to 24 hr as a singledose when corrected serum calciumlevel is 12 to 13.5 mg/dl; 90 mg over 2 to24 hr when corrected serum calcium level isgreater than 13.5 mg/dl. May be repeated asprescribed after 7 days if hypercalcemiarecurs.DOSAGE ADJUSTMENT For patients withrenal failure, dosage is limited to 30 mgover 4 to 24 hr, as prescribed. For patientspamidronate disodium 787with cardiac or renal failure, drug is givenin a smaller volume of fluid or at a slowerrate, as prescribed. To treat moderate to severe Paget’sdisease of boneI.V. INFUSIONAdults. 30 mg daily over 4 hr on 3 consecutivedays for a total dose of 90 mg. Repeatedas needed and tolerated. To treat osteolytic bone metastases ofbreast cancerI.V. INFUSIONAdults. 90 mg over 2 hr every 3 to 4 wk. To treat osteolytic bone metastases ofmultiple myelomaI.V. INFUSIONAdults. 90 mg over 4 hr every mo.Mechanism of ActionInhibits bone resorption, possibly byimpairing attachment of osteoclast precursorsto mineralized bone matrix, thusreducing the rate of bone turnover inPaget’s disease and osteolytic metastases.Pamidronate also reduces the flow of calciumfrom resorbing bone into bloodstream.IncompatibilitiesDon’t mix pamidronate with calciumcontaininginfusion solutions, such asRinger’s solution.ContraindicationsHypersensitivity to pamidronate, other bisphosphonates,or their componentsInteractionsDRUGScalcium-containing preparations; vitamin Dpreparations, such as calcifediol and calcitriol:Antagonized pamidronate effects whenused to treat hypercalcemiathalidomide: Increased risk of renal dysfunctionin patients with multiple myelomaAdverse ReactionsCNS: Confusion, fever, psychosis, visualhallucinationsCV: HypotensionEENT: ConjunctivitisGI: Abdominal cramps, anorexia, GI bleeding,indigestion, nausea, vomitingGU: Azotemia, focal segmental glomerulosclerosis,nephrotic syndrome, hematuria,renal toxicity leading to failureHEME: Leukopenia, lymphopeniaMS: Bone pain, muscle spasms or stiffness,P

788pancreatinosteonecrosis (mainly of jaw)RESP: DyspneaSKIN: Pruritus, rashOther: Anaphylaxis, angioedema, flulikesymptoms, hyperkalemia, hypernatremia,hypocalcemia, hypokalemia, hypomagnesemia,hypophosphatemia, injection sitepain and swelling, reactivation of herpessimplex and zoster infectionsNursing Considerations• Make sure patient has had a dental checkupbefore invasive dental procedures duringpamidronate therapy, especially if hehas cancer; is receiving chemotherapy,head or neck radiation, or a corticosteroid;or has poor oral hygiene. Risk of osteonecrosisis increased in these patients.WARNING Don’t give more than 90 mg atany one time because of increased risk ofserious adverse effect on kidneys.• Monitor patient for hypocalcemia, especiallyif patient has had thyroid surgery.• Stay alert for fever during first 3 days oftherapy, especially in patients receivinghigh doses. If fever develops, obtainpatient’s CBC with differential, as ordered.• Obtain serum creatinine level before eachtreatment. Notify prescriber of abnormalresults because drug may need to be withheldor dosage adjusted until creatininelevel returns to normal.• Assess patient with anemia, leukopenia, orthrombocytopenia for worsening of thecondition during first 2 weeks of therapy.PATIENT TEACHING• Stress need to comply with prescribedadministration schedule for pamidronate.• Advise patient to avoid calcium and vitaminD supplements during therapy.• Instruct patient on proper oral hygieneand on need to notify prescriber aboutinvasive dental procedures.pancreatinDonnazyme: 500 mg pancreatin,1,000 units lipase, 12,500 units protease,12,500 units amylaseHi-Vegi-Lip: 2,400 mg pancreatin,4,800 units lipase, 60,000 units protease,60,000 units amylase4X Pancreatin: 2,400 mg pancreatin,12,000 units lipase, 60,000 units protease,60,000 units amylase8X Pancreatin: 7,200 mg pancreatin,22,500 units lipase, 180,000 units protease,180,000 units amylasePancrezyme 4X: 2,400 mg pancreatin,12,000 units lipase, 60,000 units protease,60,000 units amylaseClass and CategoryChemical class: Pancreatic enzymeTherapeutic class: Digestant, pancreaticenzyme replacementPregnancy category: CIndications and Dosages To treat pancreatic insufficiency,including steatorrheaCAPSULES, TABLETSAdults. 8,000 to 24,000 units of lipase withmeals or snacks, adjusted as prescribed,according to need for steatorrhea control.For severe insufficiency, up to 36,000 unitsof lipase with meals or snacks.Mechanism of ActionReleases the enzymes pancreatin, lipase,amylase, and protease, mainly in the duodenumand upper jejunum. These enzymesfacilitate the hydrolysis of fats into glyceroland fatty acids, starches into dextrins andsugars, and proteins into peptides.Pancreatin acts locally in the GI tract but isquickly inactivated by gastric acid.ContraindicationsAcute exacerbation of chronic pancreaticdisease; acute pancreatitis; hypersensitivityto pancreatin, pancrelipase, or porkInteractionsDRUGSacarbose, miglitol: Decreased effectiveness ofthese drugsaluminum hydroxide, H 2 -receptor antagonists,omeprazole, sodium bicarbonate:Increased gastric pH, prolonged enzymaticaction of pancreatincalcium carbonate– and magnesium hydroxide–containingantacids: Decreased pancreatineffectivenessiron supplements: Decreased iron absorptionAdverse ReactionsEENT: StomatitisGI: Abdominal cramps or pain, diarrhea,intestinal obstruction, nausea

SKIN: Rash, urticariaOther: HyperuricemiaNursing ConsiderationsWARNING Don’t administer pancreatin topatient who is allergic to pork.• Assess patient for GI disturbances andhyperuricemia when giving high doses ofpancreatin.• If patient opens capsules and sprinklescontents on food, watch for signs orsymptoms of sensitization (chest tightness,dyspnea, nasal congestion, wheezing),which may result from repeated inadvertentinhalation of powder.• Be aware that brands of pancreatin aren’tinterchangeable because the same dosesdon’t contain equivalent amounts of drug.PATIENT TEACHING• Instruct patient to take pancreatin beforeor with meals or snacks to maximize effectiveness.• To prevent capsule or tablet from lodgingin esophagus, advise patient to take drugwith a beverage while sitting upright, toswallow it quickly, and to follow with 1 or2 mouthfuls of solid food.• Caution patient not to chew tablets; doingso may irritate mouth, lips, and tongue.• If patient has trouble swallowing capsules,advise her to open capsule and sprinkle itscontents on food without inhaling them.• Caution patient not to take antacids thatcontain calcium carbonate or magnesiumhydroxide during therapy.pancrelipaseCotazym: 8,000 units lipase, 30,000 unitsprotease, 30,000 units amylaseCotazym-S: 5,000 units lipase,20,000 units protease,20,000 units amylaseCreon: 6,000 units lipase, 19,000 unitsprotease, 30,000 units amylaseCreon: 12,000 units lipase, 38,000 unitsprotease, 60,000 units amylaseCreon: 24,000 units lipase, 76,000 unitsprotease, 120,000 units amylaseIlozyme: 11,000 units lipase, 30,000 unitsprotease, 30,000 units amylaseKu-Zyme HP: 8,000 units lipase,30,000 units protease, 30,000 unitsamylasepancrelipase 789Pancrease: 4,500 units lipase,25,000 units protease, 20,000 unitsamylasePancrease MT: 4: 4,000 units lipase,12,000 units protease, 12,000 unitsamylasePancrease MT 10: 10,000 units lipase,30,000 units protease, 30,000 unitsamylasePancrease MT 16: 16,000 units lipase,48,000 units protease, 48,000 unitsamylasePancrease MT 20: 20,000 units lipase,44,000 units protease, 56,000 unitsamylaseProtilase: 4,000 units lipase, 25,000 unitsprotease, 20,000 units amylaseUltrase MT 12: 12,000 units lipase,39,000 units protease, 39,000 unitsamylaseUltrase MT 20: 20,000 units lipase,65,000 units protease, 65,000 unitsamylaseViokase Tablets: 8,000 units lipase,30,000 units protease, 30,000 unitsamylaseViokase Powder: 16,800 units lipase,70,000 units protease, 70,000 unitsamylaseZenpep: 5,000 units lipase, 17,000 unitsprotease, 27,000 units amylaseZenpep: 10,000 units lipase, 34,000 unitsprotease, 55,000 units amylaseZenpep: 15,000 units lipase, 51,000 unitsprotease, 82,000 units amylaseZenpep: 20,000 units lipase, 68,000 unitsprotease, 109,000 units amylaseZymase: 12,000 units lipase, 24,000 unitsprotease, 24,000 units amylaseClass and CategoryChemical class: Porcine pancreatic enzymeTherapeutic class: Pancreatic enzymereplacementPregnancy category: CIndications and Dosages To treat pancreatic insufficiency,including steatorrheaCAPSULES, DELAYED-RELEASE CAPSULES, POWDER,TABLETSAdults and adolescents. 33,000 to44,000 units of lipase before or with mealsor snacks; adjusted as prescribed. ForP

790pantoprazole sodiumpatients with severe deficiency, possibly upto 88,000 units of lipase with meals orsnacks or dosing frequency increased toevery hr.Children ages 7 to 12. 4,000 to 12,000 unitsof lipase with meals and snacks; adjusted asneeded and tolerated.Children ages 1 to 6. 4,000 to 8,000 units oflipase with meals and 4,000 units of lipasewith each snack; adjusted as needed andtolerated.Infants ages 6 to 11 months. 2,000 units oflipase with meals; adjusted as needed andtolerated.Mechanism of ActionReleases high levels of the enzymes lipase,amylase, and protease, mainly in duodenumand upper jejunum. These enzymes facilitatehydrolysis of fats into glycerol and fattyacids, starches into dextrins and sugars, andproteins into peptides.ContraindicationsAcute exacerbation of chronic pancreaticdisease; acute pancreatitis; hypersensitivityto pancreatin, pancrelipase, or porkInteractionsDRUGSacarbose, miglitol: Decreased effectiveness ofthese drugsaluminum hydroxide, H 2 -receptor antagonists,omeprazole, sodium bicarbonate:Increased gastric pH, prolonged enzymaticaction of pancrelipasecalcium carbonate– and magnesium hydroxide–containingantacids: Decreased pancrelipaseeffectivenessiron supplements: Decreased iron absorptionAdverse ReactionsEENT: StomatitisGI: Abdominal cramps or pain, diarrhea,intestinal obstruction, nauseaHEME: AnemiaSKIN: Rash, urticariaOther: HyperuricemiaNursing ConsiderationsWARNING Don’t administer pancrelipase topatient who is allergic to pork.• Be aware that brands of pancrelipase aren’tinterchangeable because the same dosesdon’t contain equivalent amounts of drug.• Mix powder with fluid or soft, nondairyfood.• If needed, open delayed-release capsulesand mix contents (enteric-coated spheres,microspheres, or microtablets) with liquidor soft food that requires no chewing. Giveimmediately because enteric coating willdissolve after prolonged contact withfoods at a pH greater than 6.• If patient opens capsules and sprinklescontents on food, assess for signs of sensitization(chest tightness, dyspnea, nasalcongestion, wheezing), which may resultfrom repeated inadvertent inhalation ofpowder.• Give drug before or with meals andsnacks, and follow with a glass of water orjuice.• Expect drug to cause stomatitis if held inmouth.• Check stool for fecal fat content, as ordered.• Monitor patient for iron deficiency anemiabecause serum iron level may declineduring pancrelipase therapy.PATIENT TEACHING• Instruct patient to take pancrelipase beforeor with meals and snacks and to followwith a glass of water or juice.• Instruct patient not to chew capsules (orcapsule contents) or crush tablets and toswallow immediately because drug maycause irritation if held in mouth.• Urge patient not to inhale powder fromdelayed-release capsules; doing so maycause chest tightness, shortness of breath,stuffy nose, trouble breathing, and wheezing.• Inform patient that sneezing and tearingalso may result from contact with powder.• Caution patient not to use antacids; theymay decrease drug effectiveness.• Inform patient that her stool may havefoul smell.pantoprazolesodiumPantoloc (CAN), ProtonixClass and CategoryChemical class: Substituted benzimidazoleTherapeutic class: Antiulcer, gastric acidproton pump inhibitorPregnancy category: B

Indications and Dosages To treat gastroesophageal reflux disease(GERD)DELAYED-RELEASE TABLETSAdults. 40 mg daily for up to 8 wk.Repeated for another 4 to 8 wk if healingdoesn’t occur.I.V. INFUSIONAdults. 40 mg daily infused over 2 min or15 min for 7 to 10 days, followed by oraldoses. To maintain healing of erosive esophagitisand reduce relapse of daytime andnighttime symptoms in patients withGERDDELAYED-RELEASE TABLETSAdults. 40 mg daily for up to 12 mo. To treat pathological hypersecretionassociated with Zollinger-Ellisonsyndrome or other neoplastic conditionsI.V. INFUSIONAdults. 80 mg every 12 hr infused over2 min or 15 min; adjusted based onpatient’s acid output measurements up to80 mg every 8 hr.Route Onset Peak DurationP.O. 1 day 1 wk 1 wkI.V. 1 day Unknown 1 wkMechanism of ActionInterferes with gastric acid secretion byinhibiting the hydrogen-potassiumadenosinetriphosphatase (H + -K + -ATPase)enzyme system, or proton pump, in gastricparietal cells. Normally, the proton pumpuses energy from hydrolysis of ATPase todrive H + and chloride (Cl – ) out of parietalcells and into the stomach lumen inexchange for potassium (K + ), which leavesthe stomach lumen and enters parietal cells.After this exchange, H + and Cl – combine inthe stomach to form hydrochloric acid(HCl). Pantoprazole irreversibly inhibits thefinal step in gastric acid production byblocking the exchange of intracellular H +and extracellular K + , thus preventing H +from entering the stomach and additionalHCl from forming.IncompatibilitiesMidazolam and products containing zincmay cause precipitation or discoloration.pantoprazole sodium 791ContraindicationsHypersensitivity to pantoprazole, substitutedbenzimidazoles (omeprazole, lansoprazole,rabeprazole sodium), or their componentsInteractionsDRUGSampicillin, cyanocobalamin, digoxin, ironsalts, ketoconazole: Possibly impairedabsorption of these drugsatazanavir: Significantly decreased atazanavirlevelwarfarin: Increased INR, PT, and bleedingriskAdverse ReactionsCNS: Anxiety, asthenia, confusion, dizziness,headache, hypertonia, hypokinesia,insomnia, malaise, migraine, speech disordervertigoCV: Chest pain, hypercholesterolemia,hyperlipidemiaEENT: Anterior ischemic optic neuropathy,blurred vision, increased salivation, pharyngitis,rhinitis, sinusitis, tinnitusENDO: HyperglycemiaGI: Abdominal pain, atrophic gastritis, constipation,diarrhea, elevated liver functiontests results, flatulence, gastroenteritis,hepatotoxicity, indigestion, nausea, pancreatitis,vomitingGU: Elevated serum creatinine level, interstitialnephritisHEME: PancytopeniaMS: Arthralgia, back or neck pain, rhabdomyolysisRESP: Bronchitis, dyspnea, increasedcough, upper respiratory tract infectionSKIN: Erythema multiforme, rash, Stevens-Johnson syndrome, toxic epidermal necrolysisOther: Anaphylaxis, angioedema, elevatedcreatine kinase and phosphokinase levels,flulike symptoms, generalized pain, hyperuricemia,infection, injection site reactionNursing Considerations• Ensure the continuity of gastric acid suppressionduring transition from oral toI.V. pantoprazole (or vice versa) becauseeven a brief interruption of effective suppressioncan lead to serious complications.• Don’t give pantoprazole within 4 weeks oftesting for Helicobacter pylori becauseP

792paricalcitolantibiotics, proton pump inhibitors, andbismuth preparations suppress H. pyloriand may lead to false-negative results.Drug also may cause false-positive resultsin urine screening tests for tetrahydrocannabinol.Consult guidelines for pantoprazoleuse before testing.• Flush I.V. line with D 5 W, normal salinesolution, or lactated Ringer’s injectionbefore and after giving drug.• When giving I.V. over 2 minutes, reconstitutewith 10 ml of normal saline injection.Solution may be stored up to 2 hours atroom temperature.• When giving I.V. over 15 minutes, reconstitutewith 10 ml normal saline injection.Then, further reconstitute with 100 ml(for GERD) or 80 ml (for pathologicalhypersecretion in Zollinger-Ellison syndrome)of D 5 W, normal saline injection,or lactated Ringer’s injection. Solutionmay be stored up to 2 hours before furtherdilution and up to 22 hours before use.• Expect to monitor PT or INR during therapyif patient takes an oral anticoagulant.• If therapy lasts more than 3 years, patientmay not be able to absorb vitamin B 12because of hypochlorhydria or achlorhydria.Treatment for cyanocobalamin deficiencymay be needed.PATIENT TEACHING• Instruct patient to swallow pantoprazoletablets whole and not to chew or crushthem.• Advise patient to expect relief of symptomswithin 2 weeks of starting therapy.• Advise patient who takes warfarin to followbleeding precautions and to notifyprescriber immediately if bleeding occurs.paricalcitolZemplarClass and CategoryChemical class: Sterol derivative, vitamin DanalogueTherapeutic class: AntihyperparathyroidPregnancy category: Not ratedIndications and Dosages To prevent and treat secondary hyperparathyroidismin patients with chronicrenal failure stage 3 or 4I.V. INJECTIONAdults. Initial: 0.04 to 0.1 mcg/kg (2.8 to7 mcg) no more than every other day at anytime during dialysis. Maintenance: If initialdosage doesn’t produce a satisfactoryresponse, 2 to 4 mcg given every 2 to 4 wk.Maximum: 0.24 mcg/kg/dose or up to16.8 mcg/dose.Children age 5 and over. Initial: 0.04 mcg/kg three times weekly if baseline intactparathyroid hormone (iPTH) level is lessthan 500 pg/ml, or 0.08 mcg/kg three timesweekly if baseline iPTH level equals orexceeds 500 pg/ml. Maintenance: If initialdosage isn’t adequate, adjust in 0.04-mcg/kgincrements as needed.DOSAGE ADJUSTMENT If serum PTH levelremains the same or increases, dosage isincreased. If PTH level decreases by lessthan 30%, dosage is increased. If PTH leveldecreases by 30% to 60%, dosage is maintained.If PTH level decreases by more than60%, dosage is decreased. If PTH level is1.5 to 3 times the upper limit of normal,dosage is maintained.DOSAGE ADJUSTMENT Dosage is immediatelyreduced or drug stopped if serum calciumlevel is elevated or serum calciumphosphorusproduct exceeds 75. Dosagerestarted at a lower dose when these levelsreturn to normal.CAPSULESAdults. Initial: If baseline iPTH level is lessthan 500 pg/ml, 1 mcg daily or 2 mcg threetimes weekly, doses separated by at least1 day. If iPTH level exceeds 500 pg/ml,2 mcg daily or 4 mcg three times weekly,doses separated by at least 1 day.Maintenance: Dosage adjusted in 1-mcgincrements based on iPTH level relative tobaseline.Route Onset Peak DurationI.V. Unknown Unknown 15 hrMechanism of ActionReduces serum PTH level by an unknownmechanism. In chronic renal failure,decreased renal synthesis of vitamin D leadsto chronic hypocalcemia. In response,parathyroid glands secrete PTH to stimulatevitamin D synthesis, but serum calciumlevels can’t normalize because of renal failure.

ContraindicationsEvidence of vitamin D toxicity, hypercalcemia,hypersensitivity to paricalcitol orcomponentsInteractionsDRUGSatazanavir, clarithromycin, indinavir, itraconazole,ketoconazole, nefazodone, nelfinavir,ritonavir, saquinavir, telithromycin,voriconazole: Increased effects of oral paricalcitoldrugs, such as cholestyramine, that impairabsorption of fat-soluble vitamins: Possiblyimpaired absorption of oral paricalcitolAdverse ReactionsCNS: Arthritis, asthenia, chills, depression,dizziness, fever, headache, insomnia, lightheadedness,malaise, neuropathy, syncope,vertigoCV: Cardiomyopathy, chest pain, congestiveheart failure, edema, hypertension,hypotension, MI, orthostatic hypotension,palpitationsEENT: Amblopia, bronchitis, dry mouth,epistaxis, laryngeal edema, pharyngitis, retinalabnormality, rhinitis, sinusitis, taste perversionENDO: HypoglycemiaGI: Abdominal pain, constipation, diarrhea,dyspepsia, gastritis, gastroenteritis, GIbleeding, nausea, vomitingGU: Abnormal kidney function, uremia, UTIMS: Back pain, leg cramps, myalgiaRESP: Increased cough, pneumoniaSKIN: Ecchymosis, hypertrophy, pruritus,rash (including vesiculobullous), ulceration,urticariaOther: Acidosis, allergic reaction, angioedema,dehydration, generalized edema, gout,hyperkalemia, hyperphosphatemia, hypervolemia,hypokalemia, infections, influenza,sepsisparoxetine 793Nursing Considerations• Before giving drug, look for particles anddiscoloration; if present, discard drug.• Give as I.V. bolus; discard unused portion.• Monitor serum calcium and phosphoruslevels, as ordered, twice weekly to guidedosage adjustments and then monthly.WARNING Paricalcitol may lead to vitaminD toxicity and hypercalcemia. Early evidenceincludes arthralgia, constipation,dry mouth, headache, metallic taste, myalgia,nausea, somnolence, vomiting, andweakness. Late evidence includes albuminuria,anorexia, arrhythmias, azotemia, conjunctivitis(calcific), decreased libido, elevatedBUN and serum ALT and AST levels,vascular calcification, hypercholesterolemia,hypertension, hyperthermia,irritability, mild acidosis, nephrocalcinosis,nocturia, pancreatitis, photophobia, polydipsia,polyuria, pruritus, rhinorrhea, andweight loss.• If toxicity occurs, notify prescriber immediatelyand expect to decrease or stopdrug. Place patient on bed rest and givefluids, low-calcium diet, and a laxative, asprescribed. If patient has a hypercalcemiccrisis and dehydration, expect to infusenormal saline solution and a loop diureticto prompt renal calcium excretion.• Expect to check patient’s serum PTH levelevery 3 months.• If patient also takes digoxin, monitor herfor evidence of digitalis glycoside toxicity,which is potentiated by hypercalcemia.• Store drug at 25° C (77° F).PATIENT TEACHING• Advise patient to follow a diet high in calciumand low in phosphorus.• Explain that phosphate binders may beneeded to control serum phosphorus level.• Review early evidence of hypercalcemiaand vitamin D toxicity. Tell patient to contactprescriber immediately if it develops.• Urge patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• If patient takes digoxin, explain evidenceof toxicity and the need to contact prescriberimmediately if it develops.paroxetinehydrochloridePaxil, Paxil CRparoxetine mesylatePexevaClass and CategoryChemical class: Phenylpiperidine derivativeTherapeutic class: Antidepressant, antiobsessional,antipanicPregnancy category: DP

794paroxetineIndications and Dosages To treat major depressionC.R. TABLETSAdults. Initial: 25 mg daily, increased asprescribed and tolerated by 12.5 mg dailyevery wk. Maximum: 62.5 mg daily.ORAL SUSPENSION, TABLETSAdults. Initial: 20 mg daily, increased asprescribed and tolerated by 10 mg dailyevery wk. Maximum: 50 mg daily. To treat obsessive-compulsive disorderORAL SUSPENSION, TABLETSAdults. Initial: 20 mg daily, increased asprescribed and tolerated by 10 mg dailyevery wk. Usual: 20 to 60 mg daily.Maximum: 60 mg daily. To treat panic disorderC.R. TABLETSAdults. Initial: 12.5 mg daily, increased by12.5 mg daily every wk as needed.Maximum: 75 mg daily.ORAL SUSPENSION, TABLETSAdults. Initial: 10 mg daily, increased asprescribed and tolerated by 10 mg dailyevery wk. Usual: 10 to 60 mg daily.Maximum: 60 mg daily. To treat social anxiety disorderC.R. TABLETSAdults. Initial: 12.5 mg daily, increased by12.5 mg daily every wk as needed.Maximum: 37.5 mg daily.ORAL SUSPENSION, TABLETS (HYDROCHLORIDE)Adults. Initial: 20 mg daily, increased asprescribed and tolerated by 10 mg dailyevery wk. Usual: 20 to 60 mg daily.Maximum: 60 mg daily. To treat generalized anxiety disorderORAL SUSPENSION, TABLETS (HYDROCHLORIDE)Adults. Initial: 20 mg daily, increased asprescribed and tolerated by 10 mg dailyevery wk. Usual: 20 to 50 mg daily.Maximum: 60 mg daily. To treat posttraumatic stress disorderORAL SUSPENSION, TABLETS (HYDROCHLORIDE)Adults. Initial: 20 mg daily, increased asprescribed and tolerated by 10 mg dailyevery wk. Usual: 20 to 50 mg daily.Maximum: 50 mg daily. To treat premenstrual dysphoric disorderC.R. TABLETSAdults. Initial: 12.5 mg daily in the morning,increased as needed after 1 wk to 25 mgdaily. Or, 12.5 mg daily in the morning onlyduring luteal phase of menstrual cycle (2-wkperiod before onset of monthly cycle),increased as needed after 1 wk to 25 mgdaily in the morning during luteal phase ofmenstrual cycle.DOSAGE ADJUSTMENT For patients who areelderly, debilitated, or have creatinine clearanceless than 30 ml/min/1.73 m 2 , initially10 mg daily; maximum, 40 mg daily. AvoidC.R. form. For patients taking C.R. tabletswith creatinine clearance less than 30 ml/min/1.73 m 2 , initially 12.5 mg daily; maximum,50 mg daily.Route Onset Peak DurationP.O. 1–4 wk Unknown UnknownMechanism of ActionExerts antidepressant, antiobsessional, andantipanic effects by potentiating serotoninactivity in CNS and inhibiting serotoninreuptake at presynaptic neuronal membrane.Blocked serotonin reuptake increaseslevels and prolongs activity of serotonin atsynaptic receptor sites.ContraindicationsHypersensitivity to paroxetine or its components,pimozide therapy, use within 14 daysof an MAO inhibitor, thioridazine therapyInteractionsDRUGSantacids: Hastened release of C.R. paroxetineaspirin, NSAIDs, warfarin: Increased anticoagulantactivity and risk of bleedingastemizole: Increased risk of arrhythmiasatomoxetine; risperidone; other drugs metabolizedby CYP2D6, such as amitriptyline,desipramine, fluoxetine, imipramine, phenothiazines,tamoxifen, type IC antiarrhythmics:Increased plasma levels of these drugsbarbiturates, primidone: Decreased bloodparoxetine levelcimetidine: Possibly increased bloodparoxetine levelcisapride, isoniazid, MAO inhibitors, procarbazine:Possibly serotonin syndromecodeine, haloperidol, metoprolol, perphenazine,propranolol, risperidone, thioridazine:Decreased metabolism and increasedeffects of these drugscyproheptadine: Decreased paroxetine effectsdextromethorphan: Decreased dextromethorphanmetabolism and increased risk

of toxicitydigoxin: Possibly decreased digoxin effectsencainide, flecainide, propafenone, quinidine:Potentiated toxicity of these drugsfosamprenavir, ritonavir: Decreased plasmaparoxetine levellithium: Possibly increased blood paroxetinelevel, increased risk of serotonin syndromemethadone: Decreased methadone metabolism,increased risk of adverse effectsphenytoin: Possibly phenytoin toxicitypimozide: Increased risk of prolonged QTintervalprocyclidine: Increased blood procyclidinelevel and anticholinergic effectsserotonergic drugs such as linezolid, St. John’swort, tramadol, triptans, and tryptophan:Increased risk of serotonin syndrometamoxifen: Decreased tamoxifen effectivenesstheophylline: Possibly increased blood theophyllinelevel and risk of toxicitythioridazine: Increased thioridazine level,possibly leading to prolonged QT intervaland life-threatening ventricular arrhythmiastramadol: Increased risk of serotonin syndromeand seizurestricyclic antidepressants: Increased metabolismand blood antidepressant levels;increased risk of toxicity, including seizuresAdverse ReactionsCNS: Agitation, akathisia, asthenia, confusion,decreased concentration, dizziness,drowsiness, emotional lability, hallucinations,headache, insomnia, mania, neurolepticmalignant syndrome, psychomotoragitation, restlessness, serotonin syndrome,somnolence, suicidal ideation, tremorCV: Palpitations, tachycardiaEENT: Blurred vision, dry mouth, rhinitis,taste perversionGI: Abdominal cramps or pain, anorexia,constipation, diarrhea, flatulence, nausea,vomitingGU: Decreased libido, difficult ejaculation,impotence, sexual dysfunction, urine retentionMS: Back pain, myalgia, myasthenia,myopathySKIN: Diaphoresis, rashOther: Weight gain or lossNursing Considerations• Shake oral suspension well. Measure withan oral syringe or calibrated device.paroxetine 795• Don’t give enteric-coated form withantacids.• Watch for akathisia (inner sense of restlessness)and psychomotor agitation, especiallyduring the first few weeks of therapy.• Watch patient closely (especially children,adolescents, and young adults), for suicidaltendencies, particularly when therapystarts and dosage changes, because depressionmay worsen temporarily during thesetimes, possibly leading to suicidal ideation.• Watch for mania, which may result fromany antidepressant in a susceptible patient.• Monitor patient closely for evidence of GIbleeding, especially if patient also takes adrug known to cause GI bleeding, such asaspirin, an NSAID, or warfarin.WARNING Monitor patient closely for serotoninsyndrome exhibited by agitation,hallucinations, coma, tachycardia, labileblood pressure, hyperthermia, hyperreflexia,incoordination, nausea, vomiting, ordiarrhea. Notify prescriber immediatelybecause serotonin syndrome may be lifethreatening,and provide supportive care.WARNING Be aware that serotonin syndromein its most severe form may resembleneuroleptic malignant syndrome,which includes hyperthermia, musclerigidity, and autonomic instability withpossibly rapid changes in vital signs andmental status. Stop drug immediately, andprovide supportive care.• To minimize adverse reactions, expect totaper drug rather than stopping abruptly.PATIENT TEACHING• Advise patient to take paroxetine in themorning to minimize insomnia and totake it with food if adverse GI reactionsdevelop.• Instruct patient to avoid taking C.R.paroxetine within 2 hours of an antacid.• Tell patient to swallow C.R. tablets wholeand not to cut, crush, or chew them.• Suggest that patient avoid hazardous activitiesuntil drug’s CNS effects are known.• Tell family or caregiver to observe patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes andespecially if patient is a child, teenager, oryoung adult.• Explain that full effect may take 4 weeks.• Urge patient to avoid alcohol during therapy;effects with paroxetine are unknown.P

796pegfilgrastim• Tell patient not to take aspirin or NSAIDsduring therapy because they increase therisk of bleeding. If patient takes warfarin,tell her to use bleeding precautions and tonotify prescriber at once if bleedingoccurs.• Inform patient that episodes of acutedepression may persist for months orlonger and that they require continuedfollow-up.• Instruct patient not to stop drug abruptlybut to taper dosage as instructed.• Alert female patients of childbearing agethat paroxetine may cause birth defectsand persistent pulmonary hypertension inthe newborn if taken during the firsttrimester of pregnancy. Stress the need foreffective contraception and to notify prescriberif pregnancy occurs or is suspected.• Caution patient to alert all prescribersabout paroxetine therapy because ofpotentially serious drug interactions.pegfilgrastimNeulastaClass and CategoryChemical class: Recombinant granulocytecolony-stimulating factor conjugateTherapeutic class: Antineutropenic,hematopoietic stimulatorPregnancy category: CIndications and Dosages To reduce the risk of infection, as manifestedby febrile neutropenia, after myelosuppressivechemotherapySUBCUTANEOUS INJECTIONAdults. 6 mg with each chemotherapy cycle.Mechanism of ActionInduces formation of neutrophil progenitorcells by binding to receptors on granulocytes,which then divide. Pegfilgrastim alsopotentiates the effects of mature neutrophils,thus reducing fever and the risk ofinfection from severe neutropenia. It ispharmacologically identical to human granulocytecolony-stimulating factor.ContraindicationsHypersensitivity to filgrastim, pegfilgrastim,or their components or to proteins derivedfrom Escherichia coliInteractionsDRUGSlithium: Increased neutrophil productionAdverse ReactionsCNS: FeverGI: Elevated liver function test results,splenic rupture, splenomegalyGU: Elevated uric acid levelHEME: Leukocytosis, sickle cell crisisMS: Bone painRESP: Acute respiratory distress syndrome,dyspnea, hypoxia, pulmonary infiltratesSKIN: Acute febrile neutrophilic dermatosis(Sweet’s syndrome), erythema, flushing,rash, urticariaOther: Anaphylaxis, angioedema, antibodyformation to pegfilgrastim, injection sitereactions (pain, induration, erythema)Nursing Considerations• Avoid giving pegfilgrastim for 14 daysbefore and 24 hours after cytotoxicchemotherapy.• Check CBC, hematocrit, and plateletcount before and periodically during therapy.• Let drug warm to room temperaturebefore injection. Use prefilled syringe andneedles.• Don’t shake the solution.• Discard drug that contains particles, is discolored,or was stored more than 48 hoursat room temperature.WARNING If signs of allergy occur, stoppegfilgrastim infusion and notify prescriberat once. If anaphylaxis occurs, giveantihistamine, epinephrine, corticosteroid,and bronchodilator, as ordered.WARNING Patients receiving filgrastim (parentdrug) have had splenic rupture andacute respiratory distress syndrome. Assesspatient for fever, respiratory distress, andupper abdominal or shoulder tip pain.• Assess patients with sickle cell disease forsigns of sickle cell crisis; urge hydration.• Give nonopioid and opioid analgesics, asordered, if patient experiences bone pain.• Store drug at 2° to 8° C (36° to 46° F), andprotect from freezing and light.• Be aware that needle cover contains drynatural rubber and should not be handledby persons with a latex allergy.PATIENT TEACHING• Urge patient to promptly report possibly

serious reactions (trouble breathing, rash,chest tightness, left upper abdominal pain,shoulder tip pain) and evidence of infection(fever, chills).• If patient will self-administer, teach herhow to prepare, give, and store drug.• Alert her that needle cover contains drynatural rubber and should not be handledif she has a latex allergy.• Tell patient to rotate injection sites amongthigh, abdomen (except for 2 inchesaround navel), buttocks, and outer, upperarms. Caution her to avoid tender, hard,red, or bruised areas.• Urge patient to discard used needles andsyringes in a puncture-resistant containerand not to reuse them.• Stress the importance of follow-up tests.• Advise patient to store pegfilgrastim inrefrigerator and not to freeze it. Tell her todiscard drug if left unrefrigerated for morethan 48 hours.pegvisomantSomavertClass and CategoryChemical class: Human growth hormone(GH) receptor antagonistTherapeutic class: Growth suppressantPregnancy category: BIndications and Dosages To treat acromegaly in patients with aninadequate response to surgery, radiation,or other medical treatment or forwhom such treatment is inappropriateSUBCUTANEOUS INJECTIONAdults. Initial: 40 mg as loading dose onday 1; then 10 mg daily. Maintenance:Adjusted every 4 to 6 wk in 5-mg incrementsif insulin-like growth factor-I (IGF-I)levels are abnormal. Maximum: 30 mgdaily.ContraindicationsHypersensitivity to pegvisomant, its components,or latexInteractionsDRUGSinsulin, oral antidiabetics: Enhanced actionof insulin and oral antidiabetics, possiblyNursing Considerations• Obtain liver enzyme levels before startingpegvisomant, as ordered. If they’re elevatedbut 3 times or less normal, expect tomonitor them monthly for 6 months,quarterly for 6 months, and then twiceyearly for the next year. If they’re morethan 3 times normal, expect to withholddrug until the cause of elevation has beendetermined.• Reconstitute drug by injecting 1 ml ofdiluent provided (sterile water for injection)into vial, aiming the stream againstvial wall. Hold vial between the palms ofboth hands and roll gently to dissolvepowder. Don’t shake. Give within 6 hoursof reconstitution, and discard any remainingamount.• Watch for evidence of liver dysfunctionduring therapy. If liver enzyme levels riseto 3 to 5 times normal but patient has noevidence of liver dysfunction (jaundice,bilirubinuria, fatigue, nausea, vomiting,right-upper-quadrant pain, ascites, unexplainededema, easy bruising) or increasesin serum total bilirubin level, expect therapyto continue but liver enzymes to bemonitored weekly and a complete hepaticworkup to be done. If enzyme levels are atleast 5 times above normal or transaminaselevel is at least 3 times above normalwith increased total bilirubin (with orwithout evidence of hepatic dysfunction),notify prescriber immediately and expectto stop drug. If patient develops evidenceof hepatic dysfunction, regardless of liverenzyme levels, notify prescriber immediately,and expect a complete liver workupto be performed. If liver damage is conpegvisomant797resulting in hypoglycemiaopioids: Decreased pegvisomant levelAdverse ReactionsCNS: Dizziness, paresthesiaCV: Chest pain, hypertension, peripheraledemaEENT: Ear infection, sinusitisGI: Diarrhea, elevated liver function testresults, nauseaMS: Back painRESP: Upper respiratory tract infectionSKIN: BlistersOther: Cold, flulike symptoms, injectionsite lipohypertrophy and pain, weight gainP

GHGH798penbutolol sulfateMechanism of ActionIn acromegaly, elevated blood levels ofgrowth hormone (GH) overstimulate theliver to produce excessive amounts ofinsulin-like growth factors (IGFs), such asIGF-1. Excessive IGFs before pubertystimulate the linear growth of bones,causing the patient’s unusual height andextremely long arms and legs. Afterpuberty, the excessive hormone secretioncauses periosteal bone proliferation,resulting in widening of the hands andfeet, and coarsening of the facial features,as well as other complications.Pegvisomant selectively blocks GHcell surface receptors. As a result, the liverdelivers less IGF-1 and other proteins tothe blood, preventing the overgrowth ofbone and other tissues.Blood Blood vessel vesselIGF-1IGF-1IGF-1IGF-1IGF-1IGF-1IGF-1IGF-1IGF-1IGF-1IGF-1IGF-1GHGHBlood Blood stream streamBlood Blood vessel vesselIGF-1IGF-1IGF-1IGF-1Blood streamBlood streamPegvisomantGH GHGH GH receptorsCell CellmembraneGH GHGH GH receptorsCell Cellmembranefirmed, expect drug to be stopped.• Monitor patient’s IGF-1 levels every 4 to6 weeks, as ordered, until they’ve normalizedand then every 6 months. Notify prescriberif levels are decreased or elevated.Be aware that GH levels should not beused to make dosage adjustments becausepegvisomant interferes with laboratorymeasurement of GH.PATIENT TEACHING• Teach patient how to reconstitute andadminister pegvisomant.• Tell patient about the need for frequentlaboratory studies and their importance toproperly adjust drug dosage and detectdrug-related abnormalities.• Advise patient to stop drug immediatelyand notify prescriber if her skin or whitesof her eyes become yellow or she has otherevidence of liver dysfunction, such as darkurine, light-colored stools, little or noappetite for several days, nausea, tiredness,or abdominal pain.• Instruct woman of childbearing age toreport known or suspected pregnancy.• Caution patient to tell prescriber about allother drugs she’s taking.penbutolol sulfateLevatolClass and CategoryChemical class: Nonselective betaadrenergicblockerTherapeutic class: AntihypertensivePregnancy category: Not ratedIndications and Dosages To manage hypertensionTABLETSAdults. 20 mg daily.DOSAGE ADJUSTMENT For elderly patients,dosage individualized according to sensitivityto drug.Route Onset Peak DurationP.O. Unknown 1.5–3 hr UnknownMechanism of ActionMay reduce blood pressure by competingwith beta-adrenergic receptor agonists,which helps reduce cardiac output, decreasesympathetic outflow to peripheral blood

vessels, and inhibit renin release by kidneys.ContraindicationsAsthma, bradycardia (fewer than 45 beats/min), cardiogenic shock, heart failure,hypersensitivity to penbutolol or its components,second- or third-degree AV blockInteractionsDRUGSallergen immunotherapy, allergenic extractsfor skin testing: Increased risk of serious systemicreaction or anaphylaxisamiodarone: Additive depressant effect oncardiac conduction, negative inotropiceffectsanesthetics (hydrocarbon inhalation):Increased risk of myocardial depression andhypotensioncalcium channel blockers, clonidine, diazoxide,guanabenz, other hypotension-producingdrugs, reserpine: Additive hypotension andpossibly other beta blocker effectscimetidine: Possibly increased blood penbutolollevelestrogens: Decreased antihypertensive effectof penbutololfentanyl and its derivatives: Possiblyincreased risk of initial bradycardia afterinduction doses of fentanyl derivative (withlong-term penbutolol use)insulin, oral antidiabetic drugs: Possiblyimpaired glucose control and masking ofhypoglycemia symptoms such as tachycardialidocaine: Decreased lidocaine clearance,increased risk of lidocaine toxicityMAO inhibitors: Increased risk of significanthypertensionneuromuscular blockers: Possibly potentiatedand prolonged action of these drugsNSAIDs: Possibly decreased hypotensiveeffect of penbutololother beta blockers: Additive beta blockereffectsphenothiazines: Increased blood levels ofboth drugsphenytoin (parenteral): Additive cardiacdepressant effectssympathomimetics, xanthines: Possiblyinhibited effects of penbutolol and thesedrugspenbutolol sulfate 799Adverse ReactionsCNS: Anxiety, depression, dizziness, drowsiness,fatigue, insomnia, light-headedness,nervousness, syncope, weaknessCV: Bradycardia, chest pain, edema, peripheralvascular insufficiencyEENT: Nasal congestionGI: Constipation, diarrhea, epigastric pain,nausea, vomitingGU: ImpotenceRESP: Bronchospasm, dyspneaNursing Considerations• Expect varied drug effectiveness in elderlypatients, who may be more sensitive toantihypertensive effects because ofreduced drug clearance by kidneys.WARNING Avoid stopping penbutololabruptly because doing so may precipitateMI, myocardial ischemia, severe hypertension,or ventricular arrhythmias, particularlyin patients with cardiovascular disease.Watch for tachycardia because drugalso may mask some signs of hyperthyroidism.Abrupt withdrawal of drug inpatients with hyperthyroidism or thyrotoxicosiscan precipitate thyroid storm.• Monitor blood pressure and cardiac output,as appropriate, in patients who have ahistory of systolic heart failure or left ventriculardysfunction. Drug’s negative inotropiceffect can depress cardiac output.• Monitor patients with diabetes mellituswho take antidiabetics because penbutololcan prolong hypoglycemia or promotehyperglycemia. It also can mask evidenceof hypoglycemia, especially tachycardia,palpitations, and tremor.• Watch for impaired circulation in elderlypatients with age-related peripheral vasculardisease or patients with Raynaud’s phenomenon.Elderly patients are also atincreased risk for beta blocker–inducedhypothermia.• Monitor drug refill frequency to helpdetermine patient compliance.PATIENT TEACHING• Instruct patient to take penbutolol at thesame time every day and not to changedosage without consulting prescriber.• Advise patient not to stop taking drugabruptly, but to taper dosage graduallyunder prescriber’s supervision.• Instruct patient with diabetes mellitus toregularly monitor blood glucose level andtest urine for ketones.P

800penicillamine• Advise patient to consult prescriber beforetaking OTC drugs, especially cold products.• Urge patient to avoid hazardous activitiesuntil CNS effects of drug are known.• Instruct patient to inform prescriber ofchest pain, fainting, light-headedness, orshortness of breath, any of which mayindicate the need for a dosage change.• Inform patient that penbutolol doesn’tcure hypertension. Encourage her to followrecommended diet and lifestylechanges.penicillamineCuprimine, DepenClass and CategoryChemical class: Degradation product ofpenicillinTherapeutic class: Antirheumatic, antiurolithic,chelating agentPregnancy category: DIndications and Dosages To treat cystinuriaCAPSULES, TABLETSAdults and adolescents. 500 mg q.i.d.Children. 7.5 mg/kg q.i.d. To treat rheumatoid arthritisCAPSULES, TABLETSAdults and adolescents. Initial: 125 or250 mg daily. Dosage increased by 125 or250 mg daily every 2 to 3 mo. Maximum:1,500 mg daily. To treat Wilson’s diseaseCAPSULES, TABLETSAdults and adolescents. Dosage individualizedup to 2 g daily in divided doses q.i.d.by measuring urinary copper excretion.DOSAGE ADJUSTMENT For elderly patients,125 mg daily initially, then increased by125 mg daily every 2 to 3 mo, up to maximumof 750 mg daily. For pregnantwomen, maximum dose of 1 g daily. Forwomen having planned cesarean section,dosage limited to 250 mg daily during last6 wk of pregnancy and until wound healingcompleted.Mechanism of ActionCombines with copper to form a ringshapedcomplex that’s excreted in urine,thereby reducing copper levels in the body.Penicillamine also lowers urine cystine levelsby binding with cystine to form penicillamine-cysteinedisulfide, which is moresoluble than cystine and more easily excretedin urine. The decrease in urine cystinelevel also helps prevent formation of cystinecalculi and may help existing cystine calculidissolve over time. In addition, penicillamineimproves lymphocyte function byreducing IgM rheumatoid factor andimmune complexes in serum and synovialfluid, which may play a role in treatment ofrheumatoid arthritis.Route Onset Peak DurationP.O. 2–3 mo* Unknown UnknownContraindicationsHypersensitivity to penicillin, penicillamine,or their components; penicillaminerelatedaplastic anemia or agranulocytosis;renal insufficiency (for patients withrheumatoid arthritis)InteractionsDRUGS4-aminoquinolines, bone marrow depressants,gold compounds, immunosuppressants(excluding glucocorticoids), phenylbutazone:Possibly increased risk of serious hematologicor renal adverse reactionsiron supplements: Possibly decreased effectivenessof penicillaminepyridoxine: Decreased effectiveness of pyridoxine,possibly increased risk of anemia orperipheral neuritis reactionAdverse ReactionsCNS: Agitation, anxiety, fever, mentalchanges, myasthenic syndrome, neuropathyEENT: Altered or loss of taste, optic neuritis,stomatitis, tinnitusGI: Anorexia, diarrhea, hepatic dysfunction,intrahepatic cholestasis, mild epigastricpain, pancreatitis, nausea, toxic hepatitis,vomitingGU: Glomerulonephropathy, hematuria,proteinuria, renal failureHEME: Agranulocytosis, aplastic anemia,hemolytic anemia, leukopenia, thrombocytopeniaMS: Arthralgia, dystonia, muscle weakness* For rheumatoid arthritis; 1 to 3 mo forWilson’s disease.

SKIN: Pemphigus, pruritus, rash, urticariaOther: Lupuslike symptoms, lymphadenopathyNursing Considerations• Use penicillamine cautiously in elderlypatients because they’re at greater risk forrash, altered taste, and renal impairment.• Give penicillamine 1 hour before or 2 hoursafter meals and at least 1 hour before orafter any other drug, food, or milk. Givelast dose of day at least 3 hours afterevening meal to maximize absorption.• For patient who has difficulty swallowingcapsules or tablets, open capsule and mixcontents in 15 to 30 ml of pureed fruit orfruit juice to mask drug’s sulfur odor.Alternatively, ask pharmacist to prepareelixir for oral administration.• Expect to give 25 mg pyridoxine, as prescribed,to patients receiving penicillaminebecause penicillamine increases intakerequirements for this vitamin.• Watch for febrile reactions in patients whodeveloped a fever during previous penicillaminetherapy. Expect to stop drug ifpatient develops drug-induced fever.• Assess skin and mucous membranes forpossible sensitivity reactions, such as skinlesions and mouth ulcers. Be prepared todiscontinue drug as prescribed.• Expect to monitor urine laboratory testresults twice weekly during first month oftherapy, then every 2 weeks for next5 months, and monthly thereafter. Watchfor proteinuria or hematuria, which mayprecipitate nephrotic syndrome, especiallyin patients with renal disease or history ofrenal insufficiency. Also, weigh patientdaily, watch for edema, and monitorintake and output because penicillaminemay worsen underlying renal disease.WARNING Monitor patient’s WBC and differentialcell count, hemoglobin, andplatelet count, as ordered, and assess skin,lymph nodes, and body temperature forabnormalities twice weekly during firstmonth of therapy, then every 2 weeks fornext 5 months, and monthly thereafterbecause drug may cause potentially serioushematologic reactions.• Because of the potential for cross-sensitivitybetween penicillamine and penicillin,monitor for allergic reaction in patientspenicillamine 801with a history of penicillin allergy.• Notify prescriber if patient reportsdecreased sense of taste, especially for saltyand sweet foods. Expect normal taste sensationto be restored (except in patientswith Wilson’s disease) by giving of 5 to10 mg of copper a day, as prescribed.• Monitor patients with diabetes mellitusfor reduced insulin requirements to preventrisk of nighttime hypoglycemiabecause penicillamine may promote formationof anti-insulin antibodies.• Check liver function tests, as ordered,every 6 months (every 3 months for firstyear if patient has Wilson’s disease) duringpenacillamine therapy because drug maycause serious hepatic dysfunction.PATIENT TEACHING• Advise patient to take penicillamine on anempty stomach.• Instruct men and nonpregnant womenwith cystinuria to increase fluid intake andfollow prescribed low-methionine diet tominimize cystine production and enhancedrug’s effectiveness. Urge patient to drinkabout 1 pint of fluid at bedtime and againduring the night because this is whenurine is more concentrated.• Tell patient to notify prescriber immediatelyif he develops a fever, sore throat,chills, bruising, or bleeding because drugmay need to be stopped.• Instruct patient being treated for Wilson’sdisease to follow a diet low in copper,avoiding such foods as broccoli, chocolate,copper-enriched cereals, liver, molasses,mushrooms, nuts, and shellfish. Informher that it may take 1 to 3 months of therapyfor her condition to improve.• Advise patient to consult prescriber beforehaving dental work done during penicillaminetherapy because drug can promotemouth ulcers.• Instruct patient to avoid consuming ironduring penicillamine therapy because ironcan decrease drug’s effectiveness.• Explain that sense of taste may decreaseduring penicillamine therapy. Advisepatient to notify prescriber if it becomesintolerable.• Inform patient with rheumatoid arthritisthat improvement may take 2 to 3 monthsof therapy.• Caution female patient to notify prescriberP

802penicillinimmediately if she becomes or may bepregnant because dosage may need to bereduced to prevent serious birth defects.penicillin GbenzathineBicillin C-R, Bicillin C-R 900/300,Bicillin L-A, Megacillin (CAN),Permapenpenicillin GpotassiumMegacillin (CAN), Pentids, Pfizerpenpenicillin GprocaineAyercillin (CAN), Crysticillin 300 AS,Pfizerpen-AS, Wycillinpenicillin Gsodiumpenicillin VpotassiumApo-Pen-VK (CAN), Beepen-VK,Betapen-VK, Ledercillin VK,Nadopen-V 200 (CAN), Nadopen-V 400(CAN), Novo-Pen-VK (CAN), Nu-Pen VK(CAN), Pen Vee ( CAN), Pen Vee K,V-Cillin K (CAN), VeetidsClass and CategoryChemical class: PenicillinTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat systemic infections caused bygram-positive organisms (includingBacillus anthracis, Corynebacteriumdiphtheriae, enterococci, Listeria monocytogenes,Staphylococcus aureus, andS. epidermidis), gram-negative organisms(including Neisseria gonorrhoeae,N. meningitidis, Pasteurella multocida,and Streptobacillus moniliformis [ratbitefever]), and gram-positive anaerobes(including Actinomyces israelii[actinomycosis], Clostridium perfringens,C. tetani, Peptococcus species,Peptostreptococcus species, and spirochetes,especially Treponema carateum[pinta], T. pallidum, and T. pertenue[yaws])ORAL SOLUTION, TABLETS (PENICILLIN GPOTASSIUM)Adults and adolescents. 200,000 to500,000 units (125 to 312 mg) every 4 to6hr.Maximum: 2 million units daily.Children. 4,167 to 15,000 units/kg every4 hr, 6,250 to 22,500 units/kg every 6 hr, or8,333 to 30,000 units/kg every 8 hr.TABLETS (PENICILLIN V POTASSIUM)Adults and adolescents. 200,000 to800,000 units (125 to 500 mg) every 6 to8hr.Maximum: 11,520,000 units(7,200 mg) dailyChildren. 4,167 to 13,280 units (2.5 to8.3 mg)/kg every 4 hr, 6,250 to 20,000 units(3.75 to 12.5 mg)/kg every 6 hr, or 8,333 to26,720 units (5 to 16.7 mg)/kg every 8 hr.I.V. INFUSION, I.M. INJECTION (PENICILLIN GPOTASSIUM, PENICILLIN G SODIUM)Adults and adolescents. 1 to 5 millionunits every 4 to 6 hr. Maximum: 80 millionunits daily.Children. 8,333 to 16,667 units/kg every4 hr or 12,500 to 25,000 units/kg every 6 hr.Premature and full-term neonates.30,000 units/kg every 12 hr.I.M. INJECTION (PENICILLIN G PROCAINE)Adults and adolescents. 600,000 to1,200,000 units daily in divided doses every12 to 24 hr. To treat moderately severe to severestreptococcal infectionsI.M. INJECTION (PENICILLIN G BENZATHINE)Adults and children weighing more than45 kg (100 lb). 1.2 million units as a singleinjection.Children weighing 27 to 45 kg (59 to100 lb). 900,000 units as a single injection.Children weighing less than 27 kg.300,000 to 600,000 units as single injection. To treat congenital syphilisI.M. INJECTION (PENICILLIN G BENZATHINE:BICILLIN L-A ONLY)Children under age 2. 50,000 units/kg as asingle injection. To treat syphilis of less than 1 year’sdurationI.M. INJECTION (PENICILLIN G BENZATHINE:

BICILLIN L-A ONLY)Adults and adolescents. 2.4 million units asa single injection.Children. 50,000 units/kg up to adultdosage as a single injection. Maximum:2.4 million units/dose. To treat syphilis of more than 1 year’sdurationI.M. INJECTION (PENICILLIN G BENZATHINE:BICILLIN L-A ONLY)Adults and adolescents. 2.4 million unitsevery wk for 3 wk.Children. 50,000 units/kg every wk for3wk. To treat bacterial meningitisI.V. INFUSION, I.M. INJECTION (PENICILLIN GPOTASSIUM)Adults. 50,000 units/kg every 4 hr or24 million units daily in divided doses every2 to 4 hr.Mechanism of ActionInhibits final stage of bacterial cell wallsynthesis by competitively binding topenicillin-binding proteins inside the cellwall. Penicillin-binding proteins are responsiblefor various steps in bacterial cell wallsynthesis. By binding to these proteins,penicillin leads to cell wall lysis.IncompatibilitiesDon’t mix any penicillin in the samesyringe or container with aminoglycosidesbecause aminoglycosides will be inactivated.Don’t mix penicillin G with drugs thatmay result in a pH below 5.5 or above 8.ContraindicationsHypersensitivity to penicillin or its componentsInteractionsDRUGSACE inhibitors, potassium-containing drugs,potassium-sparing diuretics: Increased riskof hyperkalemia (penicillin G potassium)chloramphenicol, erythromycin, sulfonamides,tetracycline, thrombolytics: Possiblyinterference with penicillin’s bactericidaleffectcholestyramine, colestipol: Possibly impairedabsorption of oral penicillin Gmethotrexate: Decreased methotrexateclearance, increased risk of toxicityoral contraceptives: Decreased contraceptiveeffectiveness (with penicillin V)penicillin 803probenecid: Increased blood penicillin levelFOODSacidic beverages, such as fruit juices: Possiblyaltered effects of oral penicillin GAdverse ReactionsCNS: Confusion, dizziness, dysphasia, hallucinations,headache, lethargy, sciatic nerveirritation, seizuresCV: Labile blood pressure, palpitationsEENT: Black “hairy” tongue, oral candidiasis,stomatitis, taste perversionGI: Abdominal pain, diarrhea, elevated liverfunction test results (transient), indigestion,nausea, pseudomembranous colitisGU: Interstitial nephritis (acute), vaginalcandidiasisMS: Muscle twitchingSKIN: RashOther: Electrolyte imbalances; injection sitenecrosis, pain, or rednessNursing Considerations• Obtain body tissue and fluid samples forculture and sensitivity tests as orderedbefore giving first dose. Expect to begindrug therapy before test results are known.• Reconstitute vials of penicillin for injectionwith sterile water for injection, D 5 W,or sodium chloride for injection.• Administer penicillin at least 1 hourbefore other antibiotics.• Inject I.M. form deep into large musclemass. Apply ice to relieve pain.WARNING Give penicillin G benzathine andpenicillin G procaine only by deep I.M.injection; I.V. injection may be fatal, andintra-arterial injection may cause extensivetissue and organ necrosis.• Be aware that I.M. drug is absorbed slowly,which may make allergic reactions difficultto treat.• Assess patient for signs of secondary infection,such as profuse, watery diarrhea. Ifsuch diarrhea develops, contact prescriberand expect to obtain a stool specimen torule out pseudomembranous colitiscaused by Clostridium difficile. If diarrheaoccurs, notify prescriber and expect towithhold pencillin and treat with fluids,electrolytes, protein, and an antibioticeffective against C. difficile.• Monitor serum sodium level and assess forearly signs of heart failure in patientsreceiving high doses of penicillin G sodium.P

804pentamidine isethionate• When giving penicillin G potassium topatient at risk for hypertension or fluidoverload, be aware that each gram of pencillinG potassium also contains 1.02 mEqof sodium.PATIENT TEACHING• Instruct patient to report previous allergiesto penicillins and to notify prescriberimmediately about adverse reactions,including fever.• Advise patient who uses oral contraceptivesto use an additional form of contraceptionduring penicillin V therapy.• Urge patient to tell prescriber if diarrheadevelops, even 2 months or more afterpenicillin therapy ends.pentamidineisethionateNebuPent, Pentacarinat (CAN), Pentam300, Pneumopent (CAN)Class and CategoryChemical class: Diamidine derivativeTherapeutic class: AntiprotozoalPregnancy category: CIndications and Dosages To prevent Pneumocystis jiroveci(carinii) pneumoniaORAL INHALATION (NEBUPENT, PENTACARINAT)Adults and adolescents. 300 mg every 4 wkor 150 mg every 2 wk, using nebulizer andcontinuing until chamber is empty (30 to45 min).ORAL INHALATION (PNEUMOPENT)Adults and adolescents. Initial: 60 mgevery 24 to 72 hr for 5 doses over 2 wk,using ultrasonic nebulizer and continuinguntil nebulizer chamber is empty (about15 min). Maintenance: 60 mg every 2 wk,using ultrasonic nebulizer and continuinguntil nebulizer chamber is empty. To treat P. jiroveci (carinii) pneumoniaI.V. INFUSION, I.M. INJECTIONAdults and children. 4 mg/kg daily for14 to 21 days, given deep I.M. or by I.V.infusion over 1 to 2 hr.DOSAGE ADJUSTMENT Dosage possiblyreduced or I.V. infusion time or dosinginterval extended for patients with renalfailure.Mechanism of ActionMay bind to DNA and inhibit DNAreplication in Pneumocystis jiroveci (carinii).Pentamidine also may inhibit dihydrofolatereductase, an enzyme needed to convertdihydrofolic acid to tetrahydrofolic acid inthis organism. This action inhibits formationof coenzymes essential to growth andreplication of P. jiroveci.IncompatibilitiesDon’t mix pentamidine with other drugs orwith saline solutions because precipitationmay occur.ContraindicationsHistory of anaphylactic reaction to pentamidineor its components (inhalationform)InteractionsDRUGSbone marrow depressants, drugs that causeblood dyscrasias: Increased risk of adversehematologic effectsdidanosine: Increased risk of pancreatitiserythromycin (I.V.): Increased risk of torsadesde pointesfoscarnet: Increased risk of severe butreversible hypocalcemia, hypomagnesemia,and nephrotoxicitynephrotoxic drugs: Increased risk of nephrotoxicityAdverse ReactionsCNS: Chills, confusion, dizziness, fatigue,fever, hallucinations, headache (I.V., I.M.forms)CV: Arrhythmias, edema, hypotension, prolongedQT interval, torsades de pointes,ventricular tachycardia (I.V., I.M. forms)EENT: Bitter or metallic taste (all forms),pharyngitis (inhalation form)ENDO: Diabetes mellitus, hyperglycemia(I.V., I.M. forms); hypoglycemia (all forms)GI: Abdominal pain, anorexia, diarrhea,elevated liver function test results, nausea,vomiting (I.V., I.M. forms); pancreatitis (allforms)GU: Elevated serum creatinine level (I.V.,I.M. forms); renal insufficiency (inhalationform)HEME: Anemia, leukopenia, thrombocytopenia,unusual bleeding or bruising (I.V.,I.M. forms)MS: Myalgia (I.V., I.M. forms)

RESP: Bronchospasm, chest pain or congestion,cough, dyspnea, extrapulmonarypneumocystosis, pneumothorax (inhalationform)SKIN: Night sweats (I.V., I.M. forms); rash(all forms)Other: Hyperchloremic acidosis; hyperkalemia;hypocalcemia; hypomagnesemia; infusionsite sterile abscess (I.V. form); injectionsite induration, pain, and phlebitis (I.M.form)pentazocine lactate 805Nursing Considerations• Store pentamidine at room temperature,protected from light. Use within 24 hoursafter reconstitution.• For I.V. use, dissolve contents of 300-mgvial with 3 to 5 ml sterile water for injectionor D 5 W. Further dilute in 50 to250 ml D 5 W and infuse over 1 to 2 hours.• For I.M. use, dissolve contents of vial in3 ml sterile water for injection and injectdeep into large muscle mass. Be aware thatI.M. administration increases risk of sterileabscess formation at injection site.• When giving drug I.V. or I.M., keeppatient supine and monitor blood pressurefrequently during and after administration.Keep emergency resuscitationequipment readily available.• Assess for hypoglycemia and arrhythmiasin patient receiving I.V. or I.M. pentamidine.Although uncommon, these adversereactions can be severe.• For inhalation, reconstitute contents ofvial with 6 ml sterile water for injection(NebuPent or Pentacarinat) or 3 to 5 mlsterile water for injection or inhalation(Pneumopent). Reconstitute immediatelybefore use. Don’t use normal saline solutionbecause it causes precipitation. Placereconstituted drug in Respirgard II nebulizer,and set flow rate at 5 to 7 L/min forNebuPent or Pentacarinat. Don’t mix withother drugs. For Pneumopent, placereconstituted drug in Fisoneb ultrasonicnebulizer and set flow rate at mid-flowmark.• Administer aerosolized pentamidine withpatient in supine or recumbent positionfor best distribution of drug.• If patient who uses inhalation form has ahistory of asthma or smoking, notify prescriberif bronchospasm or a cough develops.She may need an aerosolized bronchodilatorbefore each dose of pentamidine.• Monitor CBC; platelet count; liver functiontest results; BUN, serum creatinineand calcium, and blood glucose levels; andECG tracing throughout therapy, asordered.• Monitor blood glucose level because pentamidineuse can induce insulin releasefrom pancreas and severe hypoglycemiathat can last from 1 day to several weeks.• Be aware that hyperglycemia and diabetesmellitus can occur up to several monthsafter parenteral therapy stops.PATIENT TEACHING• Stress importance of complying with prescribedadministration schedule whenpentamidine is used to prevent P. jiroveci(carinii) pneumonia.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to notify prescriber aboutunusual bleeding or bruising and to takeprecautions to avoid bleeding, as by usinga soft-bristled toothbrush and an electricshaver.• Caution patient about possible hypoglycemiceffects of pentamidine therapy.• Advise patient to have follow-up laboratorystudies to test for diabetes mellitus,which can occur up to several monthsafter stopping pentamidine therapy.pentazocine lactateTalwinClass, Category, and ScheduleChemical class: Synthetic opioidTherapeutic class: AnalgesicPregnancy category: CControlled substance schedule: IVIndications and Dosages To relieve moderate to severe painI.V., I.M., OR SUBCUTANEOUS INJECTIONAdults. Initial: 30 mg every 3 to 4 hr, p.r.n.Maximum: 30 mg/single dose I.V., 60 mg/single dose I.M. or subcutaneously, or360 mg/24 hr for all parenteral forms. To relieve obstetric painI.V. INJECTIONAdults. 20 mg when contractions becomeregular; repeated 2 or 3 times every 2 toP

806pentazocine lactate3 hr, as prescribed.I.M. INJECTIONAdults. 30 mg as a single dose.Route Onset Peak DurationI.V. 2–3 min 15–30 min 2–3 hrI.M., 15–20 30–60 min 2–3 hrSubQ minMechanism of ActionBinds with opioid receptors, mainly kappaand sigma receptors, at many CNS sites toalter perception of and emotional responseto pain.IncompatibilitiesDon’t mix pentazocine in same syringe witha soluble barbiturate because precipitationwill occur.ContraindicationsHypersensitivity to pentazocine or its componentsInteractionsDRUGSanticholinergics: Increased risk of urineretention and severe constipationantidiarrheals, antiperistaltics: Increased riskof severe constipation and CNS depressionantihypertensives, diuretics, other hypotensionproducingdrugs: Additive hypotensiveeffectsbuprenorphine: Decreased pentazocine effectiveness,increased respiratory depressionCNS depressants: Increased CNS depression,increased risk of habituationhydroxyzine, other opioid analgesics:Increased analgesia, CNS depression, andhypotensive effectsMAO inhibitors: Increased risk of unpredictable,severe, even fatal adverse reactionsmetoclopramide: Antagonized metoclopramideeffects on GI motilitynaloxone: Antagonized analgesic, CNS, andrespiratory depressant effects of pentazocinenaltrexone: Withdrawal symptoms inpatients physically dependent on pentazocineneuromuscular blockers: Increased respiratorydepressionACTIVITIESalcohol use: Additive CNS depression andincreased risk of habituationAdverse ReactionsCNS: Chills, dizziness, drowsiness, euphoria,fatigue, headache, insomnia, light-headedness,nervousness, nightmares, paresthesia,restlessness, weaknessCV: Hypotension, tachycardiaEENT: Blurred vision, diplopia, dry mouth,laryngeal edema, laryngospasmGI: Constipation, hepatotoxicity, nausea,vomitingGU: Decreased urine output, dysuria, urinaryfrequency, urine retentionMS: Muscle rigidity (with large doses)RESP: Atelectasis, bronchospasm, dyspnea,hypoventilation, wheezingSKIN: Diaphoresis, erythema multiforme,facial flushing, pruritus, rash, Stevens-Johnson syndrome, toxic epidermal necrolysis,urticariaOther: Facial edema; injection site burning,pain, redness, or swelling; physical and psychologicaldependenceNursing Considerations• Use pentazocine with extreme caution inpatients with head injury, intracraniallesion, or increased intracranial pressure.Drug may mask neurologic evidence.• Use pentazocine cautiously in patientsphysically dependent on opioid agonistsbecause drug may prompt withdrawalsymptoms; in patients with acute MIbecause drug’s cardiovascular effects canincrease cardiac workload; in patients withrenal or hepatic dysfunction because drugis metabolized in liver and excreted inurine; and in patients with respiratoryconditions because drug depresses respiratorysystem.• When giving repeated parenteral doses,use I.M. or I.V. route when possible and asprescribed because subcutaneous routemay cause severe tissue damage at injectionsite. Rotate I.M. sites to avoid tissuedamage.• After giving parenteral form, expect totaper dosage gradually, as prescribed, toreduce the risk of withdrawal symptoms.PATIENT TEACHING• Caution patient that prolonged use ofpentazocine may result in dependence.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Caution patient not to use alcohol or OTCdrugs without consulting prescriber.

• Advise patient to report possible allergicreaction, such as a rash or itching.pentobarbitalsodiumNembutal, Nova Rectal (CAN),Novopentobarb (CAN)Class, Category, and ScheduleChemical class: BarbiturateTherapeutic class: Anticonvulsant, sedativehypnoticPregnancy category: DControlled substance schedule: II (oral,parenteral), III (rectal)Indications and Dosages To provide daytime sedationELIXIRAdults. 20 mg t.i.d. or q.i.d.Children. 2 to 6 mg/kg daily.SUPPOSITORIESAdults. 30 mg b.i.d. to q.i.d.Children. 2 mg/kg t.i.d. To provide short-term treatment ofinsomniaCAPSULES, ELIXIRAdults. 100 mg at bedtime.I.V. INJECTIONAdults. Initial: 100 mg, with additionalsmall doses at 1-min intervals, as prescribed.Maximum: 500 mg.I.M. INJECTIONAdults. 150 to 200 mg at bedtime.SUPPOSITORIESAdults and adolescents over age 14. 120 to200 mg at bedtime.Children ages 12 to 14. 60 to 120 mg atbedtime.Children ages 5 to 12. 60 mg at bedtime.Children ages 1 to 4. 30 to 60 mg at bedtime.Infants ages 2 months to 1 year. 30 mg atbedtime. To provide preoperative sedationCAPSULES, ELIXIRAdults. 100 mg before surgery.Children. 2 to 6 mg/kg before surgery.Maximum: 100 mg/dose.I.M. INJECTIONAdults. 150 to 200 mg before surgery.Children. 2 to 6 mg/kg before surgery.pentobarbital sodium 807Maximum: 100 mg/dose.SUPPOSITORIESChildren ages 12 to 14. 60 to 120 mg beforesurgery.Children ages 5 to 12. 60 mg before surgery.Children ages 1 to 4. 30 to 60 mg beforesurgery.Infants ages 2 months to 1 year. 30 mgbefore surgery. To provide emergency treatment ofseizures associated with eclampsia,meningitis, status epilepticus, tetanus, ortoxic reactions to local anesthetics orstrychnineI.V. INJECTIONAdults. 100 mg, with additional small dosesat 1-min intervals, as prescribed. Maximum:500 mg.Children. 50 mg, with additional smalldoses at 1-min intervals, as prescribed, untildesired effect occurs.I.M. INJECTIONChildren. 50 mg, with additional smalldoses at 1-min intervals, as prescribed, untildesired effect occurs.DOSAGE ADJUSTMENT Dosage possiblyreduced for elderly or debilitated patientsand those with hepatic dysfunction.Route Onset Peak DurationP.O., P.R. 15–60 min 1–4 hr 3–4 hrI.V. In 1 min Unknown 15 minI.M. 10–25 min Unknown 3–4 hrMechanism of ActionInhibits ascending conduction in reticularformation, which controls CNS arousal toproduce drowsiness, hypnosis, and sedation.Pentobarbital also decreases spread ofseizure activity in cortex, thalamus, andlimbic system. It promotes an increasedthreshold for electrical stimulation in themotor cortex, which may contribute toanticonvulsant effects.ContraindicationsHepatic disease; history of addiction to hypnoticsor sedatives; hypersensitivity to pentobarbital,barbiturates, or their components;nephritis; porphyria; severe respiratory diseasewith airway obstruction or dyspneaInteractionsDRUGSacetaminophen: Possibly decreased effects ofP

808pentosan polysulfate sodiumacetaminophen (long-term pentobarbitaluse)carbamazepine, chloramphenicol, corticosteroids,cyclosporine, dacarbazine, digoxin,disopyramide, doxycycline, griseofulvin,metronidazole, oral contraceptives, phenylbutazone,quinidine, theophyllines, vitaminD: Decreased effectiveness of these drugsCNS depressants: Increased CNS depressionand risk of habituationdivalproex sodium, valproic acid: Increasedrisk of CNS toxicity and neurotoxicityguanadrel, guanethidine: Possibly increasedrisk of orthostatic hypotensionhalogenated hydrocarbon anesthetic:Increased risk of hepatotoxicity (with longtermpentobarbital use)haloperidol: Possibly decreased blood haloperidollevel, possibly altered seizure patternor frequencyhydantoins: Possibly interference withhydantoin metabolismleucovorin: Possibly decreased anticonvulsanteffect of pentobarbitalmaprotiline: Possibly enhanced CNS depressionand decreased therapeutic effects ofpentobarbitalmexiletine: Possibly decreased blood mexiletineleveloral anticoagulants: Possibly decreasedeffects of these drugs, possibly increasedrisk of bleeding when pentobarbital stopstricyclic antidepressants: Possibly decreasedtherapeutic effects of these drugsACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Agitation, anxiety, ataxia, confusion,delusions, depression, dizziness, drowsiness,fever, hallucinations, headache, insomnia,irritability, nervousness, nightmares, paradoxicalstimulation, seizures, syncope,tremorCV: Orthostatic hypotensionEENT: Vision changesGI: Anorexia, constipation, hepatic dysfunction,nausea, vomitingHEME: AgranulocytosisMS: Arthralgia, bone pain, muscle twitchingor weaknessRESP: Respiratory depressionSKIN: Exfoliative dermatitis, rash, Stevens-Johnson syndromeOther: Physical and psychological dependence,weight lossNursing Considerations• Use pentobarbital with extreme caution inpatients with depression, a history of drugabuse, or suicidal tendencies.• Use drug cautiously in elderly or debilitatedpatients and those with acute or chronicpain because it may induce paradoxicalstimulation.• When using I.V. route, inject drug at50 mg/min or less to avoid adverse respiratoryand circulatory reactions.• If patient shows premonitory signs ofhepatic coma, withhold drug and notifyprescriber immediately.• Monitor I.V. site closely and avoid extravasation.Drug is highly alkaline and maycause local tissue damage and necrosis.PATIENT TEACHING• Inform patient that pentobarbital is habitforming,and stress the importance of takingit exactly as prescribed.• Instruct patient who takes elixir form touse a calibrated measuring device and toclose container tightly after use.• Instruct patient who uses suppositories torefrigerate them.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Urge patient to avoid alcohol and otherCNS depressants because they mayincrease drug’s adverse CNS effects.pentosanpolysulfate sodiumElmironClass and CategoryChemical class: Low-molecular-weightheparin-like compoundTherapeutic class: Local anti-inflammatory(bladder-specific)Pregnancy category: BIndications and Dosages To relieve bladder discomfort or paincaused by interstitial cystitisCAPSULESAdults. 100 mg t.i.d. for up to 3 mo, possiblyfollowed by another 3 mo if no

improvement and no adverse reactions.Mechanism of ActionAdheres to mucosal membrane of bladderwall and may block irritating solutes fromreaching cells, thereby decreasing local painand discomfort.ContraindicationsHypersensitivity to pentosan, otherstructurally related compounds, or theircomponentsInteractionsDRUGSalteplase (recombinant), aspirin (high doses),heparin, oral anticoagulants, streptokinase:Increased risk of hemorrhageAdverse ReactionsCNS: Depression, dizziness, emotionallability, headacheGI: Abdominal pain, diarrhea, elevated liverenzyme levels, hepatic dysfunction, indigestion,nausea, rectal hemorrhageHEME: Unusual bleeding or bruisingSKIN: Alopecia, rashNursing Considerations• Use pentosan with extreme caution inpatients with conditions that increasebleeding risk, such as aneurysm, diverticula,GI ulceration, hemophilia, polyps, andthrombocytopenia (especially heparininduced).• Use drug cautiously in patients withhepatic dysfunction because drug is desulfatedin liver and spleen.• Monitor patient for abnormal bleeding,such as unexplained bruises and epistaxis,because drug is a weak anticoagulant.PATIENT TEACHING• Instruct patient to take pentosan with afull glass of water at least 1 hour before or2 hours after meals.• Explain the pattern of exacerbations andremissions with interstitial cystitis.Reassure patient that symptoms shouldimprove within 3 months after startingpentosan therapy.• Advise patient to take bleeding precautionsduring therapy, such as using anelectric shaver and a soft-bristled toothbrush.• If alopecia develops, explain that it’s usuallyconfined to a single area.pentoxifyllineTrentalpentoxifylline 809Class and CategoryChemical class: Xanthine derivativeTherapeutic class: Blood viscosity reducerPregnancy category: CIndications and Dosages To treat peripheral vascular diseaseE.R. TABLETSAdults. 400 mg t.i.d. with meals.DOSAGE ADJUSTMENT Dosage possiblyreduced to 400 mg b.i.d. for patients whoexperience adverse GI or CNS reactions.Route Onset Peak DurationP.O. 2–4 wk Unknown UnknownMechanism of ActionRelieves symptoms of peripheral vasculardisease by:• reducing blood viscosity by decreasingplasma fibrinogen level and inhibitingRBC and platelet aggregation• improving erythrocyte flexibility byinhibiting phosphodiesterase and increasingthe amount of cAMP in RBCs• decreasing peripheral vascular resistanceand improving microcirculatory bloodflow and tissue oxygenation.ContraindicationsHypersensitivity to pentoxifylline, methylxanthines(such as caffeine, theophylline,and theobromine), or their components;recent cerebral or retinal hemorrhageInteractionsDRUGSantihypertensives: Potentiated antihypertensiveeffectscefamandole, cefoperazone, cefotetan,heparin, oral anticoagulants, other plateletaggregation inhibitors, plicamycin, thrombolytics,valproic acid: Increased risk ofbleedingcimetidine: Increased blood pentoxifyllinelevel, increased risk of adverse effectssympathomimetics, xanthines: EnhancedCNS stimulationACTIVITIESsmoking: Possibly decreased therapeuticP

810perindopril erbumineeffects of pentoxifyllineAdverse ReactionsCNS: Asceptic meningitis, dizziness,headacheGI: Indigestion, nausea, vomitingNursing Considerations• Use pentoxifylline cautiously in elderlypatients and those with hepatic or renaldysfunction.• Give drug with meals and an antacid, ifneeded, to reduce adverse GI reactions.PATIENT TEACHING• Instruct patient to swallow pentoxifyllineE.R. tablets whole and not to crush, break,or chew them.• Advise patient to take drug with meals toreduce GI irritation. If adverse GI reactionsoccur anyway, advise her to also takean antacid with meals.• Although symptoms may not improve forseveral weeks, urge patient to continuetaking drug as prescribed to achieve maximumtherapeutic effect.• Instruct patient not to smoke during therapybecause smoking constricts blood vesselsand may reduce drug effectiveness.• Urge patient to report adverse reactions;dosage may need reduction.perindoprilerbumineAceonClass and CategoryChemical class: Perindoprilat prodrugTherapeutic class: AntihypertensivePregnancy category: DIndications and Dosages To manage hypertensionTABLETSAdults. Initial: 4 mg daily as a single doseor in divided doses b.i.d., increased as prescribeduntil blood pressure is controlled ormaximum dosage is reached. Maintenance:4 to 8 mg daily. Maximum: 8 mg daily.DOSAGE ADJUSTMENT If patient takes adiuretic, initial dosage possibly reduced to2 to 4 mg daily; if patient has renal failure,initial dosage possibly reduced to 2 mgdaily. To reduce risk of cardiovascular death ornonfatal MI in patients with stablecoronary artery diseaseTABLETSAdults. Initial: 4 mg daily for 2 wk; thenincreased to 8 mg daily. Maintenance: 8 mgdaily.DOSAGE ADJUSTMENT If patient is elderly,2 mg daily for 1 wk, increased to 4 mg dailyfor 1 wk and then to 8 mg daily if tolerated.Mechanism of ActionIs converted to the active metabolite perindoprilat,which competes with angiotensinI binding sites, blocking conversionof angiotensin I to angiotensin II, a potentvasoconstrictor. As a result, this ACEinhibitor reduces vasoconstriction andblood pressure. Decreased angiotensin IIalso reduces aldosterone secretion, increasingrenal excretion of water and sodium.ContraindicationsHistory of angioedema with ACE inhibitortreatment; hypersensitivity to perindopril,other ACE inhibitors, or their componentsInteractionsDRUGSdiuretics: Increased risk of hypotensionlithium: Increased blood lithium level andrisk of toxicitypotassium-sparing diuretics, potassium supplements:Increased risk of hyperkalemiasodium aurothiomalate: Increased risk ofnitritoid reaction with facial flushing, nausea,vomiting, and hypotensionAdverse ReactionsCNS: Amnesia, anxiety, dizziness, fatigue,fever, headache, hypertonia, migraine, syncope,vertigoCV: Chest pain, ECG changes, heart murmur,hypotension, orthostatic hypotension,palpitations, PVCsEENT: Conjunctivitis, earache, epistaxis,hoarseness, pharyngitis, rhinitis, sinusitis,sneezing, tinnitusGI: Abdominal pain, diarrhea, elevated liverfunction test results, flatulence, increasedappetite, indigestionGU: Flank pain, renal calculi, urinary frequencyand urgency, vaginitisHEME: Hematoma, leukopenia, neutropeniaMS: Arthritis, back pain, gout, limb pain,myalgia, neck pain

RESP: CoughSKIN: Canker sores, diaphoresis, dry skin,ecchymosis, erythema, pruritus, rashOther: Angioedema, facial edemaNursing Considerations• Use cautiously with heart failure, renalartery stenosis, or renal dysfunction.• Also use cautiously in elderly patients, andwatch closely for adverse effects such asdizziness or vertigo, because these patientshave an increased risk of falling.• Monitor patients with hepatic dysfunctionfor enhanced therapeutic drug effectsbecause drug’s bioavailability is increased.• Monitor serum potassium level to detecthyperkalemia, especially in patients withrenal insufficiency or diabetes mellitus andthose who use a potassium-containing saltsubstitute or take a potassium-sparingdiuretic or potassium supplement.PATIENT TEACHING• Instruct patient to take perindopril exactlyas prescribed, even if she feels well.WARNING Urge patient to stop taking drugand notify prescriber immediately if sheexperiences signs of angioedema.• Advise patient to notify prescriber at onceabout fever, sore throat, or other signs thatmay indicate neutropenia.• Urge patient to avoid potassium supplementsand potassium-containing salt substitutesunless prescriber approves.• Instruct patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise woman to promptly report suspected,known, or intended pregnancy.Drug will need to be discontinued.perphenazineApo-Perphenazine (CAN), PMSPerphenazine (CAN), Trilafon, TrilafonConcentrateClass and CategoryChemical class: Piperazine phenothiazineTherapeutic class: Antiemetic, antipyschoticPregnancy category: Not ratedIndications and Dosages To treat psychotic disordersORAL SOLUTIONHospitalized adults and adolescents. 8 toperphenazine 81116 mg b.i.d. to q.i.d., adjusted as prescribedand tolerated. Maximum: 64 mg daily.TABLETSAdults and adolescents. 4 to 16 mg b.i.d. toq.i.d., adjusted as prescribed and tolerated.Maximum: 64 mg daily.I.M. INJECTIONAdults and adolescents. 5 to 10 mg every6 hr, adjusted as prescribed and tolerated.Maximum: 15 mg daily for outpatients,30 mg daily for hospitalized patients. To treat severe nausea and vomitingTABLETSAdults and adolescents. 8 to 16 mg daily individed doses, decreased as appropriate.Maximum: 24 mg daily.I.V. INFUSION OR INJECTIONAdults and adolescents. 1 mg every 1 to2 min, up to 5 mg total.I.M. INJECTIONAdults and adolescents. 5 mg, increased to10 mg as ordered for rapid control of severevomiting. Maximum: 15 mg daily for outpatients,30 mg daily for hospitalizedpatients.DOSAGE ADJUSTMENT Initial dose possiblyreduced and gradually increased for elderly,emaciated, or debilitated patients.Adolescents may need low adult dosage.Route Onset Peak DurationP.O. Several wk 4–7 days UnknownI.M. Unknown 1–2 hr 6 hrMechanism of ActionDepresses areas of the brain that controlactivity and aggression, including cerebralcortex, hypothalamus, and limbic system,by an unknown mechanism. Perphenazinealso prevents nausea and vomiting byinhibiting or blocking dopamine receptorsin medullary chemoreceptor trigger zoneand peripherally by blocking vagus nerve inthe GI tract.IncompatibilitiesDon’t mix perphenazine oral solution withbeverages that contain caffeine or tannins(such as coffee, colas, and teas) or pectinates(such as apple juice) because they’rephysically incompatible.ContraindicationsBlood dyscrasias; bone marrow depression;cerebral arteriosclerosis; coma; concurrentP

812perphenazineuse of CNS depressants (large doses); coronaryartery disease; hepatic impairment;hypersensitivity to perphenazine, otherphenothiazines, or their components;myeloproliferative disorders; severe CNSdepression; severe hypertension orhypotension; subcortical brain damageInteractionsDRUGSaluminum- and magnesium-containingantacids, antidiarrheals (adsorbent):Decreased absorption of oral perphenazineamantadine, anticholinergics, antidyskinetics,antihistamines: Increased adverse anticholinergiceffectsamphetamines: Decreased therapeuticeffects of both drugsanticonvulsants: Decreased seizure threshold,inhibited metabolism and toxicity ofanticonvulsantantithyroid drugs: Increased risk of agranulocytosisapomorphine: Additive CNS depression,decreased emetic response to apomorphineif perphenazine is given firstappetite suppressants (except phenmetrazine):Antagonized anorectic effect ofappetite suppressantsbeta blockers: Increased blood levels of bothdrugs and risk of arrhythmias, hypotension,irreversible retinopathy, and tardive dyskinesiabromocriptine: Possibly interference withbromocriptine’s effectsCNS depressants: Increased CNS and respiratorydepression and hypotensive effectsdopamine: Antagonized peripheral vasoconstrictionwith high doses of dopamineephedrine: Decreased vasopressor responseto ephedrineepinephrine: Blocked alpha-adrenergiceffects of epinephrine, possibly causingsevere hypotension and tachycardiahepatotoxic drugs: Increased risk of hepatotoxicityhypotension-causing drugs: Increased risk ofsevere orthostatic hypotensionlevodopa: Inhibited antidyskinetic effects oflevodopalithium: Possibly neurotoxicity (disorientation,extrapyramidal symptoms, unconsciousness)maprotiline, selective serotonin reuptakeinhibitors, tricyclic antidepressants:Prolonged and intensified sedative andanticholinergic effects of these drugs orperphenazinemetrizamide: Decreased seizure thresholdopioid analgesics: Increased CNS and respiratorydepression, increased risk of orthostatichypotension and severe constipationototoxic drugs, especially antibiotics: Possiblymasking of some symptoms of ototoxicity,such as dizziness, tinnitus, and vertigoprobucol, other drugs that prolong QTinterval: Prolonged QT interval, which mayincrease risk of ventricular tachycardiathiazide diuretics: Possibly hyponatremiaand water intoxicationACTIVITIESalcohol use: Increased CNS and respiratorydepression, hypotensive effects, and risk ofheatstrokeAdverse ReactionsCNS: Behavioral changes, cerebral edema,dizziness, drowsiness, extrapyramidal reactions(such as akathisia, dystonia, pseudoparkinsonism),fever, headache, neurolepticmalignant syndrome, seizures, suicidalideation, syncope, tardive dyskinesia (persistent)CV: Bradycardia, cardiac arrest, hypertension,hypotension, orthostatic hypotension,tachycardiaEENT: Blurred vision, dry mouth, glaucoma,laryngeal edema, miosis, mydriasis,nasal congestion, ocular changes (cornealopacification, retinopathy)ENDO: Decreased libido, galactorrhea,gynecomastia, syndrome of inappropriateADH secretionGI: Anorexia, constipation, diarrhea, fecalimpaction, nausea, vomitingGU: Bladder paralysis, ejaculation failure,menstrual irregularities, polyuria, urinaryfrequency, urinary incontinence, urineretentionHEME: Agranulocytosis, eosinophilia,hemolytic anemia, leukopenia, pancytopenia,thrombocytopenic purpuraRESP: AsthmaSKIN: Diaphoresis, eczema, erythema,exfoliative dermatitis, hyperpigmentation,jaundice, pallor, photosensitivity, pruritus,urticariaOther: Anaphylaxis, angioedema

Nursing Considerations• Perphenazine shouldn’t be used to treatdementia-related psychosis in the elderlybecause of an increased mortality risk.• Use perphenazine cautiously in patientswith depression or hepatic, pulmonary, orrenal dysfunction and in elderly patients,who are at increased risk for increasedplasma concentrations and tardive dyskinesia.• For I.V. use, dilute drug to 0.5 mg/ml withsodium chloride for injection. Protect solutionfrom light. Slight yellowing is acceptable,but discard solution if it’s markedlydiscolored or contains precipitate.• Obtain blood samples for CBC and liverand renal function tests, as ordered, todetect adverse reactions.• Monitor temperature frequently, and notifyprescriber if it rises; a significantincrease suggests drug intolerance.• Monitor blood pressure of patient whotakes large doses of perphenazine, especiallyif surgery is indicated, because of theincreased risk of hypotension.• Watch patient closely (especially children,adolescents, and young adults), for suicidaltendencies, particularly when perphenazinetherapy starts and dosagechanges, because depression may worsentemporarily during these times, possiblyleading to suicidal ideation.PATIENT TEACHING• Instruct patient to take drug exactly asprescribed to ensure optimal effectivenessand minimize adverse reactions.• Remind patient who takes oral solution touse a calibrated measuring device.• Instruct patient taking oral solution todilute every 5 ml (teaspoon) of drug in2 fluid oz of water, milk, tomato juice,fruit juice (except apple), soup, or carbonatedbeverage. Caution against using beveragesthat contain caffeine or tannins(cola, coffee, tea).• Caution patient not to spill oral solutionon skin or clothing because it can causecontact dermatitis and damage clothing.• Urge patient to avoid alcohol and otherCNS depressants during perphenazinetherapy and to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to avoid excessive sun exposureand to protect skin when outdoors.Nursing Considerations• Notify prescriber if yellowish skin or scleraedevelop in patient taking phenazopyridinebecause this may indicate drug accuphenazopyridinehydrochloride 813• Instruct patient to notify prescriber aboutpersistent or severe adverse reactions.• Urge patient to comply with long-termfollow-up to detect adverse reactions anddetermine possible need for perphenazinedosage adjustments.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes andparticularly if patient is a child, teenager, oryoung adult.phenazopyridinehydrochlorideAzo-Standard, Baridium, Eridium,Geridium, Phenazo (CAN),Phenazodine, Pyridiate, Pyridium,Urodine, Urogesic, ViridiumClass and CategoryChemical class: Azo dyeTherapeutic class: Urinary analgesicPregnancy category: BIndications and Dosages To relieve burning and pain on urination,and urinary frequency and urgencyTABLETSAdults and adolescents. 200 mg t.i.d. withor without food for no longer than 2 days.Children. 4 mg/kg t.i.d. with food for nolonger than 2 days.Mechanism of ActionExerts a topical or local anesthetic effect onurinary tract mucosa as drug is excreted inurine. Phenazopyridine’s exact mechanismis unknown.ContraindicationsHypersensitivity to phenazopyridine or itscomponents, renal insufficiencyAdverse ReactionsCNS: HeadacheGI: Indigestion, nausea, vomitingGU: Reddish orange urineSKIN: Pruritus, rashOther: Discoloration of body fluidsP

814InteractionsDRUGSanticholinergics, antidyskinetics, antihistamines:Increased anticholinergic effect, prolongedCNS depression (antihistamines)anticonvulsants: Increased CNS depression,possibly altered pattern of seizuresbeta blockers: Increased risk of bradycardiabromocriptine: Possibly interference withbromocriptine effectsbupropion: Increased risk of bupropion toxicitybuspirone: Increased risk of hypertensioncaffeine-containing drugs: Increased risk ofdangerous arrhythmias and severe hypertensioncarbamazepine, cyclobenzaprine, maprotiline,other MAO inhibitors: Increased risk ofhyperpyretic crisis, hypertensive crisis,severe seizures, and death; altered pattern ofseizures (with carbamazepine)CNS depressants: Increased CNS depressiondextromethorphan: Increased risk of excitation,hypertension, and hyperpyrexiadiuretics: Increased hypotensive effectdoxapram: Increased vasopressor effects ofeither drugfluoxetine: Increased risk of agitation, confusion,GI symptoms, hyperpyreticepisodes, hypertensive crisis, potentiallyfatal serotonin syndrome, restlessness, andsevere seizures.guanadrel, guanethidine: Increased risk ofhypertensionhaloperidol, loxapine, molindone, phenothiazines,pimozide, thioxanthenes: Prolongedand intensified anticholinergic, hypotensive,and sedative effects of these drugs orphenelzineinsulin, oral antidiabetic drugs: Increasedhypoglycemic effectslevodopa: Increased risk of sudden, moderateto severe hypertensionlocal anesthetics (with epinephrine or levonordefrin):Possibly severe hypertensionmeperidine, other opioid analgesics:Increased risk of coma, hyperpyrexia,hypotension, immediate excitation, rigidity,seizures, severe hypertension, severe respiratorydepression, sweating, vascular collapse,and deathmethyldopa: Increased risk of hallucinaphenelzinesulfatemulation from impaired renal excretion.Expect prescriber to discontinue drug.• Be aware that phenazopyridine treatmentshould be limited to 2 days in patientswith UTI.PATIENT TEACHING• Instruct patient not to take drug for longerthan 2 days and to notify prescriber ifsymptoms persist beyond that time.• If GI distress develops, advise patient totake drug with meals.• Inform patient that drug turns urineorange to red and may discolor other bodyfluids, such as tears.• Advise patient not to wear contact lensesduring therapy because they may becomestained.phenelzine sulfateNardilClass and CategoryChemical class: Hydrazine derivativeTherapeutic class: AntidepressantPregnancy category: CIndications and Dosages To treat depressionTABLETSAdults. Initial: 1 mg/kg daily, increasedgradually as prescribed and tolerated.Maintenance: 45 mg daily. Maximum:90 mg daily.DOSAGE ADJUSTMENT For elderly patients,initially may be reduced to 0.8 to 1 mg/kgdaily in divided doses, increased as orderedand tolerated to maximum of 60 mg daily.Route Onset Peak DurationP.O. 7–10 days 4–8 wk 10 daysContraindicationsCardiovascular disease; cerebrovascular disease;heart failure; hepatic disease; historyof headaches; hypersensitivity to phenelzineor its components; hypertension; pheochromocytoma;severe renal impairment; use ofanesthetics, antihypertensives, bupropion,buspirone, carbamazepine, CNS depressants,cyclobenzaprine, dextromethorphan,meperidine, selective serotonin-reuptakeinhibitors, sympathomimetics, or tricyclicantidepressants; use within 14 days of otherMAO inhibitor

phenelzine sulfate 815Mechanism of ActionPhenelzine relieves symptoms of unipolardepressive disorders by inhibiting theenzyme monoamine oxidase (MAO).Normally, MAO breaks down monoamineneurotransmitters, such as serotonin,as shown below left. By inhibitingthis enzyme, phenelzine increases theconcentration of serotonin in the vesiclesof monoamine nerve endings, allowingmore serotonin to be released and engagewith receptors on postsynaptic cells, asshown below right. A serotonin deficiencymay be responsible in part for endogenousdepression.SerotoninproductionMonoaminenerve nerveending endingPhenelzineSerotoninproductionMAOMAOSerotoninMAOMAOPostsynapticcell cellSerotoninreceptortions, headache, hyperexcitability, andsevere hypertensionmethylphenidate: Increased CNS stimulanteffect of methylphenidatemetrizamide: Decreased seizure threshold,increased risk of seizuresoral anticoagulants: Increased anticoagulantactivityparoxetine, sertraline, trazodone, tricyclicantidepressants: Increased risk of potentiallyfatal serotonin syndromephenylephrine (nasal or ophthalmic):Potentiated vasopressor effect of phenylephrinerauwolfia alkaloids: Increased risk of moderateto severe hypertension, CNS depression(when phenelzine is added to rauwolfiaalkaloid therapy), CNS excitationand hypertension (when rauwolfia alkaloidis added to phenelzine therapy)spinal anesthetics: Increased risk of hypotensionsuccinylcholine: Possibly increased neuromuscularblockade of succinylcholinesympathomimetics: Prolonged and intensifiedcardiac stimulant and vasopressoreffectstryptophan: Increased risk of confusion, disorientation,hyperreflexia, hyperthermia,hyperventilation, mania or hypomania, andshiveringFOODSfoods and beverages high in tyramine orother pressor amines, such as aged cheese;beer; fava beans or other broad beans; curedmeat or sausage; liqueurs; overripe fruit; redand white wine; reduced-alcohol and alcoholfreebeer and wine; sauerkraut; sherry;smoked or pickled fish, meats, and poultry;yeast or protein extracts: Increased risk ofsudden, severe hypertensionACTIVITIESalcohol use: Increased CNS depressanteffects and hypertensive crisisAdverse ReactionsCNS: Agitation, dizziness, drowsiness, headache,overstimulation, restlessness, sedation,sleep disturbance, suicidal ideation, weaknessCV: Bradycardia, edema, hypertensive crisis,orthostatic hypotension, palpitations,tachycardiaEENT: Blurred vision, dry mouth, photophobiaENDO: Hypoglycemia in diabetic patientsGI: Abdominal pain, constipation, diarrhea,P

816phenobarbitalelevated liver function test results, increasedappetite, nauseaGU: Impotence, priapism, sexual dysfunction,urinary frequency, urine retentionMS: Muscle twitchingSKIN: Diaphoresis, rashOther: Hypernatremia, weight gainNursing Considerations• Use phenelzine cautiously in patients withepilepsy because drug may alter seizurethreshold.• Use phenelzine cautiously in patients withdiabetes mellitus because insulin sensitivitymay increase, predisposing patient tohypoglycemia.• Expect to observe some therapeutic effectwithin 7 to 10 days, but keep in mind thatfull effect may not occur for 4 to 8 weeks.• Monitor cardiovascular status closely forchanges in heart rate (especially if patientreceives more than 30 mg daily) and signsof life-threatening hypertensive crisis.Question patient often about headachesand palpitations. If either occurs, notifyprescriber and expect to discontinue drug.• Keep phentolamine readily available totreat hypertensive crisis. Give 5 mg by slowI.V., as prescribed, to reduce blood pressurewithout causing excessive hypotension.Use external cooling measures, asprescribed, to manage fever.• To avoid hypertensive crisis, expect to wait10 to 14 days, as prescribed, when switchingpatient from one MAO inhibitor toanother or when switching from a dibenzazepine-relateddrug, such as amitriptylineor perphenazine.• Watch closely for suicidal tendencies, especiallyin children, adolescents, and youngadults and especially when therapy startsor dosage changes.PATIENT TEACHING• Inform patient and family members thattherapeutic effects of phenelzine may takeseveral weeks to appear and that sheshould continue taking drug as prescribed.• Caution patient to rise slowly from a lyingor sitting position to minimize effects oforthostatic hypotension.WARNING Instruct patient to avoid the followingfoods, beverages, and drugs duringphenelzine therapy and for 2 weeks afterward:alcohol-free and reduced-alcoholbeer and wine; appetite suppressants; beer;broad beans; cheese (except cottage andcream cheese); chocolate and caffeine inlarge quantities; dry sausage (includingGenoa salami, hard salami, pepperoni, andLebanon bologna); hay fever drugs;inhaled asthma drugs; liver; meat extract;OTC cold and cough preparations(including those containing dextromethorphan),nasal decongestants(tablets, drops, or spray); pickled herring;products that contain tryptophan; protein-richfoods that may have undergoneprotein changes by aging, pickling, fermenting,or smoking; sauerkraut; sinusdrugs; weight-loss preparations; yeastextracts (including brewer’s yeast in largequantities); yogurt; and wine.• Advise patient to inform all health careproviders (including dentists) that shetakes an MAO inhibitor because certaindrugs are contraindicated within 2 weeks.• Urge patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Stress the importance of reporting headachesand other unusual, persistent, orsevere symptoms.• Tell family or caregiver to watch closely forsuicidal tendencies, especially in children,adolescents, and young adults and especiallywhen therapy starts or dosagechanges.• Urge patient with diabetes who’s takinginsulin or an oral antidiabetic to checkblood glucose level often during therapybecause phenelzine may affect glucosecontrol.phenobarbitalAncalixir (CAN), Barbita, SolfotonphenobarbitalsodiumLuminalClass, Category, and ScheduleChemical class: BarbiturateTherapeutic class: Anticonvulsant, sedativehypnoticPregnancy category: DControlled substance schedule: IV

Indications and Dosages To treat seizuresCAPSULES, ELIXIR, TABLETSAdults. 60 to 250 mg daily as a single doseor in divided doses.Children. 1 to 6 mg/kg daily as a singledose or in divided doses.I.V. INJECTIONAdults. 100 to 320 mg, repeated as neededand as prescribed. Maximum: 600 mg daily.Children. Initial: 10 to 20 mg/kg as a singledose. Maintenance: 1 to 6 mg/kg daily. To treat status epilepticusI.V. INFUSION OR INJECTIONAdults. 10 to 20 mg/kg given slowly andrepeated as needed and as prescribed.Children. 15 to 20 mg/kg over 10 to 15 min. To provide short-term treatment ofinsomniaCAPSULES, ELIXIR, TABLETSAdults. 100 to 320 mg at bedtime.I.V., I.M., OR SUBCUTANEOUS INJECTIONAdults. 100 to 325 mg at bedtime. To provide daytime sedationCAPSULES, ELIXIR, TABLETSAdults. 30 to 120 mg daily in divided dosesb.i.d. or t.i.d.Children. 2 mg/kg t.i.d.I.V., I.M., OR SUBCUTANEOUS INJECTIONAdults. 30 to 120 mg daily in divided dosesb.i.d. or t.i.d. To provide preoperative sedationCAPSULES, ELIXIR, TABLETSChildren. 1 to 3 mg/kg before surgery.I.M. INJECTIONAdults. 130 to 200 mg 60 to 90 min beforesurgery.I.V. OR I.M. INJECTIONChildren. 1 to 3 mg/kg 60 to 90 min beforesurgery.DOSAGE ADJUSTMENT Dosage possiblyreduced for elderly or debilitated patients tominimize confusion, depression, and excitement.Route Onset Peak DurationP.O. 20–60 min Unknown UnknownI.V. 5 min 30 min 4–6 hrI.M., 5–20 min Unknown 4–6 hrSubQMechanism of ActionInhibits ascending conduction of impulsesphenobarbital 817in the reticular formation, which controlsCNS arousal to produce drowsiness, hypnosis,and sedation. Phenobarbital alsodecreases the spread of seizure activity incortex, thalamus, and limbic system. It promotesan increased threshold for electricalstimulation in the motor cortex, which maycontribute to its anticonvulsant properties.ContraindicationsHepatic disease; history of addiction tohypnotics or sedatives; hypersensitivity tophenobarbital, other barbiturates, or theircomponents; nephritis; porphyria; severerespiratory disease with airway obstructionor dyspneaInteractionsDRUGSacetaminophen: Decreased acetaminopheneffectiveness with long-term phenobarbitaltherapyamphetamines: Delayed intestinal absorptionof phenobarbitalanesthetics (halogenated hydrocarbon):Possibly hepatotoxicityanticonvulsants (hydantoin): Unpredictableeffects on metabolism of anticonvulsantanticonvulsants (succinimide), including carbamazepine:Decreased blood levels andelimination half-lives of these drugscalcium channel blockers: Possibly excessivehypotensioncarbonic anhydrase inhibitors: Enhancedosteopenia induced by phenobarbitalchloramphenicol, corticosteroids, cyclosporine,dacarbazine, digoxin, metronidazole, quinidine:Decreased effectiveness of these drugsfrom enhanced metabolismCNS depressants: Additive CNS depressioncyclophosphamide: Possibly reduced half-lifeand increased leukopenic activity of cyclophosphamidedisopyramide: Possibly ineffectiveness ofdisopyramidedoxycycline, fenoprofen: Shortened half-lifeof these drugsgriseofulvin: Possibly decreased absorptionand effectiveness of griseofulvinguanadrel, guanethidine: Possibly increasedorthostatic hypotensionhaloperidol: Decreased seizure threshold,decreased blood haloperidol levelketamine (high doses): Increased risk ofhypotension and respiratory depressionP

818phenobarbitalleucovorin: Interference with phenobarbital’santiconvulsant effectlevothyroxine, oral contraceptives, phenylbutazone,tricyclic antidepressants: Decreasedeffectiveness of these drugsloxapine, phenothiazines, thioxanthenes: Decreasedseizure thresholdMAO inhibitors: Prolonged phenobarbitaleffects, possibly altered pattern of seizureactivitymaprotiline: Increased CNS depression,decreased seizure threshold at high doses,decreased phenobarbital effectivenessmethoxyflurane: Possibly hepatotoxicity andnephrotoxicitymethylphenidate: Increased risk of phenobarbitaltoxicitymexiletine: Decreased blood mexiletine leveloral anticoagulants: Decreased anticoagulantactivity, increased risk of bleedingwhen phenobarbital is discontinuedpituitary hormones (posterior): Increasedrisk of arrhythmias and coronary insufficiencyprimidone: Altered pattern of seizures,increased CNS effects of both drugsvalproate, valproic acid: Decreased phenobarbitalmetabolism, increased risk of barbituratetoxicityvitamin D: Decreased phenobarbital effectivenessxanthines: Increased xanthine metabolism,antagonized hypnotic effect of phenobarbitalACTIVITIESalcohol use: Additive CNS depressionAdverse ReactionsCNS: Anxiety, depression, dizziness, drowsiness,headache, irritability, lethargy, moodchanges, paradoxical stimulation, sedation,vertigoCV: Hypotension, sinus bradycardiaEENT: Miosis, ptosisGI: Constipation, diarrhea, nausea, vomitingGU: Decreased libido, impotence, sexualdysfunctionMS: Arthralgia, bone tendernessRESP: Bronchospasm, respiratory depressionSKIN: Dermatitis, photosensitivity, rash,urticariaOther: Injection site phlebitis (I.V.), physicaland psychological dependenceNursing Considerations• Be aware that phenobarbital shouldn’t begiven during third trimester of pregnancybecause repeated use can cause dependencein neonate. It also shouldn’t be givento breast-feeding women because it maycause CNS depression in infants.• Use I.V. route cautiously in patients withCV disease, hypotension, pulmonary disease,or shock because drug may causeadverse hemodynamic or respiratoryeffects.• Because drug can cause respiratorydepression, assess respiratory rate anddepth before use, especially in patient withbronchopneumonia, pulmonary disease,respiratory tract infection, or status asthmaticus.• Give elixir undiluted or mix with water,milk, or fruit juice. Use a calibrated deviceto measure doses.• If necessary, crush tablets and mix withfood or fluids.• Reconstitute sterile powder with at least10 ml sterile water for injection. Don’t usereconstituted solution if it fails to clearwithin 5 minutes. Further dilute prescribeddose with normal saline solutionor D 5 W and infuse over 30 to 60 minutes.• Don’t give more rapidly than 60 mg/minby I.V. injection.• During I.V. use, monitor blood pressure,respiratory rate, and heart rate andrhythm. Anticipate increased risk of hypotension,even at recommended rate. Keepresuscitation equipment readily available.• During I.M. use, don’t inject more than5 ml into any one I.M. site to prevent sterileabscess formation.• Be aware that drug may cause physical andpsychological dependence.• Expect that phenobarbital’s CNS effectsmay exacerbate major depression, suicidaltendencies, or other mental disorders.• Take safety precautions for elderlypatients, as appropriate, because they’remore likely to experience confusion,depression, and excitement as adverseCNS reactions.• Anticipate that phenobarbital may causeparadoxical stimulation in children.• Be aware that drug may trigger signs andsymptoms in patients with acute intermittentporphyria.

PATIENT TEACHING• Instruct patient to take phenobarbitalelixir undiluted or to mix it with water,milk, or fruit juice. Advise her to use a calibrateddevice to measure doses.• If patient has trouble swallowing tablets,suggest crushing and adding to food orfluid.• Caution patient about possible drowsinessand reduced alertness. Advise her to avoidpotentially hazardous activities untildrug’s CNS effects are known.• Urge patient to avoid alcohol during therapy.• Inform parents that a child may react withparadoxical excitement. Tell them to notifyprescriber if this occurs.• Instruct woman to report suspected,known, or intended pregnancy. Adviseagainst breast-feeding during therapy.phentolaminemesylateRegitineClass and CategoryChemical class: ImidazolineTherapeutic class: Antihypertensive, diagnosticaid, vasodilatorPregnancy category: Not ratedIndications and Dosages To diagnose pheochromocytomaI.V. INJECTIONAdults. 2.5 mg as a single dose. After negativeresult, repeat test with 5-mg dose, asprescribed.Children. 1 mg as a single dose. After negativeresult, repeat test with 0.1-mg/kg dose,as prescribed. To manage hypertension before or duringpheochromocytomectomyI.V. OR I.M. INJECTIONAdults. 5 mg 1 to 2 hr before surgery,repeated as needed and as prescribed.During surgery, 5 mg I.V., as ordered.Children. 1 mg 1 to 2 hr before surgery,repeated as needed and as prescribed.During surgery, 1 mg I.V., as ordered. To prevent dermal necrosis or sloughingafter extravasation of I.V. norepinephrinephentolamine mesylate 819I.V. INJECTIONAdults, children, and infants. 10 mg/L ofI.V. fluid that contains norepinephrine atrate determined by patient response. To treat dermal necrosis or sloughingafter extravasation of I.V. norepinephrineINTRADERMAL INJECTIONAdults. 5 to 10 mg in 10 ml of normalsaline solution infiltrated in affected areawithin 12 hr of extravasation.Children. 0.1 to 0.2 mg/kg. Maximum:10 mg.Mechanism of ActionBlocks the actions of circulating epinephrineand norepinephrine by antagonizingalpha 1 and alpha 2 receptors. Phentolaminecauses peripheral vasodilation throughdirect relaxation of vascular smooth muscleand alpha blockade. Positive inotropic andchronotropic effects increase cardiac output.A positive inotropic effect primarilyraises blood pressure, but in larger doses,phentolamine causes peripheral vasodilationand can reduce blood pressure.In patients with pheochromocytoma,phentolamine causes systolic and diastolicblood pressures to fall dramatically. Inthose without pheochromocytoma, it causesblood pressure to fall or rise slightly orremain the same.ContraindicationsAngina, hypersensitivity to phentolamineor its components, MIInteractionsDRUGSantihypertensives: Additive hypotensiveeffectdopamine: Antagonized vasopressor activityof dopamineepinephrine, methoxamine, norepinephrine,phenylephrine: Inhibited alpha adrenergiceffects of these drugsmetaraminol: Possibly decreased vasopressoreffect of metaraminolACTIVITIESalcohol use: Additive vasodilation, increasedrisk of hypotension and tachycardiaAdverse ReactionsCNS: DizzinessCV: Angina; arrhythmias, including tachycardia;hypotensionP

820phenylephrine hydrochlorideEENT: Nasal congestionGI: Diarrhea, nausea, vomitingGU: Ejaculation disorders, priapismMS: Muscle weaknessSKIN: FlushingNursing Considerations• Reconstitute each 5-mg vial phentolaminewith 1 ml sterile water for injection.• Use reconstituted solution immediately;don’t store unused portion.• Dilute 5 to 10 mg of reconstituted solutionin 500 ml D 5 W. Inspect drug for particlesand discoloration before administering.• When diagnosing pheochromocytoma,hold nonessential drugs, as ordered, for atleast 24 hours (preferably 48 to 72) beforetest.• Before giving I.V. test dose for pheochromocytoma,place patient in supine positionand assess baseline blood pressurewith readings every 10 minutes for at least30 minutes.• In pheochromocytoma, expect excessivehypotension after patient receives drug.• Take safety precautions according to facilitypolicy if patient experiences dizziness.PATIENT TEACHING• Instruct patient to move slowly after phentolamineadministration to minimizedizziness and avoid falls.phenylephrinehydrochlorideAlconefrin Nasal Drops 12, AlconefrinNasal Drops 25, Alconefrin Nasal Drops50, Alconefrin Nasal Spray 25, Doktors,Duration, Neo-Synephrine, Neo-Synephrine Nasal Drops, Neo-Synephrine Nasal Jelly, Neo-SynephrineNasal Spray, Neo-Synephrine PediatricNasal Drops, Nostril Spray Pump,Nostril Spray Pump Mild, Rhinall,Rhinall-10 Children’s Flavored NoseDrops, Vicks SinexClass and CategoryChemical class: Sympathomimetic amineTherapeutic class: Antiarrhythmic, decongestant,vasoconstrictor, vasopressorPregnancy category: C (parenteral), Notrated (nasal)Indications and Dosages To manage mild to moderate hypotensionI.V. INJECTIONAdults. Initial: 0.1 to 0.5 mg. Usual: 0.2 mg,repeated no more than every 10 to 15 min.I.M. OR SUBCUTANEOUS INJECTIONAdults. Initial: 1 to 5 mg. Usual: 2 to 5 mg(range, 1 to 10 mg), repeated no more thanevery 10 to 15 min, as prescribed. To treat severe hypotension or shockI.V. INFUSIONAdults. Initial: 100 to 180 mcg/min (0.1 to0.18 mg/min) until blood pressure is stable.Maintenance: 40 to 60 mcg/min (0.04 to0.06 mg/min). Infusion concentration andflow rate adjusted as prescribed, based onpatient response. To prevent hypotension during spinalanesthesiaI.M. OR SUBCUTANEOUS INJECTIONAdults. 2 to 3 mg 3 or 4 min before injectionof spinal anesthetic.Children. 0.5 to 1 mg for each 11.3 kg(25 lb). To treat hypotension during spinalanesthesiaI.V. INJECTIONAdults. Initial: 0.2 mg, increased by nomore than 0.2 mg, as prescribed.Maximum: 0.5 mg/dose.Children. 0.5 to 1 mg for each 11.3 kg(25 lb). To treat paroxysmal supraventriculartachycardiaI.V. INJECTIONAdults. Initial: Up to 0.5 mg by rapid injection;later doses increased 0.1 to 0.2 mghigher than preceding dose, as prescribed.Maximum: 1 mg/dose. To treat sinus, nasal, and eustachiantube congestionNASAL JELLY OR SOLUTIONAdults and children age 12 and over. 2 or3 drops or sprays of 0.25% or 0.5% solutionevery 4 hr, p.r.n., or small quantity of0.5% nasal jelly in each nostril every 3 to4 hr, p.r.n. A 1% solution may be used forsevere congestion.Children ages 6 to 12. 2 or 3 drops orsprays of 0.25% solution in each nostrilevery 4 hr, p.r.n.Children ages 2 to 6. 2 or 3 drops or spraysof 0.125% or 0.16% solution in each nostrilevery 4 hr, p.r.n.

Mechanism of ActionDirectly stimulates alpha-adrenergicreceptors and inhibits the intracellularenzyme adenyl cyclase, which then inhibitsproduction of cAMP. Inhibition of cAMPcauses arterial and venous constriction andincreases peripheral vascular resistance andsystolic blood pressure. With greater-thantherapeuticdoses, phenylephrine directlystimulates beta-adrenergic receptors in themyocardium, which increases activity ofadenyl cyclase and produces positive inotropicand chronotropic effect. Intranasaluse directly stimulates alpha-adrenergicreceptors on the nasal mucosa, constrictinglocal vessels and decreasing blood flow andmucosal edema.Route Onset Peak DurationI.V. Immediate Unknown 15–20minI.M. 10–15 min Unknown 30 min–2 hrSubQ 10–15 min Unknown 50 min–1 hrNasal Unknown Unknown 30 min–4 hrIncompatibilitiesDon’t combine nasal form with alkalies,butacaine, ferrous salts, metals, or oxidizingagents.ContraindicationsHypersensitivity to bisulfites, phenylephrine,or their components; severe coronary arterydisease or hypertension; use within 14 daysof MAO inhibitor; ventricular tachycardiaInteractionsDRUGSalpha blockers, haloperidol, loxapine, phenothiazines,thioxanthenes: Possiblydecreased vasoconstrictor effect of phenylephrine;decreased decongestant effect ofnasal phenylephrine (with phenothiazines)antihypertensives, diuretics: Possiblydecreased antihypertensive effectsatropine: Possibly enhanced vasopressoreffect of phenylephrinebeta blockers: Decreased therapeutic effectsof both drugsbretylium: Possibly potentiated vasopressoreffect and arrhythmiasphenylephrine hydrochloride 821doxapram: Increased vasopressor effect ofboth drugsergot alkaloids: Possibly cerebral blood vesselrupture, increased vasopressor effect,peripheral vascular ischemia, and gangrene(with ergotamine)guanadrel, guanethidine: Increased vasopressoreffect of phenylephrine, increasedrisk of severe hypertension and arrhythmiashydrocarbon inhalation anesthetics:Increased risk of serious arrhythmiasMAO inhibitors: Increased and prolongedcardiac stimulation, increased vasopressoreffect, increased risk of severe cardiovascularand cerebrovascular effects, hyperpyrexia,vomitingmaprotiline, tricyclic antidepressants:Increased risk of severe cardiovasculareffects (including arrhythmias, hyperpyrexia,severe hypertension); possibly increasedor decreased sensitivity to I.V. phenylephrinemecamylamine, methyldopa: Decreasedhypotensive effects of these drugs, increasedvasopressor effect of phenylephrinenitrates: Possibly decreased vasopressoreffect of phenylephrine and decreasedantianginal effect of nitratesoxytocin: Possibly severe, persistent hypertensionphenoxybenzamine: Decreased vasoconstrictoreffect of phenylephrine, possibly hypotensionand tachycardiatheophylline: Possibly enhanced toxicity(including cardiotoxicity); decreased theophyllinelevel (with nasal phenylephrine)thyroid hormones: Increased cardiovasculareffects of both drugsurinary acidifiers: Possibly increased eliminationand decreased therapeutic effects(with nasal phenylephrine)urinary alkalizers: Possibly decreased eliminationand toxic effects (with nasal phenylephrine)Adverse ReactionsCNS: Dizziness, headache, insomnia, nervousness,paresthesia, restlessness, sleep disturbance(nasal), tremor, weaknessCV: Angina, bradycardia, hypertension,hypotension, palpitations, peripheral vasoconstrictionthat may lead to necrosis organgrene, tachycardia, ventricular arrhythmiasEENT: Burning, dry, or stinging nasalP

822phenytoinmucosa; rebound congestion; and rhinitis(nasal forms)GI: Nausea, vomitingRESP: DyspneaSKIN: Extravasation with tissue necrosisand sloughing, pallorOther: Allergic reactionNursing Considerations• Don’t dilute phenylephrine for I.M. orsubcutaneous use.• To reduce the risk of tissue extravasation,don’t inject subcutaneous drug intradermally.• For I.V. use, dilute with D 5 W or sodiumchloride for injection and prepare as prescribed—usually10 mg/500 ml.• After nasal application, rinse spray bottletip or nasal dropper with hot water anddry with clean tissue. Wipe tip of nasaljelly tube with clean tissue.• To prevent transmission of infection, don’tuse nasal form on more than one patient.• Assess for signs and symptoms of angina,arrhythmias, and hypertension becausephenylephrine may increase myocardialoxygen demand and the risk of proarrhythmiasand blood pressure changes.WARNING If patient has thyroid disease,watch for increased sensitivity to catecholaminesand possible thyrotoxicity orcardiotoxicity.WARNING Be aware that extravasation maycause tissue necrosis, gangrene, and otherreactions around injection site. Expect touse phentolamine if extravasation occurs.PATIENT TEACHING• If patient uses nasal form, explain thatexcessive use may cause rebound congestion.Urge her not to exceed recommendeddosage and to use for only 3 to 5 days.• Teach patient who uses nasal form how tocare for spray bottle, dropper, or tube.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.phenytoinDilantin-30 (CAN), Dilantin-125,Dilantin Infatabsphenytoin sodiumDilantin, Dilantin Kapseals, PhenytexClass and CategoryChemical class: Hydantoin derivativeTherapeutic class: AnticonvulsantPregnancy category: CIndications and Dosages To treat tonic-clonic, simple, or complexpartial seizures in patients who havehad no prior treatmentCHEWABLE TABLETS, ORAL SUSPENSION(PHENYTOIN)Adults and adolescents. Initial: 125 mgsuspension or 100 to 125 mg tablet t.i.d.,adjusted every 7 to 10 days as needed andtolerated.Children. Initial: 5 mg/kg daily in divideddoses b.i.d. or t.i.d., adjusted as needed andtolerated. Maintenance: 4 to 8 mg/kg dailyin divided doses b.i.d. or t.i.d. Maximum:300 mg daily.EXTENDED CAPSULES (PHENYTOIN SODIUM)Adults and adolescents. Initial: 100 mgt.i.d., adjusted every 7 to 10 days as neededand tolerated. Maintenance: Once seizuresare controlled, adjusted dosage given dailyif needed and tolerated.DOSAGE ADJUSTMENT For hospitalizedpatients without hepatic or renal disease,oral loading dose of 400 mg followed in2 hr by 300 mg and then in 2 more hr byanother 300 mg for a total of 1 g.Children. Initial: 5 mg/kg daily in divideddoses b.i.d. or t.i.d., adjusted as needed andtolerated. Maintenance: 4 to 8 mg/kg dailyin divided doses b.i.d. or t.i.d. Maximum:300 mg daily.PROMPT CAPSULES (PHENYTOIN SODIUM)Adults and adolescents. 100 mg t.i.d.,adjusted every 7 to 10 days as needed andtolerated.Children. Initial: 5 mg/kg daily in divideddoses b.i.d. or t.i.d., adjusted as needed andtolerated. Maintenance: 4 to 8 mg/kg dailyin divided doses b.i.d. or t.i.d. Maximum:300 mg daily. To treat status epilepticusI.V. INJECTION (PHENYTOIN SODIUM)Adults and adolescents. Initial: 15 to20 mg/kg by slow push in 50 ml sodiumchloride injection at no more than 50 mg/min. Maintenance: Beginning within 12 to24 hr of initial dose, 5 mg/kg daily P.O. individed doses b.i.d. to q.i.d., or 100 mg I.V.every 6 to 8 hr.

Children. 15 to 20 mg/kg at no more than1 mg/kg/min. Maximum: 50 mg/min.DOSAGE ADJUSTMENT For elderly or very illpatients and those with CV or hepatic disease,dosage reduced to 25 mg/min, as prescribed,or possibly as low as 5 to 10 mg/min to reduce the risk of adverse reactions. To prevent or treat seizures during neurosurgeryI.V. INJECTION (PHENYTOIN SODIUM)Adults. 100 to 200 mg every 4 hr at nomore than 50 mg/min during or immediatelyafter neurosurgery.Mechanism of ActionLimits the spread of seizure activity and thestart of new seizures by regulating voltagedependentsodium and calcium channels inneurons, inhibiting calcium movementacross neuronal membranes, and enhancingsodium-potassium ATP activity in neuronsand glial cells. These actions all help stabilizethe neurons.IncompatibilitiesDon’t mix phenytoin in same syringe withany other drugs or with any I.V. solutionsother than sodium chloride for injectionbecause precipitate will form.ContraindicationsAdams-Stokes syndrome, hypersensitivityto phenytoin or its components, SA block,second- or third-degree heart block, sinusbradycardiaInteractionsDRUGSacetaminophen: Possibly hepatotoxicity,decreased acetaminophen effectsactivated charcoal, antacids, calcium salts,enteral feedings, sucralfate: Decreasedabsorption of oral phenytoinallopurinol, benzodiazepines, chloramphenicol,cimetidine, disulfiram, fluconazole, isoniazid,itraconazole, methylphenidate, metronidazole,miconazole, omeprazole, phenacemide,ranitidine, sulfonamides, trazodone,trimethoprim: Decreased metabolism andincreased effects of phenytoinamiodarone, ticlopidine: Possibly increasedblood phenytoin levelantifungals (azole): Increased blood phenytoinlevel, decreased blood antifungal levelantineoplastics, nitrofurantoin, pyridoxine:Decreased phenytoin effectsphenytoin 823barbiturates: Variable effects on blood phenytoinlevelbupropion, clozapine, loxapine, MAO inhibitors,maprotiline, molindone, phenothiazines,pimozide, thioxanthenes, tricyclic antidepressants:Decreased seizure threshold,decreased anticonvulsant effectscalcium channel blockers: Increased metabolismand decreased effects of these drugs,possibly increased blood phenytoin levelcarbamazepine: Decreased blood level andeffects of carbamazepine, possibly phenytointoxicitycarbonic anhydrase inhibitors: Increased riskof osteopenia from phenytoinchlordiazepoxide, diazepam: Possiblyincreased blood phenytoin level, decreasedeffects of these drugsclonazepam: Possibly decreased blood leveland effects of clonazepam, possibly phenytointoxicitycorticosteroids, cyclosporine, dicumarol,digoxin, disopyramide, doxycycline, estrogens,furosemide, lamotrigine, levodopa,methadone, metyrapone, mexiletine, oralcontraceptives, quinidine, sirolimus, tacrolimus,theophylline: Increased metabolismand decreased effects of these drugsdopamine: Increased risk of severe hypotensionand bradycardia (with I.V. phenytoin)fluoxetine: Increased blood phenytoin leveland risk of phenytoin toxicityfolic acid, leucovorin: Decreased blood phenytoinlevel, increased risk of seizureshaloperidol: Decreased effects of haloperidol,decreased anticonvulsant effect ofphenytoinhalothane anesthetics: Increased risk ofhepatotoxicity and phenytoin toxicityifosfamide: Decreased phenytoin effects,possibly increased toxicityinfluenza virus vaccine: Possibly decreasedphenytoin effectsinsulin, oral antidiabetic drugs: Possiblyhyperglycemia, increased blood phenytoinlevel (with tolbutamide)levonorgestrel, mebendazole, streptozocin,sulfonylureas: Decreased effects of thesedrugslidocaine, propranolol (possibly other betablockers): Increased cardiac depressanteffects (with I.V. phenytoin), possiblydecreased blood level and increased adverseeffects of phenytoinP

824phenytoinlithium: Increased risk of lithium toxicity,increased risk of neurologic symptoms withnormal blood lithium levelmeperidine: Increased metabolism anddecreased effects of meperidine, possiblymeperidine toxicitymethadone: Possibly increased metabolismof methadone and withdrawal symptomsneuromuscular blockers: Shorter duration ofaction and decreased effects of neuromuscularblockersoral anticoagulants: Decreased metabolismand increased effects of phenytoin; earlyincrease and then decrease in anticoagulationparoxetine: Decreased bioavailability ofboth drugsphenylbutazone, salicylates: Increased phenytoineffects, possibly phenytoin toxicityprimidone: Increased primidone effects,possibly primidone toxicityrifampin: Increased hepatic metabolism ofphenytoinvalproic acid: Possibly decreased phenytoinmetabolism, resulting in increased phenytoineffects; possibly decreased blood valproicacid levelvitamin D: Possibly decreased vitamin Deffects, resulting in rickets or osteomalacia(with long-term use of phenytoin)ACTIVITIESalcohol use: Additive CNS depression,increased phenytoin clearanceAdverse ReactionsCNS: Ataxia, confusion, depression, dizziness,drowsiness, excitement, fever, headache,involuntary motor activity, lethargy,nervousness, peripheral neuropathy, restlessness,slurred speech, suicidal ideation,tremor, weaknessCV: Cardiac arrest, hypotension, vasculitisEENT: Amblyopia, conjunctivitis, diplopia,earache, epistaxis, eye pain, gingival hyperplasia,hearing loss, loss of taste, nystagmus,pharyngitis, photophobia, rhinitis, sinusitis,taste perversion, tinnitusENDO: Gynecomastia, hyperglycemiaGI: Abdominal pain, anorexia, constipation,diarrhea, epigastric pain, hepatic dysfunction,hepatic necrosis, hepatitis, nausea,vomitingGU: Glycosuria, priapism, renal failureHEME: Acute intermittent porphyria (exacerbation),agranulocytosis, anemia,eosinophilia, leukopenia, pancytopenia,thrombocytopeniaMS: Arthralgia, arthropathy, bone fractures,muscle twitching, osteomalacia, polymyositisRESP: Apnea, asthma, bronchitis, cough,dyspnea, hypoxia, increased sputum production,pneumonia, pneumothorax, pulmonaryfibrosisSKIN: Exfoliative dermatitis, jaundice, maculopapularor morbilliform rash, purpuricdermatitis, Stevens-Johnson syndrome,toxic epidermal necrolysis, unusual hairgrowth, urticariaOther: Facial feature enlargement, injectionsite pain, lupus-like symptoms, lymphadenopathy,polyarteritis, weight gain or lossNursing ConsiderationsWARNING Patients of Asian ancestry whohave the genetic allelic variant HLA-B1502 develop serious and sometimes fataldermatologic reactions ten times moreoften than people without this variantwhen given carbamazepine, anotherantiepileptic drug. Because early data suggesta similar effect with phenytoin, thisdrug shouldn’t be used as a substitute forcarbamazepine in these patients.• Be aware that preferred administrationroutes for phenytoin are oral and I.V.injection. With I.M. administration,phenytoin has a variable absorption rate.• If patient has difficulty swallowing, openprompt (rapid-release) capsules and mixcontents with food or fluid.• Shake oral suspension before measuringdose, and use a calibrated measuringdevice.• To minimize GI distress, give phenytoinwith or just after meals.• Inspect I.V. form for particles and discolorationbefore administering.WARNING Avoid rapid I.V. injectionbecause it may cause cardiac arrest, CNSdepression, or severe hypotension.• To decrease vein irritation, follow I.V.injection with flush of sodium chloride forinjection through same I.V. catheter.• Continuously monitor ECG tracings andblood pressure when administering I.V.phenytoin.• Frequently assess I.V. site for signs ofextravasation because drug can cause tissuenecrosis.

• If patient has an NG tube in place, minimizedrug absorption by polyvinyl chloridetubing by diluting suspension threefoldwith sodium chloride for injection,D 5 W, or sterile water. After administration,flush tube with at least 20 ml diluent.• Separate oral phenytoin administration byat least 2 hours from antacids and calciumsalts.• Expect continuous enteral feedings to disruptphenytoin absorption and, possibly,reduce blood phenytoin level. Discontinuetube feedings 1 to 2 hours before and afterphenytoin administration, as prescribed.Anticipate giving increased phenytoindoses to compensate for reduced bioavailabilityduring continuous tube feedings.• Monitor phenytoin level. Therapeutic levelranges from 10 to 20 mcg/L.WARNING Monitor patient’s hematologicstatus during therapy because phenytoincan cause blood dyscrasias. A patient witha history of agranulocytosis, leukopenia,or pancytopenia may have an increasedrisk of infection because phenytoin cancause myelosuppression.• Anticipate that drug may worsen intermittentporphyria.• Frequently monitor blood glucose level ofpatient with diabetes mellitus becausedrug can stimulate glucagon secretion andimpair insulin secretion, either of whichcan raise blood glucose level.• Monitor thyroid hormone levels in patientreceiving thyroid replacement therapybecause phenytoin may decrease circulatingthyroid hormone levels and increasethyroid-stimulating hormone level.• Be aware that long-term phenytoin therapymay increase patient’s requirements forfolic acid or vitamin D supplements.However, keep in mind that a diet high infolic acid may decrease seizure control.• Monitor patient closely for evidence ofsuicidal thinking or behavior, especiallywhen therapy starts or dosage changes.physostigmine salicylate 825PATIENT TEACHING• Instruct patient to crush or thoroughlychew phenytoin chewable tablets beforeswallowing or to shake oral solution wellbefore using.• Advise patient to take drug exactly as prescribedand not to change brands ordosage or stop taking drug unless instructedby prescriber.• Instruct patient to avoid taking antacids orcalcium products within 2 hours ofphenytoin.• Urge patient to avoid alcohol during therapy.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Inform patient with diabetes mellitusabout the increased risk of hyperglycemiaand the possible need for increased antidiabeticdrug dosage during therapy. Adviseher to check blood glucose level often.• Stress the importance of good oralhygiene, and encourage patient to informher dentist that she’s taking phenytoin.• Encourage patient to obtain medical identificationthat indicates her diagnosis anddrug therapy.• Urge caregivers to watch patient closely forevidence of suicidal tendencies, especiallywhen therapy starts or dosage changes andto report concerns at once to prescriber.• Encourage woman who becomes pregnantwhile taking phenytoin to enroll in theNorth American antiepileptic drug pregnancyregistry by calling 1-888-233-2334.Explain that the registry is collectinginformation about the safety of antiepilepticdrugs during pregnancy.physostigminesalicylateAntiliriumClass and CategoryChemical class: Salicylic acid derivativeTherapeutic class: Anticholinergic antidote,cholinesterase inhibitorPregnancy category: Not ratedIndications and Dosages To counteract toxic anticholinergiceffects (anticholinergic syndrome)I.V. OR I.M. INJECTIONAdults and adolescents. 0.5 to 2 mg at nomore than 1 mg/min; then 1 to 4 mg,repeated every 20 to 30 min as needed andas prescribed.Children. 0.02 mg/kg I.V., at no more than0.5 mg/min, repeated every 5 to 10 min asprescribed. Maximum: 2 mg/dose.P

826Mechanism of ActionBlocks sympathetic stimulation of beta 1receptors in the heart and beta 2 receptors invascular and bronchial smooth muscle bycompeting with adrenergic neurotransmitpindololMechanism of ActionInhibits destruction of acetylcholine byacetylcholinesterase. This action increasesacetylcholine concentration at cholinergictransmission sites and prolongs and exaggerateseffects of acetylcholine that areblocked by toxic doses of anticholinergics.Route Onset Peak DurationI.V. 3–8 min 5 min 30–60 minI.M. 3–8 min 20–30 min 30–60 minContraindicationsAsthma; cardiovascular disease; diabetesmellitus; gangrene; GI or GU obstruction;hypersensitivity to physostigmine, sulfites,or their componentsInteractionsDRUGScholine esters: Enhanced effects of carbacholand bethanechol with concurrent use ofphysostigmine, enhanced effects of acetylcholineand methacholine with prior use ofphysostigminesuccinylcholine: Prolonged neuromuscularparalysisAdverse ReactionsCNS: CNS stimulation, fatigue, hallucinations,restlessness, seizures (with too-rapidI.V. delivery), weaknessCV: Bradycardia (with too-rapid I.V. delivery),irregular heartbeat, palpitationsEENT: Increased salivation, lacrimation,miosisGI: Abdominal pain, diarrhea, nausea,vomitingGU: Urinary urgencyMS: Muscle twitchingRESP: Bronchospasm, chest tightness, dyspnea(with too-rapid I.V. administration),increased bronchial secretions, wheezingSKIN: DiaphoresisNursing Considerations• Use physostigmine cautiously in patientswith bradycardia, epilepsy, or Parkinson’sdisease.• Avoid rapid I.V. delivery, which may leadto bradycardia, respiratory distress, orseizures.• Check pulse and respiratory rates, bloodpressure, and neurologic status often.• Monitor ECG tracing during I.V. use.• Closely monitor patient with asthma forasthma attack because physostigmine mayprecipitate attack by causing bronchoconstriction.• Watch for seizures in patient with a historyof seizures because physostigmine caninduce seizures by stimulating CNS.WARNING Be alert for life-threateningcholinergic crisis, which may indicatephysostigmine overdose and may includeconfusion, diaphoresis, hypotension, miosis,muscle weakness, nausea, paralysis(including respiratory paralysis), salivation,seizures, sinus bradycardia, and vomiting.If you detect such signs, prepare togive atropine (the antidote) and use resuscitationequipment. Keep in mind thatatropine counteracts only muscariniccholinergic effects; paralytic effects maycontinue.PATIENT TEACHING• Reassure patient that vital signs will bemonitored often to help prevent or detectadverse reactions.• Instruct patient to notify prescriber atonce about evidence of cholinergic crisis.pindololNovoPindol (CAN), SynPindol (CAN),ViskenClass and CategoryChemical class: Nonselective beta blockerTherapeutic class: AntihypertensivePregnancy category: BIndications and Dosages To manage hypertensionTABLETSAdults. Initial: 5 mg b.i.d., increased by10 mg daily every 3 to 4 wk, as prescribed.Maintenance: 10 to 30 mg daily. Maximum:60 mg daily (U.S.), 45 mg daily (Canada).Route Onset Peak DurationP.O. Unknown 1–2 hr Up to 24 hr

ters, such as catecholamines. Pindolol’s negativechronotropic effects slow the restingheart rate and reduce exercise-inducedtachycardia. Its negative inotropic effectsreduce cardiac output, myocardial contractility,systolic and diastolic blood pressure,and myocardial oxygen consumption duringstress or exercise. Among beta blockers,pindolol has the most intrinsic sympathomimeticactivity and nonselective antagonism.ContraindicationsAdvanced AV block; asthma; bronchospasm;cardiogenic shock; heart failure;hepatic disease; hypersensitivity to pindolol,other beta blockers, or their components;hypotension (with systolic pressure lessthan 100 mm Hg); sinus bradycardiaInteractionsDRUGSallergy extracts or immunotherapy, iodinatedcontrast media: Increased risk of systemicreaction or anaphylaxisaluminum salts, barbiturates, calcium salts,certain penicillins, cholestyramine, colestipol,NSAIDs, rifampin, salicylates, sulfinpyrazone:Decreased blood level and effects ofpindololantihypertensives: Additive hypotensiveeffectbeta blockers, digoxin: Increased risk ofbradycardiacalcium channel blockers, quinidine: Possiblyincreased effects of both drugs, symptomaticbradycardia (with diltiazem or verapamil),excessive hypertension or heart failure(with nifedipine)cimetidine: Increased blood pindolol levelepinephrine: Possibly hypertension followedby bradycardiaergotamine: Possibly severe peripheral vasoconstrictionwith pain and cyanosisestrogens: Decreased antihypertensive effectfentanyl, fentanyl derivatives: Risk of bradycardiaafter anesthesia inductioninsulin, oral antidiabetic drugs: Maskedsymptoms of hypoglycemia, increased riskof hyperglycemialidocaine: Increased risk of lidocaine toxicityMAO inhibitors: Possibly hypertensionneuromuscular blockers: Possibly increasedor prolonged neuromuscular blockadephenothiazines: Increased blood levels ofpindolol 827both drugsphenytoin: Possibly increased cardiacdepressant effectsprazosin, reserpine: Increased risk of orthostatichypotension, bradycardia (with reserpine)quinolones: Possibly increased bioavailabilityof pindololxanthines: Possibly decreased effects of bothdrugs, decreased xanthine clearanceAdverse ReactionsCNS: Anxiety, confusion, depression, dizziness,fatigue, fever, hallucinations, hypothermia,insomnia, memory loss, paresthesia,peripheral neuropathy, stroke, syncope,weaknessCV: Arrhythmias (including AV block andbradycardia), chest pain, decreased peripheralcirculation, heart failure, hyperlipidemia,hypotension, MI, orthostatic hypotension,peripheral edema and ischemia,thrombosis of renal or mesenteric arteryEENT: PharyngitisENDO: Hyperglycemia, hypoglycemiaGI: Colitis (ischemic), constipation, diarrhea,elevated liver function test results, gastritis,nausea, pancreatitis, vomitingGU: Cystitis, decreased libido, renal colic,renal failure, urinary frequency, urine retention,UTIHEME: Agranulocytosis, bleeding, eosinophilia,leukopenia, nonthrombocytopenicpurpura, thrombocytopenia, thrombocytopenicpurpura, unusual bleeding or bruisingMS: Arthralgia, back painRESP: Bronchospasm, pulmonary edema,pulmonary emboliSKIN: Acne; alopecia; crusted, red, or scalyskin; diaphoresis; eczema; exfoliative dermatitis;hyperpigmentation; pruritus; purpura;rashOther: Angioedema, positive ANA titerNursing Considerations• Check blood pressure and pulse rate often,especially at start of pindolol therapy. Alsomonitor fluid intake and output and dailyweight, and assess for evidence of heartfailure, such as dyspnea, edema, fatigue,and jugular vein distention.• Be aware that drug shouldn’t be stoppedabruptly because MI, myocardial ischemia,severe hypertension, or ventriculararrhythmias may result.P

828pioglitazone hydrochloride• Expect to discontinue drug up to 2 daysbefore surgery, as prescribed, to reduce therisk of heart failure.• Assess distal circulation and peripheralpulses in patient with Raynaud’s phenomenonor other peripheral vascular disorderbecause drug can worsen these conditions.• Be aware that pindolol can mask tachycardiafrom hyperthyroidism; abrupt withdrawalcan cause thyroid storm. Drug alsomay potentiate diplopia and muscle weaknessin patient with myasthenia gravis;decrease blood glucose level, prolong ormask symptoms of hypoglycemia, andpromote hyperglycemia in patient withdiabetes mellitus; and worsen psoriasis.PATIENT TEACHING• Instruct patient to weigh herself daily duringpindolol therapy and to notify prescriberif she gains more than 2 lb (0.9 kg)in 1 day or 5 lb (2.3 kg) in 1 week.• Caution patient not to stop drug abruptly.• Advise patient to rise slowly from a seatedor lying position to minimize effects oforthostatic hypotension.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to contact prescriberabout bleeding or bruising, cough atnight, depression, dizziness, edema, rash,shortness of breath, slow pulse rate, orsore throat.• Advise diabetic patient to monitor herblood glucose level more often during pindololtherapy because drug may masksymptoms of hypoglycemia.• Inform patient with psoriasis that drugmay aggravate this condition.pioglitazonehydrochlorideActosClass and CategoryChemical class: ThiazolidinedioneTherapeutic class: AntidiabeticPregnancy category: CIndications and Dosages To achieve glucose control in type 2diabetes mellitus as monotherapy orin combination with insulin, metformin,or a sulfonylureaTABLETSAdults. Initial: 15 or 30 mg daily.Maximum: 45 mg daily.DOSAGE ADJUSTMENT For patients takinginsulin, insulin dosage decreased by 10% to25%, as prescribed, once glucose levelreaches 100 mg/dl or less. If hypoglycemiaoccurs, dosage of any concurrent antidiabeticis reduced, as prescribed.Mechanism of ActionDecreases insulin resistance by enhancingthe sensitivity of insulin-dependent tissues,such as adipose tissue, skeletal muscle, andthe liver, and reduces glucose output fromthe liver. Drug activates peroxisome proliferator-activatedreceptor-gamma (PPARg)receptors, which modulate transcription ofinsulin-responsive genes involved in glucosecontrol and lipid metabolism. In this way,pioglitazone reduces hyperglycemia, hyperinsulinemia,and hypertriglyceridemia inpatients with type 2 diabetes mellitus andinsulin resistance. However, to work effectively,pioglitazone needs endogenousinsulin. Unlike sulfonylureas, it doesn’tincrease pancreatic insulin secretion.ContraindicationsDiabetic ketoacidosis, hypersensitivity topioglitazone or its components, New YorkHeart Association (NYHA) Class III or IVheart falure, severe hepatic dysfunction, type1 diabetes mellitusInteractionsDRUGSgemfibrozil, rifampin: Possibly altered glucosecontrolketoconazole: Possibly decreased metabolismof pioglitazoneoral contraceptives: Possibly decreased effectivenessof oral contraceptivesAdverse ReactionsCNS: HeadacheCV: Congestive heart failure, edemaEENT: Blurred vision, decreased visual acuity,macular edema, pharyngitis, sinusitis,tooth disordersHEME: Decreased hemoglobin level andhematocritMS: Fractures, myalgiaRESP: Upper respiratory tract infectionOther: Weight gain

Nursing Considerations• Be aware that pioglitazone isn’t recommendedfor patients with symptopmaticheart failure.• Be prepared to monitor liver function testresults before therapy begins, every 2months during first year, and annuallythereafter, as ordered, because drug isextensively metabolized in the liver. Expectto stop drug if jaundice develops or ALTvalues exceed 2.5 times normal.WARNING Monitor patient for signs andsymptoms of congestive heart failure—such as shortness of breath, rapid weightgain, or edema—because pioglitazone cancause fluid retention that may lead to orworsen heart failure. Notify prescriberimmediately of any deterioration in thepatient’s cardiac status, and expect to discontinuethe drug, as ordered.• Assess for signs and symptoms ofhypoglycemia, especially if patient is alsotaking another antidiabetic drug.• Monitor fasting glucose level, as ordered,to evaluate effectiveness of therapy.• Monitor glycosylated hemoglobin level toassess drug’s long-term effectiveness.PATIENT TEACHING• Stress the need for patient to continueexercise program, diet control, and weightmanagement during pioglitazone therapy.• Advise patient to notify prescriber immediatelyif she experiences shortness ofbreath, fluid retention, or sudden weightgain because drug may need to be discontinued.• Urge patient to report vision changespromptly and expect to have an eye examinationby an ophthalmologist regardlessof when the last examination occurred.• Instruct patient to keep appointments forliver function tests, as ordered, typicallyevery 2 months during first year of therapyand annually thereafter.• Inform female patient who uses oral contraceptivesthat drug decreases their effectiveness;suggest that she use anothermethod of contraception while taking pioglitazone.• Also inform female patient that she maybe at risk for fractures during pioglitazonetherapy, and urge her to take safety precautionsto prevent falls and otherinjuries.piperacillin sodium 829piperacillin sodiumPipracilClass and CategoryChemical class: Piperazine derivative ofampicillin, acylureidopenicillinTherapeutic class: AntibioticPregnancy category: BIndications and Dosages To treat moderate to severe bacterialinfections, including bone and jointinfections, gynecologic infections, intraabdominalinfections, lower respiratorytract infections, septicemia, and skinand soft-tissue infections, caused by susceptiblestrains of Acinetobacter species,anaerobic cocci, Bacteroides species,Enterobacter species, Escherichia coli,Haemophilus influenzae, Klebsiellaspecies, Proteus species, Pseudomonasaeruginosa, and Serratia speciesI.V. INFUSIONAdults and adolescents. 12 to 18 g daily or200 to 300 mg/kg daily in divided dosesevery 4 to 6 hr. Maximum: 24 g daily. To treat bacterial meningitisI.V. INFUSIONAdults and adolescents. 4 g every 4 hr or75 mg/kg every 6 hr. Maximum: 24 g daily. To treat uncomplicated UTI and community-acquiredpneumonia caused bysusceptible organisms, including E. coli,Klebsiella species, and Serratia speciesI.V. INFUSION, I.M. INJECTIONAdults. 6 to 8 g daily or 100 to 125 mg/kgdaily in divided doses every 6 to 12 hr. To treat complicated UTI caused by susceptibleorganisms, includingAcinetobacter species, Klebsiella species,and Serratia speciesI.V. INFUSIONAdults. 8 to 16 g daily or 125 to 200 mg/kgdaily in divided doses every 6 to 8 hr. To treat uncomplicated gonorrheacaused by susceptible strains of NeisseriagonorrhoeaeI.M. INJECTIONAdults. 2 g as a single dose 30 min after 1-gdose of probenecid P.O. To provide surgical prophylaxis in intraabdominalprocedures, including GI andbiliary surgeryP

830piperacillin sodiumI.V. INFUSIONAdults. 2 g 20 to 30 min before anesthesia,2 g during surgery, and 2 g every 6 hr for24 hr after surgery. To provide surgical prophylaxis inabdominal hysterectomyI.V. INFUSIONAdults. 2 g 20 to 30 min before anesthesia,2 g just after surgery, and 2 g 6 hr later. To provide surgical prophylaxis in vaginalhysterectomyI.V. INFUSIONAdults. 2 g 20 to 30 min before anesthesia,then 2 g 6 and 12 hr after initial dose. To provide surgical prophylaxis incesarean sectionI.V. INFUSIONAdults. 2 g after cord is clamped, then 2 g4 and 8 hr after initial dose.Mechanism of ActionBinds to specific penicillin-binding proteinsand inhibits the third and final stage of bacterialcell wall synthesis by interfering withan autolysin inhibitor. Uninhibited autolyticenzymes destroy the cell wall and resultin cell lysis.IncompatibilitiesDon’t mix piperacillin sodium in same containerwith aminoglycosides because ofchemical incompatibility (depending onconcentrations, diluents, pH, and temperature).Don’t mix with solutions that containonly sodium bicarbonate because of chemicalinstability.ContraindicationsHypersensitivity to cephalosporins, penicillins,or their componentsInteractionsDRUGSaminoglycosides: Additive or synergisticeffects against some bacteria, possiblymutual inactivationanti-inflammatory drugs (including aspirinand NSAIDs), heparin, oral anticoagulants,platelet aggregation inhibitors, sulfinpyrazone,thrombolytics: Increased risk of bleedinghepatotoxic drugs (including labetalol andrifampin): Increased risk of hepatotoxicitymethotrexate: Increased blood methotrexatelevel and risk of toxicityprobenecid: Increased blood piperacillinlevel and risk of toxicityvecuronium: Possibly prolonged perioperativeneuromuscular blockade of vecuroniumAdverse ReactionsCNS: Dizziness, fever, hallucinations,headache, lethargy, seizures, strokeCV: Cardiac arrest, hypotension, palpitations,tachycardia, vasodilation, vasovagalreactionsEENT: Oral candidiasis, pharyngitisGI: Diarrhea, epigastric distress, intestinalnecrosis, nausea, pseudomembranous colitis,vomitingGU: Hematuria, impotence, nephritis,neurogenic bladder, priapism, proteinuria,renal failure, vaginal candidiasisHEME: Agranulocytosis, eosinophilia,hemolytic anemia, leukopenia, neutropenia,pancytopenia, prolonged bleeding time,thrombocytopeniaMS: ArthralgiaRESP: Dyspnea, pulmonary embolism, pulmonaryhypertensionSKIN: Exfoliative dermatitis, mottling, rash,toxic epidermal necrolysis, urticariaOther: Anaphylaxis; facial edema; hypokalemia;hyponatremia; injection site pain,phlebitis, and skin ulcer; superinfectionNursing Considerations• Expect to obtain blood, sputum, or othersamples for culture and sensitivity testingbefore giving piperacillin and to start therapybefore results are available.• Be aware that sunlight may darkenpiperacillin powder for dilution but won’talter drug potency.• For initial dilution for I.V. infusion, reconstituteeach gram of drug with at least5 ml sterile water for injection, sodiumchloride for injection, D 5 W, dextrose 5%in normal saline solution, or bacteriostaticwater that contains parabens or benzylalcohol. Shake solution vigorously afteradding diluent, and inspect for particlesand discoloration before giving.• For further dilution, use sodium chloridefor injection, D 5 W, dextrose 5% in normalsaline solution, lactated Ringer’s solution,or dextran 6% in normal saline solution.Solutions diluted with lactated Ringer’ssolution should be given within 2 hours.• For intermittent infusion, infuse appropriatedose over 20 to 30 minutes.• Give aminoglycosides 1 hour before or

after piperacillin; use a separate site, I.V.bag, and tubing.• For I.M. injection, reconstitute each gramof piperacillin with at least 2 ml of anappropriate diluent listed above.• Don’t give more than 2 g I.M. in one site.Use deltoid area cautiously and only if welldeveloped to avoid injuring radial nerve.• Watch for bleeding or excessive bruisingbecause drug can decrease platelet aggregation,especially in patients with renalfailure. If bleeding occurs, notify prescriberand expect to stop piperacillin.• Monitor CBC regularly, as ordered, todetect hematologic abnormalities, such asleukopenia and neutropenia.• Monitor serum potassium level to detecthypokalemia from urinary potassium loss.• Check for diarrhea during and after therapybecause it may indicate pseudomembranouscolitis caused by Clostridium difficile.If diarrhea occurs, notify prescriberand expect to withhold piperacillin andtreat with fluids, electrolytes, protein, andan antibiotic effective against C. difficile.• Watch for hypersensitivity reactions, especiallyif patient has cystic fibrosis. Notifyprescriber, and expect to stop drug.PATIENT TEACHING• Advise patient to consult prescriber beforeusing OTC drugs during piperacillin therapybecause of the risk of interactions.• Inform patient that increased bruisingmay occur if she takes anti-inflammatorydrugs during piperacillin therapy.• Advise patient to notify prescriber aboutsigns of superinfection, such as whitepatches on tongue or in mouth.• Urge patient to tell prescriber about diarrheathat’s severe or lasts longer than 3days. Remind patient that watery orbloody stools can occur 2 or more monthsafter antibiotic therapy and can be serious,requiring prompt treatment.• Instruct patient to complete full course oftherapy, even if symptoms subside.pirbuterol acetateMaxair, Maxair AutohalerClass and CategoryChemical class: Sympathomimetic aminepirbuterol acetate 831Therapeutic class: BronchodilatorPregnancy category: CIndications and Dosages To prevent or treat bronchospasmcaused by COPD, to treat bronchospasmcaused by asthmaORAL INHALATIONAdults and adolescents. 1 or 2 inhalations(200 to 400 mcg) every 4 to 6 hr.Maximum: 12 inhalations (2.4 mg) daily.Route Onset Peak DurationOral in- In 5 min In 30–90 3–6 hrhalationminMechanism of ActionAttaches to beta 2 receptors on bronchial cellmembranes, which stimulates the intracellularenzyme adenyl cyclase to convertadenosine triphosphate (ATP) to cAMP.The increased intracellular level of cAMPrelaxes bronchial smooth-muscle cells andinhibits histamine release. Pirbuterol alsostabilizes mast cells and inhibits the releaseof histamine.ContraindicationsHypersensitivity to pirbuterol or its components,tachycardiaInteractionsDRUGSbeta-adrenergic bronchodilators: Additiveeffectsbeta blockers (ophthalmic): Possiblydecreased pirbuterol effects, increased riskof bronchospasmbeta blockers (systemic): Decreased effects ofboth drugs, increased risk of bronchospasmMAO inhibitors, tricyclic antidepressants:Potentiated cardiovascular effectsAdverse ReactionsCNS: Anxiety, confusion, depression, dizziness,headache, nervousness, tiredness, tremorCV: Arrhythmias (including PVCs andtachycardia), chest pain, ECG changes(including flattening of T waves, prolongedQT interval, and ST-segment depression),hypotension, palpitationsEENT: Dry mouthGI: Abdominal cramps, diarrhea, nausea,vomitingRESP: Bronchospasm, coughP

832piroxicamSKIN: Alopecia, rash, urticariaOther: Facial edema, hypokalemiaNursing Considerations• For patient with a cardiovascular disorder,such as arrhythmia, hypertension, or ischemiccardiac disease, monitor blood pressureand heart rate and rhythm to detectsignificant changes after pirbuterol use.• Be aware that elderly patients have greaterrisk of adverse reactions than youngeradults.WARNING Stop giving drug and notify prescriberimmediately if patient has paradoxicalbronchospasm, a life-threateningadverse reaction.PATIENT TEACHING• Teach patient how to use an inhaler andspacer correctly, and urge her to keep theinhaler readily available at all times.• Recommend the use of an autohaler ifpatient has trouble coordinating inhalationswith a regular inhaler.• Advise patient to clean the inhaler’smouthpiece at least once daily.• Caution patient against overusing drugbecause doing so may increase adversereactions.• Teach patient how to use peak flow meterand determine her personal best reading.WARNING Advise patient to notify prescriberif symptoms worsen, if bronchospasmoccurs more frequently, if sheneeds to use the inhaler more often, or ifthe inhaler becomes less effective.piroxicamApo-Piroxicam (CAN), Feldene,Novo-Pirocam (CAN), Nu-Pirox (CAN),PMS-Piroxicam (CAN)Class and CategoryChemical class: Oxicam derivativeTherapeutic class: Anti-inflammatory, antirheumaticPregnancy category: Not ratedIndications and Dosages To treat acute and chronic osteoarthritisand rheumatoid arthritisCAPSULESAdults. Initial: 20 mg once daily or 10 mgb.i.d.Mechanism of ActionBlocks the activity of cyclooxygenase, theenzyme needed for prostaglandin synthesis.Prostaglandins, important mediators of theinflammatory response, cause local vasodilationwith swelling and pain. By blockingcyclooxygenase activity and inhibitingprostaglandins, this NSAID reduces inflammatorysymptoms and pain.Route Onset Peak DurationP.O. Unknown Several Unknowndays to1 wk*ContraindicationsAngioedema, asthma, bronchospasm, nasalpolyps, rhinitis, or urticaria induced byaspirin, iodides, or other NSAIDs; hypersensitivityto piroxicam or its componentsInteractionsDRUGSacetaminophen: Possibly increased adverserenal effects with long-term use of bothdrugsantihypertensives: Possibly decreased orreversed effects of antihypertensivesaspirin, other NSAIDs: Increased risk ofbleeding and adverse GI effects, possiblyincreased blood piroxicam levelcefamandole, cefoperazone, cefotetan:Increased risk of hypoprothrombinemiaand bleedingcolchicine: Increased risk of GI bleeding,hemorrhage, and ulcerscorticosteroids, potassium supplements:Increased risk of adverse GI effectscyclosporine: Increased risk of nephrotoxicityfrom both drugs, increased bloodcyclosporine leveldiuretics: Decreased antihypertensive,diuretic, and natriuretic effects of diureticsgold compounds, nephrotoxic drugs:Increased risk of adverse renal effectsheparin, oral anticoagulants, thrombolytics:Increased anticoagulant effects, increasedrisk of hemorrhageinsulin, oral antidiabetic drugs: Possiblyincreased hypoglycemic effect of thesedrugslithium: Possibly increased blood lithium* With severe inflammation, 2 wk or more.

level and toxicitymethotrexate: Decreased methotrexateclearance and increased risk of methotrexatetoxicityplatelet aggregation inhibitors: Increased riskof bleeding and GI ulceration or hemorrhageplicamycin, valproic acid: Increased risk ofhypoprothrombinemia and GI bleeding,hemorrhage, and ulcerationprobenecid: Possibly increased blood level,effectiveness, and risk of toxicity of piroxicamACTIVITIESalcohol use: Increased risk of adverse GIeffectsAdverse ReactionsCNS: Anxiety, aseptic meningitis, asthenia,cerebral hemorrhage, confusion, depression,dizziness, dream disturbances, drowsiness,fever, headache, insomnia, ischemicstroke, malaise, nervousness, paresthesia,somnolence, syncope, transient ischemicattack, tremor, vertigoCV: Deep vein thrombosis, edema, heartfailure, hypertension, MI, peripheral edema,tachycardiaEENT: Blurred vision, dry mouth, epistaxis,glossitis, stomatitis, tinnitusENDO: HypoglycemiaGI: Abdominal pain; anorexia; constipation;diarrhea; elevated liver function test results;esophagitis; flatulence; gastritis; GI bleeding,perforation, or ulceration; heartburn;hematemesis; hepatitis; indigestion; jaundice;liver failure; melena; nausea; vomitingGU: Acute renal failure, cystitis, dysuria,elevated serum creatinine level, hematuria,interstitial nephritis, nephrotic syndrome,oliguria, polyuria, proteinuria, renal failureor insufficiencyHEME: Agranulocytosis, anemia, aplasticanemia, coagulation abnormalities,eosinophilia, leukopenia, pancytopenia,thrombocytopeniaRESP: Asthma, dyspneaSKIN: Alopecia, diaphoresis, ecchymosis,erythema, erythema multiforme, exfoliativedermatitis, photosensitivity, pruritus, purpura,rash, Stevens-Johnson syndrome,toxic epidermal necrolysis, urticariaOther: Anaphylaxis, angioedema, flulikesymptoms, hyperkalemia, infection, sepsis,weight loss or gainpiroxicam 833Nursing Considerations• Administer piroxicam with food todecrease GI upset.• Use piroxicam with extreme caution inpatients with a history of ulcer disease orGI bleeding because NSAIDs such aspiroxicam increase risk of GI bleeding andulceration. Expect to use piroxicam for theshortest time possible in these patients.• Be aware that serious GI tract ulceration,bleeding, and perforation may occur withoutwarning symptoms. Elderly patientsare at greater risk. To minimize risk, givedrug with food. If GI distress occurs, withholddrug and notify prescriber at once.• Use piroxicam cautiously in patients withhypertension, and monitor blood pressureclosely throughout therapy. Drug maycause hypertension or worsen it.WARNING Monitor patient closely forthrombotic events, including MI andstroke, because NSAIDs increase the risk.WARNING If patient has bone marrow suppressionor is receiving antineoplastic drugtherapy, monitor laboratory results(including WBC count), and watch forevidence of infection because anti-inflammatoryand antipyretic actions of piroxicammay mask signs and symptoms, suchas fever and pain.• Especially if patient is elderly or takingdrug long-term, watch for less commonbut serious adverse GI reactions, includinganorexia, constipation, diverticulitis, dysphagia,esophagitis, gastritis, gastroenteritis,gastroesophageal reflux disease, hemorrhoids,hiatal hernia, melena, stomatitis,and vomiting.• Monitor liver function test results because,rarely, elevated levels may progress tosevere hepatic reactions, including fatalhepatitis, liver necrosis, and hepatic failure.• Monitor BUN and serum creatinine levelsin patients with heart failure, impairedrenal function, or hepatic dysfunction;those taking diuretics or ACE inhibitors;and elderly patients because drug maycause renal failure.• Monitor CBC for decreased hemoglobinlevel and hematocrit because drug mayworsen anemia.• Assess patient’s skin routinely for rash orother signs of hypersensitivity reactionP

834pitavastatinbecause piroxicam and other NSAIDs maycause serious skin reactions without warning,even in patients with no history ofNSAID hypersensitivity. Stop drug at firstsign of reaction, and notify prescriber.WARNING Be aware that drug may causepremature closure of ductus arteriosus ingrowing fetus during third trimester ofpregnancy. Be prepared to suggest referralfor high-risk pregnancy.PATIENT TEACHING• Advise patient to take piroxicam withmeals to minimize GI distress. Also directher to take drug with a full glass of waterand to remain upright for 30 minutesafterward to decrease risk of drug lodgingin esophagus and causing irritation.• Instruct patient to swallow capsules wholeand not to crush, break, chew, or openthem.• Advise patient to avoid alcohol, aspirin,and other NSAIDs, unless prescribed,while taking piroxicam.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• If patient also takes an anticoagulant,advise her to watch for and immediatelyreport bleeding problems, such as bloodyor tarry stools and bloody vomitus.• If patient also takes insulin or an oralantidiabetic, advise her to closely monitorblood glucose level to prevent hypoglycemia.Urge her to carry candy or othersimple sugars to treat mild hypoglycemia.Advise her to notify prescriber if hypoglycemicepisodes are frequent or severe.• Explain that piroxicam may increase riskof serious adverse cardiovascular reactions;urge patient to seek immediatemedical attention if signs or symptomsarise, such as chest pain, shortness ofbreath, weakness, and slurring of speech.• Tell patient that piroxicam may increaserisk of serious adverse GI reactions; stressthe need to seek immediate medical attentionfor such signs and symptoms as epigastricor abdominal pain, indigestion,black or tarry stools, or vomiting blood ormaterial that looks like coffee grounds.• Alert patient to possibility of rare but seriousskin reactions. Urge her to seek immediatemedical care for rash, blisters, itching,fever, or other signs of hypersensitivity.• Instruct female patient to consult prescriberif she becomes pregnant becausedrug may cause premature closure of ductusarteriosus in growing fetus.pitavastatinLivaloClass and CategoryChemical class: HMG-CoA reductaseinhibitorTherapeutic class: Antihyperlipidemic, statinPregnancy category: XIndications and Dosages To decrease elevated total cholesterol,LDL, apolipoprotein B, and triglyceridelevels and increase HDL level as adjunctto diet in patients with primary hyperlipidemiaor mixed dyslipidemiaTABLETSAdults. Initial: 2 mg once daily, increased asneeded. Maximum: 4 mg once dailyDOSAGE ADJUSTMENT For patients withmoderate renal impairment (glomerular filtrationrate 30 to 60 ml/min/1.73m 2 ) orpatients receiving dialysis, initial dosagereduced to 1 mg once daily, with maximumof 2 mg once daily. For patients takingerythromycin, dosage shouldn’t exceed1 mg daily; for patients taking rifampin,dosage shouldn’t exceed 2 mg daily.Route Onset Peak DurationP.O. Unknown 1 hr UnknownMechanism of ActionReduces plasma cholesterol and lipoproteinlevels by inhibiting HMG-CoA reductaseand cholesterol synthesis in the liver.Consequently, number of LDL receptors onliver cells increases, and LDL uptake andbreakdown are enhanced. With sustainedinhibition of cholesterol synthesis in theliver, levels of very low-density lipoproteinsare decreased.ContraindicationsActive liver disease (including unexplainedpersistent LFT elevation), breast-feeding,concurrent cyclosporine therapy, hypersensitivityto pitavastatin or its components,women who are pregnant or may becomepregnant

InteractionsDRUGScyclosporine, erythromycin, lopinavir andritonavir, rifampin: Increased pitavastatinexposurefibrates such as gemfibrozil: Increased risk ofmyopathyniacin: Increased risk of adverse skeletalmuscle effectsAdverse ReactionsCNS: HeadacheEENT: NasopharyngitisENDO: Elevated blood glucose levelGI: Constipation, diarrhea, elevated liverenzyme levelsGU: Acute renal failure, myoglobinuriaMS: Arthralgia, back or extremity pain,myopathy, myositis, rhabdomyolysisSKIN: Pruritus, rash, urticariaOther: Elevated creatine phosphkinaselevel, influenzaNursing Considerations• Be aware that pitavastatin isn’t recommendedfor patients with severe renalimpairment who aren’t on dialysis and forpatients currently receiving lopinavir andritonavir therapy because of increased riskof serious adverse effects.• Note that pravastatin, another HMG-CoAreductase inhibitor, sounds similar topitavastatin and could be confusing. Makesure of correct drug before giving.• Use pitavastatin cautiously in patientswith risk factors for myopathy, such as ageover 65, presence of renal impairment,being inadequately treated for hypothyroidism,or concurrent use of niacincontainingproducts or fibrates. Monitorpatient throughout therapy for muscularcomplaints and an elevated blood creatinekinase level, as ordered. Drug should bediscontinued if patient’s creatine kinaselevel becomes markedly elevated ormyopathy is suspected or confirmed.• Expect liver function tests to be donebefore pitavastatin starts, after 6 and12 weeks of therapy, with each dosageincrease, and every 6 months thereafter.• Expect to monitor patient’s lipid levelsafter 4 weeks of therapy to determine drugeffectiveness and periodically thereafter, asordered. Expect dosage to be adjusted iflipid levels remain elevated.polymyxin B sulfate 835PATIENT TEACHING• Stress that pitavastatin is an adjunct to,not a substitute for, a low-cholesterol diet.• Tell patient to take drug at the same timeeach day to maintain its effects.• Instruct patient to report unexplainedmuscle pain, tenderness, or weakness, especiallyif accompanied by malaise or fever.• Advise patient to limit alcohol ingestionwhile taking pitavastatin because alcoholinducedliver dysfunction may be difficultto differentiate from pitavastatin-inducedliver dysfunction.• Instruct patient to consult prescriberbefore taking OTC niacin products becauseof increased risk of adverse muscle effects.• Caution women of childbearing age thatdrug is contraindicated in pregnancybecause drug could be harmful to thebaby. If pregnancy is suspected, patientshould notify prescriber immediately.polymyxin B sulfateAerosporinClass and CategoryChemical class: Bacillus polymyxa derivativeTherapeutic class: AntibioticPregnancy category: Not ratedIndications and Dosages To treat infections resistant to less toxicdrugs, such as bacteremia, septicemia,and UTI caused by susceptible organisms,including Enterobacter aerogenes,Escherichia coli, Haemophilus influenzae,and Klebsiella pneumoniaeI.V. INFUSIONAdults and children age 2 and over.15,000 to 25,000 units/kg daily in divideddoses every 12 hr or as a continuous infusion.Maximum: 2 million units daily.Infants and children under age 2. Up to40,000 units/kg daily in divided doses every12 hr or as a continuous infusion.I.M. INJECTIONAdults and children age 2 and over.25,000 to 30,000 units/kg daily in divideddoses every 4 to 6 hr. Maximum: 2 millionunits daily.Infants and children under age 2. Up to40,000 units/kg daily in divided doses everyP

836Nursing Considerations• Be aware that patients receiving polymyxinB sulfate are hospitalized to allow appropriatesupervision.• Obtain blood, urine, or other samples forculture and sensitivity tests, as ordered,before giving drug. Expect to start drugbefore results are known. Keep in mindthat baseline renal function tests shouldhave been performed before administration.Check test results, if available, andnotify prescriber of abnormalities.• For I.M. injection, reconstitute sterilepowder with 2 ml of sterile water forinjection or sodium chloride for injection.• Be aware that I.M. route isn’t usually recommended(especially for infants andchildren) because it can cause severe painat injection site.• For I.V. infusion, dissolve polymyxin B in300 to 500 ml of D 5 W and infuse over60 to 90 minutes.• For intrathecal route, add 10 ml sodiumchloride for injection to polymyxin B vial.• Inspect for particles and discolorationbefore giving drug.• During therapy, monitor renal function,including BUN and serum creatinine levpolymyxinB sulfate4 to 6 hr.DOSAGE ADJUSTMENT Dosage reduced by50% for patients with creatinine clearanceof 5 to 20 ml/min/1.73 m 2 ; by 85% forpatients with creatinine clearance of lessthan 5 ml/min/ 1.73 m 2 . To prevent bacteriuria and bacteremiain patients with an indwellingcatheterBLADDER IRRIGATIONAdults and children age 2 and over.Combination of 200,000 units (20 mg)polymyxin B sulfate and 57 mg neomycinsulfate added to 1,000 ml normal salinesolution daily as a continuous bladder irrigationfor up to 10 days; rate adjusted asprescribed, based on patient’s urine output. To treat meningitis caused by susceptiblestrains of Pseudomonas aeruginosa orH. influenzaeINTRATHECAL INJECTIONAdults and children age 2 and over.50,000 units daily for 3 to 4 days, then50,000 units every other day for at least2 wk after CSF cultures are negative andglucose content is normal.Infants and children under age 2.20,000 units daily for 3 to 4 days, then25,000 units every other day for at least2 wk after CSF cultures are negative andglucose content is normal.Mechanism of ActionBinds to cell membrane phospholipids ingram-negative bacteria, increasing permeabilityof cell membrane. Polymyxin B alsoacts as a cationic detergent, altering osmoticbarrier of membrane and causing essentialintracellular metabolites to leak out. Bothactions lead to cell death.IncompatibilitiesDon’t mix polymyxin B sulfate withamphotericin B, calcium salts, chloramphenicol,chlorothiazide, heparin sodium,magnesium salts, nitrofurantoin, penicillins,prednisolone, and tetracyclines.They’re incompatible.ContraindicationsHypersensitivity to polymyxin B or its componentsInteractionsDRUGSgeneral anesthetics, neuromuscular blockers,skeletal muscle relaxants: Increased or prolongedskeletal muscle relaxation, possiblyrespiratory paralysisnephrotoxic and neurotoxic drugs (such asaminoglycosides, amphotericin B, colistin,sodium citrate, streptomycin, tobramycin,and vancomycin): Increased risk of nephrotoxicityand neurotoxicityAdverse ReactionsCNS: Ataxia, confusion, dizziness, drowsiness,fever, giddiness, headache, increasedleukocyte and protein levels in CSF, neurotoxicity,paresthesia (circumoral or peripheral),slurred speechCV: ThrombophlebitisEENT: Blurred vision, nystagmusGU: Albuminuria, azotemia, cylindruria,decreased urine output, hematuria,nephrotoxicityHEME: EosinophiliaRESP: Respiratory muscle paralysisSKIN: Rash, urticariaOther: Anaphylaxis, drug-induced fever,facial flushing, injection site pain, stiff neck(with intrathecal injection), superinfection

els, especially in patients with a history ofrenal insufficiency.WARNING Be aware that declining urineoutput and rising BUN level suggestnephrotoxicity, which also is characterizedby albuminuria, azotemia, cylindruria,excessive excretion of electrolytes, hematuria,leukocyturia, and rising blood druglevel. Notify prescriber immediately if youdetect any of these signs.WARNING Notify prescriber immediately ifpatient experiences blurred vision, circumoralor peripheral paresthesia, confusion,dizziness, drowsiness, facial flushing,giddiness, myasthenia, nystagmus, orslurred speech. These may be signs of neurotoxicity,a serious adverse reaction thatmay lead to respiratory arrest or paralysisif untreated.• Assess for signs of superinfection, such asmouth sores, severe diarrhea, and whitepatches on tongue or in mouth, especiallyin debilitated or elderly patients.• Monitor fluid intake and output and provideadequate fluids to reduce the risk ofnephrotoxicity.PATIENT TEACHING• Encourage patient to maintain adequatefluid intake during polymyxin B therapy.• Instruct patient to notify prescriber atonce about diarrhea, mouth sores, or vaginitis,possible early signs of superinfection.posaconazoleNoxafilClass and CategoryChemical class: TriazoleTherapeutic class: AntifungalPregnancy category: CIndications and Dosages To prevent invasive aspergillus andcandida infections in patients at highrisk because of severe immunocompromisefrom such conditions as graftversus-hostdisease with hematopoieticstem-cell transplant or hematologicmalignancies with prolonged neutropeniafrom chemotherapyORAL SUSPENSIONAdults. 200 mg (5 ml) t.i.d. until recoveryfrom neutropenia or immunosuppression.posaconazole 837 To treat oropharyngeal candidiasisORAL SUSPENSIONAdults. Initial: 100 mg (2.5 ml) b.i.d. onfirst day, followed by 100 mg (2.5 ml) oncedaily for 13 days. To treat oropharyngeal candidiasisrefractory to itraconazole and or fluconazoleORAL SUSPENSIONAdults. 400 mg (10 ml) b.i.d. until underlyingcondition improves.Route Onset Peak DurationP.O. Unknown 3–5 hr UnknownMechanism of ActionBlocks synthesis of ergosterol, an essentialcomponent of fungal cell membrane, byinhibiting 14 alpha-demethylase, an enzymeneeded for conversion of lanosterol toergosterol. Lack of ergosterol increases cellularpermeability, and cell contents leak.ContraindicationsConcurrent therapy with sirolimus; hypersensitivityto posaconazole, its components,or other azole antifungals; use with ergotalkaloids or CYP3A4 substrates such asastemizole, cisapride, halofantrine,pimozide, quinidine, and terfenadineInteractionsDRUGSastemizole, cisapride, halofantrine, pimozide,quinidine, terfenadine: Increased risk of prolongedQT interval and torsades de pointesatazanavir, calcium channel blockers,cyclosporine, midazolam, phenytoin,rifabutin, ritonavir, sirolimus, tacrolimus:Increased plasma levels of these drugs, withincreased risk of adverse reactionscimetidine, efavirenz, phenytoin, rifabutin:Possibly decreased plasma level ofposaconazoledigoxin: Increased risk of digitalis toxicityergot alkaloids: Increased plasma ergot alkaloidlevel and increased risk of ergotismesomeprazole, metoclopramide: Possiblebreakthrough fungal infectionsHMG-CoA reductase inhibitors: Increasedplasma statin level and increased risk ofrhabdomyolysisvinca alkaloids: Increased plasma vincaalkaloid level and increased risk of neurotoxicityP

838potassiumAdverse ReactionsCNS: Anxiety, asthenia, dizziness, fatigue,fever, headache, insomnia, rigors, tremor,weaknessCV: Edema, hypertension, hypotension,QT-interval prolongation, tachycardiaEENT: Blurred vision, epistaxis, herpes simplex,mucositis, pharyngitis, taste perversionENDO: Hyperglycemia, hypocalcemiaGI: Abdominal pain, anorexia, bilirubinemia,constipation, diarrhea, dyspepsia, elevatedliver enzyme levels, hepatomegaly,jaundice, nausea, vomitingGU: Acute renal failure, elevated blood creatininelevel, vaginal hemorrhageHEME: Anemia, neutropenia, thrombocytopeniaMS: Arthralgia, back or musculoskeletalpainRESP: Coughing, dyspnea, pneumonia,upper respiratory tract infectionSKIN: Diaphoresis, petechiae, pruritus,rashOther: Bacteremia, cytomegalovirus infection,dehydration, hypokalemia, hypomagnesemia,weight lossNursing Considerations• Use cautiously in patients who have had ahypersensitivity reaction to other azolesbecause of risk for cross-sensitivity.• Use cautiously in patients with renal orhepatic dysfunction.• Use cautiously in patients with potentiallyproarrhythmic conditions becauseposaconazole may prolong QT interval.• Obtain baseline assessment of liver functionand check periodically during therapy.If elevations occur or patient has evidenceof abnormal liver function, notifyprescriber.PATIENT TEACHING• Advise patient to use the measuring spoonsupplied by manufacturer and to rinse itwith water after each use.• Instruct patient to take posaconazole withor within 20 minutes after a full meal orliquid nutritional supplement to increasedrug absorption. Tell patient that he alsomay take posaconazole with an acidic carbonatedbeverage such as gingerale.• Tell patient to report severe diarrhea orvomiting because these conditions mayinterfere with drug effectiveness.potassium acetate(contains 2 or 4 mEq of elementalpotassium per 1 ml of injection)potassiumbicarbonate(contains 6.5 mEq of elemental potassiumper tablet, 20 or 25 mEq of elementalpotassium per effervescent tablet for oralsolution)KCare ET, K-Electrolyte, K-Ide, Klor-Con/EF, K-Lyte, K-Vescentpotassiumbicarbonate andpotassium chloride(contains 20 mEq of elemental potassiumper 2.8-g granule packet; 20, 25, or50 mEq of elemental potassium pereffervescent tablet for oral solution)Klorvess Effervescent Granules, K-Lyte/Cl, K-Lyte/Cl 50, Neo-K (CAN),Potassium Sandoz (CAN)potassiumbicarbonate andpotassium citrate(contains 25 or 50 mEq of elementalpotassium per effervescent tablet for oralsolution)Effer-K, K-Lyte DSpotassium chloride(contains 8 or 10 mEq of elemental potassiumper E.R. capsule; 6.7, 8, 10, 12, or20 mEq of elemental potassium per E.R.tablet; 10, 20, 30, or 40 mEq of elementalpotassium per 15 ml of oral solution; 10,15, 20, or 25 mEq of elemental potassiumper packet for oral solution; 20 mEq ofelemental potassium per packet for oralsuspension; 0.1, 0.2, 0.3, 0.4, 1.5, 2, 3, or10 mEq of elemental potassium per 1 mlof injection)Apo-K (CAN), Cena-K, Gen-K, K-8,

K-10 (CAN), K 10, Kalium Durules(CAN), Kaochlor 10%, Kaochlor S-F10%, Kaon-Cl, Kato, Kay Ciel, KCare, KCL 5% (CAN), K-Dur, K-Ide,K-Lease, K-Long (CAN), K-Lor,Klor-Con 10, Klor-Con Powder, Klor-Con/25 Powder, Klorvess 10% Liquid,Klotrix, K-Lyte/Cl Powder, K-Med 900(CAN), K-Norm, K-Sol, K-Tab, Micro-K,Micro-K 10, Potasalan, Roychlor 10%(CAN), Rum-K, Slow-K, Ten-Kpotassium citrate(contains 5 mEq or 10 mEq of elementalpotassium per tablet)Urocit-Kpotassiumgluconate(contains 20 mEq of elemental potassiumper 15 ml of elixir; 2, 2.3, or 2.5 mEq ofelemental potassium per tablet)Glu-K, Kaon, Kaylixir, K-G Elixir,Potassium-Rougier (CAN)potassiumgluconate andpotassium chloride(contains 20 mEq of elemental potassiumper 15 ml of oral solution; 20 mEq of elementalpotassium per 5-g packet for oralsolution)Kolyumpotassiumgluconate andpotassium citrate(contains 20 mEq of elemental potassiumper 15 ml of oral solution)Twin-Ktrikates(contains 15 mEq of elemental potassiumper 5 ml of oral solution)Tri-Kpotassium 839Class and CategoryChemical class: Electrolyte cationTherapeutic class: Electrolyte replacementPregnancy category: CIndications and Dosages To prevent or treat hypokalemia inpatients who can’t ingest sufficientdietary potassium or who are losingpotassium because of a condition (suchas hepatic cirrhosis or prolonged vomiting)or drug (such as potassium-wastingdiuretics or certain antibiotics)EFFERVESCENT TABLETS (POTASSIUMBICARBONATE)Adults and adolescents. 25 to 50 mEq/gonce or twice daily, as needed and tolerated.Maximum: 100 mEq daily.EFFERVESCENT TABLETS (POTASSIUM BICARBONATEAND POTASSIUM CHLORIDE)Adults and adolescents. 20, 25, or 50 mEqonce or twice daily, as needed and tolerated.Maximum: 100 mEq daily.EFFERVESCENT TABLETS (POTASSIUM BICARBONATEAND POTASSIUM CITRATE)Adults and adolescents. 25 or 50 mEq onceor twice daily, as needed and tolerated.Maximum: 100 mEq daily.ELIXIR (POTASSIUM GLUCONATE)Adults and adolescents. 20 mEq b.i.d. toq.i.d., as needed and tolerated. Maximum:100 mEq daily.Children. 2 to 3 mEq/kg daily in divideddoses.E.R. CAPSULES (POTASSIUM CHLORIDE)Adults and adolescents. 40 to 100 mEqdaily in divided doses b.i.d. or t.i.d. fortreatment; 16 to 24 mEq daily in divideddoses b.i.d. or t.i.d. for prevention.Maximum: 100 mEq daily.E.R. TABLETS (POTASSIUM CHLORIDE)Adults and adolescents. 6.7 to 20 mEq t.i.d.Maximum: 100 mEq daily.GRANULE PACKETS (POTASSIUM BICARBONATE ANDPOTASSIUM CHLORIDE)Adults and adolescents. 20 mEq once ortwice daily, as needed and tolerated.Maximum: 100 mEq daily.GRANULES FOR ORAL SUSPENSION (POTASSIUMCHLORIDE)Adults and adolescents. 20 mEq 1 to 5 times/day, as needed. Maximum: 100 mEq daily.ORAL SOLUTION (POTASSIUM CHLORIDE)Adults and adolescents. 20 mEq once dailyP

840potassiumto q.i.d., as needed and tolerated.Maximum: 100 mEq daily.Children. 1 to 3 mEq/kg daily in divideddoses.ORAL SOLUTION (POTASSIUM GLUCONATE ANDPOTASSIUM CHLORIDE, POTASSIUM GLUCONATE ANDPOTASSIUM CITRATE)Adults and adolescents. 20 mEq b.i.d. toq.i.d., as needed and tolerated. Maximum:100 mEq daily.Children. 2 to 3 mEq/kg daily in divideddoses.POWDER PACKET FOR ORAL SOLUTION(POTASSIUM CHLORIDE)Adults. 15 to 25 mEq b.i.d. to q.i.d., asneeded and tolerated. Maximum: 100 mEqdaily.Children. 1 to 3 mEq/kg daily in divideddoses, as needed and tolerated.POWDER PACKET FOR ORAL SOLUTION (POTASSIUMGLUCONATE AND POTASSIUM CHLORIDE)Adults and adolescents. 20 mEq b.i.d. toq.i.d., as needed and tolerated. Maximum:100 mEq daily.Children. 2 to 3 mEq/kg daily in divideddoses.ORAL TRIKATES SOLUTION (POTASSIUM ACETATE,POTASSIUM BICARBONATE, AND POTASSIUMCITRATE)Adults and adolescents. 15 mEq t.i.d. toq.i.d., as needed and tolerated. Maximum:100 mEq daily.Children. 2 to 3 mEq/kg daily in divideddoses.TABLETS (POTASSIUM GLUCONATE)Adults and adolescents. 5 to 10 mEq b.i.d.to q.i.d., as needed and tolerated.Maximum: 100 mEq daily.I.V. INFUSION (POTASSIUM ACETATE ANDPOTASSIUM CHLORIDE)Adults and adolescents with serum potassiumlevel above 2.5 mEq/L. Up to 10 mEq/hr. Maximum: 200 mEq daily.Adults and adolescents with serum potassiumlevel below 2 mEq/L, ECG changes,or paralysis. Up to 20 mEq/hr. Maximum:400 mEq daily.Children. 3 mEq/kg daily.DOSAGE ADJUSTMENT Dosage adjusted asprescribed based on patient’s ECG patternsand serum potassium level. To treat renal tubular acidosis with calciumstones, hypocitraturic calciumoxalate nephrolithiasis of any etiology,and uric acid lithiasis with or withoutcalcium stonesTABLETS (POTASSIUM CITRATE)Adults. For patients with severe hypocitraturia,15 mEq four times daily with mealsor 20 mEq three times daily with meals. Forpatients with mild to moderate hypocitraturia,10 mEq three times daily with meals.Mechanism of ActionActs as the major cation in intracellularfluid, activating many enzymatic reactionsessential for physiologic processes, includingnerve impulse transmission and cardiacand skeletal muscle contraction. Potassiumalso helps maintain electroneutrality in cellsby controlling exchange of intracellular andextracellular ions. It also helps maintainnormal renal function and acid-base balance.IncompatibilitiesDon’t mix potassium chloride for injectionin same syringe with amino acid solutions,lipid solutions, or mannitol because thesedrugs may precipitate from solution.Administration with blood or blood productscan cause lysis of infused RBCs.ContraindicationsAcute dehydration, Addison’s disease(untreated), concurrent use of potassiumsparingdiuretics, crush syndrome, disordersthat may delay drug passing throughGI tract (potassium citrate), heat cramps,hyperkalemia, hypersensitivity to potassiumsalts or their components, peptic ulcer disease(potassium citrate), renal impairmentwith azotemia or oliguria, severe hemolyticanemia, UTI (potassium citrate)InteractionsDRUGSACE inhibitors, beta blockers, blood products,cyclosporine, heparin, NSAIDs, potassiumcontainingdrugs, potassium-sparing diuretics:Increased risk of hyperkalemiaamphotericin B, corticosteroids (glucocorticoids,mineralocorticoids), gentamicin, penicillins,polymyxin B: Possibly hypokalemiaanticholinergics, drugs with anticholinergicactivity: Increased risk of GI ulceration,stricture, and perforationcalcium salts (parenteral): Possibly arrhythmiasdigoxin: Increased risk of digitalis toxicity

insulin, laxatives, sodium bicarbonate:Decreased serum potassium levelsodium polystyrene sulfonate: Possiblydecreased serum potassium level and fluidretentionthiazide diuretics: Possibly hyperkalemiawhen diuretic is discontinuedFOODSlow-salt milk, salt substitutes: Increased riskof hyperkalemiaAdverse ReactionsCNS: Confusion, paralysis, paresthesia,weaknessCV: Arrhythmias, ECG changesEENT: Throat pain when swallowingGI: Abdominal pain; bloody stools; diarrhea;flatulence; GI bleeding, perforation, orulceration; intestinal obstruction; nausea;vomitingRESP: DyspneaSKIN: RashOther: HyperkalemiaNursing Considerations• Administer oral potassium with or immediatelyafter meals.• Mix potassium chloride for oral solutionor potassium gluconate elixir in coldwater, orange juice, tomato juice (ifpatient isn’t sodium restricted), or applejuice, and stir for 1 full minute beforeadministering.• Mix potassium bicarbonate, potassiumbicarbonate and potassium chloride, andpotassium bicarbonate and potassium citrateeffervescent tablets with cold waterand allow to dissolve completely.• Be aware that liquid form of oral potassiumis prescribed for patients with delayedgastric emptying, esophageal compression,or intestinal obstruction or stricture todecrease the risk of tissue damage.WARNING Be aware that direct injection of apotassium concentrate may be immediatelyfatal. Dilute potassium concentrate forinjection with adequate volume of solutionbefore I.V. use. Maximum suggestedconcentration is 40 mEq/L, althoughstronger concentrations (up to 80 mEq/L)may be used for severe hypokalemia.Inappropriate solutions or improper techniquemay cause extravasation, fever,hyperkalemia, hypervolemia, I.V. siteinfection, phlebitis, venospasm, andpotassium 841venous thrombosis.• Infuse potassium slowly to avoid phlebitisand decrease risk of adverse cardiac reactions.Keep in mind that different forms ofpotassium salts contain different amountsof elemental potassium per gram and thatnot all forms are dosage equivalent.• Monitor serum potassium level before andduring administration of I.V. potassium.WARNING Be aware that some forms ofpotassium contain tartrazine, which maycause an allergic reaction, such as asthma.Some forms may also contain aluminum,which may become toxic in a patient withimpaired renal function.• Regularly assess patient for signs of hypokalemia,such as arrhythmias, fatigue, andweakness, and for signs of hyperkalemia,such as arrhythmias, confusion, dyspnea,and paresthesia.• Because adequate renal function is neededfor potassium supplementation, monitorserum creatinine level and urine outputduring administration. Notify prescriberabout signs of decreased renal function.PATIENT TEACHING• Inform patient that potassium is part of anormal diet and that most meats, seafoods,fruits, and vegetables contain sufficientpotassium to meet recommended dailyintake. Also advise her not to exceed recommendeddaily amount of potassium.• Teach patient the correct way to take prescribedpotassium. This can vary fromswallowing a tablet with a full glass ofwater to mixing certain preparations withhalf to full glass of cold water or juice.• Caution patient not to crush or chew E.R.forms unless instructed otherwise.• Instruct patient to take drug with or rightafter food.• Teach patient how to take her radial pulse,and advise her to notify prescriber aboutsignificant changes in heart rate orrhythm.• Advise patient to watch stools for changesin color and consistency and to notify prescriberif they become black, tarry, or red.• Inform patient that although she may seewaxy form of E.R. tablet in stools, she hasreceived all of the potassium.• Urge patient to keep follow-up laboratoryappointments as directed by prescriber todetermine serum potassium level.P

842potassium iodidepotassium iodide(KI, SSKI)Pima, Thyro-BlockClass and CategoryChemical class: IodineTherapeutic class: Antithyroid, radiationprotectantPregnancy category: DIndications and Dosages To prepare for thyroidectomyORAL SOLUTIONAdults and children. 50 to 250 mg t.i.d. for10 to 14 days before surgery. To manage thyrotoxic crisisORAL SOLUTIONAdults. 50 to 250 mg t.i.d. or 500 mg every4 hr. To protect thyroid gland during radiationexposureORAL SOLUTION, SYRUP, TABLETSAdults and adolescents. 100 to 150 mg24 hr before administration of or exposureto radioactive isotopes of iodine and dailyfor 3 to 10 days afterward. Maximum: 12 gdaily.Children age 1 and over. 130 mg daily for10 days after administration of or exposureto radioactive isotopes of iodine.Children under age 1. 65 mg daily for10 days after administration of or exposureto radioactive isotopes of iodine.Route Onset Peak DurationP.O.* 24 hr 10–15 days Up to 6 wkMechanism of ActionInhibits release of thyroid hormone intocirculation, thus alleviating symptomscaused by excessive thyroid hormone stimulation.Potassium iodide also blocks thyroiduptake of radioactive iodine isotopesreleased as a result of radiation exposure.ContraindicationsAcute bronchitis, Addison’s disease, dehydration,heat cramps, hyperkalemia, hypersensitivityto iodides or their components,hyperthyroidism, iodism, renal impairment,tuberculosis* For antithyroid effects.InteractionsDRUGSantithyroid drugs, lithium: Increased risk ofhypothyroidism and goitercaptopril, enalapril, lisinopril, potassiumsparingdiuretics: Increased risk of hyperkalemiaAdverse ReactionsCNS: Confusion, fatigue, headache, heavinessor weakness in legs, paresthesiaCV: Irregular heartbeatEENT: Burning in mouth or throat,increased salivation, metallic taste, soreteeth or gumsGI: Diarrhea, epigastric pain, indigestion,nausea, vomitingHEME: EosinophiliaMS: ArthralgiaSKIN: Acneiform lesions, urticariaOther: Angioedema, lymphadenopathyNursing Considerations• Be aware that potassium iodide shouldn’tbe given to patients with tuberculosisbecause drug may cause pulmonary irritationand increased secretions.WARNING Monitor serum potassium levelregularly in patients with renal impairmentbecause of the risk of hyperkalemia.• Monitor thyroid function test results periodicallyto assess drug’s effectiveness.PATIENT TEACHING• Advise patient taking potassium iodideoral solution or syrup to use a calibratedmeasuring device to ensure accurate doses.• Urge patient to mix solution or syrup in afull glass (8 oz) of water, fruit juice, milk,or broth to improve taste and lessen GIreactions. Advise patient taking tabletform to dissolve each tablet in half a glass(4 oz) of water or milk before ingestion.• If crystals form in solution, advise patientto place the closed container in warmwater and gently shake to dissolve.• Instruct patient to discard bottle andobtain a new one if solution turns brownishyellow.potassiumphosphatesK-Phos Original, Neutra-Phos-K

potassium andsodium phosphatesK-Phos M.F., K-Phos-Neutral, K-PhosNo. 2, Neutra-Phossodium phosphatesClass and CategoryChemical class: Anion, soluble saltsTherapeutic class: Antiurolithic, electrolytereplenisher, urinary acidifierPregnancy category: CIndications and Dosages As adjunct to treat UTI, to prevent renalcalculus formationMONOBASIC TABLETS (POTASSIUM PHOSPHATES)Adults and adolescents. 1 g in 180 to240 ml water q.i.d., after meals and at bedtime.MONOBASIC TABLETS (POTASSIUM AND SODIUMPHOSPHATES)Adults and adolescents. 250 mg in 240 mlwater q.i.d., after meals and at bedtime.Dosage interval may be increased to every2 hr if urine is difficult to acidify.Maximum: 2 g/24 hr. To prevent or treat hypophosphatemiaCAPSULES (POTASSIUM PHOSPHATES)Adults and children age 4 and over. 1.45 gin 75 ml water or juice q.i.d., after mealsand at bedtime.Children up to age 4. 200 mg in 60 mlwater or juice q.i.d., after meals and at bedtime.CAPSULES (POTASSIUM AND SODIUM PHOSPHATES)Adults and children age 4 and over. 1.25 gin 75 ml water or juice q.i.d., after mealsand at bedtime.Children up to age 4. 200 mg in 60 mlwater or fruit juice q.i.d., after meals and atbedtime.MONOBASIC TABLETS (POTASSIUM PHOSPHATES)Adults and children age 4 and over. 1 g in180 to 240 ml water q.i.d., after meals andat bedtime.Children up to age 4. 200 mg in 60 mlwater q.i.d., after meals and at bedtime.MONOBASIC TABLETS (POTASSIUM AND SODIUMPHOSPHATES)Adults and children age 4 and over.250 mg in 240 ml water q.i.d., after mealspotassium phosphates 843and at bedtime.Children up to age 4. 200 mg in 60 mlwater q.i.d., after meals and at bedtime.ORAL SOLUTION (POTASSIUM PHOSPHATES,POTASSIUM AND SODIUM PHOSPHATES)Adults and children age 4 and over. 250 mgq.i.d., after meals and at bedtime.Children up to age 4. 200 mg q.i.d., aftermeals and at bedtime.TABLETS (POTASSIUM AND SODIUM PHOSPHATES)Adults and children age 4 and over. 250 mgin a full glass of water q.i.d., after meals andat bedtime.Children up to age 4. 200 mg in 60 mlwater q.i.d., after meals and at bedtime.I.V. INFUSION (SODIUM PHOSPHATES)Adults and adolescents. 10 to 15 mmol(310 to 465 mg) daily.Children. 1.5 to 2 mmol (46.5 to 62 mg)/kgdaily.Mechanism of ActionReverses symptoms of hypophosphatemiaby replenishing the body’s supply of phosphate;acidifies urine by causing hydrogento be exchanged for sodium in renal distaltubule; and inhibits formation of calciumrenal calculi by preventing solidification ofcalcium oxalate.IncompatibilitiesDon’t add phosphates to calcium- ormagnesium-containing solutions becauseprecipitate may form.ContraindicationsHyperkalemia (potassium formulations),hypernatremia (sodium formulations),hyperphosphatemia, magnesium ammoniumphosphate urolithiasis accompanied byinfection, severe renal insufficiency, UTIcaused by urea-splitting organismsInteractionsDRUGSACE inhibitors, cyclosporine, heparin (longtermuse), NSAIDs, potassium-containingdrugs, potassium-sparing diuretics: Increasedrisk of hyperkalemia (potassium forms only)aluminum- or magnesium-containing antacids:Possibly impaired phosphate absorptionanabolic steroids, androgens, corticosteroids,estrogens: Increased risk of edema (sodiumformulations only)calcium-containing drugs: Increased risk ofP

844pralidoxime chloridecalcium deposition in soft tissuesiron supplements: Decreased absorption oforal ironphosphate-containing drugs, vitamin D:Increased risk of hyperphosphatemiasalicylates: Increased blood salicylate levelzinc supplements: Reduced zinc absorptionFOODSlow-salt milk, salt substitutes: Increased riskof hyperkalemiaoxalates (in spinach and rhubarb), phyates(in bran and whole grains): Decreasedabsorption of phosphateAdverse ReactionsCNS: Anxiety, confusion, dizziness, fatigue,headache, paresthesia, seizures, tremor,weaknessCV: Arrhythmias, edema of legs, tachycardiaGI: Diarrhea, epigastric pain, nausea, thirst,vomitingGU: Decreased urine outputMS: Muscle cramps or weaknessRESP: DyspneaOther: Hyperkalemia, hypernatremia,hyperphosphatemia, hypocalcemia, weightgainNursing Considerations• Monitor serum phosphorus level, asappropriate, in patient who receives phosphatesand has a condition that may beassociated with elevated phosphorus level,such as chronic renal disease, hypoparathyroidism,and rhabdomyolysis; phosphatesmay further increase serum phosphoruslevel.• Monitor serum calcium level, as appropriate,in patient who receives phosphatesand has a condition that may be associatedwith a low calcium level, such as acutepancreatitis, chronic renal disease,hypoparathyroidism, osteomalacia, rhabdomyolysis,and rickets; phosphates mayfurther decrease serum calcium level.• Monitor serum potassium level, as appropriate,if patient who receives potassiumphosphate has a condition linked to elevatedpotassium level, such as acute dehydration,adrenal insufficiency, extensivetissue breakdown (as in severe burns),myotonia congenita, pancreatitis, rhabdomyolysis,and severe renal insufficiency; shemay have increased risk of hyperkalemia.• Monitor serum sodium level in patientwho receives sodium phosphates and has acondition that may be worsened by sodiumexcess, such as heart failure, hypernatremia,hypertension, peripheral or pulmonaryedema, preeclampsia, renalimpairment, and severe hepatic disease.• Monitor urine pH, as ordered, to assesseffectiveness of drug used to acidify urine.• When administering sodium phosphates,monitor ECG tracing frequently duringI.V. infusion to detect arrhythmias.PATIENT TEACHING• Instruct patient to take phosphates aftermeals to avoid GI upset and decrease laxativeeffect.• Stress importance of not swallowing capsulesor tablets whole; instead, advisepatient to soak tablets in water or fruitjuice for 2 to 3 minutes to dissolve them.• Suggest chilling diluted drug to improveflavor, but caution against freezing.• Encourage increased intake of fluids (8 oz/hour, if not contraindicated) to preventrenal calculi.• Urge patient to notify prescriber immediatelyabout muscle weakness or cramps,unexplained weight gain, or shortness ofbreath.• Instruct patient who needs an iron supplementto take it 1 to 2 hours after takingphosphates.pralidoximechloride(2-PAM chloride,2-pyridine aldoximemethochloride)Protopam ChlorideClass and CategoryChemical class: Quaternary ammoniumoximeTherapeutic class: Anticholinesterase antidotePregnancy category: CIndications and Dosages As adjunct to reverse organophosphatepesticide toxicityI.V. INFUSION, I.M. OR SUBCUTANEOUS INJECTIONAdults. Initial: 1 to 2 g in 100 ml normalsaline solution infused over 15 to 30 min,

given concurrently with atropine 2 to 6 mgevery 5 to 60 min until muscarinic signsand symptoms disappear; may be repeatedin 1 hr and then every 3 to 8 hr if muscleweakness persists. If I.V. route isn’t feasible,administer I.M. or subcutaneously.Children. Initial: 20 mg/kg in 100 ml normalsaline solution infused over 15 to30 min, given concurrently with atropine(dosage individualized); may be repeated in1 hr and then every 3 to 8 hr if muscleweakness persists. If I.V. route isn’t feasible,administer I.M. or subcutaneously. To treat anticholinesterase overdose secondaryto myasthenic drugs (includingambenonium, neostigmine, and pyridostigmine)I.V. INJECTIONAdults. Initial: 1 to 2 g, followed by 250 mgevery 5 min. To treat exposure to nerve agentsI.V. INJECTIONAdults. Initial: 1 atropine-containingautoinjector followed by 1 pralidoximecontainingautoinjector as soon asatropine’s effects are evident; both injectionsrepeated every 15 min for 2 additionaldoses if nerve agent symptoms persist.DOSAGE ADJUSTMENT Dosage reduced forpatients with renal insufficiency.Mechanism of ActionReverses muscle paralysis by removingphosphoryl group from inhibited cholinesterasemolecules at neuromuscular junctionof skeletal and respiratory muscles.Reactivation of cholinesterase restoresbody’s ability to metabolize acetylcholine,which is inhibited by organophosphate pesticides,anticholinesterase overdose, ornerve agent poisoning.ContraindicationsHypersensitivity to pralidoxime chloride orits componentsInteractionsDRUGSaminophylline, morphine, phenothiazines,reserpine, succinylcholine, theophylline:Increased symptoms of organophosphatepoisoningbarbiturates: Potentiated barbiturate effectsAdverse ReactionsCNS: Dizziness, drowsiness, headachepramipexole dihydrochloride 845CV: Increased systolic and diastolic bloodpressure, tachycardiaEENT: Accommodation disturbances,blurred vision, diplopiaGI: Nausea, vomitingMS: Muscle weaknessRESP: HyperventilationOther: Injection site painNursing Considerations• Be aware that pralidoxime must be givenwithin 36 hours of toxicity to be effective.• Use drug with extreme caution in patientswith myasthenia gravis being treated fororganophosphate poisoning because pralidoximemay precipitate myasthenic crisis.• Reconstitute drug according to manufacturer’sguidelines and administrationroute.• For intermittent infusion, further dilutewith normal saline solution to 100 ml andinfuse over 15 to 30 minutes.• Avoid too-rapid delivery, which may causehypertension, laryngospasm, musclespasms, neuromuscular blockade, andtachycardia. Also be sure to avoid intradermalinjection.• Closely monitor neuromuscular statusduring therapy.• Monitor BUN and serum creatinine levels,as appropriate, in patients with renalinsufficiency because drug is excreted inurine.• When pralidoxime is administered withatropine, expect signs of atropination,such as dry mouth and nose, flushing,mydriasis, and tachycardia, to occur earlierthan might be expected when atropine isgiven alone.PATIENT TEACHING• Inform patient receiving I.M. pralidoximethat she’ll experience pain at the injectionsite for 40 to 60 minutes afterward.• Reassure patient that she’ll be closelymonitored throughout therapy.pramipexoledihydrochlorideMirapexClass and CategoryChemical class: Benzothiazolamine derivativeP

846pramipexole dihydrochlorideTherapeutic class: AntidyskineticPregnancy category: CIndications and Dosages To treat Parkinson’s disease, with orwithout concurrent levodopa therapyTABLETSAdults. Initial: 0.125 mg t.i.d. for 1 wk,increased weekly thereafter as follows: forweek 2, 0.25 mg t.i.d.; for week 3, 0.5 mgt.i.d.; for week 4, 0.75 mg t.i.d.; for week 5,1 mg t.i.d.; for week 6, 1.25 mg t.i.d.; andfor week 7, 1.5 mg t.i.d. Maintenance: 1.5 to4.5 mg daily in divided doses t.i.d.Maximum: 4.5 mg daily.DOSAGE ADJUSTMENT For patients withrenal impairment, dosage reduced as follows:for creatinine clearance of 35 to59 ml/min/1.73 m 2 , initial dose of 0.125 mgb.i.d., maximum of 3 mg daily; for creatinineclearance of 15 to 34 ml/min/1.73 m 2 ,initial dose of 0.125 mg daily, maximum of1.5 mg daily. Drug shouldn’t be given topatients with creatinine clearance of lessthan 15 ml/min/1.73 m 2 . To treat restless legs syndromeTABLETSAdults. Initial: 0.125 mg once daily,2 to3 hours before bedtime. Increased in 4 to7 days to 0.25 mg once daily 2 to 3 hoursbefore bedtime as needed. Further increasedin 4 to 7 days to 0.5 mg once daily 2 to 3hours before bedtime, as needed.DOSAGE ADJUSTMENT For patients withmoderate to severe renal impairment (creatinineclearance 20 to 60 ml/min/1.73 m 2 )dosage interval for titration, if needed,increased to 14 days.Mechanism of ActionMay stimulate dopamine receptors in thebrain, thereby easing symptoms of Parkinson’sdisease, which is thought to be causedby a dopamine deficiency.ContraindicationsHypersensitivity to pramipexole or its componentsInteractionsDRUGScarbidopa, levodopa: Possibly increased peakblood levodopa level and potentiation oflevodopa’s dopaminergic adverse effectsdiltiazem, quinidine, quinine, ranitidine, triamterene,verapamil: Decreased pramipexoleclearancehaloperidol, metoclopramide, phenothiazines,thioxanthenes: Decreased pramipexole effectivenessAdverse ReactionsCNS: Abnormal behavior, amnesia, anxiety,asthenia, confusion, dream disturbances,drowsiness, dyskinesia, dystonia, fatigue,fever, hallucinations, headache, insomnia,malaise, paranoia, restlessness, syncopeCV: Edema, orthostatic hypotensionEENT: Diplopia, dry mouth, rhinitis, visionchangesGI: Anorexia, constipation, dysphagia, nauseaGU: Altered libido, impotence, urinary frequency,urinary incontinenceMS: Arthralgia, myalgia, myastheniaRESP: PneumoniaSKIN: Diaphoresis, rashOther: Eating disorders (binge or compulsiveeating, hyperphagia), intense urges forcertain activities (such as gambling andsex), weight gain or lossNursing Considerations• Use pramipexole cautiously in patientswith hallucinations, hypotension, or retinalproblems (such as macular degeneration).Drug may worsen these conditions.• Also use cautiously in patients with renalimpairment because pramipexole eliminationmay be decreased.• Take safety precautions per facility policyuntil drug’s CNS effects are known.• Avoid stopping pramipexole abruptlybecause doing so may cause a symptomcomplex resembling neuroleptic malignantsyndrome and consisting of hyperpyrexia,muscle rigidity, altered level of consciousness,and autonomic instability.• Assess patient for skin changes regularlybecause melanomas may occur at a higherrate in patients with Parkinson’s disease. Itisn’t clear if this is a result of the disease ordrugs used to treat it.PATIENT TEACHING• Advise patient to take pramipexole withmeals if nausea occurs.• Caution patient about possible dizziness,drowsiness, or light-headedness, whichmay result from orthostatic hypotension.Advise her not to rise quickly from a lyingor sitting position to minimize theseeffects.

• Instruct patient to notify prescriber immediatelyabout vision problems or urinaryfrequency or incontinence.• Inform patient that improvement inmotor performance and activities of dailyliving may take 2 to 3 weeks.• Urge patient to have regular skin examinationsby a dermatologist or other qualifiedhealth professional.• Advise patient to notify prescriber aboutintense urges, as for gambling or sex.Dosage may need to be reduced or drugdiscontinued.pramlintide acetateSymlinClass and CategoryChemical class: Synthetic analogue ofhuman amylin, a pancreatic beta cellhormoneTherapeutic class: AntidiabeticPregnancy category: CIndications and Dosages To achieve euglycemia in patients withtype 1 diabetes who use mealtimeinsulin therapy but have not achieveddesired glucose controlSUBCUTANEOUS INJECTIONAdults. Initial: 15 mcg just before majormeals with 50% reduced dosage of preprandialrapid-acting or short-acting insulin,including fixed-mix insulins such as 70/30.When nausea has abated at least 3 days,dosage increased in increments of 15 mcg.Maintenance: 30 to 60 mcg before majormeals.DOSAGE ADJUSTMENT Dosage decreased to30 mcg if nausea occurs and persists athigher dosages. To achieve euglycemia in patients withtype 2 diabetes who use mealtimeinsulin, with or without a sulfonylureaand/or metformin, and have notachieved desire glucose controlSUBCUTANEOUS INJECTIONAdults. Initial: 60 mcg immediately beforemajor meals combined with dosage reductionof preprandial rapid-acting or shortactinginsulin, including fixed-mix insulinssuch as 70/30, by 50%. When nausea hasbeen absent for 3 to 7 days, dosagepramlintide acetate 847increased to 120 mcg before major meals.DOSAGE ADJUSTMENT Dosage decreased to60 mcg before major meals if nausea occursand persists with 120-mcg dosage.Route Onset Peak DurationSubQ Unknown 19–21 min 3 hrMechanism of ActionSlows the rate at which food is releasedfrom stomach to small intestine, thusreducing initial postprandial rise in serumglucose level. Pramlintide also suppressesglucagon secretion and promotes satiety,thus furthering weight loss, which also lowersserum glucose level.Pramlintide is a synthetic analogue ofamylin, a naturally occurring neuroendocrinehormone secreted with insulin bypancreatic beta cells. In diabetes, secretionof insulin and amylin is reduced or absent.ContraindicationsGastroparesis, hypersensitivity to pramlintide,cresol or its components; hypoglycemiaunawarenessIncompatibilitiesDon’t mix in same syringe as insulinbecause pharmacokinetic parameters ofpramlintide become altered.InteractionsDRUGSdrugs that alter GI motility (such as anticholinergics)or slow intestinal absorption ofnutrients (such as alpha-glucosidaseinhibitors): Altered effects of these drugsoral drugs: Delayed absorptionAdverse ReactionsCNS: Dizziness, fatigue, headacheEENT: Blurred vision, pharyngitisENDO: Insulin-induced hypoglycemiaGI: Abdominal pain, anorexia, nausea,vomitingMS: ArthralgiaRESP: CoughingSKIN: DiaphoresisOther: Hypersensitivity reactions; localinjection site reaction, such as redness,swelling, or pruritusNursing Considerations• Because of the risks involved with pramlintidetherapy, insulin-using patients withP

848or sulfonamide antibiotics because of anincreased risk of hypoglycemia.• Expect pramlintide to be stopped ifpatient develops recurrent hypoglycemiathat requires medical assistance, developspersistent nausea, or becomes noncompliantwith therapy or follow-up visits.PATIENT TEACHING• Alert patient that insulin-induced hypoglycemiamay occur within 3 hours ofinjecting pramlintide. Review signs andsymptoms and appropriate treatment. Tellpatient to notify prescriber if hypoglycemiaoccurs because insulin dosage willneed to be reduced.• Stress need to monitor blood glucose leveloften, especially before and after eating.• Tell patient to inject drug subcutaneouslyimmediately before major meals using aninsulin syringe to draw up dose and usingthe same technique as with insulin administration,including rotating sites. Or, ifpatient has been prescribed the SymlinPen injector, show her how to use it.Advise patient to inject drug into herabdomen or thigh and not to use her armas an injection site because absorptionmay be too variable.• Warn patient not to mix pramlintide andinsulin together in the same syringe.• Warn patient that nausea is common withpramlintide; urge her to notify prescriberbecause dosage may need to be decreased.• Caution patient that if she misses a dose,she should skip the missed dose and continuewith the next scheduled dose.• Instruct patient to keep unopened pramlintidevials in the refrigerator; vials thathave been opened may be kept in therefrigerator or at room temperature. Vialsshould be discarded 28 days after opening.• Caution patient to avoid hazardous activitiesthat require mental alertness untileffects of pramlintide are known.• Reassure patient that pramlintide won’talter her awareness of or her body’sresponse to insulin-induced hypoglycemia.• Alert patient that she’ll need close followupcare, at least weekly until a target doseof pramlintide has been reached, she’s toleratingthe drug well, and her blood glucoselevel is stable.• Instruct women of childbearing age tonotify prescriber about planned, suspectpramlintideacetatetype 1 or 2 diabetes must have failed toachieve adequate glycemic control despiteindividualized insulin management andmust be receiving ongoing care with guidanceof insulin prescriber and a diabeteseducator before pramlintide is prescribed.• Expect that certain patients won’t be prescribedpramlintide because its risks mayoutweigh its benefits. These includepatients with poor compliance with currentinsulin regimen, poor compliancewith monitoring blood glucose level, a glycosylatedhemoglobin greater than 9%,recurrent severe hypoglycemia thatrequired assistance during past 6 months,hypoglycemia unawareness, gastroparesis,concurrent therapy with drugs that stimulateGI motility, and pediatric patients.• Before pramlintide therapy starts, makesure patient’s pre-meal insulin dosage hasbeen reduced by 50%.• Give drug immediately before main meals.• Monitor patient’s pre- and post-mealblood glucose levels regularly to determineeffectiveness of pramlintide and insulintherapy and to detect hypoglycemia.• For 3 hours after each dose of pramlintide,monitor patient closely for hypoglycemia,which may be severe, especially in patientswith type 1 diabetes. Effects may includehunger, headache, sweating, tremor, irritability,and trouble concentrating. Theymay occur with a rapid decrease in bloodglucose level regardless of glucose values.• Although pramlintide doesn’t cause hypoglycemia,it’s use with insulin increases therisk of insulin-induced severe hypoglycemia,which can result in loss of consciousness,coma, or seizures. If hypoglycemiaoccurs, provide supportive care,including glucagon if prescribed, and notifyprescriber. Expect insulin dosageaccompanying pramlintide to be reduced.• Keep in mind that early warning symptomsof hypoglycemia may be different orless severe if patient has had diabetes for along time; has diabetic nerve disease; takesa beta blocker, clonidine, guanethidine, orreserpine; or is under intensified diabetescontrol.• Closely monitor patients taking oralantidiabetics, ACE inhibitors, disopyramide,fibrates, fluoxetine, MAO inhibitors,pentoxifylline, propoxyphene, salicylates,

ed, or known pregnancy because drugtherapy will need to be adjusted.• Explain that local injection site reactions,such as redness, swelling or itching, mayoccur but usually resolve in a few weeks.prasugrelEffientClass and CategoryChemical class: ThienopyridineTherapeutic class: Platelet activation andaggregation inhibitor, antiplateletPregnancy category: BIndications and Dosages To reduce rate of thrombotic cardiovascularevents in patients with acute coronarysyndrome who will be managedwith percutaneous coronary interventionbecause of unstable angina, non-ST-elevationMI, or ST-elevation MITABLETSAdults. Initial: 60 mg as a loading dose andthen 10 mg once daily. Maintenance: 10 mgonce daily.DOSAGE ADJUSTMENT For patients weighingless than 60 kg (132 lb), daily maintenancedosage may be reduced to 5 mg once daily.Route Onset Peak DurationP.O. 2 hr 30 min 7–10 daysMechanism of ActionAfter forming active metabolite, irreversiblybinds to ADP receptors on platelets toinhibit platelet activation and aggregationfor the lifetime of the platelet, which is 7 to10 days. Without platelet activation andaggregation, thrombus cannot form.ContraindicationsActive bleeding, history of transientischemic attack or stroke, hypersensitivityto prasugrel or its componentsInteractionsDRUGSfibrinolytic agents, heparin, NSAIDs (chronicuse), warfarin: Increased risk of bleedingAdverse ReactionsCNS: Dizziness, fatigue, fever, headache,prasugrel 849intracranial hemorrhageCV: Atrial fibrillation, bradycardia, hypercholesterolemia,hyperlipidemia, hypertension,hypotension, peripheral edemaEENT: Epistaxis, retinal hemorrhageGI: Diarrhea, GI or retroperitoneal hemorrhage,hepatic dysfunction, nauseaHEME: Anemia, leukopenia, mild to lifethreateningbleeding, severe thrombocytopenia,thrombotic thrombocytopenic purpuraMS: Back or limb painRESP: Cough, dyspnea, hemoptysisSKIN: Subcutaneous hematoma, rashOther: Allergic reaction, angioedema,malignancies, noncardiac chest painNursing Considerations• Be aware that patient should be receivingdaily aspirin therapy (75 mg or 325 mg)throughout prasugrel therapy.• Drug isn’t recommended for patients age75 or older (except in high-risk situationssuch as the presence of diabetes or historyof previous MI) or in patients who haveactive bleeding or a history of a transientischemic attack or stroke. Monitor patientsclosely who have other risk factors forbleeding, which include a body weight lessthan 60 kg, a history of bleeding, or concurrentuse of drugs that increase risk ofbleeding, such as warfarin, heparin, fibrinolytictherapy, or chronic use of NSAIDs.• Prasugrel shouldn’t be given to patientslikely to undergo emergency coronaryartery bypass graft (CABG) surgerybecause of increased bleeding risk. Drugshould be discontinued at least 7 daysbefore any surgery.WARNING Monitor patient closely forbleeding because prasugrel can cause lifethreateninghemorrhage. Report hypotensionin patients who have recently undergonecoronary angiography, percutaneouscoronary intervention, CABG surgery, orother surgical procedures while takingdrug. In this setting, expect therapy tocontinue because stopping prasugrel, especiallyin first few weeks after acute coronarysyndrome, increases the risk ofadverse cardiovascular effects.• Because prasugrel inhibits platelet aggregationfor the lifetime of the platelet,which is 7 to 10 days, withholding a doseP

850pravastatin sodiumis unlikely help in managing a bleedingevent or the risk of bleeding associatedwith an invasive procedure. Expect toadminister exogenous platelets but only6 hours after prasugrel loading dose or4 hours after maintenance dose was given.• Monitor patient’s CBC regularly, asordered, watching for evidence of thromboticthrombocytopenic purpura, such asfever, neurologic abnormalities, renal dysfunction,and abnormal blood counts.Notify prescriber immediately becausecondition can be fatal. Expect to implementemergency treatment, such asplasmapheresis.PATIENT TEACHING• Stress importance of taking prasugrelexactly as prescribed, without lapses intherapy, for drug to be effective andadverse reactions to be reduced.• Instruct patient to take daily dose ofaspirin as prescribed.• Discourage use of NSAIDs, including OTCproducts, during prasugrel therapybecause of risk of bleeding.• Caution patient that bleeding may lastlonger than usual. Instruct him to reportunusual bleeding or bruising.• Instruct patient to inform health careproviders that he takes prasugrel.• Urge patient to take precautions againstbleeding, such as using an electric shaverand a soft-bristled toothbrush.• Advise patient to avoid activities thatcould cause traumatic injury and bleeding.pravastatin sodiumPravacholClass and CategoryChemical class: Mevinic acid derivativeTherapeutic class: AntihyperlipidemicPregnancy category: XIndications and Dosages To prevent coronary and cardiovascularevents in patients at risk, to treat hyperlipidemiaTABLETSAdults. Initial: 10 to 40 mg daily at bedtime,increased every 4 wk, as needed.Maintenance: 10 to 80 mg at bedtime.DOSAGE ADJUSTMENT For patients with significantrenal or hepatic impairment, thosetaking immunosuppressants, and elderlypatients, initial dosage reduced to 10 mgdaily at bedtime. For elderly patients andthose taking immunosuppressants, maintenancedosage usually limited to 20 mg daily. To treat pediatric heterozygous familialhypercholesterolemiaTABLETSAdolescents ages 14 to 18. 40 mg daily atbedtime.Children ages 8 to 14. 20 mg daily at bedtime.Mechanism of ActionInhibits cholesterol synthesis in liver byblocking the enzyme needed to converthydroxymethylglutaryl-CoA (HMG-CoA)to mevalonate, a cholesterol precursor.When cholesterol synthesis is blocked, theliver also increases breakdown of LDL cholesterol.ContraindicationsActive hepatic disease or unexplained, persistentelevated liver function test results;breastfeeding; hypersensitivity to pravastatinor its components; pregnancyInteractionsDRUGScholestyramine, colestipol: Decreased pravastatinbioavailabilitycyclosporine, erythromycin, gemfibrozil,immunosuppressants, niacin: Increased riskof rhabdomyolysis and acute renal failureoral anticoagulants: Increased bleeding orprolonged PTAdverse ReactionsCNS: Anxiety, depression, dizziness, fatigue,headache, nervousness, sleep disturbanceCV: Angina pectoris, chest painEENT: Blurred vision, diplopia, rhinitisENDO: Abnormal thyroid functionGI: Abdominal pain, constipation, diarrhea,elevated liver function test results, flatulence,heartburn, indigestion, nausea, pancreatitis,vomitingGU: Dysuria, nocturia, urinary frequencyMS: Arthralgia, musculoskeletal cramps orpain, myalgia, myopathy, rhabdomyolysisRESP: Cough, dyspnea, upper respiratorytract infectionSKIN: RashOther: Angioedema

Nursing Considerations• Use pravastatin cautiously in patients withrenal or hepatic impairment and in elderlypatients.• Monitor liver function test results beforepravastatin therapy starts, before dosageincreases, and periodically throughouttherapy, as prescribed.• Give drug 1 hour before or 4 hours aftergiving cholestyramine or colestipol.• Report unexplained muscle aches or weaknessand significant increases in CK levelto prescriber because drug rarely causesrhabdomyolysis with acute renal failurecaused by myoglobinuria. Expect to stopdrug and provide supportive care.• Monitor patient’s BUN and serum creatininelevels periodically for abnormal elevations.• Monitor blood lipoprotein level, as indicated,to evaluate response to therapy.PATIENT TEACHING• Instruct patient to take drug at bedtime,without regard to meals.• Advise patient to notify prescriber at onceabout muscle pain, tenderness, weakness,and other evidence of myopathy.• Urge woman of childbearing age to use areliable method of contraception duringpravastatin therapy and to notify prescriberat once if she becomes pregnant orthinks she may be pregnant.• Instruct patient not to stop taking pravastatinwithout consulting prescriber, evenwhen cholesterol level returns to normal.prazosinhydrochlorideMinipressClass and CategoryChemical class: Quinazoline derivativeTherapeutic class: AntihypertensivePregnancy category: CIndications and Dosages To manage hypertensionCAPSULESAdults. Initial: 1 mg b.i.d. or t.i.d.Maintenance: 6 to 15 mg daily in divideddoses b.i.d. or t.i.d. Maximum: 40 mg daily.Children. Initial: 50 to 400 mcg/kg daily inprazosin hydrochloride 851divided doses b.i.d. or t.i.d. Maximum:7 mg/dose, 15 mg daily.TABLETSAdults. Initial: 0.5 mg b.i.d. or t.i.d. for atleast 3 days; then increased to 1 mg b.i.d. ort.i.d., if tolerated, for an additional 3 days.Subsequent dosages adjusted gradually, asneeded and tolerated. Maintenance: 6 to15 mg daily in divided doses b.i.d. or t.i.d.Maximum: 40 mg daily.Children. Initial: 50 to 400 mcg/kg daily individed doses b.i.d. or t.i.d. Maximum:7 mg/dose, 15 mg daily.DOSAGE ADJUSTMENT For elderly patientsand those with renal impairment, initialdosage possibly reduced to 1 mg once totwice daily.Route Onset Peak DurationP.O. 0.5–1.5 hr 2–4 hr* 7–10 hrMechanism of ActionSelectively and competitively inhibitsalpha 1 -adrenergic receptors. This actionpromotes peripheral arterial and venous dilationand reduces peripheral vascularresistance, thereby lowering blood pressure.ContraindicationsHypersensitivity to prazosin, other quinazolines,or their componentsInteractionsDRUGSantihypertensives, beta blockers, diuretics,phosphodiesterase-5 inhibitors: Increasedrisk of hypotension and syncopedopamine: Antagonized peripheral vasoconstrictiveeffect of dopamine (high doses)ephedrine: Decreased vasopressor responseto ephedrineepinephrine: Possibly severe hypotensionand tachycardiametaraminol: Decreased vasopressor effectof metaraminolmethoxamine, phenylephrine: Possiblydecreased vasopressor effect and shortenedduration of action of these drugsNSAIDs, sympathomimetics: Decreasedeffectiveness of prazosinAdverse ReactionsCNS: Asthenia, dizziness, drowsiness,* For a single dose; 3 to 4 wk for multipledoses.P

852prednisolonefatigue, headache, insomnia, malaise, nervousness,syncopeCV: Angina, bradycardia, edema, orthostatichypotension, palpitations, vasculitisEENT: Dry mouth, eye painENDO: GynecomastiaGI: NauseaGU: Urinary frequency, urinary incontinenceSKIN: UrticariaOther: Hypersensitivity reactionNursing Considerations• Use prazosin cautiously in patients withrenal impairment because of increasedsensitivity to prazosin’s effects; in thosewith angina pectoris because drug mayinduce or aggravate angina; in those withnarcolepsy because prazosin may worsencataplexy; and in elderly patients becausethey’re at increased risk for drug-inducedhypotension.• Monitor blood pressure regularly to evaluateeffectiveness of therapy.PATIENT TEACHING• Instruct patient who is starting prazosin totake drug at bedtime to minimize effectsof first-dose hypotension.• Stress need to take drug even if feeling well.• Advise patient to avoid drinking alcohol,standing for long periods, and exercisingin hot weather because these activitiesincrease risk of orthostatic hypotension.• Suggest rising slowly from lying or sittingposition to minimize orthostatic hypotension.• Urge patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to notify prescriber immediatelyabout adverse reactions, especiallydizziness and fainting.• Instruct patient not to take any drugs,including OTC forms, without consultingprescriber, to avoid serious interactions.prednisoloneCotolone, Delta-Cortef, PreloneprednisoloneacetateArticulose-50, Flo-Pred, Key-Pred,Predacort 50, Predalone 50, Predate 50,Predcor-25, Predcor-50, Pred-Ject 50prednisolonesodium phosphateOrapred ODT, PediapredprednisolonetebutateNor-Pred T.B.A., Predalone T.B.A.,Predate TBA, Predcor-TBAClass and CategoryChemical class: GlucocorticoidTherapeutic class: Anti-inflammatory,immunosuppressantPregnancy category: CIndications and Dosages To treat adrenal insufficiency and acuteand chronic inflammatory andimmunosuppressive disordersSYRUP, TABLETS (PREDNISOLONE);DISINTEGRATING TABLETS, ORAL SOLUTION(PREDNISOLONE SODIUM PHOSPHATE); ORALSUSPENSION (PREDNISOLONE ACETATE)Adults and adolescents. 5 to 60 mg daily orin divided doses. Maximum: 250 mg daily.I.M. INJECTION (PREDNISOLONE ACETATE)Adults and adolescents. 4 to 60 mg daily.INTRA-ARTICULAR, INTRALESIONAL, ORSOFT-TISSUE INJECTION (PREDNISOLONE ACETATE,PREDNISOLONE TEBUTATE)Adults and adolescents. 4 to 100 mg ofprednisolone acetate, repeated as needed, or4 to 40 mg of prednisolone tebutate, repeatedevery 1 to 3 wk, as needed. To treat adrenocortical insufficiency inchildrenSYRUP, TABLETS (PREDNISOLONE);DISINTEGRATING TABLETS, ORAL SOLUTION(PREDNISOLONE SODIUM PHOSPHATE); ORALSUSPENSION (PREDNISOLONE ACETATE)Children. 0.14 mg/kg daily in divided dosest.i.d.I.M. INJECTION (PREDNISOLONE ACETATE)Children. 0.14 mg/kg over a 24-hr periodin divided doses t.i.d. every third day. To treat acute exacerbations of multiplesclerosisSYRUP, TABLETS (PREDNISOLONE);DISINTEGRATING TABLETS, ORAL SOLUTION

(PREDNISOLONE SODIUM PHOSPHATE); ORALSUSPENSION (PREDNISOLONE ACETATE)Adults. 200 mg daily for 1 wk, followed by80 mg every other day for 1 mo.Route Onset Peak DurationP.O.* Unknown 1–2 hr 1.25–1.5daysI.M. † Slow Unknown UnknownIntra- 1– 2 days Unknown 1–3 wkarticular,intralesional,soft-tissueinjection ‡Mechanism of ActionBinds to intracellular glucocorticoid receptorsand suppresses inflammatory andimmune responses by:• inhibiting neutrophil and monocyte accumulationat inflammation site and suppressingtheir phagocytic and bactericidalactivity• stabilizing lysosomal membranes• suppressing antigen response of macrophagesand helper T cells• inhibiting synthesis of inflammatoryresponse mediators, such as cytokines,interleukins, and prostaglandins.ContraindicationsHypersensitivity to prednisolone or itscomponents, idiopathic thrombocytopenicpurpura (I.M. form), systemic fungal infectionInteractionsDRUGSacetaminophen: Possibly hepatotoxicity(long-term use or high acetaminophendoses)acetazolamide: Possibly hypernatremia oredemaamphotericin B (parenteral): Possibly severehypokalemiaanabolic steroids, androgens: Possibly edemaand severe acneanticholinergics: Increased intraocular pressureasparaginase: Increased hyperglycemic* Prednisolone† Prednisolone acetate‡ Prednisolone tebutateprednisolone 853effect of asparaginase, possibly neuropathyand disturbances in erythropoiesiscarbonic anhydrase inhibitors: Possibly hypocalcemia,hypokalemia, and osteoporosisdigoxin: Possibly arrhythmias and digitalistoxicity from hypokalemiadiuretics: Possibly decreased natriuretic anddiuretic effects of diuretics, severe hypokalemia(with potassium-depleting diuretics)ephedrine: Increased metabolic clearance ofprednisoloneestrogens, oral contraceptives: Decreasedclearance, increased elimination half-life,and increased therapeutic and toxic effectsof prednisolonefolic acid: Increased folic acid requirements(with long-term prednisolone use)heparin, oral anticoagulants, streptokinase,urokinase: Possibly decreased anticoagulanteffect and increased risk of GI ulcerationand bleedingimmunosuppressants: Increased risk ofinfection, lymphomas, and other lymphoproliferativedisordersisoniazid: Decreased blood isoniazid levelmexiletine: Possibly accelerated metabolismand decreased blood level of mexiletineneuromuscular blockers: Increased neuromuscularblockadeNSAIDs: Increased risk of GI ulceration andbleeding, possibly added therapeutic effectwhen NSAIDs are used to treat arthritispotassium supplements: Decreased effectivenessof both drugsrifampin, other hepatic enzyme inducers:Decreased prednisolone effectritodrine: Increased risk of pulmonaryedema in pregnant womensalicylates: Possibly decreased blood salicylatelevel, increased risk of GI ulcerationand bleedingsodium-containing drugs: Possibly edemaand hypertensionsomatrem, somatropin: Inhibited growthresponse to somatrem or somatropinstreptozocin: Increased risk of hyperglycemiatoxoids, vaccines: Possibly loss of antibodyresponse, increased risk of neurologic complicationstricyclic antidepressants: Possibly worsenedadverse psychiatric effects of prednisolonetroleandomycin: Increased therapeutic andtoxic effects of prednisoloneFOODSP

854prednisolonesodium-containing foods: Increased risk ofedema and hypertensionACTIVITIESalcohol use: Increased risk of GI ulcerationand bleedingAdverse ReactionsCNS: Euphoria, headache, insomnia, nervousness,psychosis, restlessness, seizures,vertigoCV: Edema, heart failure, hypertensionEENT: Cataracts, exophthalmos, glaucoma,increased ocular pressureENDO: Adrenal insufficiency, Cushing’ssyndrome, growth suppression in children,hyperglycemiaGI: Anorexia, GI bleeding and ulceration,increased appetite, indigestion, intestinalperforation, nausea, pancreatitis, vomitingGU: Menstrual irregularitiesMS: Avascular necrosis of joints, bone fractures,muscle atrophy or weakness, myalgia,osteoporosis, tendon rupture (local injectiononly)SKIN: Acne; cutaneous or subcutaneousatrophy (with frequent repository injections);diaphoresis; ecchymosis; flushing;petechiae; striae; thin, fragile skinOther: Delayed wound healing, hypernatremia,hypokalemia, injection site scarring,negative nitrogen balanceNursing ConsiderationsWARNING Avoid using prednisolone inpatients with a history of active tuberculosisbecause drug can reactivate the disease.• Give once-daily doses in the morning tomirror body’s normal cortisol secretion.• Inspect injectable form for particulatesand discoloration before administering.• For I.M. injection, shake suspension wellbefore withdrawing. Keep in mind thatI.M. injections are contraindicated inpatients with idiopathic thrombocytopenicpurpura.• For intra-articular injection, attach a 20Gto 24G needle to empty syringe, usingaseptic technique, so prescriber canremove a few drops of synovial fluid toconfirm that needle is in the joint. Theaspirating syringe is then exchanged witha prenisolone-filled syringe to inject druginto joint.• Because prednisolone can produce manyadverse reactions, assess patient regularlyfor evidence of such reactions, includingheart failure and hypertension. Also monitorpatient’s intake, output, and dailyweight.• Monitor growth pattern in children; prednisolonemay retard bone growth.• Prolonged use may cause hypothalamicpituitary-adrenalsuppression.WARNING Withdraw drug gradually, asordered, if therapy lasts longer than2 weeks. Stopping abruptly may causeacute adrenal insufficiency or, possibly,death.• Be aware that patient may be at risk foremotional instability or psychic disturbancewhile taking prednisolone, especiallyif predisposed to them or taking highdoses.PATIENT TEACHING• Instruct patient to take oral prednisolonewith food to decrease stomach upset andto take once-daily dose in the morning.• Stress nweed to take drug exactly as prescribed;taking too much increases risk ofserious adverse reactions.• Instruct patient taking orally disintegratingtablets to remove tablet from blisterpack only when ready to take drug and toplace tablet on tongue. Warn her not tosplit, cut, or break tablets.• Caution patient not to discontinue drugabruptly.• Urge patient to avoid alcohol during therapybecause of increased risk of GI ulcersand bleeding.• Urge patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to avoid people with contagiousinfections because drug has animmunosuppressant effect. Urge her tonotify prescriber immediately about exposureto measles or chickenpox.• Caution against receiving vaccinations orother immunizations and coming in contactwith people who have recentlyreceived oral poliovirus vaccine.• Teach patient about potential side effectsof prednisolone therapy, including restlessness,mood swings, nervousness, anddelayed wound healing.• Instruct patient to notify prescriber immediatelyabout joint pain, swelling, tarrystools, and visual disturbances. Alsoinstruct her to report signs of infection or

prednisone 855injury for up to 12 months after therapy.• Advise patient to restrict joint use afterintra-articular injection and to obtainactivity guidelines from prescriber.• Instruct diabetic patient to check herblood glucose level often because prednisolonemay cause hyperglycemia.• Advise patient to comply with follow-upvisits to assess drug’s effectiveness anddetect adverse reactions.• Urge patient to carry medical identificationrevealing prednisolone therapy.prednisoneApo-Prednisone (CAN), DeltasoneLiquid Pred, Meticorten, Orasone 1,Orasone 5, Orasone 10, Prednicen-M,Prednicot, Prednisone Intensol,Sterapred, Sterapred DS,Winpred (CAN)Class and CategoryChemical class: GlucocorticoidTherapeutic class: Anti-inflammatory,immunosuppressantPregnancy category: Not ratedIndications and Dosages To treat adrenal insufficiency and acuteand chronic inflammatory andimmunosuppressive disordersORAL SOLUTION, SYRUP, TABLETSAdults and adolescents. 5 to 60 mg daily asa single dose or in divided doses.Maximum: 250 mg daily. To treat adrenogenital syndromeORAL SOLUTION, SYRUP, TABLETSAdults and adolescents. 5 to 10 mg daily.Children. 5 mg/m 2 daily in divided dosesb.i.d. To treat acute exacerbations of multiplesclerosisORAL SOLUTION, SYRUP, TABLETSAdults. 200 mg daily for 1 wk, then 80 mgevery other day for 1 mo. Maximum:250 mg daily. To treat nephrosis in childrenORAL SOLUTION, SYRUP, TABLETSChildren age 10 and over. 20 mg q.i.d.Children ages 4 to 10. 15 mg q.i.d.Children ages 18 months to 4 years. 7.5 to10 mg q.i.d. To treat rheumatic carditis, leukemia,and tumors in childrenORAL SOLUTION, SYRUP, TABLETSChildren. 0.5 mg/kg q.i.d. for 2 to 3 wk;then 0.375 mg/kg q.i.d. for 4 to 6 wk. As adjunct to treat tuberculosis in children(with concurrent antituberculartherapy)ORAL SOLUTION, SYRUP, TABLETSChildren. 0.5 mg/kg q.i.d. for 2 mo.Route Onset Peak DurationP.O. Rapid 1–2 hr 1.25–1.5 daysMechanism of ActionBinds to intracellular glucocorticoid receptorsand suppresses inflammatory andimmune responses by:• inhibiting neutrophil and monocyte accumulationat inflammation site and suppressingtheir phagocytic and bactericidalactivity• stabilizing lysosomal membranes• suppressing antigen response of macrophagesand helper T cells• inhibiting synthesis of inflammatoryresponse mediators, such as cytokines,interleukins, and prostaglandins.ContraindicationsHypersensitivity to prednisone or its components,systemic fungal infectionInteractionsDRUGSacetaminophen: Possibly hepatotoxicity(long-term use or high acetaminophendoses)acetazolamide sodium: Possibly hypernatremiaor edemaamphotericin B (parenteral): Possibly severehypokalemiaanabolic steroids, androgens: Possibly edemaand severe acneantacids: Decreased absorption of prednisone(with long-term use)anticholinergics: Increased intraocular pressureasparaginase: Increased hyperglycemiceffect of asparaginase, possibly neuropathyand disturbances in erythropoiesiscarbonic anhydrase inhibitors: Possibly hypocalcemia,hypokalemia, and osteoporosisdigoxin: Possibly arrhythmias and digitalistoxicity from hypokalemiadiuretics: Possibly decreased natriureticP

856prednisoneand diuretic effects of diuretics, severehypokalemia (with potassium-depletingdiuretics)ephedrine: Increased metabolic clearance ofprednisoneestrogens, oral contraceptives: Decreasedclearance, increased elimination half-life,and increased therapeutic and toxic effectsof prednisonefolic acid: Increased folic acid requirements(with long-term prednisone use)heparin, oral anticoagulants, streptokinase,urokinase: Possibly decreased anticoagulanteffect and increased risk of GI ulcerationand bleedingimmunosuppressants: Increased risk ofinfection, lymphomas, and other lymphoproliferativedisordersisoniazid: Decreased blood isoniazid levelmexiletine: Possibly accelerated metabolismand decreased blood level of mexiletineneuromuscular blockers: Increased neuromuscularblockadeNSAIDs: Increased risk of GI ulceration andbleeding, possibly added therapeutic effectwhen NSAIDs are used to treat arthritispotassium supplements: Decreased effectivenessof both drugsritodrine: Increased risk of pulmonaryedema in pregnant womensalicylates: Possibly decreased blood salicylatelevel, increased risk of GI ulcerationand bleedingsodium-containing drugs: Possibly edemaand hypertensionsomatrem, somatropin: Inhibited growthresponse to somatrem or somatropinstreptozocin: Increased risk of hyperglycemiatoxoids, vaccines: Possibly loss of antibodyresponse, increased risk of neurologic complicationstricyclic antidepressants: Possibly exacerbatedadverse psychiatric effects of prednisonetroleandomycin: Increased therapeutic andtoxic effects of prednisoneFOODSsodium-containing foods: Increased risk ofedema and hypertensionACTIVITIESalcohol use: Increased risk of GI ulcerationand bleedingAdverse ReactionsCNS: Euphoria, headache, insomnia, nervousness,psychosis, restlessness, seizures,vertigoCV: Edema, heart failure, hypertensionEENT: Cataracts, exophthalmos, glaucoma,increased ocular pressureENDO: Adrenal insufficiency, Cushing’ssyndrome, growth suppression in children,hyperglycemiaGI: Anorexia, GI bleeding and ulceration,increased appetite, indigestion, intestinalperforation, nausea, pancreatitis, vomitingGU: Menstrual irregularitiesMS: Avascular necrosis of joints, bone fractures,muscle atrophy or weakness, myalgia,osteoporosisSKIN: Acne; diaphoresis; ecchymosis; flushing;petechiae; striae; thin, fragile skinOther: Delayed wound healing, hypernatremia,hypokalemia, negative nitrogen balanceNursing Considerations• Administer once-daily doses of prednisonein the morning to match body’s normalcortisol secretion schedule.• Because prednisone can produce manyadverse reactions, assess regularly for signsand symptoms of such reactions as heartfailure and hypertension. Also monitorfluid intake and output and daily weight.• Monitor growth pattern in children.Prednisone may retard bone growth.• Be aware that prolonged use of prednisonemay cause hypothalamic-pituitary-adrenalsuppression.WARNING Withdraw prednisone gradually,as ordered, if therapy lasts longer than2 weeks. Stopping abruptly may causeacute adrenal insufficiency and, possibly,death.PATIENT TEACHING• Instruct patient to take prednisone withfood to decrease GI distress and to takeonce-daily dose in the morning.• Stress importance of taking drug exactly asprescribed; taking more than prescribedincreases risk of serious adverse reactions.• Caution patient not to stop drug abruptly.• Urge patient to avoid alcohol during therapybecause of increased risk of GI ulcersand bleeding.• Urge patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to avoid people with contagiousinfections because drug has animmunosuppressant effect. Urge her to

notify prescriber immediately about possibleexposure to measles or chickenpox.• Caution against receiving vaccinations orother immunizations and coming in contactwith people who have recentlyreceived oral poliovirus vaccine.• Instruct patient to notify prescriber immediatelyabout joint pain, swelling, tarrystools, and visual disturbances. Alsoinstruct her to report signs of infection orinjury for up to 12 months after therapy.• Instruct diabetic patient to check bloodglucose level often because prednisonemay cause hyperglycemia.• Advise patient to comply with follow-upvisits to assess drug effectiveness anddetect adverse reactions.• Urge patient to carry medical identificationrevealing prednisone therapy.pregabalinLyricaClass and CategoryChemical class: Structural derivative ofgamma-aminobutyric acid (GABA)Therapeutic class: Analgesic, anticonvulsantPregnancy category: CIndications and Dosages To relieve neuropathic pain associatedwith diabetic peripheral neuropathyCAPSULESAdults. Initial: 50 mg t.i.d., increased to100 mg t.i.d. within 1 wk as needed. To relieve postherpetic neuralgia; asadjunct therapy to manage partial onsetseizuresCAPSULESAdults. Initial: 75 mg b.i.d. or 50 mg t.i.d.,increased to 150 mg b.i.d. or 100 mg t.i.d.within 1 week as needed. Then increased to300 mg b.i.d. or 200 mg t.i.d. in 2 to4 weeks as needed. To manage fibromyalgiaCAPSULESAdults. Initial: 75 mg b.i.d., increased to150 mg b.i.d. in 1 wk, as needed, and thento 225 mg b.i.d. in 1 wk as needed.Maximum: 450 mg daily.DOSAGE ADJUSTMENT If creatinine clearanceis 30 to 60 ml/min/1.73 m 2 , daily dosagereduced by 50%. If clearance is 15 to 30 ml/Adverse ReactionsCNS: Abnormal gait, amnesia, anxiety,asthenia, ataxia, balance disorder, confusion,depression, difficulty concentrating,dizziness, euphoria, extrapyramidal syndrome,fatigue, fever, headache, hypertonia,hypesthesia, incoordination, intracranialhypertension, myoclonus, nervousness,neuropathy, paresthesia, psychotic deprespregabalin857min/1.73 m 2 , daily dosage reduced by 75%and frequency reduced to once or twicedaily. If clearance is less than 15 ml/min/1.73 m 2 , daily dosage reduced to as low as25 mg daily. If patient is having hemodialysis,daily dosage is reduced and supplementaldose given immediately after every 4-hour hemodialysis session as follows: Ifreduced daily dosage is 25 mg daily, givesupplemental dose of 25 to 50 mg. Ifreduced daily dosage is 25 to 50 mg daily,give supplemental dose of 50 to 75 mg. Ifreduced daily dosage is 75 mg, give supplementaldose of 100 to 150 mg.Route Onset Peak DurationP.O. Unknown 1.5 hr UnknownMechanism of ActionBinds to alpha 2 -delta site, an auxiliary subunitof voltage calcium channels, in CNStissue where it may reduce calcium-dependentrelease of several neurotransmitters,possibly by modulating calcium channelfunction. With fewer neurotransmitters,pain sensation and seizure activity decline.ContraindicationsHypersenstivity to pregabalin or its componentsInteractionsDRUGSACE inhibitors: Increased risk of pregabalininducedangioedemaCNS depressants: Additive CNS effects suchas somnolencelorazepam, oxycodone: Additive effects oncognitive and gross motor functionthiazolidinedione antidiabetics: Possiblyincreased risk of peripheral edema andweight gainACTIVITIESalcohol use: Additive effects on cognitiveand gross motor functionP

858primidonesion, schizophrenic reaction, somnolence,stupor, suicidal ideation, tremor, twitching,vertigoCV: Chest pain, heart failure, peripheraledema, ventricular fibrillationEENT: Amblyopia, blurred vision, conjunctivitis,decreased visual acuity, diplopia, drymouth, nystagmus, otitis media, sinusitis,tinnitus, visual field defectENDO: HypoglycemiaGI: Abdominal distention or pain, constipation,diarrhea, flatulence, gastroenteritis, GIhemorrhage, increased appetite, nausea,vomitingGU: Acute renal failure, anorgasmia,decreased libido, glomerulitis, impotence,nephritis, urinary frequency, urinary incontinence,urine retentionHEME: Decreased platelet count, leukopenia,thrombocytopeniaMS: Arthralgia, back pain, elevated creatinekinase level, leg or muscle cramps, myalgia,myastheniaRESP: Apnea, dyspneaSKIN: Ecchymosis, exfoliative dermatitis,pruritusOther: Anaphylaxis, angioedema, facialedema, hypersensitivity reaction, Stevens-Johnson syndrome, weight gainNursing Considerations• Pregabalin therapy should be stoppedgradually over at least 1 week to decreaserisk of seizure activity and avoid unpleasantsymptoms such as diarrhea, headache,insomnia, and nausea.• If patient has evidence of hypersensitivity(red skin, urticaria, rash, dyspnea, facialswelling, wheezing), stop drug at once,notify prescriber, and give supportive care.• Monitor patient closely for adverse reactions.Notify prescriber if significantadverse reactions persist.• Monitor patient closely for evidence ofsuicidal thinking or behavior, especiallywhen therapy starts or dosage changes.PATIENT TEACHING• Warn against stopping pregabalin abruptly.• Urge patient to avoid hazardous activitiesuntil she knows how drug affects her.• Instruct patient to notify prescriber if shehas changes in vision or unexplained musclepain, tenderness, or weakness, especiallyif these muscle symptoms are accompaniedby malaise or fever.• Alert patient that drug may cause edemaand weight gain.• If patient also takes a thiazolidinedioneantidiabetic, tell her these effects may beintensified. If significant, tell patient tonotify prescriber.• Inform male patient who plans to father achild that drug could impair his fertility.• Instruct diabetic patients to inspect theirskin while taking pregabalin.• Urge caregivers to watch patient closely forevidence of suicidal tendencies, especiallywhen therapy starts or dosage changes andto report concerns at once to prescriber.• Urge woman who becomes pregnant whiletaking pregabalin for seizures to enroll inthe North American antiepileptic drugpregnancy registry by calling 1-888-233-2334. Explain that the registry is collectinginformation about the safety of antiepilepticdrugs during pregnancyprimidoneApo-Primidone (CAN), Myidone,Mysoline, PMS Primidone (CAN),Sertan (CAN)Class and CategoryChemical class: Prodrug of phenobarbitalTherapeutic class: AnticonvulsantPregnancy category: Not ratedIndications and Dosages To manage generalized tonic-clonicseizures, nocturnal myoclonic seizures,complex partial seizures, and simplepartial seizures caused by epilepsyCHEWABLE TABLETS, ORAL SUSPENSION, TABLETSAdults and children age 8 and over. Initial:100 or 125 mg at bedtime for first 3 days;then increased to 100 or 125 mg b.i.d. fornext 3 days, followed by 100 or 125 mgt.i.d. for next 3 days. On 10th day, beginmaintenance dosage as prescribed.Maintenance: 250 mg t.i.d. or q.i.d., adjustedas needed. Maximum: 2 g daily.Children up to age 8. Initial: 50 mg at bedtimefor first 3 days; then increased to50 mg b.i.d. for next 3 days, followed byincrease to 100 mg b.i.d. for next 3 days. On10th day, begin maintenance dosage.Maintenance: 125 to 250 mg t.i.d., adjustedas needed.

Mechanism of ActionPrevents seizures by decreasing excitabilityof neurons and increasing motor cortex’sthreshold of electrical stimulation.ContraindicationsHypersensitivity to primidone, phenobarbital,or their components; porphyriaInteractionsDRUGSacetaminophen: Decreased acetaminopheneffectiveness, increased risk of hepatotoxicityadrenocorticoids, chloramphenicol, cyclosporine,dacarbazine, disopyramide, doxycycline,levothyroxine, metronidazole, mexiletine, oralanticoagulants, oral contraceptives (estrogencontaining),quinidine, tricyclic antidepressants:Decreased effectiveness of these drugsamphetamines: Possibly delayed absorptionof primidoneanticonvulsants: Possibly altered pattern ofseizurescarbamazepine: Decreased effectiveness ofprimidonecarbonic anhydrase inhibitors: Increased riskof osteopeniaCNS depressants: Possibly enhanced CNSand respiratory depressant effects of bothdrugscyclophosphamide: Reduced half-life andincreased leukopenic activity of cyclophosphamideenflurane, halothane, methoxyflurane:Increased risk of hepatotoxicity; increasedrisk of nephrotoxicity (with methoxyflurane)fenoprofen: Decreased elimination half-lifeof fenoprofenfolic acid: Increased folic acid requirementsgriseofulvin: Decreased antifungal effects ofgriseofulvinguanadrel, guanethidine: Possibly aggravatedorthostatic hypotensionhaloperidol, loxapine, maprotiline, molindone,phenothiazines, thioxanthenes: Possiblylowered seizure threshold and increasedCNS depressionleucovorin: Possibly decreased anticonvulsanteffects of primidone (with large doses)MAO inhibitors: Possibly prolonged primidoneeffects and altered seizure patternmethylphenidate: Possibly increased bloodprimidone level, resulting in toxicityphenobarbital: Increased sedative effects ofprimidone 859either drug, possibly altered seizure patternphenylbutazone: Decreased primidone effectiveness,increased metabolism anddecreased half-life of phenylbutazonerifampin: Decreased blood primidone levelvalproic acid: Increased blood primidonelevel, leading to increased CNS depressionand neurotoxicity; decreased valproic acidhalf-life and increased hepatotoxicity riskvitamin D: Decreased effects of vitamin Dxanthines: Increased metabolism and clearanceof xanthines (except dyphylline)ACTIVITIESalcohol use: Possibly increased CNS and respiratorydepressant effects of primidoneAdverse ReactionsCNS: Ataxia, confusion, dizziness, drowsiness,excitement, mental changes, moodchanges, restlessnessEENT: Diplopia, nystagmusGI: Anorexia, nausea, vomitingGU: ImpotenceRESP: DyspneaOther: Folic acid deficiencyNursing Considerations• Monitor blood levels of primidone andphenobarbital (its active metabolite), asordered, to determine therapeutic level ordetect toxic levels.• Anticipate that drug may cause confusion,excitement, or mood changes in elderlypatients and children.• Assess for signs of folic acid deficiency:mental dysfunction, neuropathy, tiredness,and weakness.PATIENT TEACHING• Instruct patient to crush primidone tabletsand mix with food or fluids, as needed.• Advise patient taking oral suspension toshake bottle well and measure doses with acalibrated device.• Suggest that patient take drug with mealsto minimize adverse GI reactions.• Urge patient not to stop taking primidoneabruptly because doing so can precipitateseizures.• Caution patient about possible decreasedalertness.• Advise her to avoid hazardous activitiesuntil drug’s CNS effects are known.• Urge patient to avoid consuming alcoholand other CNS depressants during primidonetherapy.P

860probenecidprobenecidBenemid, Benuryl (CAN), ProbalanClass and CategoryChemical class: Sulfonamide derivativeTherapeutic class: Antibiotic adjunct,antigout, uricosuricPregnancy category: Not ratedIndications and Dosages To treat chronic gouty arthritis andhyperuricemia due to chronic goutTABLETSAdults and adolescents. Initial: 250 mgb.i.d. for 1 wk; then increased to maintenancedosage. Maintenance: 500 mg b.i.d.; ifnot effective or 24-hr uric acid excretionisn’t greater than 700 mg, dosage increasedby 500 mg/day every 4 wk, as needed andprescribed, up to a maximum of 3 g daily. Ifno acute attacks of gout occur over next6 mo and serum uric acid level is withinnormal limits, dosage decreased, as prescribed,by 500 mg every 6 mo until lowesteffective maintenance dose is reached.Maximum: 3 g daily.DOSAGE ADJUSTMENT Dosage possiblyincreased for patients with mild renal dysfunction,except for elderly patients, whorequire a dosage reduction. As adjunct to antibiotic therapy withpenicillins and some cephalosporinsTABLETSAdults, adolescents age 14 and over, andchildren weighing more than 50 kg(110 lb). 500 mg q.i.d.; if given with I.V. orI.M. antibiotic, administer at least 30 minbefore antibiotic.Children ages 2 to 14 weighing up to50 kg. 25 mg/kg as single dose, then10 mg/kg q.i.d.; if given with I.V. or I.M.antibiotic, give at least 30 min beforeantibiotic. As adjunct to treat sexually transmitteddiseasesTABLETSAdults and adolescents. 1 g as single dose,given with appropriate antibiotic. As adjunct to treat pediatric gonorrheaTABLETSPostpubertal children and children weighingmore than 45 kg (99 lb). 1 g as singledose, given with appropriate antibiotic. As adjunct to treat neurosyphilisTABLETSAdults and adolescents. 500 mg q.i.d. with1 daily dose (2.4 million units) of penicillinG procaine for 10 to 14 days.Route Onset Peak DurationP.O. Unknown 30 min* 8 hr†Mechanism of ActionIncreases urinary excretion of uric acid andlowers serum uric acid level, which mayprevent or resolve urate deposits, tophusformation, and joint changes. Eventually,incidence of acute gout attacks decreases.Probenecid also inhibits renal excretion ofpenicillins and some cephalosporins, therebyincreasing their serum concentrationand prolonging their duration of action.ContraindicationsAge less than 2 years, blood dyscrasias,hypersensitivity to probenecid or its components,renal calculi (urate)InteractionsDRUGSacyclovir: Decreased renal tubular secretionof acyclovirallopurinol: Additive antihyperuricemiceffectsaminosalicylate sodium, cephalosporins, ciprofloxacin,clofibrate, dapsone, ganciclovir,imipenem, methotrexate, nitrofurantoin, norfloxacin,penicillins: Increased and possiblyprolonged blood levels of these drugs,increased risk of toxicityantineoplastics (rapidly cytolytic): Possiblyuric acid nephropathydiazoxide, mecamylamine, pyrazinamide:Increased risk of hyperuricemia, decreasedprobenecid effectivenessdyphylline: Increased half-life of dyphyllinefurosemide: Increased blood furosemidelevelheparin: Increased and prolonged anticoagulanteffectindomethacin, ketoprofen, other NSAIDs:Possibly increased adverse effectslorazepam, oxazepam, temazepam: Increased* For renal clearance of uric acid; 2 hr foreffect on blood antibiotic level.† For effect on blood antibiotic level;unknown for renal clearance of uric acid.

effects of these drugs, possibly excessivesedationriboflavin: Decreased GI absorption of riboflavinrifampin, sulfonamides: Increased blood levelsof these drugs and, possibly, toxicitysalicylates: Decreased uricosuric effects ofprobenecidsodium benzoate and sodium phenylacetate:Decreased renal elimination of these drugssulfonylureas: Increased sulfonylurea halflifethiopental: Prolonged thiopental effectzidovudine: Increased risk of zidovudinetoxicityACTIVITIESalcohol use: Increased risk of hyperuricemia,decreased probenecid effectivenessAdverse ReactionsCNS: Dizziness, headacheEENT: Sore gumsGI: Anorexia, nausea, vomitingGU: Hematuria, renal calculi (urate), renalcolic, urinary frequencyMS: Costovertebral pain; joint pain, redness,and swellingSKIN: Facial flushing, pruritus, rash, urticariaNursing Considerations• Be aware that probenecid therapy shouldn’tstart until acute gout attack has subsided.If acute attack starts during therapy,continue therapy as prescribed.• Use drug cautiously in patients with pepticulcer disease.• Expect to give sodium bicarbonate (3 to7.5 g daily) or potassium citrate (7.5 gdaily), as prescribed, to keep urine alkalineand prevent renal calculus formation.• Monitor CBC, serum uric acid level, andliver and renal function test results duringtherapy.• Closely monitor patients receiving intermittenttherapy because they’re more likelyto develop allergic reactions.• Check blood glucose level often in diabeticpatient who takes a sulfonylurea becauseof the risk of drug interactions.PATIENT TEACHING• Advise patient to take probenecid withmeals to minimize GI distress.• Encourage patient to increase fluid intake(up to 3 L daily, if not contraindicated) toprocainamide hydrochloride 861help prevent renal calculus formation.• Instruct patient to notify prescriber immediatelyif she has signs of an acute goutattack (joint pain, swelling, and redness)or of renal calculi (flank pain and blood inurine).• Caution patient against taking salicylateswhile taking probenecid. Instead, adviseacetaminophen to treat mild pain or fever.procainamidehydrochlorideProcan SR, Promine, Pronestyl,Pronestyl-SRClass and CategoryChemical class: Ethyl benzamidemonohydrochlorideTherapeutic class: AntiarrhythmicPregnancy category: CIndications and Dosages To treat life-threatening ventriculararrhythmiasCAPSULES, TABLETSAdults. 50 mg/kg daily in 8 divided doses(every 3 hr), adjusted as needed and tolerated.Maximum: 6 g daily (maintenance).Children. 12.5 mg/kg q.i.d.E.R. TABLETSAdults. Maintenance: 50 mg/kg daily individed doses q.i.d. (every 6 hr), adjusted asneeded and tolerated. Maximum: 6 g daily(maintenance).I.V. INFUSION OR INJECTIONAdults. Initial: 100 mg diluted in D 5 W andgiven at no more than 50 mg/min.Repeated every 5 min until arrhythmia iscontrolled or maximum total dose of 1 g isreached. Or, 10 to 15 mg/kg I.V. bolus givenat 25 to 50 mg/min. Maintenance: 1 to4 mg/min by continuous infusion.I.M. INJECTIONAdults. 50 mg/kg daily in divided dosesevery 3 to 6 hr. To treat ventricular extrasystoles andarrhythmias associated with anesthesiaand surgeryI.V. INFUSION OR INJECTIONAdults. Initial: 100 mg diluted in D 5 W andgiven at no more than 50 mg/min. Dosagerepeated every 5 min until arrhythmia isP

862procainamide hydrochloridecontrolled or maximum total dose of 1 g isreached. Or, 10 to 15 mg/kg I.V. bolus givenat 25 to 50 mg/min. Maintenance: 1 to4 mg/min by continuous infusion.I.M. INJECTIONAdults. 100 to 500 mg every 3 to 6 hr.DOSAGE ADJUSTMENT For elderly patients orthose with cardiac or hepatic insufficiency,dosage possibly reduced or dosing intervalsincreased. For patients with creatinineclearance less than 50 ml/min/1.73 m 2 , initialdosage reduced to 1 to 2 mg/min.Route Onset Peak DurationP.O. Unknown Unknown 60– 90 minP.O. Unknown 60–90 Unknown(E.R.)minI.V. Unknown Immediate UnknownI.M. 10–30 min 15–60 min UnknownMechanism of ActionProlongs recovery period after myocardialrepolarization by inhibiting sodium influxthrough myocardial cell membranes. Thisaction prolongs refractory period, causingmyocardial automaticity, excitability, andconduction velocity to decline.ContraindicationsComplete heart block, hypersensitivity toprocainamide or its components, systemiclupus erythematosus, torsades de pointesInteractionsDRUGSantiarrhythmics: Additive cardiac effectsanticholinergics, antidyskinetics, antihistamines:Possibly intensified atropine-likeadverse effects, increased risk of ileusantihypertensives: Additive hypotensiveeffectsantimyasthenics: Possibly antagonized effectof antimyasthenic on skeletal musclebethanechol: Possibly antagonized cholinergiceffect of bethanecholbone marrow depressants: Possibly increasedleukopenic or thrombocytopenic effectsbretylium: Possibly decreased inotropiceffect of bretylium and enhanced hypotensionneuromuscular blockers: Possibly increasedor prolonged neuromuscular blockadepimozide: Possibly prolonged QT interval,leading to life-threatening arrhythmiasAdverse ReactionsCNS: Chills, disorientation, dizziness, lightheadednessCV: Heart block (second-degree), hypotension,pericarditis, prolonged QT interval,tachycardiaEENT: Bitter tasteGI: Abdominal distress, anorexia, diarrhea,nausea, vomitingHEME: Agranulocytosis, neutropenia,thrombocytopeniaMS: Arthralgia, myalgiaRESP: Pleural effusionSKIN: Pruritus, rashOther: Drug-induced feverNursing Considerations• Place patient in a supine position beforegiving procainamide I.M. or I.V. to minimizehypotensive effects. Monitor bloodpressure often and ECG tracings continuouslyduring administration and for30 minutes afterward.• Inspect parenteral solution for particlesand discoloration before giving drug; discardif particles are present or solution isdarker than light amber.• When possible, give drug by I.V. infusionor injection, as prescribed, rather than byI.M. injection.• If drug is to be given I.M. and patient’splatelet count is below 50,000/mm 3 , notifyprescriber at once because patient maydevelop bleeding, bruising, or hematomasfrom procainamide-induced bone marrowsuppression and thrombocytopenia.Expect to give procainamide I.V.• For I.V. injection, dilute procainamidewith D 5 W according to manufacturer’sinstructions before administration.• For I.V. infusion, dilute 200 to 1,000 mg ofprocainamide to a concentration of 2 or4 mg/ml using 50 to 500 ml of D 5 W.• Administer I.V. infusion with an infusionpump or other controlled-delivery device.• Don’t exceed 500 mg in 30 minutes by I.V.infusion or 50 mg/min by I.V. injectionbecause heart block or cardiac arrest mayoccur.• Anticipate that patient has reached maximumclinical response when ventriculartachycardia resolves, hypotension develops,or QRS complex is 50% wider thanoriginal width.• Expect to give first oral dose 3 to 4 hours

after last I.V. dose.PATIENT TEACHING• Instruct patient to swallow E.R. procainamidetablets whole, without breaking,crushing, or chewing them.• If patient has trouble swallowing, tell herto crush regular-release tablets or opencapsules and mix contents with food orfluid.• Instruct patient to take drug 1 hour beforeor 2 hours after meals with a full glass ofwater. Inform her that she may take drugwith food if GI irritation develops.• Urge patient to obtain needed dental workbefore therapy starts or after blood countreturns to normal because drug can causemyelosuppression and increased risk ofbleeding and infection. Encourage goodoral hygiene during therapy, and urgepatient to consult prescriber before havingdental procedures.• Advise patient to notify prescriber immediatelyabout bruising, chills, diarrhea,fever, or rash.prochlorperazineCompazine, Stemetil (CAN)prochlorperazineedisylateCompazineprochlorperazinemaleateCompazine Spansule, Nu-Prochlor(CAN), Stemetil (CAN)Class and CategoryChemical class: Phenothiazine, piperazineTherapeutic class: Antianxiety, antiemetic,antipsychoticPregnancy category: Not ratedIndications and Dosages To control nausea and vomiting relatedto surgeryI.V. INFUSION OR INJECTION (PROCHLORPERAZINEEDISYLATE)Adults and adolescents. 5 to 10 mg at arate not to exceed 5 mg/ml 15 to 30 minprochlorperazine 863before anesthesia or during or after surgery,as needed. Dosage repeated once, if necessary.Maximum: 10 mg/dose, 40 mg daily.I.M. INJECTION (PROCHLORPERAZINE EDISYLATE)Adults and adolescents. 5 to 10 mg 1 to2 hr before anesthesia or during or aftersurgery, as needed. Repeated once in30 min, if needed. Maximum: 10 mg/dose,40 mg daily. To control severe nausea and vomitingE.R. CAPSULES (PROCHLORPERAZINE MALEATE)Adults and adolescents. 15 to 30 mg dailyin the morning, or 10 mg every 12 hr.Maximum: 40 mg daily.ORAL SOLUTION (PROCHLORPERAZINE EDISYLATE)Adults and adolescents. 5 to 10 mg t.i.d. orq.i.d. Maximum: 40 mg daily.Children weighing 18 to 39 kg (40 to86 lb). 2.5 mg t.i.d. or 5 mg b.i.d.Maximum: 15 mg daily.Children weighing 14 to 18 kg (31 to40 lb). 2.5 mg b.i.d. or t.i.d. Maximum:10 mg daily.Children weighing 9 to 14 kg (20 to 31 lb).2.5 mg once or twice daily. Maximum:7.5 mg daily.TABLETS (PROCHLORPERAZINE MALEATE)Adults and adolescents. 5 to 10 mg t.i.d. orq.i.d. Maximum: 40 mg daily.I.V. INFUSION OR INJECTION (PROCHLORPERAZINEEDISYLATE)Adults and adolescents. 2.5 to 10 mg at arate not to exceed 5 mg/min. Maximum:40 mg daily.I.M. INJECTION (PROCHLORPERAZINE EDISYLATE)Adults and adolescents. 5 to 10 mg every3 to 4 hr, p.r.n. Maximum: 40 mg daily.Children ages 2 to 12. 132 mcg/kg/dose tomaximum of 10 mg on day 1; thenincreased as needed. Maximum: On day 1,10 mg; thereafter, 25 mg daily for childrenages 6 to 12, 20 mg daily for children ages2 to 6.SUPPOSITORIES (PROCHLORPERAZINE)Adults and adolescents. 25 mg b.i.d.Children weighing 18 to 39 kg. 2.5 mgt.i.d. or 5 mg b.i.d. Maximum: 15 mg daily.Children weighing 14 to 18 kg. 2.5 mgb.i.d. or t.i.d. Maximum: 10 mg daily.Children weighing 9 to 14 kg. 2.5 mg onceor twice daily. Maximum: 7.5 mg daily. To manage psychotic disorders, such asschizophreniaORAL SOLUTION (PROCHLORPERAZINE EDISYLATE)P

864prochlorperazineAdults and adolescents. 5 to 10 mg t.i.d. orq.i.d., increased gradually every 2 to 3 days,as needed and tolerated. Maximum: 150 mgdaily.Children ages 2 to 12. 2.5 mg b.i.d. or t.i.d.Maximum: On day 1, 10 mg for all children;thereafter, 25 mg daily for children ages 6 to12, 20 mg daily for children ages 2 to 6.TABLETS (PROCHLORPERAZINE MALEATE)Adults and adolescents. 5 to 10 mg t.i.d. orq.i.d., increased gradually every 2 to 3 days,as needed and tolerated. Maximum: 150 mgdaily.I.M. INJECTION (PROCHLORPERAZINE EDISYLATE)Adults and adolescents. Initial: 10 to 20 mg,repeated every 2 to 4 hr, as prescribed, tobring symptoms under control (usually 3 to4 doses). Maintenance: 10 to 20 mg every4 to 6 hr. Maximum: 200 mg daily.Children ages 2 to 12. 132 mcg/kg/dose onday 1; then increased as needed. Maximum:On day 1, 10 mg for all children; thereafter,25 mg daily for children ages 6 to 12,20 mg/day for children ages 2 to 6. To treat anxiety short-termE.R. CAPSULES (PROCHLORPERAZINE MALEATE)Adults and adolescents. 15 mg daily in themorning, or 10 mg every 12 hr. Maximum:20 mg/day for no longer than 12 wk.ORAL SOLUTION, TABLETS (PROCHLORPERAZINEEDISYLATE)Adults and adolescents. 5 mg t.i.d. or q.i.d.Maximum: 20 mg daily for no longer than12 wk.I.V. INFUSION OR INJECTION (PROCHLORPERAZINEEDISYLATE)Adults and adolescents. 2.5 to 10 mg at nomore than 5 mg/min. Maximum: 40 mgdaily.I.M. INJECTION (PROCHLORPERAZINE EDISYLATE)Adults and adolescents. 5 to 10 mg every3 to 4 hr, p.r.n.DOSAGE ADJUSTMENT Initial dose usuallyreduced and subsequent dosage increasedmore gradually for elderly, emaciated, anddebilitated patients.Mechanism of ActionAlleviates psychotic symptoms by blockingdopamine receptors, depressing release ofselected hormones, and producing alphaadrenergicblocking effect in the brain.Prochlorperazine also alleviates nauseaand vomiting by centrally blocking dopaminereceptors in the medullary chemoreceptortrigger zone and by peripherallyblocking the vagus nerve in the GI tract.Anticholinergic effects and alphaadrenergicblockade reduce anxiety bydecreasing arousal and filtering internalstimuli to the brain stem reticular activatingsystem.Route Onset Peak DurationP.O., I.V., Up to several Up to UnknownI.M., P.R. wk* 6 moIncompatibilitiesDon’t mix prochlorperazine in same syringewith other drugs. Precipitate may formwhen prochlorperazine edisylate is mixed insame syringe with morphine sulfate.ContraindicationsAge less than 2 years, blood dyscrasias, bonemarrow depression, cerebral arteriosclerosis,coma, coronary artery disease, hepaticdysfunction, hypersensitivity to phenothiazines,myeloproliferative disorders, pediatricsurgery, severe CNS depression, severehypertension or hypotension, subcorticalbrain damage, use of large quantities of CNSdepressants, weight less than 9 kg (20 lb)InteractionsDRUGSaluminum- or magnesium-containing antacids,antidiarrheals (adsorbent): Possiblyinhibited absorption of oral prochlorperazineamantadine, anticholinergics, antidyskinetics,antihistamines: Possibly intensified anticholinergicadverse effects, increased risk ofprochlorperazine-induced hyperpyreticeffectamphetamines: Decreased stimulant effectof amphetamines, decreased antipsychoticeffect of prochlorperazineanticonvulsants: Lowered seizure thresholdantithyroid drugs: Increased risk of agranulocytosisapomorphine: Possibly decreased emeticresponse to apomorphine, additive CNSdepressionappetite suppressants: Possibly antagonizedanorectic effect of appetite suppressants* For antipsychotic effects; unknown forother indications.

(except for phenmetrazine)astemizole, cisapride, disopyramide, erythromycin,pimozide, probucol, procainamide:Additive QT interval prolongation,increased risk of ventricular tachycardiabeta blockers: Increased risk of additivehypotensive effects, irreversible retinopathy,arrhythmias, and tardive dyskinesiabromocriptine: Decreased effectiveness ofbromocriptineCNS depressants: Additive CNS depressiondopamine: Possibly antagonized peripheralvasoconstriction (high doses of dopamine)ephedrine, epinephrine: Decreased vasopressoreffects of these drugshepatotoxic drugs: Increased risk of hepatotoxicityhypotension-producing drugs: Possibly severehypotension with syncopelevodopa: Inhibited antidyskinetic effect oflevodopalithium: Reduced absorption of oral prochlorperazine,increased lithium excretion,increased extrapyramidal effects, possiblymasking of early symptoms of lithium toxicityMAO inhibitors, maprotiline, tricyclic antidepressants:Possibly prolonged and intensifiedanticholinergic and sedative effects,increased antidepressant level, inhibitedprochlorperazine metabolism, increasedrisk of neuroleptic malignant syndromemephentermine: Possibly antagonized antipsychoticeffect of prochlorperazine andvasopressor effect of mephenterminemetrizamide: Increased risk of seizuresopioid analgesics: Increased risk of CNS andrespiratory depression, orthostatic hypotension,severe constipation, urine retentionototoxic drugs: Possibly masking of somesymptoms of ototoxicity, such as dizziness,tinnitus, and vertigophenytoin: Possibly inhibited phenytoinmetabolism, increased risk of phenytointoxicitythiazide diuretics: Possibly potentiatedhyponatremia and water intoxicationACTIVITIESalcohol use: Additive CNS depressionAdverse ReactionsCNS: Akathisia, altered temperature regulation,dizziness, drowsiness, extrapyramidalreactions (such as dystonia, pseudoparkinsonism,tardive dyskinesia)prochlorperazine 865CV: Hypotension, orthostatic hypotension,tachycardiaEENT: Blurred vision, dry mouth, nasalcongestion, ocular changes, pigmentaryretinopathyENDO: Galactorrhea, gynecomastiaGI: Constipation, epigastric pain, nausea,vomitingGU: Dysuria, ejaculation disorders, menstrualirregularities, urine retentionSKIN: Decreased sweating, photosensitivity,pruritus, rashOther: Weight gainNursing Considerations• Prochlorperazine shouldn’t be used totreat dementia-related psychosis in theelderly because of increased mortality risk.• Avoid contact between skin and solutionforms of prochlorperazine because contactdermatitis could result.• Inject I.M. form slowly, deep into upperouter quadrant of buttocks. Keep patientsupine for 30 minutes after injection tominimize hypotensive effects.• Rotate I.M. injection sites to prevent irritationand sterile abscesses.• Be aware that I.V. form may be givenundiluted as injection or diluted in isotonicsolution as infusion (mesylate formrequires dilution in at least 1 L). Bothforms should be given at no more than5 mg/minute.• Protect prochlorperazine from light.• Parenteral solution may develop slight yellowingthat won’t affect potency. Don’t useif discoloration is pronounced or precipitateis present.• Expect antipsychotic effects to occur in2 to 3 weeks, although range is days tomonths.WARNING Monitor closely for numerousadverse reactions that may be serious.• Adverse effects may occur up to 12 weeksafter discontinuation of E.R. capsules.PATIENT TEACHING• Instruct patient to take prochlorperazinewith food or a full glass of milk or waterto minimize GI distress.• Advise patient to swallow E.R. capsuleswhole, not to crush or chew them.• Instruct patient using suppository torefrigerate it for 30 minutes or hold itunder running cold water before removingthe wrapper if it softens during storage.P

866progestins• Teach patient correct administration techniquefor suppository.• Caution patient on long-term therapy notto stop prochlorperazine abruptly; doingso may lead to such adverse reactions asnausea, vomiting, and trembling.• Urge patient to avoid alcohol and OTCdrugs that may contain CNS depressants.• Advise patient to rise slowly from lyingand sitting positions to minimize effects oforthostatic hypotension.• Urge patient to avoid hazardous activitiesbecause of the risk of drowsiness andimpaired judgment and coordination.• Instruct patient to avoid excessive sunexposure and to wear sunscreen outdoors.• Urge patient to notify prescriber aboutinvoluntary movements and restlessness.• Explain that adverse effects may occur upto 12 weeks after stopping E.R. capsules.progestinshydroxyprogesteronecaproateGesterol LA 250, Hy/Gestrone, Hylutin,Prodrox, Pro-SpanlevonorgestrelNorplant SystemmedrogestoneColprone (CAN)medroxyprogesteroneacetateAlti-MPA (CAN), Amen, Curretab,Cycrin, Depo-Provera, Gen-Medroxy(CAN), Novo-Medrone (CAN), Proveramegestrol acetateApo-Megestrol (CAN), Megace,Megace OS (CAN)norethindroneAygestin, Norlutate (CAN)norgestrelOvretteprogesteroneCrinone, Gesterol 50, PMS-Progesterone (CAN), PrometriumClass and CategoryChemical class: Progesterone derivative,steroid hormoneTherapeutic class: Antianorectic, anticachectic,antineoplastic, ovarian hormonereplacementPregnancy category: D (hydroxyprogesterone,megestrol [tablets], progesterone); X(levonorgestrel, medroxyprogesterone [parenteral],megestrol [parenteral and suspension],norethindrone, norgestrel); NR(medrogestone, medroxyprogesterone[tablets])Indications and Dosages To treat renal cancerI.M. INJECTION (MEDROXYPROGESTERONE)Adults and adolescents. Initial: 400 mg to1 g every wk until improvement and stabilization.Maintenance: 400 mg or moreevery mo. To treat breast cancerTABLETS (MEGESTROL)Adults and adolescents. 160 mg daily assingle dose or in divided doses. To treat endometrial cancerTABLETS (MEGESTROL)Adult and adolescent women. 40 to 320 mgdaily in divided doses.I.M. INJECTION (MEDROXYPROGESTERONE)Adults and adolescents. Initial: 400 mg to1 g every wk until improvement and stabilization.Maintenance: 400 mg or moreevery mo. To treat anorexia, cachexia, or significantweight loss in patients who have AIDSSUSPENSION (MEGESTROL)Adults and adolescents. 800 mg daily forthe first mo, and then 400 or 800 mg dailyfor the next 3 mo. To treat endometriosisTABLETS (NORETHINDRONE ACETATE)Adult and adolescent women. Initial: 5 mgdaily for 2 wk, increased by 2.5 mg daily at2-wk intervals to total dose of 15 mg daily.Maintenance: 15 mg daily for 6 to 9 mounless temporarily discontinued because ofbreakthrough menstrual bleeding. As adjunct to treat endometrial sheddingin menopausal womenTABLETS (MEDROGESTONE)Adult and adolescent women. 5 to 10 mgdaily on days 15 through 25 of menstrualcycle.

To treat secondary amenorrheaTABLETS (MEDROGESTONE)Adult and adolescent women. 5 to 10 mgdaily on days 15 through 25 of menstrualcycle.TABLETS (MEDROXYPROGESTERONE)Adult and adolescent women. 5 to 10 mgdaily for 5 to 10 days, starting anytime duringmenstrual cycle.TABLETS (NORETHINDRONE ACETATE)Adult and adolescent women. 2.5 to 10 mgdaily on days 5 through 25 of menstrualcycle. Or, 2.5 to 10 mg daily for 5 to 10 daysduring last half of menstrual cycle.CAPSULES (PROGESTERONE)Adult and adolescent women. 400 mg dailyin evening for 10 days.I.M. INJECTION (HYDROXYPROGESTERONE)Adult and adolescent women. 375 mg asone-time dose.I.M. INJECTION (PROGESTERONE)Adult and adolescent women. 5 to 10 mgdaily for 6 to 10 days. Or, 100 to 150 mginjected as single dose.VAGINAL GEL (PROGESTERONE)Adult and adolescent women. 45 mg(1 applicatorful of 4% vaginal gel) everyother day for up to 6 doses. Dosageincreased, as needed, to 90 mg (1 applicatorfulof 8% vaginal gel) every other day forup to 6 doses. To treat dysfunctional uterine bleedingTABLETS (MEDROGESTONE)Adult and adolescent women. 5 to 10 mgdaily on days 15 through 25 of menstrualcycle.TABLETS (MEDROXYPROGESTERONE)Adult and adolescent women. 5 to 10 mgdaily for 5 to 10 days, starting on day 16 or21 of menstrual cycle.TABLETS (NORETHINDRONE ACETATE)Adult and adolescent women. 2.5 to 10 mgdaily on days 5 through 25 of menstrualcycle. Or, 2.5 to 10 mg daily for 5 to 10 daysduring last half of menstrual cycle.I.M. INJECTION (HYDROXYPROGESTERONE)Adult and adolescent women. 375 mg asone-time dose.I.M. INJECTION (PROGESTERONE)Adult and adolescent women. 5 to 10 mgdaily for 6 consecutive days. To induce mensesTABLETS (MEDROGESTONE)Adult and adolescent women. 5 to 10 mgprogestins 867daily on days 15 through 25 of the menstrualcycle.TABLETS (MEDROXYPROGESTERONE)Adult and adolescent women. 10 mg dailyfor 10 days, starting on day 16 of menstrualcycle. Repeated for 2 or more cycles ifbleeding is satisfactorily controlled.I.M. INJECTION (HYDROXYPROGESTERONE)Adult and adolescent women. 125 to250 mg on day 10 of menstrual cycle,repeated every 7 days until suppression isno longer desired. To prevent pregnancy (postcoital)TABLETS (LEVONORGESTREL)Adult and adolescent women. 0.75 mg assoon as possible within 72 hr of intercourse.Second dose given 12 hr later. To prevent pregnancyTABLETS (NORETHINDRONE)Adult and adolescent women. 0.35 mg daily,starting on day 1 of menstrual cycle andcontinuing uninterrupted through the year,whether or not menstrual bleeding occurs.TABLETS (NORGESTREL)Adult and adolescent women. 0.075 mgdaily starting on day 1 of menstrual cycleand continuing uninterrupted throughoutthe year, whether or not menstrual bleedingoccurs.I.M. INJECTION (MEDROXYPROGESTERONE)Adult and adolescent women. 150 mgevery 3 mo.SUBDERMAL IMPLANT (LEVONORGESTREL)Adult and adolescent women. One set ofimplants surgically inserted every 2 yr.Mechanism of ActionProgestins may diminish response toendogenous hormones in tumor cells bydecreasing the number of steroid hormonereceptors, causing a direct cytotoxic orantiproliferative effect on cell cycle growthand increased terminal cell differentiation.At higher doses, some progestins decreaseadrenal production of estradiol and androstenedione,which may decrease estrogenortestosterone-sensitive tumors. Megestrolstimulates appetite and metabolic effects,which promotes weight gain. Progestinsalso bind to cytostolic receptors that areloosely bound in cell nucleus, increasingprotein synthesis and improving cachexia.Progestins affect other hormones, especiallyestrogen, by reducing availability orstability of hormone receptor complex,P

868progestinsshutting off estrogen-responsive genes, orcausing negative feedback mechanism thatdecreases number of functioning estrogenreceptors. These actions allow menstrualcycle to function normally, alleviatingamenorrhea and dysfunctional uterinebleeding and inducing menses. Progestinsalso act to transform proliferative uterineendometrium into a more differentiated,secretory one, which is the basis for usingmedroxyprogesterone to treat some types ofamenorrhea. In a normal ovulatory cyclenot resulting in pregnancy, decline in progesteronesecretion caused by degenerationof corpus luteum in late luteal phase resultsin endometrial sloughing. A similar sloughingoccurs after 5 to 10 days of medroxyprogesterone,provided that adequateestrogen-stimulated proliferation hasoccurred during follicular phase.Selected progestins also inhibit secretionof gonadotropins from pituitary gland,which prevents ovulation, follicular maturation,thickening of cervical mucus to preventsperm penetration, and creation of anatrophic endometrium, resulting in contraceptiveeffect.ContraindicationsActive thromboembolic disorder; thrombophlebitis;significant hepatic disease; hypersensitivityto peanuts (progesterone), progestins,or their components; known or suspectedbreast cancer; pregnancy; undiagnosedgenital, uterine, or urinary tractbleedingInteractionsDRUGSaminoglutethimide: Possibly decreasedblood level of medroxyprogesteronecarbamazepine, phenobarbital, phenytoin,rifabutin, rifampin: Possibly decreased effectivenessof progestinthyroid hormone: Decreased thyroid hormoneeffectivenessAdverse ReactionsCNS: Altered or reduced coordination orspeech, depression, dizziness, drowsiness,fatigue, headache, irritability, migraine,mood changes, nervousness, postmenopausaldementia, syncope, unusualtiredness or weaknessCV: Fluid retention; hypotension; numbnessor pain in chest, arm, or leg; thromboembolismENDO: Adrenal insufficiency or suppression,breast pain or tenderness, Cushing’ssyndrome, decreased T 3 resin uptake,delayed return of fertility in women, elevatedthyroid-binding globulin, galactorrhea,hyperglycemia, vaginal spottingEENT: Gingival bleeding, swelling, or tenderness;vision changes or lossGI: Abdominal cramps or pain, diarrhea,nausea, vomitingGU: Amenorrhea, breakthrough bleeding ormetromenorrhagia, decreased libido, hypermenorrhea,ovarian enlargement or cystsHEME: Clotting and bleeding abnormalitiesMS: Back pain, decreased bone density,osteoporosis, osteoporotic fracturesRESP: DyspneaSKIN: Acne, alopecia, melasma, rashOther: Anaphylaxis; facial fullness; hotflashes; injection or implantation site irritation,pain, or redness; weight gainNursing Considerations• Be aware that progestin/estrogen therapyshouldn’t be used to prevent cardiovasculardisease or dementia.• Use progestins cautiously in patients withrisk factors for arterial vascular disease,such as hypertension, diabetes mellitus,tobacco use, hypercholesterolemia, obesity,systemic lupus erythematosus, or a familyor personal history of venous thromboembolism.Drug worsen these conditions.• Use progestins cautiously in patients whohave CNS disorders, such as seizures ordepression, because progestins may worsenthese conditions.• Be aware that drug causes significant lossof bone mineral density in adolescenceand early adulthood and isn’t recommendedfor long-term contraception. Ifother contraceptive methods are inadequate,evaluate bone mineral density routinely,as ordered.• Confirm that patient isn’t pregnant beforegiving progestin as a contraceptive.• Shake container vigorously for at least1 minute before giving medroxyprogesteroneacetate injection suspension ormegestrol acetate oral suspension.• Inject parenteral medroxyprogesteroneslowy, over 5 to 7 seconds, into deltoidmuscle. Don’t inject into gluteal muscle tolessen absorption problems that may

occur when patient sits on injection site.Pat site lightly after injection; don’t rub it.• Be aware that cyclical use of progestins isbased on a menstrual cycle of 28 days.WARNING Notify prescriber immediately ifpatient develops sudden vision loss,abnormal protrusion of eyeball, diplopia,papilledema, migraine, or other signs ofthrombotic events. Expect to discontinueprogestin if such signs occur.• Monitor patient for adrenal suppression,especially with megestrol therapy. If suspected,notify prescriber.• Expect to stop progestin/estrogen therapyin any woman who develops evidence ofcancer; cardiovascular disease such asCVA, MI, pulmonary embolism, or venousthrombosis; or dementia.PATIENT TEACHING• Explain risks of progestin/estrogen therapy,including breast, endometrial, or ovariancancer; cardiovascular disease; dementia;and gallbladder disease, especially inpostmenopausal women.• Instruct woman to notify prescriber ifuterine bleeding continues longer than 3months or if menstruation is delayed by45 days.• Warn patient taking progestin for noncontraceptivepurposes to use a contraceptivemethod to prevent pregnancy becausedrug may harm fetus.• Advise female patient to contact prescriberimmediately if she suspects pregnancy ormisses a menstrual period.• Stress importance of using a secondmethod of birth control when takingother drugs that could reduce contraceptiveeffectiveness of progestins.• Advise patient that some products maycontain peanut oil. If she is allergic topeanuts, tell her to contact pharmacist tofind out if prescribed progestin productcontains peanut oil.• Advise female patient who vomits shortlyafter taking progestin-only oral contraceptivepill not to take another dose immediatelythereafter but to wait until nextscheduled dose before resuming therapyand to use an additional contraceptivemethod for 48 hours afterward.• Caution female patient who vomits within1 hour of taking progestin for emergencycontraception to contact prescriber aboutpromethazine hydrochloride 869whether to repeat dose.• Teach woman how to use vaginal gel, ifprescribed. Tell her to avoid using othervaginal products for 6 hours before andafter to ensure gel’s complete absorption.• Direct patient to alert all prescribers aboutprogestin therapy because certain bloodtests may be affected.• Stress importance of good dental hygieneand regular dental checkups because elevatedprogestin level increases growth ofnormal oral flora, which may lead to gumtenderness, bleeding, or swelling.• Caution postmenopausal women aboutincreased risk of dementia associated withprogestin therapy.promethazinehydrochlorideAnergan 25, Anergan 50, Antinaus 50,Histantil (CAN), Pentazine, Phenazine25, Phenazine 50, Phencen-50,Phenerzine, Phenoject-50, Pro-50,Promacot, Pro-Med 50, Promet,Prorex-25, Prorex-50, Prothazine,Shogan, V-Gan-25, V-Gan-50Class and CategoryChemical class: Phenothiazine derivativeTherapeutic class: Antiemetic, antihistamine,antivertigo, sedative-hypnoticPregnancy category: CIndications and Dosages To prevent or treat motion sicknessSYRUP, TABLETSAdults and adolescents. 25 mg 30 to60 min before travel and repeated 8 to 12 hrlater, if needed. Maximum: 150 mg daily. To treat vertigoSYRUP, TABLETSAdults and adolescents. 25 mg b.i.d., p.r.n.Maximum: 150 mg daily.Children age 2 and over. 0.5 mg/kg or 10 to25 mg every 12 hr, p.r.n.SUPPOSITORIESAdults and adolescents. 25 mg b.i.d., p.r.n.Maximum: 150 mg daily.Children age 2 and over. 0.5 mg/kg or12.5 to 25 mg every 12 hr. To prevent or treat nausea and vomitingin certain types of anesthesia and surgeryP

870promethazine hydrochlorideSYRUP, TABLETSAdults and adolescents. Initial: 25 mg; then10 to 25 mg every 4 to 6 hr, p.r.n.Maximum: 150 mg daily.Children age 2 and over. 0.25 to 0.5 mg/kgor 10 to 25 mg every 4 to 6 hr, p.r.n.I.V. OR I.M. INJECTIONAdults and adolescents. 12.5 to 25 mgevery 4 hr, p.r.n. Maximum: 150 mg daily.I.M. INJECTIONChildren age 2 and over. 0.25 to 0.5 mg/kgor 12.5 to 25 mg every 4 to 6 hr, p.r.n.SUPPOSITORIESAdults and adolescents. Initial: 25 mg; then12.5 to 25 mg every 4 to 6 hr, p.r.n.Maximum: 150 mg daily.Children age 2 and over. 0.25 to 0.5 mg/kgor 12.5 to 25 mg every 4 to 6 hr. To treat signs and symptoms of allergicresponseSYRUP, TABLETSAdults and adolescents. 10 to 12.5 mgq.i.d. before meals and at bedtime, p.r.n. Or,25 mg at bedtime, p.r.n. Maximum: 150 mgdaily.Children age 2 and over. 0.125 mg/kg every4 to 6 hr or 5 to 12.5 mg t.i.d., p.r.n. Or,0.5 mg/kg or 25 mg at bedtime, p.r.n.I.V. INJECTIONAdults and adolescents. 25 mg, repeatedwithin 2 hr, if needed.I.M. INJECTION, SUPPOSITORIESAdults and adolescents. 25 mg, repeated in2 hr, p.r.n. Maximum: 150 mg daily.Children age 2 and over. 0.125 mg/kg every4 to 6 hr or 6.25 to 12.5 mg t.i.d., p.r.n. Or,0.5 mg/kg or 25 mg at bedtime, p.r.n. To provide nighttime, preoperative, orpostoperative sedationSYRUP, TABLETSAdults and adolescents. 25 to 50 mg as asingle dose. Maximum: 150 mg daily.Children age 2 and over. 0.5 to 1 mg/kg or10 to 25 mg as a single dose. Or, for preoperativesedation, 1.1 mg/kg along with1.1 mg/kg of meperidine and appropriatedose of an atropine-like drug.I.V. INJECTIONAdults and adolescents. 25 to 50 mg as asingle dose. Or, for preoperative and postoperativesedation, 25 to 50 mg combinedwith appropriately reduced dosages of analgesicsand anticholinergics.I.M. INJECTION, SUPPOSITORIESAdults and adolescents. 25 to 50 mg as asingle dose. Or, for preoperative and postoperativesedation, 25 to 50 mg combinedwith appropriately reduced dosages of analgesicsand anticholinergics.Children age 2 and over. 0.5 to 1 mg/kg or12.5 to 25 mg as a single dose. Or, for preoperativesedation, 1.1 mg/kg along with1.1 mg/kg of meperidine and an appropriatedose of an atropine-like drug. To relieve apprehension and promotesleep the night before surgerySYRUP, TABLETS, SUPPOSITORIESAdults and adolescents. 50 mg along with50 mg of meperidine and an appropriatedose of an atropine-like drug at bedtime onthe night before surgery.DOSAGE ADJUSTMENT Dosage usuallydecreased for elderly patients. To provide obstetric sedationI.V. OR I.M. INJECTIONAdults and adolescents. 50 mg for earlystages of labor, followed by 1 or 2 doses of25 to 75 mg after labor is established,repeated every 4 hr during normal labor.Route Onset Peak DurationP.O. 15–60 Unknown 4–6 hrminI.V. 3–5 min Unknown 4–6 hrI.M., P.R. 20 min Unknown 4–6 hrMechanism of ActionCompetes with histamine for H 1 -receptorsites, thereby antagonizing many histamineeffects and reducing allergy signs andsymptoms. Promethazine also preventsmotion sickness, nausea, and vertigo by actingcentrally on medullary chemoreceptivetrigger zone and by decreasing vestibularstimulation and labyrinthine function inthe inner ear. It also promotes sedation andrelieves anxiety by blocking receptor sites inCNS, directly reducing stimuli to the brain.ContraindicationsAngle-closure glaucoma; benign prostatichyperplasia; bladder neck obstruction; bonemarrow depression; breast-feeding; childrenunder age 2; coma; hypersensitivity or historyof idiosyncratic reaction to promethazine,other phenothiazines, or their components;hypertensive crisis; lower respiratorytract disorders (including asthma)

when used as an antihistamine; pyloroduodenalobstruction; stenosing peptic ulcer;use of large quantities of CNS depressantsInteractionsDRUGSamphetamines: Decreased stimulant effectof amphetaminesanticholinergics: Possibly intensified anticholinergicadverse effectsanticonvulsants: Lowered seizure thresholdappetite suppressants: Possibly antagonizedanorectic effect of appetite suppressantsbeta blockers: Increased risk of additivehypotensive effects, irreversible retinopathy,arrhythmias, and tardive dyskinesiabromocriptine: Decreased effectiveness ofbromocriptineCNS depressants: Additive CNS depressiondopamine: Possibly antagonized peripheralvasoconstriction (high doses of dopamine)ephedrine, metaraminol, methoxamine:Decreased vasopressor response to thesedrugsepinephrine: Blocked alpha-adrenergiceffects of epinephrine, increased risk ofhypotensionguanadrel, guanethidine: Decreased antihypertensiveeffects of these drugshepatotoxic drugs: Increased risk of hepatotoxicityhypotension-producing drugs: Possibly severehypotension with syncopelevodopa: Inhibited antidyskinetic effects oflevodopaMAO inhibitors: Possibly prolonged andintensified anticholinergic and CNS depressanteffects of promethazinemetrizamide: Increased risk of seizuresototoxic drugs: Possibly masking of somesymptoms of ototoxicity, such as dizziness,tinnitus, and vertigoquinidine: Additive cardiac effectsriboflavin: Increased riboflavin requirementACTIVITIESalcohol use: Additive CNS depressionAdverse ReactionsCNS: Akathisia, CNS stimulation, confusion,dizziness, drowsiness, dystonia, euphoria,excitation, fatigue, hallucinations,hysteria, incoordination, insomnia, irritability,nervousness, neuroleptic malignant syndrome,paradoxical stimulation, pseudoparkinsonism,restlessness, sedation,promethazine hydrochloride 871seizures, syncope, tardive dyskinesia, tremorCV: Bradycardia, hypertension, hypotension,tachycardiaEENT: Blurred vision; diplopia; dry mouth,nose, and throat; nasal congestion; tinnitus;vision changesENDO: HyperglycemiaGI: Anorexia, cholestatic jaundice, ileus,nausea, rectal burning or stinging (suppositoryform), vomitingGU: DysuriaHEME: Agranulocytosis, leukopenia,thrombocytopenia, thrombocytopenic purpuraRESP: Apnea, respiratory depression, tenaciousbronchial secretionsSKIN: Dermatitis, diaphoresis, jaundice,photosensitivity, rash, urticariaOther: Angioedema, paradoxical reactionsNursing Considerations• Use promethazine cautiously in childrenand elderly patients because they may bemore sensitive to its effects, patients withcardiovascular disease or hepatic dysfunctionbecause of potential adverse effects,patients with asthma because of anticholinergiceffects, and patients withseizure disorders or those who take drugsthat may affect seizure threshold becausedrug may lower seizure threshold.• Inject I.M. form deep into large musclemass, and rotate sites.WARNING Avoid inadvertent intra-arterialinjection of promethazine because it cancause arteriospasm. Also avoid injectingdrug under skin; severe tissue damage andgangrene may develop from impaired circulation.• Give I.V. injection at no more than 25 mg/min; rapid I.V. administration may producea transient drop in blood pressure.WARNING Monitor respiratory functionbecause drug may suppress cough reflexand cause thickening of bronchial secretions,aggravating such conditions as asthmaand COPD. Rarely, it may depress respirationsand induce apnea.• Monitor patient’s hematologic status asordered because promethazine may causebone marrow depression, especially whenused with other known marrow-toxicagents. Assess patient for signs and symptomsof infection or bleeding.WARNING Monitor patient for evidence ofP

872propafenone hydrochlorideneuroleptic malignant syndrome, such asfever, hypertension or hypotension, involuntarymotor activity, mental changes,muscle rigidity, tachycardia, and tachypnea.Be prepared to provide supportivetreatment and drug therapy, as prescribed.• Be aware that patient shouldn’t have intradermalallergen tests within 72 hours ofreceiving promethazine because drug maysignificantly alter flare response.PATIENT TEACHING• Tell patient to use a calibrated device toensure accurate doses of promethazinesyrup.• Teach patient correct administration techniquefor suppository, if needed.• Advise patient to avoid OTC drugs unlessapproved by prescriber.• Instruct patient to notify prescriber immediatelyif she has involuntary movementsand restlessness.• Urge patient to avoid alcohol and otherCNS depressants during therapy.• Instruct patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Suggest rinsing and use of sugarless gumor hard candy to relieve dry mouth.• Urge patient to avoid excessive sun exposureand to use sunscreen when outdoors.propafenonehydrochlorideRythmolClass and CategoryChemical class: 3-PhenylpropriophenoneTherapeutic class: Class IC antiarrhythmicPregnancy category: CIndications and Dosages To treat life-threatening ventriculararrhythmiasTABLETSAdults. Initial: 150 mg every 8 hr; after 3 or4 days, increased to 225 mg every 8 hr(U.S.) or 300 mg every 12 hr (Canada), ifneeded; after an additional 3 or 4 days, furtherincreased to 300 mg every 8 hr, ifneeded. Maximum: 900 mg daily.Mechanism of ActionProlongs recovery period after myocardialrepolarization by inhibiting sodium influxthrough myocardial cell membranes. Thisaction prolongs the refractory period, causingmyocardial automaticity, excitability,and conduction velocity to decline.ContraindicationsBronchospastic disorders, such as asthma;cardiogenic shock; electrolyte imbalances;heart failure (uncontrolled); hypersensitivityto propafenone or its components; severehypotension; sinus bradycardia or AV conductiondisturbances (without artificialpacemaker)InteractionsDRUGSamiodarone: Possibly altered cardiac conductionand repolarization; possiblyincreased blood propafenone levelanesthetics (local): Increased risk of adverseCNS effectsantiarrhythmics, fluoxetine: Increased propafenonelevel and adverse CV effectscimetidine, erythromycin, ketoconazole,paroxetine, ritonavir, saquinavir, sertraline:Possibly increased blood propafenone leveldesipramine: Possibly increased blood levelof desipramine or propafenonedigoxin: Increased risk of digitalis toxicityhaloperidol, imipramine, venlafaxine:Possibly increased levels of these drugsmetoprolol, propranolol: Increased bloodlevel and half-life of these drugsorlistat: Possibly decreased absorption ofpropafenonequinidine: Decreased propafenone metabolismrifampin: Possibly decreased propafenonelevelwarfarin: Increased blood warfarin leveland risk of bleedingFOODSgrapefruit juice: Possibly increased bloodpropafenone levelAdverse ReactionsCNS: Dizziness, fatigue, headacheCV: Angina, AV block, bradycardia, heartfailure, irregular heartbeat, tachycardia,ventricular arrhythmiasEENT: Altered taste, blurred vision, drymouthGI: Constipation, diarrhea, nausea, vomitingSKIN: Rash

Nursing Considerations• Assess patient for electrolyte imbalances,such as hyperkalemia, before startingpropafenone or any antiarrhythmic toreduce risk of adverse cardiac reactions.• Use propafenone cautiously in patientswith heart failure or myocardial dysfunctionbecause beta-blocking activity mayfurther depress myocardial contractility.• Monitor ECG tracings, blood pressure,and pulse rate, particularly at start of therapyand with dosage increases.PATIENT TEACHING• Instruct patient to take a missed dose ifshe remembers within 4 hours; otherwise,tell her to skip missed dose and to resumethe regular dosing schedule.• Advise patient not to stop propafenone orchange dosage without asking prescriber.• Urge patient to carry medical identificationshowing she that takes propafenone.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Urge patient to increase fluid intake anddietary fiber if she becomes constipated.• Explain that drug may cause an unusualtaste. Advise patient to notify prescriber iftaste interferes with compliance.propanthelinebromidePro-Banthine, Propanthel (CAN)Class and CategoryChemical class: Quaternary amineTherapeutic class: AnticholinergicPregnancy category: CIndications and Dosages As adjunct to treat peptic ulcer diseaseTABLETSAdults. 15 mg t.i.d. before meals and 30 mgat bedtime, adjusted as needed and tolerated.Maximum: 120 mg daily.Children. 0.375 mg/kg q.i.d., adjusted asneeded and tolerated.DOSAGE ADJUSTMENT For elderly patientswith mild symptoms or patients of belowaverageweight, dosage possibly reduced to7.5 mg t.i.d. or q.i.d.Mechanism of ActionPrevents the neurotransmitter acetylcholinepropantheline bromide 873from combining with receptors on postganglionicparasympathetic nerve terminal,thereby reducing smooth-muscle spasms inthe GI system, slowing GI motility, andinhibiting gastric acid secretion. All theseeffects help to heal peptic ulcers.Route Onset Peak DurationP.O. Unknown Unknown 6 hrContraindicationsAdhesions between iris and lens, angleclosureglaucoma, hemorrhage accompaniedby hemodynamic instability, hepaticdysfunction, hypersensitivity to propanthelineor its components, ileus, myastheniagravis, myocardial ischemia, obstructive GIor urinary disease, renal dysfunction, severeulcerative colitis, tachycardiaInteractionsDRUGSamantadine, other anticholinergics, tricyclicantidepressants: Additive anticholinergiceffectsantacids, antidiarrheals (adsorbent): Possiblyreduced absorption of propanthelineantimyasthenics: Possibly further reductionin intestinal motilityatenolol: Increased effects of atenololcyclopropane: Possibly ventricular arrhythmiasdigoxin: Possibly digitalis toxicityhaloperidol: Decreased antipsychotic effectof haloperidol in schizophrenic patientsketoconazole: Decreased ketoconazoleabsorptionmetoclopramide: Possibly decreased metoclopramideeffect on GI motilityopioid analgesics: Increased risk of severeconstipation and urine retentionphenothiazines: Possibly decreased antipsychoticeffectspotassium chloride: Possibly increased severityof potassium chloride–induced GI ulceration,stricture, or perforationurinary alkalizers: Delayed urinary excretionof propanthelineAdverse ReactionsCNS: Dizziness, excitement, insomnia, nervousness,paradoxical CNS stimulationCV: Palpitations, tachycardiaEENT: Blurred vision; dry mouth, nose,and throatP

874propofolGI: Constipation, dysphagia, heartburn,ileus, nausea, vomitingGU: Impotence, urinary hesitancy, urineretentionSKIN: Decreased sweating, dry skin, flushingNursing Considerations• Don’t administer propantheline within1 hour of antacids or antidiarrheals.• Monitor elderly patients closely; they mayrespond to usual dose with agitation, confusion,drowsiness, or excitement.WARNING Drug can interfere with sweatingreflex, increasing the risk of heatstroke.PATIENT TEACHING• Instruct patient to take propantheline30 to 60 minutes before meals and at bedtime,as prescribed.• Inform patient that drug may cause dizziness.Urge her to avoid hazardous activitiesuntil drug’s CNS effects are known.• Encourage patient to increase fluid andfiber intake to decrease constipation.Instruct her to report persistent constipationand urine retention.• Advise patient to avoid excessive exposureto heat to reduce risk of heat prostrationand heatstroke.• Suggest that patient relieve dry mouthwith frequent rinsing and sugar-free hardcandy or gum.propofol(disoprofol)DiprivanClass and CategoryChemical class: 2,6-diisopropylphenol derivativeTherapeutic class: Sedative-hypnoticPregnancy category: BIndications and Dosages To provide sedation for critically illpatients in intensive careI.V. INFUSIONAdults. 2.8 to 130 mcg/kg/min. Usual:27 mcg/kg/min.DOSAGE ADJUSTMENT For elderly, debilitated,or American Society of AnesthesiologistsPhysical Status (ASA-PS) III or IVpatients, induction dose decreased andmaintenance rate slower.Mechanism of ActionDecreases cerebral blood flow, cerebralmetabolic oxygen consumption, andintracranial pressure and increases cerebrovascularresistance, which may play arole in propofol’s hypnotic effects.Route Onset Peak DurationI.V. Within Unknown 3–5 min40 secIncompatibilitiesDon’t mix propofol with other drugs beforegiving. Don’t give propofol through sameI.V. line as blood or plasma productsbecause globular component of emulsionwill aggregate.ContraindicationsHypersensitivity to propofol or its components,to eggs or egg products, or to soybeansor soy productsInteractionsDRUGSCNS depressants: Additive CNS depressant,respiratory depressant, and hypotensiveeffects; possibly decreased emetic effects ofopioidsdroperidol: Possibly decreased control ofnausea and vomitingACTIVITIESalcohol use: Additive CNS depressant, respiratorydepressant, and hypotensive effectsAdverse ReactionsCV: Bradycardia, hypotensionGI: Nausea, vomitingMS: Involuntary muscle movement (transient)RESP: ApneaOther: Anaphylaxis, injection site burning,pain, or stingingNursing Considerations• Use propofol cautiously in patients withcardiac disease, peripheral vascular disease,impaired cerebral circulation, orincreased intracranial pressure becausedrug may aggravate these disorders.• To dilute before administration, use onlyD 5 W for final solution of 2 mg/ml or more.• Consult prescriber about pretreating injectionsite with 1 ml of 1% lidocaine tominimize pain, burning, or stinging thatmay occur. If ordered, lidocaine shouldn’t

e added to propofol solution in quantitiesgreater than 20 mg/200 mg propofolbecause emulsion may become unstable.Giving drug through a larger vein in forearmor antecubital fossa also may minimizeinjection site discomfort.• Shake container well before using, administerdrug promptly after opening, and usevial for a single patient. Use prefilledsyringes within 6 hours of opening.• Use a drop counter, syringe pump, or volumetricpump to safely control infusionrate. Don’t infuse drug through filter witha pore size of less than 5 microns; doing socould cause emulsion to break down.• Discard unused portion of propofol solutionplus reservoirs, I.V. tubing, and solutionsimmediately after or within 12 hoursof administration (6 hours if propofol wastransferred from original container) toprevent bacterial growth in stagnant solution.Also, protect solution from light.• Dosage must be tapered before stoppingtherapy. Stopping abruptly will causerapid awakening, anxiety, agitation andresistance to mechanical ventilation.• Expect patient to recover from sedationwithin 8 minutes.WARNING Monitor patient for propofolinfusion syndrome, especially with prolongedhigh-dose infusions. It may causesevere metabolic acidosis, hyperkalemia,lipemia, rhabdomyolysis, hepatomegalyand cardiac and renal failure. Alert prescriberat once and be prepared to provideemergency supportive care as ordered.PATIENT TEACHING• Urge patient and family to voice concernsand ask questions before administration.• Reassure patient that she’ll be monitoredclosely during administration and thatvital functions will be supported as needed.propoxyphenehydrochlorideCotanol-65, Darvon, PP-CappropoxyphenenapsylateDarvon-Npropoxyphene 875Class, Category, and ScheduleChemical class: Synthetic opioidTherapeutic class: AnalgesicPregnancy category: Not ratedControlled substance schedule: IVIndications and Dosages To relieve mild to moderate painCAPSULES, ORAL SUSPENSION, TABLETS(PROPOXYPHENE NAPYSLATE)Adults. 100 mg every 4 hr, p.r.n. Maximum:600 mg daily.CAPSULES, TABLETS (PROPOXYPHENEHYDROCHLORIDE)Adults. 65 mg every 4 hr, p.r.n. Maximum:390 mg daily.Route Onset Peak DurationP.O. 15–60 min 2 hr 4–6 hrMechanism of ActionProduces analgesia through a synergisticanalgesic effect. Propoxyphene stronglyagonizes mu receptors, blocking release ofsuch inhibitory neurotransmitters asgamma-aminobutyric acid (GABA) andacetylcholine. It also mediates analgesia bychanging pain perception at spinal cord andhigher CNS levels and by altering emotionalresponse to pain.ContraindicationsHypersensitivity to propoxyphene or itscomponents (including acetaminophen andaspirin), respiratory depression, severe asthma,upper airway obstruction, use within14 days of MAO inhibitor therapyInteractionsDRUGSamphetamines: Possibly fatal seizures (withpropoxyphene overdose)anticholinergics: Increased risk of severeconstipation and urine retentionantidiarrheals: Severe constipation, possiblyincreased CNS depressionantihypertensives: Possibly exaggerated antihypertensiveresponsebuprenorphine: Possibly decreased propoxypheneeffectiveness, increased respiratorydepressioncarbamazepine: Possibly carbamazepine toxicityCNS depressants: Increased CNS and respiratorydepression, hypotensive effects, andP

876propranolol hydrochloriderisk of habituationhydroxyzine: Increased analgesic, CNSdepressant, and hypotensive effectsMAO inhibitors: Severe, possibly fatal reactions,including hypertensive crisismetoclopramide: Possibly antagonizedeffects of metoclopramide on GI motilitynaloxone: Antagonized analgesic and CNSand respiratory depressant effects ofpropoxyphenenaltrexone: Risk of withdrawal symptoms inpatients dependent on propoxyphene, possiblydecreased analgesic effectneuromuscular blockers: Additive respiratorydepressant effectsopioid analgesics: Additive CNS and respiratorydepressant and hypotensive effectswarfarin: Increased anticoagulation effectsACTIVITIESalcohol use: Increased CNS and respiratorydepression, hypotensive effects, and risk ofhabituationnicotine chewing gum, other smoking deterrents,smoking cessation: Decreased effectivenessof propoxypheneAdverse ReactionsCNS: Dizziness, drowsiness, fatigue, insomnia,light-headedness, malaise, nervousness,sedation, tremorCV: Orthostatic hypotension, tachycardiaEENT: Blurred vision, diplopia, dry mouth,tinnitusGI: Abdominal cramps, anorexia, constipation,nausea, vomitingGU: Decreased urine outputMS: Muscle weaknessRESP: Dyspnea, respiratory depression,wheezingSKIN: Facial flushing, pruritus, rash,urticariaOther: Psychological dependenceNursing Considerations• Be aware that propoxyphene shouldn’t beused in patients who are suicidal or proneto addiction because of risk of overdose.• Use drug cautiously in patients who takeCNS depressants such as tranquilizers orantidepressants and patients who use alcoholin excess because of risk of overdose.• Use propoxyphene cautiously in patientswith hepatic or renal dysfunction becausedelayed elimination may occur. Monitorhepatic and renal function test results.WARNING Be aware that long-term, highdosepropoxyphene therapy may lead topsychological dependence in some people.Assess for opioid and alcohol use, whichincrease risk of drug abuse or dependence.• Be aware drug is also available in combinationproducts with aspirin or acetaminophenand caffeine.• Be aware that abruptly discontinuing drugcan result in withdrawal symptoms.PATIENT TEACHING• Inform patient that she may take propoxyphenewith food if she has GI distress.• Caution patient not to take more thanprescribed amount because drug may beaddictive or cause accidental overdose.• Inform patient that drug may causeblurred vision, drowsiness, dizziness, andimpaired judgment and coordination.Urge her to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to avoid alcohol and othersedatives while taking drug.• Advise smokers to inform prescriber ifthey try to stop smoking during propoxyphenetherapy because increased dosagemay be needed for effective analgesia.• Urge patient to notify prescriber immediatelyif pain isn’t relieved or worsens.propranololhydrochlorideApo-Propranolol (CAN),Detensol (CAN), Inderal, Inderal LA,Innopran XL, Novopranol (CAN),pms Propranolol (CAN)Class and CategoryChemical class: Beta-adrenergic blockerTherapeutic class: Antianginal, antiarrhythmic,antihypertensive, anti-MI, antimigraine,antitremor, hypertrophiccardiomyopathy and pheochromocytomatherapy adjunctPregnancy category: CIndications and Dosages To manage hypertensionE.R. TABLETSAdults. Initial: 80 mg daily, increased graduallyup to 160 mg daily Maximum: 640 mgdaily.

propranolol hydrochloride 877XL TABLETS (INNOPRAN XL)Adults. Initial: 80 mg once daily at bedtime,increased, as needed, to 120 mg oncedaily at bedtime.ORAL SOLUTION, TABLETSAdults. Initial: 40 mg b.i.d., increased graduallyto 120 to 240 mg daily, as needed.Maximum: 640 mg daily.Children. Initial: 0.5 to 1 mg/kg daily individed doses b.i.d. to q.i.d., adjusted asneeded. Maintenance: 2 to 4 mg/kg daily individed doses b.i.d. To treat chronic anginaE.R. TABLETSAdults. Initial: 80 mg daily, increased every3 to 7 days, as prescribed. Maximum:320 mg/day.ORAL SOLUTION, TABLETSAdults. 80 to 320 mg daily in divided dosesb.i.d., t.i.d., or q.i.d. To treat supraventricular arrhythmiasand ventricular tachycardiaORAL SOLUTION, TABLETSAdults. 10 to 30 mg t.i.d. or q.i.d., adjustedas needed.I.V. INJECTIONAdults. 1 to 3 mg at a rate not to exceed1 mg/min; repeated after 2 min and againafter 4 hr, if needed.Children. 0.01 to 0.1 mg/kg at a rate not toexceed 1 mg/min; repeated every 6 to 8 hr,as needed. Maximum: 1 mg/dose. To control tremorORAL SOLUTION, TABLETSAdults. Initial: 40 mg b.i.d., adjusted asneeded and prescribed. Maximum: 320 mgdaily. To prevent vascular migraine headachesE.R. TABLETSAdults. Initial: 80 mg daily, increased gradually,as needed. Maximum: 240 mg daily.ORAL SOLUTION, TABLETSAdults. Initial: 20 mg q.i.d., increased gradually,as needed. Maximum: 240 mg daily. As adjunct to treat hypertrophic cardiomyopathyORAL SOLUTION, TABLETSAdults. 20 to 40 mg t.i.d. or q.i.d., adjustedas needed. As adjunct to manage pheochromocytomaORAL SOLUTION, TABLETSAdults. For operable tumors, 20 mg t.i.d. to40 mg t.i.d. or q.i.d. for 3 days before surgery,concurrently with an alpha blocker.For inoperable tumors, 30 to 160 mg dailyin divided doses. To prevent MIORAL SOLUTION, TABLETSAdults. 180 to 240 mg daily in divideddoses.DOSAGE ADJUSTMENT Dosage increased ordecreased for elderly patients, depending onsensitivity to propranolol.Route Onset Peak DurationP.O. Unknown 1–1.5 hr* UnknownMechanism of ActionThrough beta-blocking action, propranolol:• prevents arterial dilation and inhibitsrenin secretion, resulting in decreasedblood pressure (in hypertension andpheochromocytoma) and relief ofmigraine headaches• decreases heart rate, which helps resolvetachyarrhythmias• improves myocardial contractility, whichhelps ease symptoms of hypertrophic cardiomyopathy• decreases myocardial oxygen demand,which helps prevent anginal pain anddeath of myocardial tissue.In addition, peripheral beta-adrenergicblockade may play a role in propranolol’sability to alleviate tremor.ContraindicationsAsthma, cardiogenic shock, greater thanfirst-degree AV block, sick sinus syndrome,or sinus bradycardia (unless pacemaker inplace); heart failure (unless secondary totachyarrhythmia responsive to propranolol),hypersensitivity to propranolol or itscomponentsInteractionsDRUGSACE inhibitors: Increased risk of hypotension,especially in presence of acute MIallergen immunotherapy, allergenic extractsfor skin testing: Increased risk of serious systemicadverse reactions or anaphylaxisamiodarone: Additive depressant effects onconduction, negative inotropic effectsanesthetics (hydrocarbon inhalation):* For regular-release form; unknown forE.R. form.P

878propranolol hydrochlorideIncreased risk of myocardial depression andhypotensionbeta blockers: Additive beta blockade effectsbupivacaine, lidocaine, mepivacaine:Decreased clearance of these drugs, possiblyincreased risk of toxicitycalcium channel blockers, clonidine, diazoxide,guanabenz, resperpine, other hypotension-producingdrugs: Additive hypotensiveeffect and, possibly, other beta blockadeeffectscatecholamine-depleting drugs, such as reserpine:Increased risk of hypotension, bradycardia,vertigo, syncope, and orthostatichypotensioncimetidine: Possibly interference with propranololclearancedigitalis glycosides: Increased risk of bradycardiadiltiazem: Increased risk of bradycardia,hypotension, high-degree heart block, andheart failuredobutamine, isoproterenol: Reversed effectsof propranololdoxazosin, terazosin: Increased risk oforthostatic hypotensionepinephrine: Increased risk of uncontrolledhypertensionestrogens: Decreased antihypertensive effectof propranololfentanyl, fentanyl derivatives: Possiblyincreased risk of initial bradycardia afterinduction doses of fentanyl or a derivative(with long-term propranolol use)glucagon: Possibly blunted hyperglycemicresponseinsulin, oral antidiabetic drugs: Possiblyimpaired glucose control, masking of tachycardiain response to hypoglycemiaMAO inhibitors, tricyclic antidepressants:Increased risk of significant hypertensionneuroleptic drugs: Increased risk of hypotensionand cardiac arrestneuromuscular blockers: Possibly potentiatedand prolonged action of these drugsNSAIDs: Possibly decreased hypotensiveeffectsphenothiazines: Increased blood levels ofboth drugsphenytoin: Additive cardiac depressanteffects (with parenteral phenytoin)prazosin: Increased risk of first-dose hypotensionpropafenone: Increased blood level and halflifeof propranololquinidine: Increased propranolol level,resulting in higher degrees of beta blockadeand orthostatic hypotensionsympathomimetics, xanthines: Possiblymutual inhibition of therapeutic effectsthyroxine: Possibly decreased T 3 levelverapamil: Increased risk of bradycardia,heart failure, and cardiovascular collapsewarfarin: Increased risk of bleedingACTIVITIESalcohol: Possibly increased plasma propranolollevelnicotine chewing gum, smoking cessation,smoking deterrents: Increased therapeuticeffects of propranololAdverse ReactionsCNS: Anxiety, depression, dizziness, drowsiness,fatigue, fever, insomnia, lethargy,nervousness, weaknessCV: AV conduction disorders, cold limbs,heart failure, hypotension, sinus bradycardiaEENT: Dry eyes, laryngospasm, nasal congestion,pharyngitisGI: Abdominal pain, constipation, diarrhea,nausea, vomitingGU: Impotence, peyronie’s disease, sexualdysfunctionHEME: AgranulocytosisMS: Muscle weaknessRESP: Bronchospasm, dyspnea, respiratorydistress, wheezingSKIN: Alopecia, erythema multiforme,erythematous rash, exfoliative dermatitis,psoriasiform rash, Stevens-Johnson syndrome,toxic epidermal necrolysis, urticariaOther: Anaphylaxis, flulike symptoms, systemiclupuslike reactionNursing Considerations• Use propranolol cautiously in patientswith bronchospastic lung disease becauseit may induce asthmatic attack.• Monitor blood pressure, apical and radialpulses, fluid intake and output, dailyweight, respiration, and circulation inextremities before and during therapy.• Give I.V. injection at no more than 1 mg/minute.WARNING Monitor ECG continuously, asordered, when giving I.V. injection. Haveemergency drugs and equipment availablein case of hypotension or cardiac arrest.• Protect injection solution from light.

• Because drug’s negative inotropic effectcan depress cardiac output, monitor cardiacoutput in patients with heart failure,particularly those with severely compromisedleft ventricular dysfunction.• Be aware that propranolol can mask tachycardiain hyperthyroidism and that abruptwithdrawal in patients with hyperthyroidismor thyrotoxicosis can cause thyroidstorm.• Monitor diabetic patient taking an antidiabeticbecause propranolol can prolonghypoglycemia or promote hyperglycemia.It also can mask signs of hypoglycemia,especially tachycardia, palpitations, andtremor, but it doesn’t suppress diaphoresisor hypertensive response to hypoglycemia.WARNING Be aware that stopping drugabruptly may cause myocardial ischemia,MI, ventricular arrhythmias, or severehypertension, especially in patients withcardiac disease. It also may cause increasedintraocular pressure to return. Dosageshould be reduced gradually.PATIENT TEACHING• Instruct patient to take propranolol at thesame time every day.• Caution patient not to change dosagewithout consulting prescriber and not tostop taking drug abruptly.• Advise patient to notify prescriber immediatelyif she has shortness of breath.• Instruct diabetic patient to regularly checkblood glucose level and urine for ketones.• Advise patient to consult prescriber beforetaking OTC drugs, especially cold products.• Urge patient to avoid hazardous activitiesuntil CNS effects of drug are known.• Advise smoker to notify prescriber immediatelyif she stops smoking because cessationmay decrease drug metabolism, callingfor dosage adjustments.• Tell patient to notify prescriber if she is orcould be pregnant because drug may needto be discontinued.propylthiouracil(PTU)Propyl-Thyracil (CAN)Class and CategoryChemical class: Thiourea derivativeTherapeutic class: AntithyroidPregnancy category: DInteractionsDRUGSamiodarone, iodinated glycerol, iodine, potaspropylthiouracil879Indications and Dosages To treat hyperthyroidismTABLETSAdults and adolescents. Initial: For mild tomoderate hyperthyroidism, 300 to 900 mgdaily in 1 to 4 divided doses until patientbecomes euthyroid; for severe hyperthyroidism,300 to 1,200 mg daily in 1 to4 divided doses until patient becomeseuthyroid. Maintenance: 50 to 600 mg dailyin 1 to 4 divided doses.Children age 10 and over. Initial: 50 to300 mg daily in 1 to 4 divided doses.Maintenance: Adjusted based on responseto initial dosage.Children ages 6 to 10. Initial: 50 to 150 mg/day in 1 to 4 divided doses. Maintenance:Adjusted based on response to initialdosage.Neonates. 10 mg/kg daily in divided doses. As adjunct to treat thyrotoxic crisisTABLETSAdults and adolescents. 200 to 400 mgevery 4 hr on day 1 plus other measures.Dosage gradually decreased as crisis subsides.DOSAGE ADJUSTMENT If creatinine clearanceis 10 to 50 ml/min/1.73 m 2 , recommendeddosage reduced by 25%; if creatinine clearanceis less than 10 ml/min/1.73 m 2 ,recommendeddosage reduced by 50%.Route Onset Peak DurationP.O. Unknown 17 wk UnknownMechanism of ActionInhibits conversion of peripheral thyroxineto triiodothyronine by interfering withincorporation of iodide into thyroglobulin;drug remains iodinated and degraded inthyroid gland. Diversion of oxidized iodineaway from thyroglobulin diminishes thyroidhormone synthesis and levels of circulatingthyroid hormone.ContraindicationsBreast-feeding, hypersensitivity to propylthiouracilor its componentsP

880protamine sulfatesium iodide: Decreased efficacy of propylthiouracildigoxin: Risk of digitalis toxicityoral anticoagulants: Possibly enhanced anticoagulanteffectsodium iodide 131 (radioactive iodine, 131 I):Decreased thyroid uptake of 131 IAdverse ReactionsCNS: Dizziness, paresthesia, peripheralneuropathyCV: VasculitisENDO: HypothyroidismGI: Abdominal pain, hepatotoxicity, nausea,vomitingHEME: Agranulocytosis, leukopeniaMS: Arthralgia, joint redness or swellingSKIN: Pruritus, rash, urticariaOther: Lupuslike symptomsNursing Considerations• Monitor CBC, PT, and liver and thyroidfunction test results in patients takingpropylthiouracil. Elevated serum triiodothyronine(T 3 ) level may be the soleindicator of inadequate treatment.• Expect to stop drug 3 to 4 days before 131 Itreatment to prevent decreased thyroiduptake of 131 I; therapy may be resumed3 to 5 days after radiation, if needed.• Serum T 3 and thyroxine levels shoulddecrease after about 3 weeks of therapy.• Expect to decrease beta blocker or theophyllinedosage once patient is euthyroid.• Monitor liver function, especially duringfirst 6 months of therapy, because drugmay cause liver failure, need for livertransplant, or death. Expect to stop drugat first sign of liver dysfunction (fatigue,weakness, vague abdominal pain, loss ofappetite, itching, easy bruising, jaundice).PATIENT TEACHING• Instruct patient to take drug with meals todecrease risk of adverse GI reactions.• Urge patient to avoid dietary sources ofiodine, such as iodized salt and shellfish.• Tell patient to check pulse rate and weightdaily and to report increased heart rateand excessive weight loss to prescriber.• Urge patient to report signs and symptomsof infection, such as fever and sorethroat, or signs and symptoms that couldreflect hepatic dysfunction, such asanorexia and right-upper-quadrant pain.• Instruct patient to notify prescriber immediatelyif she becomes pregnant.• Advise patient to report signs and symptomsof hypothyroidism, such as coldintolerance, depression, and increasedfatigue.• Tell patient to ask prescriber before usingOTC cold drugs (some contain iodides).• Advise patient to notify prescriber immediatelyif he has fatigue, weakness, vagueabdominal pain, loss of appetite, itching,easy bruising, or yellowing of eyes or skin.protamine sulfateClass and CategoryChemical class: Simple low-molecularweightproteinTherapeutic class: Heparin antagonistPregnancy category: CIndications and Dosages To treat heparin toxicity or hemorrhageassociated with heparin therapyI.V. INJECTIONAdults and children. 1 mg for each100 units of heparin to be neutralized, or asindicated by coagulation test results.Maximum: 100 mg (within 2-hr period).Route Onset Peak DurationI.V. 5 min Unknown 2 hrMechanism of ActionNeutralizes anticoagulant activity. A strongbasic polypeptide, protamine combineswith strongly acidic heparin complex toform an inactive stable salt, thereby neutralizinganticoagulant activity of both drugs.IncompatibilitiesDon’t mix protamine sulfate in samesyringe with other drugs unless they’reknown to be compatible. Several cephalosporins,penicillins, and other antibiotics areincompatible.ContraindicationsAllergy to fish, hypersensitivity to protamineor its componentsInteractionsDRUGSheparin: Neutralized anticoagulant effect ofboth drugs

Adverse ReactionsCNS: WeaknessCV: Bradycardia, hypertension, hypotension,shockGI: Nausea, vomitingHEME: Unusual bleeding or bruisingRESP: Dyspnea, pulmonary edema (noncardiogenic),pulmonary hypertensionSKIN: Flushing, sensation of warmthOther: AnaphylaxisNursing Considerations• Expect to administer I.V. protamine undiluted.However, dilute drug if needed (forpatients other than neonates) with 5 ml ofbacteriostatic water for injection containing0.9% benzyl alcohol. For neonates,reconstitute with preservative-free sterilewater for injection.• Inject drug slowly at 5 mg/minute; administerno more than 50 mg in 10 minutes or100 mg in 2 hours.WARNING Be aware that rapid delivery maycause severe hypotension and anaphylaxis.• Be prepared to obtain coagulation studies(APTT, activated clotting time) 5 to15 minutes after giving drug and to repeatthem in 2 to 8 hours to detect heparinreboundhypotension, shock, and bleeding.• Monitor vital signs, hemodynamic parameters,and fluid intake and output, andassess for flushing sensation.• Have fluids—epinephrine 1:1,000, dobutamine,or dopamine—available for allergicor hypotensive reactions.• Be aware that men with vasectomy have anincreased risk of hypersensitivity reactionbecause of possible accumulation ofantiprotamine antibodies.PATIENT TEACHING• Instruct patient to report adverse reactionsimmediately.protriptylinehydrochlorideTriptil (CAN), VivactilClass and CategoryChemical class: Dibenzocycloheptene derivativeTherapeutic class: AntidepressantPregnancy category: Not ratedprotriptyline hydrochloride 881Indications and Dosages To treat depressionTABLETSAdults. Initial: 5 to 10 mg t.i.d. or q.i.d.,increased every wk by 10 mg daily, as needed.Maximum: 60 mg daily.Children age 12 and over. Initial: 5 mgt.i.d., increased as needed.DOSAGE ADJUSTMENT For elderly patients,initial dosage limited to 5 mg t.i.d., thenadjusted as needed.Route Onset Peak DurationP.O. 2–3 wk Unknown UnknownMechanism of ActionMay block reuptake of norepinephrine andserotonin (and possibly other neurotransmitters)at neuronal membranes, thusenhancing their effects at postsynapticreceptors. These neurotransmitters mayplay a role in relieving depression symptoms.ContraindicationsAcute recovery phase after MI, hypersensitivityto protriptyline or its components, usewithin 14 days of MAO inhibitor therapyInteractionsDRUGSamantadine, anticholinergics, antidyskinetics,antihistamines: Additive anticholinergiceffects, potentiated effects of antihistaminesor protriptyline, possibly impaired detoxificationof atropine and related drugsanticonvulsants: Possibly lowered seizurethreshold and decreased anticonvulsanteffectiveness; enhanced CNS depressionantithyroid drugs: Possibly agranulocytosisbarbiturates, carbamazepine: Decreasedtherapeutic effects of protriptylinebupropion, clozapine, cyclobenzaprine, haloperidol,loxapine, maprotiline, molindone,phenothiazines, thioxanthenes: Prolongedand intensified anticholinergic and sedativeeffects, lowered seizure threshold, increasedrisk of neuroleptic malignant syndrome;increased blood protriptyline level andinhibited phenothiazine metabolism (withphenothiazine use)cimetidine: Increased risk of protriptylinetoxicityclonidine, guanadrel, guanethidine:Decreased hypotensive effects; increasedP

882pyrazinamideCNS depression (with clonidine use)CNS depressants: Possibly serious potentiationof CNS and respiratory depression andhypotensive effectdisulfiram, ethchlorvynol: Possibly transientdelirium; increased CNS depression (withethchlorvynol use)fluoxetine: Increased protriptyline levelMAO inhibitors: Increased risk of hyperpyreticcrisis, severe seizures, and deathmethylphenidate: Possibly antagonizedeffects of methylphenidate and increasedblood protriptyline levelmetrizamide: Increased risk of seizuresnaphazoline, oxymetazoline, phenylephrine,xylometazoline: Possibly increased vasopressoreffects of these drugsoral anticoagulants: Possibly increased anticoagulantactivitypimozide, probucol: Possibly prolonged QTinterval and ventricular tachycardiasympathomimetics: Possibly potentiated cardiovasculareffects, decreased vasopressoreffects of ephedrine and mephenterminethyroid hormones: Increased therapeutic andtoxic effects of both drugsACTIVITIESalcohol use: Possibly increased response toalcoholAdverse ReactionsCNS: Agitation, ataxia, confusion, dizziness,drowsiness, exacerbation of psychosis,extrapyramidal reactions, fatigue, lack ofcoordination, paresthesia, peripheral neuropathy,suicidal ideation, tremor, weaknessCV: Arrhythmias, including heart block andtachycardia; hypertension; hypotension; MI;orthostatic hypotension; palpitations; strokeEENT: Black tongue, blurred vision, drymouth, increased intraocular pressure,lacrimation, stomatitis, tongue swellingENDO: Hyperglycemia, hypoglycemiaGI: Abdominal cramps, anorexia, constipation,diarrhea, epigastric discomfort, hepaticdysfunction, nausea, vomitingGU: Impotence, libido changes, nocturia,urinary frequency and hesitancy, urineretentionSKIN: Diaphoresis, petechiae, photosensitivity,rash, urticariaOther: Facial edema, weight gain or lossNursing Considerations• Use protriptyline cautiously in patientswith a history of seizures because drug canlower seizure threshold.• Use cautiously in patients with a history ofurine retention or increased intraocularpressure because of drug’s autonomicactivity.WARNING Avoid giving protriptyline withan MAO inhibitor. If patient is beingswitched from an MAO inhibitor to protriptyline,make sure MAO inhibitor hasbeen discontinued for 14 days before startingprotriptyline.• Watch patients closely (especially children,adolescents, and young adults) for suicidaltendencies, particularly when therapystarts or dosage changes, because depressionmay worsen temporarily during thesetimes, possibly leading to suicidal ideation.PATIENT TEACHING• Inform patient that protriptyline therapymay take several weeks to reach full effect.• Instruct patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to change position slowly tominimize orthostatic hypotension.• Urge patient to avoid alcohol while takingdrug.• Suggest drinking water and using sugarlessgum or hard candy to relieve dry mouth.• Advise patient to avoid sunlight and tanningbooths and to wear protective clothing,a hat, and sunscreen when outdoors.• Instruct diabetic patient to check bloodglucose level frequently during first fewweeks of protriptyline therapy.• Urge family or caregiver to watch patientfor suicidal tendencies, especially whentherapy starts or dosage changes and particularlyif patient is a child, teenager, oryoung adult.pyrazinamidepms-Pyrazinamide (CAN),Tebrazid (CAN)Class and CategoryChemical class: Pyrazine analogue of nicotinamideTherapeutic class: AntitubercularPregnancy category: CIndications and Dosages As adjunct to treat tuberculosis, along

with other antitubercular drugsTABLETSAdults and children. 15 to 30 mg/kg daily;or, 50 to 70 mg/kg 2 or 3 times/wk.Maximum: For daily regimen, 2 g daily; fortwice/wk regimen, 4 g daily; for 3-times/wkregimen, 3 g daily.DOSAGE ADJUSTMENT For patients with HIVinfection, 20 to 30 mg/kg daily for first2 mo of therapy.Mechanism of ActionInhibits growth of Mycobacterium tuberculosisby decreasing pH level; exhibits bactericidalor bacteriostatic action, dependingon blood pyrazinamide level.ContraindicationsAcute gout, hypersensitivity to pyrazinamideor its components, severe hepaticdamageInteractionsDRUGSallopurinol, colchicine, probenecid, sulfinpyrazone:Possibly increased blood uric acidlevel and decreased antigout efficacycyclosporine: Possibly decreased blood leveland therapeutic effects of cyclosporineAdverse ReactionsCNS: FeverGI: Anorexia, hepatotoxicity, nausea, vomitingGU: DysuriaHEME: PorphyriaMS: Arthralgia, gout, myalgiaSKIN: Acne, photosensitivity, pruritus,rash, urticariaNursing Considerations• Review liver function test results beforeand every 2 to 4 weeks during therapy.• Be aware that drug can affect the accuracyof certain urine ketone strip test results.• Because drug is metabolized by liver, monitorpatient for evidence of hepatotoxicity,such as darkened urine, fever, jaundice,malaise, nausea, severe pain in feet or toes,and vomiting.PATIENT TEACHING• Explain importance of complying withlong-term pyrazinamide therapy.• Tell diabetic patient about possiblechanges in ketone measurement duringtherapy.Mechanism of ActionImproves muscle strength compromised bymyasthenia gravis or neuromuscular blockadeby competing with acetylcholine for itsbinding site on acetylcholinesterase. Thisaction potentiates the effects of acetylchopyridostigminebromide 883• Instruct patient to report dark urine, fever,malaise, nausea, severe pain in feet or toes,vomiting, and yellowing of skin or eyes.• Inform patient of need for regular bloodtests and follow-up visits with prescriber.• Urge patient to minimize exposure to sunand to wear protective clothing, hat, sunglasses,and sunscreen when outdoors.pyridostigminebromideMestinon, Mestinon-SR (CAN),Mestinon Timespans, Regonol (CAN)Class and CategoryChemical class: Bromide dimethylcarbamateTherapeutic class: AntimyasthenicPregnancy category: Not ratedIndications and Dosages To treat symptoms of myasthenia gravisE.R. TABLETSAdults and adolescents. 180 to 540 mgonce or twice daily (at least 6 hr betweendoses).SYRUP, TABLETSAdults and adolescents. Initial: 30 to 60 mgevery 3 to 4 hr, adjusted as needed.Maintenance: 60 mg to 1.5 g daily.Children. 7 mg/kg daily in 5 or 6 divideddoses.I.V. OR I.M. INJECTIONAdults and adolescents. 2 mg every 2 to3 hr.I.M. INJECTIONNeonates of myasthenic mothers. 0.05 to0.15 mg/kg every 4 to 6 hr. To reverse the effects of neuromuscularblockersI.V. INJECTIONAdults and adolescents. 10 to 20 mg after0.6 to 1.2 mg of I.V. atropine has beengiven.DOSAGE ADJUSTMENT Dosage possiblyreduced for patients with renal impairment.P

884pyridostigmine bromideline on skeletal muscle and the GI tract.Inhibited destruction of acetylcholineallows freer transmission of nerve impulsesacross the neuromuscular junction.Route Onset Peak DurationP.O. 30–45 min 1–2 hr 3–6 hrP.O. (E.R.) 30–60 min 1–2 hr 6–12 hrI.V. 2–5 min Unknown 2–4 hrI.M. 15 min Unknown 2–4 hrContraindicationsHypersensitivity to pyridostigmine or itscomponents, mechanical obstruction of GIor urinary tractInteractionsDRUGSaminoglycosides (systemic), anesthetics(hydrocarbon inhalation), capreomycin, lidocaine(I.V.), lincomycins, polymyxins, quinine:Possibly antagonized effect of pyridostigmineon skeletal muscle; possiblydecreased neuromuscular blocking activityof these drugs (with large doses of pyridostigmine)anesthetics (local): Inhibited neuronal transmission,increased anesthesia effectsanticholinergics: Possibly masked pyridostigmineoverdose; reduced intestinal motilitycholinesterase inhibitors: Increased risk ofadditive toxicityedrophonium: Possibly worsening of statusguanadrel, guanethidine, mecamylamine,neuromuscular blockers, procainamide:Possibly prolonged phase I blocking effector reversal of nondepolarization blockadequinidine, trimethaphan: Possibly antagonizedeffects of pyridostigmineAdverse ReactionsEENT: Increased salivation, lacrimation,miosisGI: Abdominal cramps, diarrhea, increasedperistalsis, nausea, vomitingGU: Urinary frequency, incontinence, orurgencyMS: Fasciculations, muscle spasms or weaknessRESP: Increased tracheobronchial secretionsSKIN: DiaphoresisNursing Considerations• Use pyridostigmine cautiously in patientswith renal disease because drug is mainlyexcreted unchanged by kidneys. MonitorBUN and serum creatinine levels.WARNING Maintain a rigid dosing schedulebecause a missed or late dose can precipitatemyasthenic crisis.• Observe for cholinergic reactions whenadministering drug I.V. or I.M.WARNING Pyridostigmine overdose mayobscure diagnosis of myasthenic crisisbecause main symptom in both is muscleweakness. Treat cholinergic crisis by stoppinganticholinesterase, giving atropine asprescribed, and helping with endotrachealintubation and mechanical ventilation, ifneeded.• Be aware that reversal of neuromuscularblockade usually occurs in 15 to 30 minutes.Be prepared to maintain patent airwayand ventilation until normal voluntaryrespiration returns completely. Assessrespiratory measurements and muscletone with peripheral nerve stimulatordevice, as indicated.PATIENT TEACHING• Instruct patient to take pyridostigmine asdirected and on schedule. Explain that alate or missed dose can precipitate a crisis.Suggest the use of a battery-operatedalarm clock as a reminder.• Tell patient to take drug with a full glass ofwater or with food or milk if GI distressoccurs.• Warn patient not to crush or chew E.R.tablets.• Ask patient to record pyridostigminedosage, times taken, and drug effects tohelp determine optimal dosage and schedule.• Urge patient to carry medical identificationdescribing her condition and drugregimen.

Q R SquazepamDoralClass, Category, and ScheduleChemical class: BenzodiazepineTherapeutic class: Sedative-hypnoticPregnancy category: XControlled substance schedule: IVIndications and Dosages To treat insomniaTABLETSAdults. 15 mg at bedtime.DOSAGE ADJUSTMENT In elderly and debilitatedpatients, dosage may be reduced to7.5 mg at bedtime after 1 or 2 nights oftherapy.Mechanism of ActionMay antagonize mu receptors at limbic,thalamic, and hypothalamic regions of thebrain, blocking release of such inhibitoryneurotransmitters as gamma-aminobutyricacid (GABA) and acetylcholine. Centralreceptors interact with GABA receptors,allowing for greater influx of chloride intothe neuron, thereby suppressing neuronalexcitability. GABA effects may inhibit spinalafferent pathways and block the corticaland limbic arousal that normally occurswhen reticular pathways are stimulated.These effects result in various levels of CNSdepression, including sleep.ContraindicationsHypersensitivity to quazepam or its components,pregnancy, sleep apnea (known orsuspected)quazepam 885InteractionsDRUGSaddictive drugs: Possibly habituationcarbamazepine: Decreased blood quazepamlevel, possibly increased blood carbamazepinelevelcimetidine, diltiazem, disulfiram, erythromycin,fluoxetine, fluvoxamine, isoniazid, itraconazole,ketoconazole, nefazodone, oral contraceptives,propoxyphene, ranitidine, verapamil:Possibly potentiated effects ofquazepamclozapine: Possibly syncope, with respiratorydepression or arrestCNS depressants, tricyclic antidepressants:Increased CNS depressionCYP2B6 substrates such as bupropion andefavirenz: Possibly increased plasma levelsof these agents leading to increased risk ofadverse effectsdigoxin: Possibly increased blood digoxinlevel and risk of digitalis toxicitylevodopa: Possibly decreased therapeuticeffects of levodopaphenytoin: Increased risk of phenytoin toxicitytheophyllines: Possibly antagonized effects ofquazepamzidovudine: Increased risk of zidovudinetoxicityFOODSgrapefruit juice: Increased quazepam levelACTIVITIESalcohol use: Additive CNS depressionsmoking: Possibly decreased effectiveness ofquazepamAdverse ReactionsCNS: Abnormal complex behaviors, such assleep driving; amnesia (anterograde); anxiety;ataxia; confusion; depression; dizziness;drowsiness; euphoria; fatigue; headache;light-headedness; paresthesia; slurredspeech; suicidal ideation; tremor; weaknessCV: Chest pain, palpitations, tachycardiaEENT: Blurred vision, dry mouth, hyperacusis,photophobia, throat tightness, worseningof glaucomaGI: Abdominal cramps, constipation, diarrhea,heartburn, nausea, thirst, vomitingGU: Renal dysfunction, urinary incontinence,urine retentionMS: Muscle spasmsRESP: Dyspnea, increased tracheobronchialsecretionsOther: Anaphylaxis, angioedemaNursing Considerations• Use quazepam cautiously in patients withangle-closure glaucoma because of drug’santicholinergic effects; in patients withhepatic dysfunction because this conditionmay prolong quazepam’s half-life; inpatients with myasthenia gravis becausedrug may worsen condition; in patientsQRS

886quetiapine fumaratewith severe COPD because adverse effectsof quazepam may compromise respiratoryfunction; in patients with renal dysfunctionbecause accumulation of metabolitesmay result in toxicity; and in elderlypatients because of age-related decreasesin hepatic, renal, and cardiac function.WARNING Monitor patient closely for signsand symptoms of hypersensitivity reactions,such as dyspnea, throat tightness,nausea, vomiting, and swelling. If present,discontinue quazepam immediately, notifyprescriber, and provide supportive care.WARNING Notify prescriber if eye paindevelops in patient with angle-closureglaucoma.WARNING Be aware that quazepam mayintensify signs and symptoms of depression.Monitor patient closely for evidenceof suicidal ideation, and institute suicideprecautions, as needed.PATIENT TEACHING• Instruct patient to stop taking quazepamand seek emergency care if she has troublebreathing, throat tightness, nausea, vomiting,or abnormal swelling.• Advise patient that drug may cause abnormalbehaviors during sleep, such as drivinga car, eating, talking on the phone, orhaving sex without recall of the event. Iffamily members notice such behavior, or ifpatient sees evidence of it upon awakening,prescriber should be notified.• Urge patient to avoid consuming alcoholduring quazepam therapy because sedationand risk of abnormal behaviors, suchas sleep driving, may increase.• Instruct patient not to stop drug abruptlyafter prolonged use (6 weeks or more).• Instruct female patient of childbearing ageto use effective contraception during therapyand to notify prescriber immediatelyof known or suspected pregnancy.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes.quetiapine fumarateSeroquel, Seroquel XRClass and CategoryChemical class: Dibenzothiazepine derivativeTherapeutic class: AntipsychoticPregnancy category: CIndications and Dosages To treat schizophreniaTABLETSAdults. Initial: 25 mg b.i.d. on day 1.Increased by 25 to 50 b.i.d. or t.i.d. on days2 and 3. Usual: 300 to 400 mg daily by day4, in divided doses b.i.d. or t.i.d. Increasedevery 2 days in increments of 25 to 50 mgb.i.d., as needed. Maximum: 800 mg daily.E.R. TABLETSAdults. Initial: 300 mg once daily inevening. Dosage increased daily in incrementsup to 300 mg, as needed. Maximum:800 mg daily. To manage psychotic disorders otherthan schizophreniaTABLETSAdults. Initial: 25 mg b.i.d. on day 1.Dosage increased by 25 to 50 mg b.i.d. ort.i.d. on days 2 and 3. Usual: 300 to 400 mgdaily by day 4, in divided doses b.i.d. ort.i.d. Dosage increased every 2 days inincrements of 25 to 50 mg b.i.d., as needed.Maximum: 800 mg daily. To treat depressive episodes in bipolardisorderTABLETSAdults. Initial: On day one, 50 mg once atbedtime; day two, 100 mg once at bedtime;day three, 200 mg once at bedtime; dayfour, 300 mg once at bedtime. Maintenance:300 mg once daily at bedtime.E.R. TABLETSAdults. Initial: 50 mg once daily in eveningon day 1, followed by 100 mg once daily inevening on day 2, 200 mg once daily inevening on day 3, and 300 mg once daily inevening on day 4 and thereafter. As adjunct therapy with antidepressantsto treat major depressive disorderE.R. TABLETSAdults. Initial: 50 mg once daily in evening,increased to 150 mg once daily in eveningon day 3. Maximum: 300 mg daily inevening. To treat acute manic episodes in bipolarI disorderTABLETSAdults. 50 mg b.i.d., increased to 200 mgb.i.d on day 4 (in increments no greaterthan 100 mg daily) and then further

increased to 400 mg b.i.d. on day 6 (inincrements no greater than 200 mg daily),as needed. To treat acute manic episodes in bipolarI disorder as monotherapy; as adjunctwith lithium or divalproex to treat acutemanic episodes in bipolar I disorderE.R. TABLETSAdults. Initial: 300 mg once daily inevening on day 1, followed by 600 mg oncedaily in evening on day 2 and 200 to400 mg b.i.d. on day 3 and thereafter.Maintenance: 200 to 400 mg b.i.d.DOSAGE ADJUSTMENT For elderly patientsand patients with hepatic impairment, initialdosage no higher than 50 mg once dailyand increased in increments of 50 mg/daydepending on response and tolerance.Mechanism of ActionMay produce antipsychotic effects by interferingwith dopamine binding to dopaminetype 2 (D 2 )-receptor sites in the brain andby antagonizing serotonin 5-HT 2 , dopaminetype 1 (D 1 ), histamine H 1 , and adrenergicalpha 1 and alpha 2 receptors.ContraindicationsHypersensitivity to quetiapine or its componentsInteractionsDRUGSantihypertensives: Possibly enhanced antihypertensiveeffects of these drugscimetidine, erythromycin, fluconazole, itraconazole,ketoconazole: Decreased clearanceand possibly increased effects of quetiapineCNS depressants: Possibly increased CNSdepressionlorazepam: Possibly increased effects of lorazepamphenytoin, thioridazine: Increased clearanceand possibly decreased effectiveness of quetiapineACTIVITIESalcohol use: Possibly enhanced CNS depressionAdverse ReactionsCNS: Depression, dizziness, drowsiness,dystonia, extrapyramidal reactions, hypertonia,lethargy, restless leg syndrome, somnolence,suicidal ideation, tardive dyskinesiaCV: Cardiomyopathy, hypercholesterolemia,quetiapine fumarate 887myocarditis, orthostatic hypotension, palpitationsEENT: Dry mouth, nasal congestion,pharyngitis, rhinitisENDO: Hyperglycemia, syndrome of inappropriateADH secretionGI: Anorexia, constipation, indigestionHEME: Agranulocytosis, leukopenia, neutropeniaMS: Dysarthria, muscle weakness, rhabdomyolysisRESP: Cough, dyspneaSKIN: Diaphoresis, Stevens-Johnson syndromeOther: Anaphylaxis, flulike symptoms,weight gainNursing ConsiderationsWARNING Quetiapine shouldn’t be used forelderly patients with dementia-related psychosisbecause drug increases the risk ofdeath in these patients.• Monitor patients (particularly youngadults) closely for suicidal tendencies,especially when therapy starts or dosagechanges, because depression may worsentemporarily during these times.WARNING Monitor patient taking quetiapinefor predisposing factors for neurolepticmalignant syndrome, such as heat stress,physical exhaustion, dehydration, andorganic brain disease. Neuroleptic malignantsyndrome includes hyperpyrexia,muscle rigidity, altered mental status, andautonomic instability (which may includeirregular pulse or blood pressure, tachycardia,diaphoresis, and arrhythmias).• Monitor patient for signs of tardive dyskinesia,a potentially irreversible complicationcharacterized by involuntary, dyskineticmovements of tongue, mouth, jaw,eyelids, or face. Notify prescriber if suchsigns develop because quetiapine therapymay need to be stopped.• Monitor patient for orthostatic hypotension,especially during initial dosage titrationperiod. Be prepared to correct underlyingconditions, such as hypovolemia anddehydration, before starting quetiapinetherapy, as prescribed.• Monitor patient for prolonged abnormalmuscle contractions, especially during thefirst few days of quetiapine therapy, inmale patients, and in younger patients.QRS

888quinapril hydrochloride• Assess patient for hypothyroidism becausedrug can cause dose-dependent decreasesin total and free thyroxine (T 4 ) levels.• Monitor laboratory results during first3 weeks of therapy for transient elevationsin hepatic enzyme levels. Notify prescriberif they persist or worsen.• Monitor patient’s blood glucose and lipidlevels routinely, as ordered, because drugincreases the risk of hyperglycemia andhypercholesterolemia.• Check CBC often during the first fewmonths of therapy, as ordered, in patientswith a low white blood cell count or a historyof drug-induced hematologic problems.If counts drop or patient develops afever or other signs of infection, notifyprescriber and expect to discontinue drugand provide supportive care.PATIENT TEACHING• Instruct patient to take quetiapine withfood to reduce stomach upset.• Advise patient not to stop taking quetiapinesuddenly because doing so may exacerbatehis symptoms.• Inform patient that quetiapine therapymay cause dizziness or drowsiness. Advisehim not to drive or perform other activitiesthat require alertness until drug’s fullCNS effects are known.• Instruct patient to rise slowly from a seatedor lying position to reduce the risk ofdizziness or fainting.• Caution patient to avoid consuming alcoholicbeverages because they can increasedizziness and drowsiness.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes andparticularly if patient is a young adult.• Encourage patient on long-term therapyto have regular eye examinations so thatcataracts can be detected.quinaprilhydrochlorideAccuprilClass and CatgeoryChemical class: Ethylester of quinaprilatTherapeutic class: AntihypertensivePregnancy category: C (first trimester), D(later trimesters)Indications and Dosages To treat hypertensionTABLETSAdults. Initial: 10 or 20 mg daily, adjustedevery 2 wk based on clinical response.Maintenance: 20 to 80 mg daily or in divideddoses b.i.d.DOSAGE ADJUSTMENT Initial dosage reducedto 5 mg daily for patients who are dehydratedfrom previous diuretic therapy,those who are still receiving diuretic therapy,and those with creatinine clearance of30 to 60 ml/min/1.73 m 2 . Dosage reducedto 2.5 mg daily for patients with creatinineclearance of 10 to 30 ml/min/1.73 m 2 .Route Onset Peak DurationP.O. In 1 hr 2–4 hr Up to 24 hrMechanism of ActionBlocks conversion of angiotensin I toangiotensin II, leading to vasodilation, andreduces aldosterone secretion, which preventswater retention. Quinapril alsoreduces peripheral arterial resistance. Thesecombined actions lead to a reduction inblood pressure.ContraindicationsHistory of angioedema related to previoustreatment with ACE inhibitor, hypersensitivityto quinapril or its componentsInteractionsDRUGSallopurinol, bone marrow depressants,corticosteroids (systemic), procainamide:Increased risk of fatal neutropenia oragranulocytosisCNS depressants, other hypotension-producingdrugs: Additive hypotensive effectscyclosporine, potassium preparations, potassium-sparingdiuretics: Possibly hyperkalemialithium: Possibly increased blood lithiumlevel and risk of toxicityNSAIDs, sympathomimetics: Decreased antihypertensiveeffect of quinaprilsodium aurothiomalate: Possibly nitritoidreactions such as facial flushing, nausea,vomiting, and hypotensiontetracyclines: Reduced tetracycline absorption

FOODSlow-salt milk, salt substitutes: Increased riskof hyperkalemiaACTIVITIESalcohol use: Additive hypotensive effectsAdverse ReactionsCNS: Depression, dizziness, drowsiness,fatigue, fever, headache, insomnia, lightheadedness,malaise, paresthesia, sleep disturbance,syncope, vertigoCV: Chest pain, hypotension, orthostatichypotension, palpitations, tachycardiaEENT: Amblyopia, dry mouth, loss of taste,pharyngitisGI: Abdominal pain, constipation, diarrhea,indigestion, nausea, vomitingGU: ImpotenceMS: Arthralgia, back pain, myalgiaRESP: Cough, dyspneaSKIN: Alopecia, diaphoresis, flushing, photosensitivity,pruritus, rash, urticariaOther: Anaphylaxis, angioedemaNursing Considerations• Use quinapril cautiously in patients withrenal impairment.WARNING Patients with heart failure,hyponatremia, or severe volume or saltdepletion; those who’ve recently receivedintensive diuresis or an increase in diureticdosage; and those undergoing dialysis maybe at risk for excessive hypotension.Monitor blood pressure often for first2 weeks of therapy and wheneverquinapril or diuretic dosage increases. Ifexcessive hypotension occurs, notify prescriberimmediately, place patient in asupine position, and, if prescribed, infusenormal saline solution.WARNING Because of the risk of angioedema,be prepared to discontinue drugand administer emergency measures,including subcutaneous epinephrine1:1,000 (0.3 to 0.5 ml), if swelling oftongue, glottis, or larynx causes airway obstruction.• Monitor blood pressure often to assessdrug’s effectiveness.PATIENT TEACHING• Instruct patient to notify prescriber immediatelyand stop taking quinapril if he hasswelling of the face, eyes, lips, or tongue ordifficulty breathing.• Explain that drug may cause dizziness andquinidine 889light-headedness, especially for first fewdays of therapy. Advise patient to avoidhazardous activities until drug’s CNSeffects are known and to notify prescriberif he faints.• Inform woman of childbearing age of risksof taking quinapril during pregnancy,especially during the second and thirdtrimesters. Caution her to use effectivecontraception and to notify prescriberimmediately of known or suspected pregnancy.• Advise patient having surgery or anesthesiato tell specialist that he takes quinapril.• Instruct patient to consult prescriberbefore using potassium supplements orsalt substitutes that contain potassium.quinidine gluconateQuinaglute Dura-tabs, Quinate (CAN),Quin-ReleasequinidinepolygalacturonateCardioquinquinidine sulfateApo-Quinidine (CAN), Novoquinidin(CAN), Quinidex ExtentabsClass and CategoryChemical class: Dextrorotatory isomer ofquinineTherapeutic class: Class IA antiarrhythmicPregnancy category: CIndications and Dosages To prevent or treat cardiac arrhythmias,including established atrial fibrillation,atrial flutter, paroxysmal atrial fibrillation,paroxysmal atrial tachycardia,paroxysmal atrioventricular junctionalrhythm, paroxysmal ventricular tachycardianot associated with completeheart block, and premature atrial andventricular contractionsE.R. TABLETS (QUINIDINE GLUCONATE)Adults. 324 to 660 mg every 8 to 12 hr.Maximum: 1,944 mg daily.E.R. TABLETS (QUINIDINE SULFATE)Adults. 300 to 600 mg every 8 to 12 hr.QRS

890quinidineTABLETS (QUINIDINE GLUCONATE)Adults. Initial: 325 mg every 2 to 3 hr for5 to 8 doses, gradually increasing dosage asneeded and prescribed. Maintenance: 325 to488 mg t.i.d. or q.i.d.TABLETS (QUINIDINE POLYGALACTURONATE)Adults. Initial: 275 to 825 mg every 3 to4 hr for 3 or 4 doses, then increased by137.5 to 275 mg every 3rd or 4th dose untilrhythm is restored or toxic effects occur.Maintenance: 275 mg b.i.d. or t.i.d.TABLETS (QUINIDINE SULFATE)Adults. Initial: For premature atrial andventricular contractions, 200 to 300 mgt.i.d. or q.i.d.; for paroxysmal supraventriculartachycardia, 400 to 600 mg every 2 to3 hr until terminated; for atrial flutter, individualtitration after digitalization; for conversionof atrial fibrillation, 200 mg every2 to 3 hr for 5 to 8 doses, followed by subsequentdaily increases, as needed.Maintenance: 200 to 400 mg t.i.d. or q.i.d.Children. 6 mg/kg 5 times daily.I.V. INFUSION (QUINIDINE GLUCONATE)Adults. 800 mg in 40 ml of D 5 W at up to0.25 mg/kg/min.I.M. INJECTION (QUINIDINE SULFATE)Adults. 190 to 380 mg every 2 to 4 hr.Maximum: 3 g daily.Route Onset Peak DurationP.O. Unknown Unknown 6–8 hrP.O. (E.R.) Unknown Unknown 12 hrMechanism of ActionDepresses excitability, conduction velocity,and contractility of the myocardium andincreases the effective refractory period,thus suppressing arrhythmic activity in theatria, ventricles, and His-Purkinje system.ContraindicationsDigitalis toxicity; history of quinidineinducedthrombocytopenic purpura or torsadesde pointes; hypersensitivity to quinidine,other cinchona derivatives, or theircomponents; long-QT syndrome; myastheniagravis; pacemaker-dependent conductiondisturbancesInteractionsDRUGSantiarrhythmics, phenothiazines, rauwolfiaalkaloids: Additive cardiac effectsanticholinergics: Possibly intensifiedatropine-like adverse effectsantimyasthenics: Antagonized antimyastheniceffects on skeletal musclebarbiturates, rifampin: Possibly acceleratedelimination and decreased effectiveness ofquinidinecimetidine: Increased elimination half-life,possibly leading to quinidine toxicitydigoxin: Possibly digitalis toxicityhepatic enzyme inducers: Possibly decreasedblood quinidine levelneuromuscular blockers: Possibly potentiatedneuromuscular blockadeoral anticoagulants: Additive hypoprothrombinemia,increased risk of bleedingpimozide: Risk of arrhythmiasquinine: Increased risk of quinidine toxicityurinary alkalizers (such as antacids, carbonicanhydrase inhibitors, citrates, sodium bicarbonate,thiazide diuretics): Increased renaltubular reabsorption of quinidine, possiblyleading to quinidine toxicityverapamil: Possibly AV block, bradycardia,pulmonary edema, significant hypotension,and ventricular tachycardiaAdverse ReactionsCNS: Anxiety, asthenia, ataxia, confusion,delirium, difficulty speaking, dizziness,drowsiness, extrapyramidal reactions, fever,headache, hypertonia, syncope, vertigoCV: Complete heart block, orthostatichypotension, palpitations, peripheraledema, prolonged QT interval, torsades depointes, vasculitis, ventricular arrhythmias,widening QRS complexEENT: Blurred vision, change in color perception,diplopia, dry mouth, hearing loss(high-frequency), pharyngitis, photophobia,rhinitis, tinnitusGI: Abdominal pain, anorexia, constipation,diarrhea, indigestion, nausea, vomitingHEME: Agranulocytosis, hemolytic anemia,leukopenia, neutropenia, thrombocytopenia,thrombocytopenic purpuraMS: Arthralgia, myalgiaRESP: DyspneaSKIN: Diaphoresis, eczema, exfoliative dermatitis,flushing, hyperpigmentation, photosensitivity,pruritus, psoriasis, purpura,rash, urticariaOther: Angioedema, flulike symptoms,weight gain

Nursing Considerations• Give I.M. form of quinidine undiluted.• For intermittent I.V. infusion, dilute drugin 40 ml of D 5 W and administer using aninfusion pump at a rate of 0.25 mg/kg/min or less. Rapid administration maycause hypotension. Monitor ECG tracingsand blood pressure throughout administration.• Monitor therapeutic blood level of quinidine,as ordered.• Monitor heart rate and rhythm closelybecause quinidine may cause seriousadverse reactions and can be cardiotoxic,especially at dosages exceeding 2.4 g daily.Implement continuous cardiac monitoring,as ordered.• Assess for early signs and symptoms ofcinchonism, including blurred vision,change in color perception, confusion,diplopia, headache, and tinnitus, whichmay indicate quinidine toxicity.PATIENT TEACHING• Advise patient to take quinidine at thesame times every day and at evenly spacedintervals.• Instruct patient to swallow E.R. tabletswhole, with a full glass of water, preferablywhile sitting upright.• Advise patient to take drug with food if GIupset occurs.• Urge patient to inform prescriber immediatelyof blurred or double vision, changein color perception, confusion, diarrhea,fever, headache, loss of hearing, or tinnitus.quinine sulfateClass and CategoryChemical class: Cinchona alkaloidTherapeutic class: AntimalarialPregnancy category: XIndications and Dosages As adjunct to treat chloroquine-resistantmalaria caused by Plasmodium falciparumCAPSULES, TABLETSAdults. 600 to 650 mg every 8 hr for at least3 days with one of the following: 250 mg oftetracycline every 6 hr for 7 days; 1.5 g ofquinine sulfate 891sulfadoxine and 75 mg of pyrimethaminecombined as a single dose; 900 mg ofclindamycin every 8 hr for 3 days; or100 mg of doxycycline every 12 hr for7 days.Children over age 8. 8.3 mg/kg every 8 hrfor at least 3 days with one of the following:5 mg/kg of tetracycline every 6 hr for7 days; 6.7 to 13.3 mg/kg of clindamycinevery 8 hr for 3 days; or 1.25 mg/kg ofpyrimethamine and 25 mg/kg of sulfadoxinecombined as a single dose.Mechanism of ActionMay disrupt function in malarial parasiteby elevating intracellular pH in parasiticacid vesicles.ContraindicationsG6PD deficiency, history of quinineinducedblackwater fever or thrombocytopenicpurpura, hypersensitivity to quinineor its components, optic neuritis,pregnancy, tinnitusInteractionsDRUGSacetazolamide, sodium bicarbonate:Increased risk of quinine toxicityaluminum-containing antacids: Possiblydelayed or decreased quinine absorptionaminophylline, theophylline: Possiblyincreased quinine adverse effectsantimyasthenics: Possibly antagonized antimyastheniceffect on skeletal muscleastemizole, cisapride, halofantrine, mefloquine,pimozide, quinidine, terfenadine:Increased risk of prolonged QT intervalatorvastatin: Increased blood atorvastatinlevel; increased risk of myopathy or rhabdomyolysiscarbamazepine, phenobarbital, phenytoin:Possibly increased blood level of thesedrugs; possibly decreased blood quininelevelcimetidine: Possibly reduced quinine clearancedebrisoquine, desipramine, dextromethorphan,flecainide, metoprolol, paroxetine:Possibly increased bood levels of thesedrugs; increased risk of adverse reactionsdigoxin: Increased blood digoxin levelerythromycin, ketoconazole, troleandomycin:Possibly increased blood quinine levelhemolytics, neurotoxic drugs, ototoxic drugs:QRS

892Indications and Dosages To provide short-term treatment oferosive esophagitis or ulcerative gastroesophagealreflux disease (GERD)DELAYED-RELEASE TABLETSAdults. For mild to moderate disease,20 mg daily for 4 to 8 wk; course may berepeated if healing has not occurred at theend of 8 wk. For severe reflux with ulcerationor stricture formation, 40 mg daily for4 to 8 wk. To treat symptomatic GERDDELAYED-RELEASE TABLETSAdults and adolescents age 12 and over.20 mg daily for 4 wk. Course may berepeated if symptoms aren’t completelyresolved. To provide maintenance treatment oferosive esophagitis or GERDDELAYED-RELEASE TABLETSAdults. 20 mg daily. To promote healing of duodenal ulcer, asadjunct to treat Helicobacterpylori–positive duodenal ulcerDELAYED-RELEASE TABLETSAdults. 20 mg daily after breakfast for up to4 wk for ulcer healing and 2 wk when usedwith antibiotic therapy for H. pylori. As adjunct to reduce the risk ofduodenal ulcer recurrence by eradicatingH. pyloriDELAYED-RELEASE TABLETSAdults. 20 mg b.i.d with morning andevening meals in conjunction with amoxirabeprazolesodiumIncreased risk of toxicity of these drugshepatic enzyme inducers, rifampin: Possiblydecreased blood quinine levelmefloquine: Increased risk of seizuresneuromuscular blockers: Potentiated neuromuscularblockadeoral anticoagulants: Possibly increased anticoagulanteffects and risk of bleedingAdverse ReactionsCNS: HeadacheEENT: Blurred vision, hearing loss, tinnitus,vision changesENDO: HypoglycemiaGI: Abdominal or epigastric pain, diarrhea,nausea, vomitingHEME: ThrombocytopeniaNursing Considerations• Be aware that quinine shouldn’t be used inpatients with blackwater fever, which canfollow chronic malaria, because they’re atincreased risk for anemia and hemolysiswith renal failure. Quinine also isn’t recommendedfor treating or preventing nocturnalleg cramps because life-threateninghematologic reactions have occurred withpotential for chronic renal impairment.• Be aware that quinine shouldn’t be givenI.M. Doing so may cause bleeding, bruising,or hematomas because of quinine’seffect on platelets.• Monitor patient with type 2 diabetes mellitusfor alterations in blood glucose levelbecause quinine stimulates release ofinsulin and may promote hypoglycemia.• Be aware that quinine can exacerbate opticneuritis or tinnitus. It may also exacerbatemuscle weakness and cause dysphagia andrespiratory distress in myasthenic patients.• Assess for early signs and symptoms ofcinchonism, including blurred vision, confusion,diplopia, fever, headache, loss ofhearing, and tinnitus, which may indicatequinine toxicity.• Be aware that patients who developquinine-dependent antibodies coulddevelop thrombocytopenia more rapidlyand more severely upon re-exposure toquinine from any source.PATIENT TEACHING• Instruct patient not to crush or chew quininetablets; they taste bitter and can irritatethe mouth and throat.• Advise patient to take drug with food orafter meals to minimize GI irritation.• Urge patient to notify prescriber immediatelyif he experiences blurred or doublevision, confusion, fever, headache, loss ofhearing, or tinnitus, which are indicatorsof quinine toxicity.• Advise patient to avoid hazardous activitiesuntil he knows how quinine affectshim.rabeprazole sodiumAcipHexClass and CategoryChemical class: Substituted benzimidazoleTherapeutic class: AntiulcerPregnancy category: B

cillin 1000 mg b.i.d for 7 days and clarithromycin500 mg b.i.d. for 7 days. To treat hypersecretory conditions, suchas Zollinger-Ellison syndromeDELAYED-RELEASE TABLETSAdults. Initial: 60 mg daily; may beincreased, if needed, to 100 mg daily or60 mg b.i.d.DOSAGE ADJUSTMENT Dosage reductionmay be needed in severe hepatic dysfunction.Mechanism of ActionDecreases gastric acid secretion by suppressingits release at the secretory surfaceof gastric parietal cells. Rabeprazole alsoincreases gastric pH and decreases basalacid output, which helps to heal ulceratedareas. In gastric parietal cells, it’s transformedto an active sulfonamide, whichincreases the clearance rate of Helicobacterpylori.ContraindicationsHypersensitivity to rabeprazole, other substitutedbenzimidazoles (omeprazole, lansoprazole),or their componentsInteractionsDRUGScyclosporine: Possibly inhibited cyclosporinemetabolismdigoxin: Increased risk of digitalis toxicitywarfarin: Possibly increased PT, INRAdverse ReactionsCNS: Coma, delirium, disorientation, dizziness,headache, malaiseGI: Abdominal pain, diarrhea, jaundice,nausea, vomitingGU: Interstitial nephritisHEME: Agranulocytosis, hemolytic anemia,leukopenia, pancytopenia, thrombocytopeniaMS: RhabdomyolysisRESP: Interstitial pneumoniaSKIN: Erythema multiforme, rash, Stevens-Johnson syndrome, toxic epidermal necrolysisOther: Anaphylaxis, angioedema, hyperammonemiaNursing Considerations• Use rabeprazole cautiously in patientswith hepatic dysfunction.• Expect to monitor serum gastrin level inlong-term therapy to detect elevation.• Closely monitor Japanese men receivingrabeprazole for adverse reactions becausethey’re more likely than other patients tohave increased blood drug levels.PATIENT TEACHING• Instruct patient to swallow delayed-releaserabeprazole tablets whole.• Inform patients with hypersecretory conditions,such as Zollinger-Ellison syndrome,that treatment can last as long as1 year.raloxifenehydrochloride(keoxifenehydrochloride)Evistaraloxifene hydrochloride 893Class and CategoryChemical class: Benzothiophene derivativeTherapeutic class: Osteoporosis prophylacticPregnancy category: XIndications and Dosages To prevent osteoporosis in postmenopausalwomen; to reduce risk of invasivebreast cancer in postmenopausal womenwith osteoporosis; to reduce risk of invasivebreast cancer in postmenopausalwomen at high riskTABLETSAdults. 60 mg daily.Mechanism of ActionPrevents osteoporosis by binding to estrogenreceptors, which decreases bone resorptionand increases bone mineral density inpostmenopausal women.ContraindicationsHistory of thromboembolic disease, hypersensitivityto raloxifene or its components,pregnancyInteractionsDRUGSampicillin, cholestyramine: Decreased raloxifeneabsorptionwarfarin: Possibly decreased PTAdverse ReactionsCNS: Depression, fever, insomnia,migraine, strokeQRS

894ramelteonCV: Chest pain, hot flashes, peripheraledema, thromboembolism, thrombophlebitisEENT: Laryngitis, pharyngitis, sinusitisENDO: Hot flashesGI: Abdominal pain, cholelithiasis, flatulence,indigestion, nausea, vomitingGU: Cystitis, infertility, leukorrhea, UTI,vaginitisMS: Arthralgia, arthritis, leg cramps orspasms, myalgiaRESP: Cough, pneumonia, pulmonaryembolismSKIN: Diaphoresis, rashOther: Flulike symptoms, weight gainNursing Considerations• Use cautiously in patients who smoke orhave a history of stroke, TIA, atrial fibrillation,or hypertension because raloxifenemay increase the risk of stroke.• Use cautiously in patients with renalimpairment because effects of raloxifeneon renal system are unknown.WARNING Monitor patient’s limbs forimpaired circulation and pain (possiblethromboembolism).• Expect prescriber to stop drug at least72 hours before and during periods ofprolonged immobilization. Resume raloxifenetherapy as prescribed after patient isfully ambulatory.PATIENT TEACHING• Advise patient to avoid lengthy immobilityduring travel while taking raloxifenebecause of the increased risk of thromboembolism.• Instruct patient to report adverse reactionsto prescriber immediately, especially legpain or swelling, sudden chest pain, shortnessof breath, coughing up blood, or asudden change in vision.• Stress the importance of compliance withlong-term raloxifene therapy.• Advise patient that postmenopausalwomen require an average of 1,500 mg ofelemental calcium and 400 to 800 internationalunits of vitamin D daily. Vitamin Drequirement is increased in women overage 70, women with GI malabsorptionsyndromes, and women who are chronicallyill or nursing home bound. Reviewdietary sources of calcium and vitamin D,and have patient discuss supplements withprescriber, as needed.ramelteonRozeremClass and CategoryChemical class: Melatonin receptor agonistTherapeutic class: HypnoticPregnancy category: CIndications and Dosages To treat insomnia in patients havingdifficulty falling asleepTABLETSAdults. 8 mg 30 min before at bedtime.Route Onset Peak DurationP.O. Unknown 0.5–1.5 hr UnknownMechanism of ActionBinds to melatonin receptors MT1 andMT2 in the suprachiasmatic nucleus (SCN)of the hypothalamus. The SCN regulatesthe sleep-wake cycle, and endogenous melatoninprobably is involved in maintainingthe circadian rhythm underlying that cycle.ContraindicationsConcurrent therapy with fluvoxamine, historyof angioedema with previousramelteon treatment, hypersensitivity toramelteon or its components, severe hepaticdysfunctionInteractionsDRUGSbenzodiazepines, melatonin, other sedativehypnotics:Possible additive sedative effectsfluconazole, fluvoxamine, ketoconazole:Increased plasma ramelteon levelsrifampin: Decreased ramelteon effectivenessACTIVITIESalcohol use: Possibly additive CNS effectAdverse ReactionsCNS: Agitation, amnesia, anxiety, bizarrebehavior, complex behaviors such as sleepdriving, depression, dizziness, fatigue, hallucinations,headache, insomnia exacerbation,mania, somnolence, suicidal ideationEENT: Throat tightnessENDO: Decreased testosterone level,increased prolactin levelGI: Diarrhea, dysgeusia, nausea, vomitingMS: Arthralgia, myalgiaRESP: Dyspnea, upper respiratory tract

infectionOther: Anaphylaxis, angioedemaNursing Considerations• Be aware that ramelteon therapy is notrecommended for patients with severesleep apnea or COPD because its effectshave not been studied in these patientpopulations.• Use cautiously in patients with mild tomoderate hepatic dysfunction. Drug iscontraindicated in severe hepatic dysfunction.• Ramelteon is the first approved hypnoticnot classified as a controlled substance.WARNING Monitor patient closely forhypersensitivity reactions such as dyspnea,throat tightness, nausea, vomiting, andswelling. If present, discontinue ramelteonimmediately, notify prescriber, and providesupportive care.• Watch patient closely for suicidal tendencies,particularly when therapy starts anddosage changes, because depression mayworsen temporarily during these times,possibly leading to suicidal ideation.PATIENT TEACHING• Instruct patient not to take ramelteonwith or immediately after eating a high-fatmeal.• Caution patient to avoid potentially hazardousactivities after taking ramelteon;drug’s intended effect is to decrease alertness.• Advise patient that drug may cause abnormalbehaviors during sleep, such as drivinga car, eating, talking on the phone, orhaving sex without any recall of the event.If family members notice any such behavioror patient sees evidence of such behaviorupon awakening, prescriber should benotified.• Advise limiting alcohol during therapy.• Tell patient to notify prescriber if insomniaworsens or new signs or symptomsoccur.• Inform patient that drug may affect reproductivehormones; urge patient to reportcessation of menses or galactorrhea(females) or decreased libido or problemswith infertility.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes.ramiprilAltaceramipril 895Class and CategoryChemical class: Ethylester of ramiprilatTherapeutic class: AntihypertensivePregnancy category: C (first trimester), D(later trimesters)Indications and Dosages To treat heart failure after MICAPSULESAdults. Initial: 1.25 to 2.5 mg b.i.d.Maintenance: 5 mg b.i.d. To treat hypertensionCAPSULESAdults. Initial: 2.5 mg daily. Maintenance:2.5 to 20 mg once daily or in divided dosesb.i.d.DOSAGE ADJUSTMENT Initial dosage reducedto 1.25 mg daily for patients dehydratedfrom diuretics, those receiving diuretics,and those with creatinine clearance lessthan 40 ml/min/1.73 m 2 ; dosage then slowlyincreased until blood pressure is undercontrol or maximum daily dose of 5 mg isreached.Route Onset Peak DurationP.O. 1–2 hr 4 –6.5 hr 24 hrMechanism of ActionBlocks conversion of angiotensin I toangiotensin II, causing vasodilation, andreduces aldosterone secretion, which preventswater retention. Ramipril also reducesperipheral arterial resistance. Combined,these actions reduce blood pressure.ContraindicationsHypersensitivity to ramipril, its components,or any other ACE inhibitorsInteractionsDRUGSallopurinol, bone marrow depressants, corticosteroids(systemic), procainamide:Increased risk of fatal neutropenia oragranulocytosisCNS depressants, other hypotensionproducingdrugs: Additive hypotensiveeffectcyclosporine, potassium preparations,QRS

896ranitidine hydrochloridepotassium-sparing diuretics: Possibly hyperkalemiainsulin, oral antidiabetics: Increased risk ofhypoglycemialithium: Increased risk of lithium toxicityNSAIDs, sympathomimetics: Decreased antihypertensiveeffect of ramiprilsodium aurothiomalate: Increased risk ofnitritoid reaction (facial flushing, nausea,vomiting, hypotension)telmisartan: Possibly increased risk ofadverse effects, especially renal dysfunctiontetracyclines: Reduced tetracycline absorptionFOODSlow-salt milk, salt substitutes: Increased riskof hyperkalemiaACTIVITIESalcohol use: Additive hypotensive effectsAdverse ReactionsCNS: Depression, dizziness, drowsiness,fatigue, fever, headache, insomnia, lightheadedness,malaise, paresthesia, sleep disturbance,syncope, vertigoCV: Chest pain, hypotension, orthostatichypotension, palpitations, tachycardiaEENT: Amblyopia, dry mouth, loss of taste,pharyngitisGI: Abdominal pain, constipation, diarrhea,elevated liver function test results, hepaticfailure, hepatitis, nausea, vomitingGU: Acute renal failure, elevated BUN andserum creatinine levels, impotence, oliguria,progressive azotemiaHEME: Agranulocytosis, anemia, bonemarrow depression, pancytopeniaMS: Arthralgia, back pain, myalgiaRESP: Cough, dyspneaSKIN: Alopecia, diaphoresis, flushing, jaundice,onycholysis, pemphigoid, photosensitivity,pruritus, rash, Stevens-Johnson syndrome,toxic epidermal necrolysis, urticariaOther: AngioedemaNursing Considerations• Use ramipril cautiously in patients withrenal or hepatic impairment.WARNING Patients with dehydration, heartfailure, or hyponatremia; those who’verecently received intensive diuresis or anincrease in diuretic dosage; and those havingdialysis may risk excessive hypotension.Monitor such patients closely thefirst 2 weeks of therapy and wheneverramipril or diuretic dosage increases. Ifexcessive hypotension occurs, notify prescriberimmediately, place patient in asupine position, and, if prescribed, infusenormal saline solution.WARNING Because of the risk of angioedema,be prepared to stop drug and provideemergency measures, including subcutaneousepinephrine 1:1,000 (0.3 to 0.5ml), if swelling of tongue, glottis, or larynxcauses airway obstruction.• Monitor blood pressure frequently duringtherapy to assess drug’s effectiveness.• Monitor patient’s renal and hepatic functionclosely during therapy.PATIENT TEACHING• Advise patient to stop taking ramipril andinform prescriber immediately if she experiencesswelling of the face, eyes, lips, ortongue or has difficulty breathing.• Explain that drug may cause dizziness andlight-headedness, especially during firstfew days of therapy. Instruct patient tonotify prescriber immediately if she faints.• Inform female patient of childbearing ageof the risks of taking ramipril during pregnancy.Caution patient to use effectivecontraception and to report known or suspectedpregnancy immediately.• Urge patient to tell providers that shetakes ramipril before having surgery oranesthesia.• Tell patient to ask prescriber before usingsupplements or salt substitutes that containpotassium.ranitidinehydrochlorideApo-Ranitidine (CAN), Gen-Ranitidine(CAN), Novo-Ranitidine (CAN),Nu-Ranit (CAN), Zantac, ZantacEFFERdose Tablets, Zantac 150GELdose, Zantac 300 GELdoseClass and CategoryChemical class: Aminoalkyl-substitutedfuran derivativeTherapeutic class: Antiulcer agent, gastricacid secretion inhibitorPregnancy category: BIndications and Dosages To prevent duodenal and gastric ulcers

CAPSULES, EFFERVESCENT GRANULES,EFFERVESCENT TABLETS, SYRUP, TABLETSAdults and adolescents. 150 mg at bedtime. To provide short-term treatment ofactive duodenal and benign gastriculcersCAPSULES, EFFERVESCENT GRANULES,EFFERVESCENT TABLETS, SYRUP, TABLETSAdults and adolescents. 150 mg b.i.d. forgastric ulcers; 150 mg b.i.d. or 300 mg atbedtime for duodenal ulcers.Children ages 1 month to 16 years. 2 to4 mg/kg b.i.d. up to 300 mg daily.Maintenance: 2 to 4 mg/kg daily up to150 mg daily.CONTINUOUS I.V. INFUSIONAdults and adolescents. 6.25 mg/hr.Maximum: 400 mg daily.INTERMITTENT I.V. INFUSIONAdults and adolescents. 50 mg diluted tototal volume of 100 ml and infused over15 to 20 min every 6 to 8 hr. Maximum:400 mg daily.Children. 2 to 4 mg/kg daily diluted to asuitable volume and infused over 15 to20 min.I.V. INJECTIONAdults and adolescents. 50 mg diluted tototal volume of 20 ml and injected slowlyover no less than 5 min every 6 to 8 hr.Maximum: 400 mg daily.I.M. INJECTIONAdults and adolescents. 50 mg every 6 to8 hr. Maximum: 400 mg daily. To treat acute gastroesophageal refluxdiseaseCAPSULES, EFFERVESCENT GRANULES,EFFERVESCENT TABLETS, SYRUP, TABLETSAdults and adolescents. 150 mg b.i.d.EFFERVESCENT TABLETSChildren ages 1 month to 16 years. 2.5 to5 mg/kg b.i.d.INTERMITTENT I.V. INFUSIONChildren. 2 to 8 mg/kg diluted to suitablevolume and infused over 15 to 20 min t.i.d. To treat erosive esophagitisCAPSULES, EFFERVESCENT GRANULES,EFFERVESCENT TABLETS, SYRUP, TABLETSAdults and adolescents. 150 mg q.i.d.EFFERVESCENT TABLETSChildren ages 1 month to 16 years. 2.5 to5 mg/kg b.i.d. To treat hypersecretory GI conditions,ranitidine hydrochloride 897such as Zollinger-Ellison syndrome, systemicmastocytosis, and multiple endocrineadenoma syndromeCAPSULES, EFFERVESCENT GRANULES,EFFERVESCENT TABLETS, SYRUP, TABLETSAdults and adolescents. Initial: 150 mgb.i.d., adjusted as needed. Maximum: 6 gdaily in divided doses.CONTINUOUS I.V. INFUSIONAdults and adolescents. Initial: 1 mg/kg/hr,increased by 0.5 mg/kg/hr up to 2.5 mg/kg/hr. Maximum: 400 mg daily.INTERMITTENT I.V. INFUSIONAdults. 50 mg diluted to total volume of100 ml and infused over 15 to 20 min every6 to 8 hr. Maximum: 400 mg daily.I.V. INJECTIONAdults and adolescents. 50 mg diluted tototal of 20 ml and injected slowly over atleast 5 min every 6 to 8 hr. Maximum:400 mg daily.I.M. INJECTIONAdults. 50 mg every 6 to 8 hr. To prevent acid indigestion, heartburn,and sour stomach caused by eating certainfoods or drinking certain beveragesTABLETSAdults and adolescents. 75 mg 30 to60 min before food or beverages expectedto cause symptoms. Maximum: 150 mgdaily over no more than 2 continuous wk. To treat acid indigestion, heartburn, andsour stomachTABLETSAdults and adolescents. 75 mg when symptomsstart; repeated once within 24 hr, ifneeded.DOSAGE ADJUSTMENT For patients whosecreatinine clearance is less than 50 ml/min/1.73 m 2 , 150 mg P.O. every 24 hr withdosage interval increased thereafter to every12 hr, as needed. Or 50 mg I.V. every 18 to24 hr with dosage interval increased toevery 12 hr, as needed. Dosage reductionmay also be necessary for patients withhepatic dysfunction.Route Onset Peak DurationP.O., I.V., Unknown 1–3 hr 13 hrI.M.Mechanism of ActionInhibits basal and nocturnal secretion ofQRS

898ranolazinegastric acid and pepsin by competitivelyinhibiting the action of histamine at H 2receptors on gastric parietal cells. Thisaction reduces total volume of gastric juicesand, thus, irritation of GI mucosa.ContraindicationsAcute porphyria, hypersensitivity to ranitidineor its componentsInteractionsDRUGSantacids: Decreased ranitidine absorptionatazanavir, delavirdine, diazepam, gefitinib,itraconazole, ketoconazole, sucralfate:Decreased absorption of these drugsbone marrow depressants: Increased risk ofneutropenia or other blood dyscrasiasglipizide, glyburide, metoprolol, midazolam,nifedipine, phenytoin, theophylline, triazolam:Increased effects of these drugs, possiblyleading to toxic reactionsprocainamide: Possibly increased risk ofprocainamide toxicitywarfarin: Possibly altered PTACTIVITIESalcohol use: Increased blood alcohol level(with oral ranitidine)Adverse ReactionsCNS: Dizziness, drowsiness, fever,headache, insomniaCV: VasculitisGI: Abdominal distress, constipation, diarrhea,nausea, vomitingGU: Acute interstitial nephritis, impotenceMS: Arthralgia, myalgiaRESP: BronchospasmSKIN: Alopecia, erythema multiforme, rashOther: Anaphylaxis, angioedemaNursing Considerations• Be aware that ranitidine must be dilutedfor I.V. use if not using premixed solution.For I.V. injection, dilute to total of 20 mlwith normal saline solution, D 5 W, D 10 W,lactated Ringer’s solution, or 5% sodiumbicarbonate. For I.V. infusion, dilute tototal volume of 100 ml of same solutions.• Give I.V. injection at no more than 4 ml/min, intermittent I.V. infusion at 5 to7 ml/min, and continuous I.V. infusion at6.25 mg/hr (except with hypersecretoryconditions, when initial infusion rate is1 mg/kg/hr, gradually increased after4 hours, as needed, in increments of0.5 mg/kg/hr).• Don’t add additives to premixed solution.• Stop primary I.V. solution infusion duringpiggyback administration.PATIENT TEACHING• Tell patient to dissolve 150-mg effervescenttablets or granules in 6 to 8 oz wateror 25-mg effervescent tablets in at least5 ml water.• Advise patient (or parent) to wait untileffervescent tablet is completely dissolvedbefore taking (or giving to child or infant).• Caution patient not to chew effervescenttablets, swallow them whole, or let themdissolve on the tongue.• Alert patients with phenylketonuria thateffervescent tablets and granules containphenylalanine.• Tell patient that she may take drug withfood.• Tell patient to stop taking ranitidine andcontact prescriber if she has trouble swallowing,vomits blood, or passes black orbloody stools.• If needed, advise patient to take antacids,2 hours before or after ranitidine; adviseagainst taking other acid reducers withdrug.• If patient takes drug to prevent heartburn,tell her to contact prescriber about frequentchest pain or wheezing with heartburn;stomach pain; unexplained weightloss; nausea; vomiting; heartburn lastingmore than 3 months; heartburn withlight-headedness, dizziness, or sweating;chest or shoulder pain with shortness ofbreath, sweating, light-headedness, or painspreading to arms, neck, or shoulders.These problems may be serious.• Inform patient that healing of an ulcermay require 4 to 8 weeks of therapy.ranolazineRanexaClass and CategoryChemical class: PiperazineacetamideTherapeutic class: AntianginalPregnancy category: CIndications and Dosages To treat chronic angina

E.R. TABLETSAdults. Initial: 500 mg b.i.d., increased to1,000 mg b.i.d., as needed. Maximum:1,000 mg b.i.d.DOSAGE ADJUSTMENT For patients taking amoderate CYP3A inhibitor, such as diltiazemor verapamil, maximum dosagereduced to 500 mg b.i.d. For patients takingcyclosporine, dosage reduced according toclinical responseRoute Onset Peak DurationP.O. Unknown 2–5 hr UnknownMechanism of ActionExerts anti-ischemic and antianginal effectsby an unknown mechanism not dependenton reductions in heart rate or blood pressure.Ranolazine inhibits cardiac late sodiumcurrent, but how this action inhibitsangina symptoms is also unknown.ContraindicationsHypersensitivity to ranolazine or its components,hepatic impairment, QT-intervalprolongation, torsades de pointes, use ofCYP3A inducers or strong inhibitorsInteractionsDRUGSCYP3A inducers, such as carbamazepine,phenobarbital, phenytoin, rifabutin,rifampin, rifapentin, St. John’s wort:Decreased blood ranolazine level anddecreased effectivenessCYP3A substrates, such as cyclosporine:Possibly increased cyclosporine levelCYP3A inhibitors, such as clarithromycin,diltiazem, indinavir, itraconazole, ketoconazole,nefazodone, nelfinavir, ritonavir,saquinavir, verapamil: Increased bloodranolazine level and increased risk ofadverse reactionsdigoxin: Increased blood digoxin levelAdverse ReactionsCNS: Asthenia, confusion, dizziness,headache, hypoesthesia, paresthesia, tremor,vertigoCV: Bradycardia, hypotension, orthostatichypotension, palpitations, peripheraledema, QT-interval prolongationEENT: Blurred vision, dry mouth, tinnitusGI: Abdominal pain, constipation, nausea,vomitingGU: Elevated creatinine level, hematuria,renal failureHEME: Eosinophilia, leukopenia, pancytopenia,thrombocytopeniaRESP: Dyspnea, pulmonary fibrosisOther: AngioedemaNursing Considerations• Monitor patient’s QT interval, as ordered,because ranolazine prolongs it in a doserelatedmanner.• Assess effectiveness of ranolazine at preventinganginal pain.• Monitor patient’s serum creatinine, BUN,magnesium, potassium, and liver enzymelevels.PATIENT TEACHING• Instruct patient to take ranolazine exactlyas prescribed.• Inform patient that drug may be takenwith or without food.• Caution patient to swallow tablets wholeand not to crush, break, or chew them.• Advise patient to limit the amount ofgrapefruit and grapefruit juice consumedwhile taking this drug.• Advise patient to notify prescriber if seriousor persistent adverse reactions occur.rasagilineAzilectrasagiline 899Class and CategoryChemical class: PropargylamineTherapeutic class: Irreversible MAOinhibitorPregnancy category: CIndications and Dosages To treat idiopathic Parkinson’s diseaseas initial monotherapy in early-stagediseaseTABLETSAdults. 1 mg once daily. As adjunct with levodopa or levodopaand carbidopa in treatment of laterstageidiopathic Parkinson’s diseaseTABLETSAdults. 0.5 mg once daily increased to 1 mgonce daily, as needed.DOSAGE ADJUSTMENT For patients withmild hepatic failure, dosage shouldn’texceed 0.5 mg daily.QRS

900rasagilineMechanism of ActionInhibits metabolic degradation of catecholaminesand serotonin in the CNS andperipheral tissues, increasing extracellulardopamine level in the striatum. Theincreased dopamine level helps controlalterations in voluntary muscle movement(such as tremors and rigidity) inParkinson’s disease because dopamine, aneurotransmitter, is essential for normalmotor function. By stimulating peripheraland central dopaminergic 2 (D 2 ) receptorson postsynaptic cells, dopamine inhibits firingof striatal neurons (such as cholinericneurons), improving motor function.Route Onset Peak DurationP.O. Unknown 1 hr UnknownContraindicationsAcute MI; angina; cardiac arrhythmias;coronary artery disease; cerebrovasculardisease; elective surgery that requires generalanesthesia; hypersensitivity to rasagilineor its components; pheochromocytoma;moderate to severe hepatic impairment;stroke; use within 14 days of cyclobenzaprine,dextromethorphan, MAO inhibitors,meperidine, mirtazapine, tramadol,methadone, propoxyphene, St. John’s wort,or sympathomimetic aminesInteractionsDRUGSciprofloxacin and other CYP1A2 inhibitors:Increased rasagiline plasma leveldextromethorphan: Increased risk of psychosisor bizarre behaviorlevodopa, levodopa and carbidopa: Increasedrisk of dyskinesiasMAO inhibitors, sympathomimetics:Increased risk of hypertensive crisismeperidine, methadone, propoxyphene, tramadol:Increased risk of life-threateningadverse reactions characterized by coma,severe hypertension or hypotension, severerespiratory depression, seizures, malignanthyperpyrexia, excitation, and peripheralvascular collapseselective serotonin reuptake inhibitors, tetracyclicantidepressants, tricyclic antidepressants:Increased risk of severe CNS toxicitywith hyperpyrexia, behavioral and mentalstatus changes, diaphoresis, muscle rigidity,hypertension, syncope, and possible deathAdverse ReactionsCNS: Abnormal dreams, amnesia, anxiety,asthenia, ataxia, cerebral ischemia, coma,confusion, depression, difficulty thinking,dizziness, dyskinesia, dystonia, fever, hallucinations,headache, malaise, manic depressivereaction, nightmares, paresthesia,seizures, somnolence, stroke, stupor, syncope,vertigoCV: Angina, bundle branch heart block,chest pain, heart failure, MI, hypertensivecrisis, postural hypotension, thrombophlebitis,ventricular tachycardia or fibrillationEENT: Blurred vision, conjunctivitis, drymouth, gingivitis, hemorrhage, laryngealedema, retinal detachment or hemorrhage,rhinitisGI: Abdominal pain, anorexia, constipation,diarrhea, dyspepsia, dysphagia, epistaxia,gastroenteritis, gastrointestinal hemorrhage,intestinal obstruction or perforation, liverfunction test abnormalities, nausea, vomitingGU: Acute renal failure, albuminuria,decreased libido, hematuria, impotence,incontinence, priapismHEME: Anemia, leukopenia, thrombocytopeniaMS: Arthralgia, arthritis, bone necrosis,bursitis, leg cramps, myasthenia, neck painor stiffness, tenosynovitisRESP: Apnea, asthma, cough, dyspnea,pleural effusion, pneumothorax, interstitialpneumoniaSKIN: Alopecia, carcinoma, diaphoresis,ecchymosis, exfoliative dermatitis, pruritus,ulcer, vesiculobullous rashOther: Angioedema, flu syndrome, hypersensitivityreaction, hypocalcemia, weightlossNursing ConsiderationsWARNING Notify prescriber immediately ifpatient has evidence of hypertensive crisis,such as blurred vision, chest pain, difficultythinking, stupor or coma, seizures,severe headache, neck stiffness, nausea,vomiting, palpitations or signs and symptomssuggesting a stroke. Expect to stopdrug immediately if these occur.• Keep phentolamine readily available totreat hypertensive crisis. Give 5 mg by slow

I.V. infusion, as prescribed, to reduceblood pressure without causing excessivehypotension. Use external cooling measures,as prescribed, to manage fever.• Monitor patient receiving rasagline withlevodopa for worsening of pre-existingdyskinesia. If it occurs, notify prescriberand expect levodopa dosage to bedecreased.PATIENT TEACHINGWARNING Inform patient taking recommendeddosage of rasagline that dietarytyramine restriction is no longer neededexcept for avoidance of very tyramine-richfoods such as aged cheese (e.g., Stilton),which may increase blood pressure greatly.If patient doesn’t feel well soon after eatinga suspected high-tyramine meal, heshould contact prescriber immediately.• Advise patient to stop taking rasagline andto notify prescriber immediately if hedevelops blurred vision, chest pain, troublethinking, stupor or coma, seizures,severe headache, stiff neck, nausea, vomiting,palpitations, or evidence of stroke.• Suggest that patient change position slowlyto minimize orthostatic hypotension.• Alert patient that drug may cause hallucinations.If they occur, tell patient to notifyprescriber promptly.• Instruct patient to notify all prescribers ofrasagline therapy, especially if antidepressantsor antibiotics such as ciprofloxacinor a similar drug are being considered, andto avoid taking any over the counter coldmedications.rasburicaseElitekClass and CategoryChemical class: Tetrameric proteinTherapeutic class: Uric acid reducerPregnancy category: CIndications and Dosages To manage plasma uric acid levels initiallyin patients with leukemia, lymphoma,or solid tumor malignancieswho receive anticancer therapy that elevatesplasma uric acidI.V. INFUSIONAdults and children. 0.20 mg/kg infusedover 30 min daily for 5 days.rasburicase 901Mechanism of ActionConverts uric acid into an inactive and solublemetabolite at the end of the purinecatabolic pathway. This prevents plasmauric acid levels from rising due to tumorlysis from anticancer therapy.ContraindicationsGlucose-6-phosphatase dehydrogenase(G6PD) deficiency; history of anaphylaxisor hypersensitivity reactions, hemolyticreactions, or methemoglobinemia reactions;hypersensitivity to rasburicase or its componentsAdverse ReactionsCNS: Anxiety, fever, headache, paresthesia,rigors, seizuresCV: Arrhythmia, cardiac failure or arrest,cerebrovascular disorder, chest pain, hemorrhage,hypotension, myocardial infarction,pulmonary edema, thrombophlebitis,thrombosisEENT: Mucositis, retinal hemorrhageENDO: Hot flashesGI: Abdominal pain, constipation, diarrhea,ileus, intestinal obstruction, nausea, vomitingGU: Acute renal failureHEME: Anemia, hemolysis, methemoglobinemia,neutropenia, pancytopeniaRESP: Cyanosis, dyspnea, pneumonia, pulmonaryhypertension, respiratory distressSKIN: Cellulitis, rashOther: Anaphylaxis, dehydration, infection,sepsisNursing Considerations• Be aware that children at high risk forG6PD deficiency, such as patients ofAfrican or Mediterranean ancestry, shouldbe screened before administering rasburicasebecause severe hemolysis can occur.• Expect to give only one course of therapybecause of risk of severe allergic reactions.• Reconstitute rasburicase using only diluentprovided. Add 1 ml of diluent to eachvial needed, and mix by swirling very gently.Don’t shake or invert vial.• Inject reconstituted solution into an infusionbag containing the appropriate volumeof normal saline solution to obtain afinal volume of 50 ml. Infuse over 30 minutesin a different line than for infusion ofQRS

902InteractionsDRUGSanesthetics (barbiturate, inhalation), benzoremifentanilhydrochlorideother drugs. If a separate line isn’t possible,flush the line with at least 15 ml ofnormal saline solution before and afterrasburicase infusion. Don’t use filters.• Store reconstituted solution at 2° to 8° C(36° to 46° F) for no longer than 24 hours.Protect drug from light.WARNING Monitor patient closely forsevere hypersensitivity reactions, includinganaphylaxis (chest pain, dyspnea, hypotension,urticaria), hemolysis (severe anxiety,pain, dyspnea), and methemoglobinemia(anxiety, hypoxemia, shortness of breath).If such a reaction occurs, discontinue rasburicaseimmediately, notify prescriber,and start emergency treatment.Rasburicase shouldn’t be restarted aftersuch a reaction occurs.• Ensure that blood samples to measure uricacid levels are collected in chilled tubescontaining heparin anticoagulant and areimmediately placed in ice water untilanalysis is done (within 4 hours); bloodsamples left at room temperature willresult in low uric acid levels because ofenzyme degradation of uric acid at roomtemperature.PATIENT TEACHING• Explain to child and parents that chemotherapywill start 4 to 24 hours after rasburicase.• Stress the importance of reporting anyadverse reaction immediately.remifentanilhydrochlorideUltivaClass, Category, and ScheduleChemical class: Fentanyl analogueTherapeutic class: Anesthesia adjunctPregnancy category: CControlled substance schedule: IIIndications and Dosages As adjunct to induce general anesthesiaINTERMITTENT I.V. INFUSIONAdults and children age 2 and over. 0.5 to1 mcg/kg plus inhalation or I.V. anesthetic. To maintain general anesthesiaINTERMITTENT I.V. INFUSIONAdults and children age 2 and over. 0.05 to0.2 mcg/kg, followed by 0.5 to 1 mcg/kgevery 2 to 5 min, as needed. To continue analgesic effect in immediatepostoperative periodCONTINUOUS I.V. INFUSIONAdults and children age 2 and over. Initial:0.1 mcg/kg/min, adjusted by 0.025 mcg/kg/min every 5 min, as prescribed, to balancelevel of analgesia and respiratory rate.Maximum: 0.2 mcg/kg/min. To supplement local or regional anesthesiain a monitored anesthetic settingI.V. INFUSIONAdults and children age 2 and over. With abenzodiazepine: 0.05 mcg/kg/min, starting5 min before placement of local or regionalblock; after placement of block, decreasedto 0.025 mcg/kg/min and then furtheradjusted every 5 min in increments of0.025 mcg/kg/min, as needed. Without abenzodiazepine: 0.1 mcg/kg/min, starting5 min before placement of local or regionalblock; after placement of block, decreasedto 0.05 mcg/kg/min and then furtheradjusted every 5 min in increments of0.025 mcg/kg/min, as needed.I.V. INJECTIONAdults and children age 2 and over. With abenzodiazepine: 0.5 mcg/kg over 30 to60 sec as a single dose 60 to 90 sec beforelocal anesthetic is administered. Without abenzodiazepine: 1 mcg/kg administered over30 to 60 sec as a single dose 60 to 90 secbefore local anesthetic is administered.DOSAGE ADJUSTMENT For elderly patients,starting dose possibly reduced by half. Ifpatient is more than 30% over ideal bodyweight, starting dose based on ideal bodyweight.Route Onset Peak DurationI.V. 1 min 1–2 min 5–10 minIncompatibilitiesDon’t give remifentanil through same I.V.line as blood because nonspecific esterasesin blood products may inactivate drug.ContraindicationsEpidural or intrathecal administration,hypersensitivity to fentanyl analogues

epaglinide 903Mechanism of ActionRemifentanil decreases transmissionand perception of pain bystimulating mu-opioid receptorsin neurons. This action decreasesthe activity of adenyl cyclase inneurons, which in turn decreasescAMP production. With lesscAMP available, potassium (K + )is forced out of neurons, and calcium(Ca ++ ) is prevented fromentering neurons. As a result,neuron excitability declines, andfewer neurotransmitters (such assubstance P) leave the neurons,thereby decreasing pain transmission.RemifentanilNeuronCa ++K +AdenylcyclaseSubstance PMu-opioidreceptorcAMPdiazepines, propofol: Possibly synergisticeffects, increasing risk of hypotension andrespiratory depressionatropine, glycopyrrolate: Possibly reversal ofremifentanil-induced bradycardiaephedrine, epinephrine, norepinephrine:Possibly reversal of remifentanil-inducedhypotensionneuromuscular blockers: Prolonged skeletalmuscle rigidity caused by remifentanilopioid antagonists: Possibly reversal ofremifentanil’s effectsAdverse ReactionsCNS: Headache, shiveringCV: Asystole, bradycardia, hypotensionGI: Nausea, vomitingMS: Skeletal muscle rigidityRESP: Apnea, cough, dyspnea, respiratorydepression, stridor, wheezingOther: AnaphylaxisNursing Considerations• Inject remifentanil into I.V. tubing at or asclose as possible to venous cannula.• Use infusion device to deliver continuousinfusion.• Monitor vital signs and oxygenation continuouslyduring administration.• Expect analgesic effects to dissipate rapidlywhen drug is discontinued. Expect to startadequate postoperative analgesia, as prescribed,before stopping drug.WARNING After stopping drug, clear I.V.tubing to prevent inadvertent later delivery.• Monitor respiratory status continuouslybecause of risk of respiratory depressionfrom residual effects of other anestheticsfor up to 30 minutes after infusion stops.PATIENT TEACHING• Explain expected drug effects to patient,and reassure her that she’ll be monitoredcontinuously during drug administration.repaglinidePrandinClass and CategoryChemical class: MeglitinideTherapeutic class: AntidiabeticPregnancy category: CIndications and Dosages To achieve glucose control in type 2 diabetesmellitus as monotherapy inpatients whose glycosylated hemoglobin(HbA 1c ) level is less than 8%TABLETSAdults. Initial: 0.5 mg 15 to 30 min beforemeals b.i.d. Dosage doubled, as needed,every wk until adequate glucose responseobtained. Maintenance: 0.5 to 4 mg/dose upto q.i.d. Maximum: 16 mg daily in divideddoses of not more than 4 mg/dose. To achieve glucose control in type 2 diabetesmellitus as monotherapy inpatients whose HbA 1c is 8% or greaterand in combination with metformin orthiazolidinedione (pioglitazoneQRS

904repaglinidehydrochloride, rosiglitazone maleate)therapyTABLETSAdults. Initial: 1 or 2 mg 15 to 30 minbefore meals b.i.d. Dosage doubled, asneeded, every wk until adequate glucoseresponse obtained. Maintenance: 1 to 4 mg/dose up to q.i.d. Maximum: 16 mg daily individed doses of not more than 4 mg/dose.DOSAGE ADJUSTMENT For patients withmoderate to severe hepatic or renal impairment,increased time between dosageadjustments.Mechanism of ActionStimulates release of insulin from functioningpancreatic beta cells. In patients withtype 2 diabetes mellitus, a shortage of thesecells decreases blood insulin levels andcauses glucose intolerance. By interactingwith the adenosine triphosphatase(ATP)–potassium channel on the beta cellmembrane, repaglinide prevents potassiumfrom leaving the cell. This causes the betacell to depolarize and the cell membrane’scalcium channel to open. As a result, calciummoves into the cell and insulin movesout. The extent of insulin release is glucosedependent; the lower the glucose level, theless insulin is secreted from the cell.ContraindicationsConcurrent therapy with gemfibrozil, diabeticketoacidosis, hypersensitivity torepaglinide or its components, severehepatic or renal impairment, type 1 diabetesmellitusInteractionsDRUGSbarbiturates, carbamazepine, rifampin, troglitazone:Possibly increased repaglinidemetabolismbeta blockers, chloramphenicol, clarithromycin,MAO inhibitors, NSAIDs, oral anticoagulants,probenecid, salicylates, sulfonamides:Enhanced hypoglycemic effectscalcium channel blockers, corticosteroids,diuretics, estrogens, isoniazid, niacin, oralcontraceptives, phenothiazines, phenytoin,sympathomimetics, thyroid hormones:Possibly loss of glucose controlerythromycin, ketoconazole, miconazole:Possibly inhibited repaglinide metabolismgemfibrozil: Increased blood repaglinidelevel, resulting in enhanced and prolongedblood glucose–lowering effectsNPH insulin: Possibly increased risk ofanginaOATP1B1 inhibitors such as cyclosporine,trimethoprim: Increased plasma repaglinidelevelAdverse ReactionsCNS: HeadacheCV: AnginaEENT: Rhinitis, sinusitisENDO: HypoglycemiaGI: Diarrhea, elevated liver enzymes, hepatitis,nausea, pancreatitisHEME: Hemolytic anemia, leukopenia,thrombocytopeniaMS: Arthralgia, back painRESP: Bronchitis, upper respiratory tractinfectionSKIN: Alopecia, Stevens-Johnson syndromeOther: AnaphylaxisNursing Considerations• Be aware that repaglinide shouldn’t beused with NPH insulin because the combinationmay increase the risk of angina.• Expect to check HbA 1c level every3 months, as ordered, to assess patient’slong-term control of blood glucose level.• During times of increased stress, such asfrom infection, surgery, or trauma, monitorblood glucose level often and assessneed for additional insulin.PATIENT TEACHING• Instruct patient to take repaglinide 15 to30 minutes before meals and to skip dosewhenever she skips a meal.• Explain that repaglinide is an adjunct todiet in managing type 2 diabetes mellitus.• Inform patient that changes in blood glucoselevel may cause blurred vision orvisual disturbances, especially whenrepaglinide therapy starts. Reassure himthat these changes are usually transient.• Teach patient how to monitor her bloodglucose level and when to notify prescriberabout changes.• Review signs and symptoms of hyperglycemiaand hypoglycemia with patientand family. Instruct patient to notify prescriberimmediately if she experiencesanxiety, confusion, dizziness, excessivesweating, headache, increased thirst,increased urination, or nausea.

eserpine 905• Advise patient to wear or carry identificationindicating that she has diabetes.Encourage her to carry candy or othersimple carbohydrates with her to treatmild episodes of hypoglycemia.• Inform patient that her HbA 1c level will betested every 3 to 6 months until her bloodglucose level is controlled.reserpineNovoreserpine (CAN), Reserfia (CAN),Serpalan, Serpasil (CAN)Class and CategoryChemical class: Rauwolfia alkaloidTherapeutic class: AntihypertensivePregnancy category: CIndications and Dosages To treat hypertensionTABLETSAdults. 0.1 to 0.25 mg daily.Children. 0.005 to 0.02 mg/kg daily oncedaily or in divided doses b.i.d.DOSAGE ADJUSTMENT Lower dosage possiblyrequired for elderly or severely debilitatedpatients.Route Onset Peak DurationP.O. Days–3 wk 3–6 wk 1–6 wkContraindicationsActive peptic ulcer, electroconvulsive therapy,hypersensitivity to reserpine or its components,mental depression (current or historyof), ulcerative colitisInteractionsDRUGSanticholinergics: Decreased effectiveness ofanticholinergicsbarbiturates: Increased CNS depressionbeta blockers: Additive and, possibly, excessivebeta-adrenergic blockadebromocriptine: Possibly interference withMechanism of ActionReserpine reduces blood pressure bydecreasing norepinephrine stores inpresynaptic sympathetic neurons.Normally, when a nerve impulse activatesa sympathetic neuron, the nerveending releases norepinephrine, whichstimulates alpha or beta receptors on targetcell membranes, as shown below left.Stimulation of alpha receptors may producevasoconstriction; stimulation ofbeta receptors may increase heart rateand force of myocardial contraction,NorepinephrineSympatheticneuronVesiclewhich raises cardiac output. Through areuptake mechanism, some norepinephrinereturns to the neuron and is storedin vesicles for reuse.Reserpine displaces norepinephrinefrom vesicles in the nerve fiber, and MAOdegrades the displaced norepinephrine, asshown below right. These actions reducethe amount of norepinephrine availableto stimulate postsynaptic alpha and betareceptors, reducting vasoconstriction,cardiac output, and blood pressure.ReserpinedisplacesnorepinephrineQRSNorepinephrinereuptakeBeta receptorCell membraneAlphareceptorMAOdegradesnorepinephrine

906reteplasebromocriptine’s effectsdigoxin, procainamide, quinidine: Increasedrisk of arrhythmiashypotension-producing drugs: Increasedantihypertensive effect; increased risk oforthostatic hypotension or bradycardia(with guanadrel or guanethidine)levodopa: Decreased levodopa effectivenessMAO inhibitors: Increased risk of severehypertension and hyperpyrexia, additiveCNS depressionNSAIDs: Decreased antihypertensive effectsympathomimetics: Increased vasopressoreffects, decreased antihypertensive effectACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Anxiety, depression, dizziness, drowsiness,headache, nervousness, nightmares,sleep disturbance, syncope, weaknessCV: Arrhythmias, such as bradycardia; chestpain; peripheral edemaEENT: Conjunctival injection, dry mouth,epistaxis, glaucoma, hearing loss, nasal congestion,optic atrophy, uveitisENDO: Breast engorgementGI: Abdominal cramps or pain, anorexia,diarrhea, increased gastric secretions, melena,nausea, vomitingGU: Decreased libido, galactorrhea, gynecomastia,impotenceMS: MyalgiaRESP: DyspneaSKIN: PurpuraOther: Weight gainNursing Considerations• If patient has a history of depression, usereserpine cautiously because it may causedepression masked as somatic complaints.• Monitor blood pressure frequently duringdrug therapy.• Alert anesthesiologist if patient is scheduledfor surgery. Drug may cause circulatoryinstability even if withheld beforeprocedure.PATIENT TEACHING• Instruct patient to take reserpine withfood or milk to minimize stomach upset.• Caution patient about possible drowsiness,and advise her to avoid potentially hazardousactivities until drug’s CNS effects areknown.• Explain the need for frequent appointmentsto monitor blood pressure andadjust dosage at start of therapy.reteplaseRetavaseClass and CategoryChemical class: Recombinant plasminogenactivator (r-PA)Therapeutic class: ThrombolyticPregnancy category: CIndications and Dosages To improve ventricular function, preventheart failure, and reduce mortality afteracute MII.V. INJECTIONAdults. 10 units over 2 min; repeated after30 min.Mechanism of ActionConverts plasminogen to plasmin, whichworks to break up fibrin clots that haveformed in the coronary arteries. Eliminationof the clots improves cardiac bloodand oxygen flow to the area, thus improvingventricular function.IncompatibilitiesDon’t add other drugs to reteplase injectionsolution or administer them through sameI.V. line as reteplase.ContraindicationsActive internal bleeding, aneurysm, arteriovenousmalformation, bleeding diathesis,brain tumor, history of stroke or othercerebrovascular disease, hypersensitivity toreteplase or its components, intracranial orintraspinal surgery or trauma during previous2 months, severe uncontrolled hypertension(systolic 200 mm Hg or higher,diastolic 110 mm Hg or higher)InteractionsDRUGSantifibrinolytics (including aminocaproicacid, aprotinin, and tranexamic acid):Decreased effectiveness of reteplaseantineoplastics, antithymocyte globulin, certaincephalosporins (such as cefamandole,cefoperazone, and cefotetan), heparin, oralanticoagulants, platelet aggregationinhibitors (such as abciximab, aspirin, and

dipyridamole), strontium-89 chloride, sulfinpyrazone,valproic acid: Increased risk ofbleedingAdverse ReactionsCNS: Intracranial hemorrhageGI: GI bleeding, nausea, vomitingHEME: ThrombocytopeniaRESP: HemoptysisSKIN: Bleeding from wounds, ecchymosis,hematoma, purpuraOther: Allergic reaction, injection sitebleedingNursing Considerations• Expect to start reteplase, as prescribed, assoon as possible after MI symptoms begin.• Closely monitor patient with atrial fibrillation,severe hypertension, or other cardiacdisease for signs and symptoms of cerebralembolism.• To reconstitute, use diluent, syringe, needle,and dispensing pin provided.Withdraw 10 ml of preservative-free sterilewater for injection. Remove and discardneedle from syringe, and connect dispensingpin to syringe. Remove protective capfrom spike end of dispensing pin, andinsert spike into reteplase vial. Inject 10 mlof sterile water into the vial. With thespike still in the vial, swirl gently to dissolvethe powder. Don’t shake. Expect tosee slight foaming. Let the vial stand forseveral minutes. When the bubbles dissipate,withdraw 10 ml of reconstitutedsolution into the syringe (about 0.7 mlmay remain in the vial). Now detach thesyringe from the dispensing pin and attachthe 20G needle.• Use the solution within 4 hours. Discard ifit’s discolored or contains particulates.• Don’t give heparin and reteplase in thesame solution. Instead, flush the heparinline with normal saline solution or D 5 Wbefore and after reteplase injection.• Because fibrin is lysed during therapy,closely monitor all possible bleeding sites(catheter insertions, arterial and venouspunctures, cutdowns, and needle punctures).• Avoid I.M. injections, venipunctures, andnonessential handling of patient duringtherapy.• If arterial puncture is needed, use an armvessel that can be compressed, if possible.After sample is obtained, apply pressurefor at least 30 minutes; then apply a pressuredressing. Check site often for bleeding.• If bleeding occurs and can’t be controlledby local pressure, notify prescriber immediately.Be prepared to stop anticoagulanttherapy immediately and to discontinuesecond reteplase bolus, as prescribed.• Anticipate that reperfusion arrhythmias,such as premature ventricular contractionsor ventricular tachycardia, may followcoronary thrombolysis.PATIENT TEACHING• Advise patient to report adverse reactionsimmediately.rifabutinMycobutinrifabutin 907Class and CategoryChemical class: Spiropiperidyl derivativeTherapeutic class: Antimycobacterial antibioticPregnancy category: BIndications and Dosages To prevent disseminated Mycobacteriumavium complex in patients withadvanced HIV infectionCAPSULESAdults. 300 mg once daily or 150 mg b.i.d.Mechanism of ActionSuppresses RNA synthesis by inhibitingDNA-dependent RNA polymerase in a widevariety of bacteria, including Mycobacteriumavium. Exhibits dose-dependent bactericidalor bacteriostatic action.ContraindicationsHypersensitivity to rifabutin or rifamycinsInteractionsDRUGSaminophylline, barbiturates, beta blockers,chloramphenicol, clofibrate, corticosteroids,cyclosporine, dapsone, diazepam, digoxin,disopyramide, estramustine, estrogens, ketoconazole,mexiletine, oral anticoagulants, oralantidiabetic drugs, oral contraceptives (containingestrogen), oxtriphylline, phenytoin,quinidine, theophylline, tocainide, verapamil(oral): Reduced effects of these drugsQRS

908rifampinfluconazole: Increased blood rifabutin levelmethadone: Possibly withdrawal symptomszidovudine: Decreased blood zidovudinelevelAdverse ReactionsCNS: Asthenia, fever, headache, insomniaCV: Chest painEENT: Discolored saliva, tears, and sputumGI: Abdominal pain, anorexia, diarrhea,discolored feces, elevated liver function testresults, eructation, flatulence, indigestion,nausea, pseudomembranous colitis, vomitingGU: Discolored urineHEME: Neutropenia, thrombocytopeniaMS: MyalgiaSKIN: Discolored skin and sweat, rashNursing Considerations• Monitor laboratory values duringrifabutin therapy to detect neutropeniaand thrombocytopenia.• Expect drug to cause reddish orange toreddish brown discoloration of skin andbody fluids.• Be aware that drug may cause myelosuppressionand increased risk of infection.Notify prescriber immediately if signs ofinfection, such as fever, develop.• Monitor patient for diarrhea during therapyand for at least 2 months afterward;diarrhea may signal pseudomembranouscolitis caused by Clostridium difficile. Ifdiarrhea occurs, notify prescriber andexpect to withhold rifabutin and treatwith fluids, electrolytes, protein, and anantibiotic effective against C. difficile.PATIENT TEACHING• Advise patient to take rifabutin with foodif GI distress develops.• Encourage patient to have needed dentalwork done before rifabutin therapy startsto reduce the risk of bleeding or infection.• Explain that drug may turn urine, feces,saliva, sputum, sweat, tears, and skin reddishorange to reddish brown.• Caution patient against wearing soft contactlenses during therapy because drugmay permanently stain them.• Advise patient to notify prescriber aboutsigns of Mycobacterium avium complex(chills, fever, night sweats, weight loss),tuberculosis, myositis, or uveitis.• Advise woman of childbearing age thatrifabutin may decrease effectiveness of oralcontraceptives; advise her to use a nonhormonalmethod of birth control.• Urge patient to tell prescriber about diarrheathat’s severe or prolonged. Remindpatient that watery or bloody stools canoccur 2 months or more after antibiotictherapy ends and can be serious, requiringprompt treatment.rifampin(rifampicin)Rifadin, Rifadin IV, Rimactane,Rofact (CAN)Class and CategoryChemical class: Semisynthetic antibioticderivative of rifamycinTherapeutic class: Antimycobacterial antitubercularPregnancy category: CIndications and Dosages As adjunct to treat tuberculosis causedby all strains of Mycobacterium tuberculosisCAPSULES , ORAL SUSPENSION, I.V. INFUSIONAdults. 10 mg/kg daily with other antituberculardrugs for 2 mo. Maximum: 600 mgdaily.Infants and children. 10 to 20 mg/kg dailyin combination with other antituberculardrugs for 2 mo. Maximum: 600 mg daily. To eliminate meningococci from nasopharynxof asymptomatic carriers ofNeisseria meningitidisCAPSULES , ORAL SUSPENSION, I.V. INFUSIONAdults. 600 mg every 12 hr for 2 days (totalof 4 doses).Infants age 1 month and over and children.10 mg/kg every 12 hr for 2 days (totalof 4 doses). Maximum: 600 mg daily.Infants under age 1 month. 5 mg/kg every12 hr for 2 days (total of 4 doses).Maximum: 600 mg daily.DOSAGE ADJUSTMENT For patients withhepatic impairment, maximum of 8 mg/kgdaily. For patients with creatinine clearanceof 10 ml/min/1.73 m 2 or less, recommendeddosage usually decreased by 50%.Mechanism of ActionInhibits bacterial and mycobacterial RNA

synthesis by binding to DNA-dependentRNA polymerase, thereby blocking RNAtranscription. Exhibits dose-dependent bactericidalor bacteriostatic action. Rifampinis highly effective against rapidly dividingbacilli in extracellular cavitary lesions, suchas those found in the nasopharynx.IncompatibilitiesDon’t administer rifampin in the same I.V.line as diltiazem.ContraindicationsConcurrent use of nonnucleoside reversetranscriptase inhibitors or proteaseinhibitors by patients with HIV, hypersensitivityto rifamycinsInteractionsDRUGSaminophylline, oxtriphylline, theophylline:Increased metabolism and clearance ofthese theophylline preparationsanesthetics (hydrocarbon inhalation, exceptisoflurane), hepatotoxic drugs, isoniazid:Increased risk of hepatotoxicitybeta blockers, chloramphenicol, clofibrate,corticosteroids, cyclosporine, dapsone, digitalisglycosides, disopyramide, hexobarbital,itraconazole, ketoconazole, mexiletine, oralanticoagulants, oral antidiabetic drugs,phenytoin, propafenone, quinidine, tocainide,verapamil (oral): Increased metabolism,resulting in lower blood levels of thesedrugsbone marrow depressants: Increased leukopenicor thrombocytopenic effectsclofazimine: Reduced absorption ofrifampin, delaying its peak concentrationand increasing its half-lifediazepam: Enhanced diazepam elimination,resulting in decreased drug effectivenessestramustine, estrogens, oral contraceptives:Decreased estrogenic effectsmethadone: Possibly impaired absorptionof methadone, leading to withdrawal symptomsprobenecid: Increased blood level or prolongedduration of rifampin, increasing riskof toxicitynonnucleoside reverse transcriptaseinhibitors, protease inhibitors (indinavir, nelfinavir,ritonavir, saquinavir): Acceleratedmetabolism of these drugs (by patients withHIV), resulting in subtherapeutic levels;rifampin 909delayed metabolism of rifampin, increasingrisk of toxicitytrimethoprim: Increased elimination andshortened elimination half-life of trimethoprimvitamin D: Increased metabolism anddecreased efficacy of vitamin D, leading todecreased serum calcium and phosphatelevels and increased parathyroid hormonelevelsACTIVITIESalcohol use: Increased risk of hepatotoxicityAdverse ReactionsCNS: Chills, dizziness, drowsiness, fatigue,headache, paresthesiaEENT: Discolored saliva, tears, and sputum;mouth or tongue soreness; periorbitaledemaGI: Abdominal cramps, anorexia, diarrhea,discolored feces, elevated liver function testresults, epigastric discomfort, flatulence,heartburn, hepatitis, nausea, pseudomembranouscolitis, vomitingGU: Discolored urineMS: Arthralgia, myalgiaSKIN: Discolored skin and sweatOther: Facial edema, flulike symptomsNursing Considerations• Obtain blood samples or other specimensfor culture and sensitivity testing, asordered, before giving rifampin andthroughout therapy to monitor responseto drug.• Expect to monitor liver function testresults before and every 2 to 4 weeks duringtherapy. Immediately report abnormalities.• For I.V. infusion, reconstitute by adding10 ml sterile water for injection to 600-mgvial of rifampin. Swirl gently to dissolve.Withdraw appropriate dose and add to500 ml D 5 W (preferred solution) or normalsaline solution and infuse over3 hours. Or, withdraw appropriate doseand add to 100 ml D 5 W (preferred solution)or normal saline solution and infuseover 30 minutes. Use reconstituted drugpromptly because rifampin may precipitateout of D 5 W solution after 4 hours. Innormal saline solution, drug is stable up to24 hours at room temperature.• Be aware that patient receiving intermittenttherapy (once or twice weekly) is atQRS

910Nursing Considerations• Use riluzole cautiously in patients withimpaired hepatic or renal function.• Also use cautiously in elderly patients,women, and Japanese patients because ofincreased risk of toxicity from decreaseddrug clearance.• Monitor liver function test results beforeand during riluzole therapy.• Monitor patient for respiratory symptoms,such as dry cough or dyspnea. Notify prescriberif present, and expect patient tohave a chest X-ray, as ordered. If evidenceof interstitial lung disease or hypersensitivitypneumonitis is present, expect riluriluzoleincreased risk for adverse reactions.• Expect drug to discolor skin and body fluidsreddish orange to reddish brown.• Be aware that rifampin can cause myelosuppressionand increase risk of infection.Notify prescriber immediately if signs ofinfection, such as fever, develop.PATIENT TEACHING• Instruct patient to take rifampin 1 hourbefore or 2 hours after a meal with a fullglass of water.• Stress the need to take drug exactly as prescribed.Explain that interruptions canlead to increased adverse reactions.• Explain that drug may turn urine, feces,saliva, sputum, sweat, tears, and skin reddishorange to reddish brown.• Caution patient against wearing soft contactlenses during therapy because drugmay permanently stain them.• Advise patient who takes an oral contraceptiveto use an additional form of birthcontrol during rifampin therapy.• Urge patient to notify prescriber aboutflulike symptoms, anorexia, darkenedurine, fever, joint pain or swelling, malaise,nausea, vomiting, and yellowish skin oreyes, which may indicate hepatitis.• Advise patient to avoid alcohol duringrifampin therapy.• Instruct patient to notify prescriber if noimprovement occurs within 2 to 3 weeks.riluzoleRilutekClass and CategoryChemical class: BenzothiazoleTherapeutic class: Amyotrophic lateralsclerosis treatment agentPregnancy category: CIndications and Dosages To treat amyotrophic lateral sclerosisTABLETSAdults. 50 mg every 12 hr.Mechanism of ActionInhibits release of glutamic acid, an excitatoryamino acid neurotransmitter, in theCNS, thus reducing its effects on targetcells. Glutamic acid affects degeneration ofneurons; reducing its level may help slowamyotrophic lateral sclerosis.ContraindicationsHypersensitivity to riluzole or its componentsInteractionsDRUGSallopurinol, hepatotoxic drugs, methyldopa,sulfasalazine: Increased risk of hepatotoxicityamitriptyline, phenacetin, quinolones,tacrine, theophylline: Delayed elimination ofriluzoleomeprazole, rifampin: Increased riluzoleclearanceFOODScharbroiled foods: Increased riluzole eliminationACTIVITIESalcohol use: Increased risk of hepatotoxicitysmoking: Increased riluzole eliminationAdverse ReactionsCNS: Asthenia, dizziness, headache, insomnia,paresthesia (circumoral), somnolence,spasticity, vertigoCV: Peripheral edemaEENT: Dry mouth, rhinitis, stomatitisGI: Abdominal pain, anorexia, constipation,diarrhea, elevated liver function test results,flatulence, hepatitis, indigestion, nausea,vomitingHEME: NeutropeniaMS: Back or muscle pain or stiffnessRESP: Dyspnea, hypersensitivity pneumonitis,increased cough, interstitial lungdisorder, pneumoniaSKIN: Alopecia, eczema, pruritusOther: Anaphylaxis

zole to be discontinued immediately.PATIENT TEACHING• Instruct patient to take riluzole regularly,every 12 hours, either 1 hour before or2 hours after a meal, and at the same timeeach day.• Instruct patient to store riluzole at roomtemperature, protected from bright light.• Urge patient to minimize alcohol, smoking,and charred foods because they speeddrug excretion.• Tell patient to report fever, cough, or difficultybreathing.risedronate sodiumActonelClass and CategoryChemical class: Pyridinyl bisphosphonateTherapeutic class: Bone resorption inhibitorPregnancy category: CIndications and Dosages To treat Paget’s disease of bone whenserum alkaline phosphatase level is atleast twice normal and patient is symptomaticor at risk for complicationsTABLETSAdults. 30 mg daily for 2 mo. Repeatedafter 2 mo if relapse occurs or if serumalkaline phosphatase level fails to normalize. To prevent or treat glucocorticoidinducedosteoporosisTABLETSAdults. 5 mg daily. Or, for postmenopausalosteoporosis, 35 mg once/wk or 75 mgtaken on 2 consecutive days once/mo. To prevent or treat postmenopausalosteoporosisTABLETSAdults. 5 mg daily. Or, 35 mg once weekly,75 mg taken on 2 consecutive days once amonth, or 150 mg once a month To treat osteoporosis in menTABLETSAdults. 35 mg once/wk.Route Onset Peak DurationP.O. Unknown 3 mo 16 morisedronate sodium 911Mechanism of ActionHinders excessive bone remodeling characteristicof Paget’s disease by binding to boneand reducing the rate at which osteoclastsare resorbed by bone.ContraindicationsEsophageal abnormalities that delayesophageal emptying, such as stricture orachalasia; hypersensitivity to risedronate orits components; inability to stand or situpright for at least 30 minutes; hypocalcemiaInteractionsDRUGSaspirin, NSAIDs: Increased risk of GI irritationcalcium-containing preparations, includingantacids: Impaired absorption of risedronateFOODSall foods: Decreased risedronate bioavailabilityAdverse ReactionsCNS: Anxiety, asthenia, depression, dizziness,fatigue, headache, insomnia, sciatica,syncope, vertigo, weaknessCV: Chest pain, hypercholesterolemia,hypertension, peripheral edema, vasodilationEENT: Amblyopia, cataract, dry eyes,nasopharyngitis, pharyngitis, rhinitis,sinusitis, tinnitusGI: Abdominal pain, colitis, constipation,diarrhea, dyspepsia, dysphagia, eructation,esophagitis, esophageal or gastric ulcers,flatulence, gastritis, nausea, vomitingGU: UTIMS: Arthralgia; back, limb, neck, or shoulderpain; jaw osteonecrosis; leg cramps orspasms; myasthenia; myalgia; osteoarthritisRESP: Bronchitis, cough, pneumonia,upper respiratory tract infectionSKIN: Bullous reaction, pruritus, rashOther: Angioedema, flulike symptoms,hypersensitivity reaction, hypocalcemiaNursing Considerations• Risedroante isn’t recommended forpatients with severe renal impairment.• Make sure patient has had a dental checkupbefore having invasive dental proceduresduring risedroante therapy, especiallyif patient has cancer; is receivingchemotherapy, head or neck radiation, ora corticosteroid; or has poor oral hygieneQRS

912risperidonebecause risk of osteonecrosis is increasedin these patients.• Give supplemental calcium and vitamin D,as prescribed, during risedronate therapyif patient’s dietary intake is inadequate.• Give calcium supplements and antacids atdifferent time of day than risedronateadministration to avoid impaired drugabsorption and altered effectiveness.• Watch for rare but possibly severe rash,bullous skin reactions, and angioedema.PATIENT TEACHING• Instruct patient to take risedronate at least1 hour before first food or drink of day(except water) while in an upright positionand with 6 to 8 oz of water. Cautionagainst lying down for at least 30 minutesafter taking drug to keep it from lodgingin esophagus and causing irritation. Alsoinstruct patient not to chew or suck ontablet because doing so may irritate mouthor throat.• Advise patient to stop taking risedronateand to notify prescriber if GI symptomsappear or become worse.• Alert patient that drugs in the same classas risedronate have caused severe bone,joint, or muscle pain. If such symptomsappear while taking risedronate, advisepatient to contact prescriber.• If patient takes 35 mg once weekly andmisses a dose, tell her to take it the morningafter she remembers and then to takethe next dose on its usual day. If patienttakes 75 mg on 2 consecutive days oncemonthly and she misses both doses withmore than 7 days until the next scheduleddose, tell her to take the first missed doseon the morning after she remembers andthe second dose the following day. If shemisses only one of the two doses, tell herto take it the morning after she remembersand then resume her normal schedule. Ifpatient takes 150 mg once monthly andmisses a dose, urge her to contact prescriberfor instructions. Caution patientnot to take more than 150 mg within a 7-day period and not to take two tablets ofany strength on the same day.• Tell patient to take calcium supplementsor antacids at different times than risedronate.• Urge women of childbearing age to tellprescriber about planned, suspected, orknown pregnancy because of risk to fetalskeleton.• Tell patient to stop risedronate and contactprescriber about swelling or skinabnormalities.• Instruct patient on proper oral hygieneand on the need to notify prescriber aboutinvasive dental procedures.risperidoneRisperdal, Risperdal ConstaClass and CategoryChemical class: Benzisoxazole derivativeTherapeutic class: AntipsychoticPregnancy category: CIndications and Dosages To manage psychotic disordersORAL SOLUTION, ORALLY DISINTEGRATINGTABLETS, TABLETSAdults. 1 mg b.i.d. on day 1; 2 mg b.i.d. onday 2; 3 mg b.i.d. on day 3. Or, 2 mg dailyon day one; 4 mg daily on day two; 6 mgdaily on day 3. Then increased by 1 to 2 mgdaily at 1- to 2-wk intervals, as needed.Maximum: 16 mg daily.Adolescents ages 13 to 17. Initial: 0.5 mgonce daily, increased as needed every 24 hrin 0.5- to 1-mg increments. Maximum:3 mg once daily.I.M. INJECTION (RISPERDAL CONSTA)Adults. Initial: 25 mg every 2 wk, increasedas needed every 4 wk to 37.5 or 50 mg.Maximum: 50 mg every 2 wk. To treat bipolar maniaORAL SOLUTION, ORALLY DISINTEGRATINGTABLETS, TABLETSAdults. Initial: 2 or 3 mg daily, increased asneeded by 1 mg daily up to 6 mg.Maximum: 6 mg daily for no more than3wk.Children and adolescents ages 10 to 17.Initial: 0.5 mg once daily, increased as neededevery 24 hr in 0.5- to 1-mg increments.Maximum: 2.5 mg once daily. To treat bipolar mania as monotherapyor as adjunct to lithium or valproatetherapyI.M. INJECTION (RISPERDAL CONSTA)Adults. 25 mg every 2 wk., increased, asneeded to 37.5 mg or 50 mg. Maximum:

50 mg every 2 wk.DOSAGE ADJUSTMENT Initially 0.5 mg b.i.d.for elderly or debilitated patients, thosewith renal or hepatic impairment, andthose at risk for hypotension. Increased by0.5 mg b.i.d. every wk, as needed. Givendaily after target dosage maintained for 2 or3 days. Maximum for patients with severehepatic dysfunction, 4 mg daily; for elderlypatients, 3 mg daily. Initially 12.5 mg forpatients receiving drug I.M. who have renalor hepatic impairment, take other drugsthat increase risperidone blood level, orhave a history of tolerating psychotropicdrugs poorly. For adolescents and childrenwith persistent somnolence, dose may besplit and given twice daily. To treat irritability associated withautistic disorderORAL SOLUTION, ORALLY DISINTEGRATINGTABLETS, TABLETSChildren age 5 and over and adolescentsweighing less than 20 kg (44 lb). Initial:0.25 mg daily, increased after 4 days to0.5 mg daily. Dosage further increased, asneeded in 2 wk intervals in 0.25 mg increments.Children age 5 and over and adolescentsweighing 20 kg or more. Initial: 0.5 mgdaily, increased after 4 days to 1 mg daily.Dosage further increased, as needed in 2 wkintervals in 0.5 mg increments.Mechanism of ActionSelectively blocks serotonin and dopaminereceptors in the mesocortical tract of theCNS to suppress psychotic symptoms.IncompatibilitiesDon’t mix oral solution with cola or tea.ContraindicationsHypersensitivity to risperidone or its componentsInteractionsDRUGSantihypertensives: Increased antihypertensiveeffectsbromocriptine, levodopa, pergolide: Possiblyantagonized effects of these drugscarbamazepine: Increased risperidone clearancewith long-term concurrent useclozapine: Decreased risperidone clearancewith long-term concurrent useCNS depressants: Additive CNS depressionrisperidone 913fluoxetine, paroxetine: Increased plasmarisperidone levelACTIVITIESalcohol use: Additive CNS depressionAdverse ReactionsCNS: Aggressiveness, agitation, akathisia,anxiety, asthenia, confusion, decreased concentration,dizziness, dream disturbances,drowsiness, dyskinesia, dystonia, fatigue,fever, headache, lassitude, memory loss,nervousness, neuroleptic malignant syndrome,parkinsonism, restlessness, seizures,somnolence, tremorCV: Atrial fibrillation, chest pain, hypercholesterolemia,orthostatic hypotension, palpitations,QT-interval prolongation, tachycardiaEENT: Decreased or increased salivation,dry mouth, pharyngitis, retinal arteryocclusion, rhinitis, sinusitis, vision changesENDO: Diabetic ketoacidosis (patients withdiabetes), elevated prolactin level, galactorrhea,hyperglycemia, pituitary adenomaGI: Abdominal pain, anorexia, constipation,diarrhea, indigestion, intestinal obstruction,nausea, vomitingGU: Amenorrhea, decreased libido, dysmenorrhea,dysuria, hypermenorrhea,incontinence, increased appetite, polyuria,sexual dysfunction, UTIHEME: Agranulocytosis, leukopenia, neutropeniaMS: Arthralgia, back pain, myalgiaRESP: Cough, dyspnea, sleep apnea, upperrespiratory tract infectionSKIN: Diaphoresis, dry skin, hyperpigmentation,photosensitivity, pruritus, rash,seborrheaOther: Anaphylaxis, angioedema, injectionsite induration, pain, redness, or swelling;weight gain or lossNursing Considerations• Use risperidone cautiously in debilitatedpatients, elderly patients, and patients withhepatic or renal dysfunction or hypotensionbecause of their increased sensitivityto drug. Also use risperidone cautiously inpatients with a history of seizures;although rare, seizures may occur in thosewith schizophrenia.WARNING Be aware that risperidone shouldnot be used to treat elderly patients withdementia-related psychosis because itQRS

914rivastigmine tartrateincreases risk of death in these patients.• Be aware that oral risperidone or anotherantipsychotic should be continued for3 weeks after long-acting I.M. form ofrisperidone is first administered to providean adequate therapeutic plasma level untilrisperidone release from injection site hasbegun. If the patient has never receivedoral risperidone, an oral trial should beprescribed before use of I.M. form todetermine patient’s tolerance of the drug.• Remove I.M. form from refrigerator andallow it to come to room temperaturebefore reconstitution. Follow manufacturer’sguidelines for reconstitution, usingonly the diluent supplied in the dose pack.• Give I.M. form using only the needle suppliedin the dose pack. Inject entire contentsof syringe into the upper outer quadrantof gluteal area within 2 minutes ofreconstitution. If drug can’t be given rightafter reconstitution, shake the upright vialvigorously back and forth until particlesare resuspended. Discard reconstituteddrug if not used within 6 hours. Neveradminister I.M. form intravenously.• Monitor for orthostatic hypotension, especiallyin patients with cardiac or cerebrovasculardisease.WARNING Immediately notify prescriberand expect to stop giving risperidone ifpatient shows evidence of neurolepticmalignant syndrome (altered mental status,autonomic instability, hyperpyrexia,muscle rigidity), which can be fatal.• Monitor patient’s blood glucose and lipidlevels as ordered because drug increasesthe risk of hyperglycemia and hypercholesterolemia.• Monitor patient’s CBC, as ordered,because serious adverse hematologic reactionsmay occur, such as agranulocytosis,leukopenia, or neutropenia. More frequentmonitoring during the first few months ofrisperidone therapy is recommended forpatients with a history of drug-inducedleukopenia or neutropenia or who havehad a significantly low WBC count in thepast. If abnormalities occur during therapy,monitor patient for fever or other signsof infection, notify prescriber, and expectdrug to be discontinued if severe.PATIENT TEACHING• Instruct patient to dilute risperidone oralsolution with water, coffee, orange juice,or low-fat milk but not with cola or tea.• Tell patient prescribed orally disintegratingtablets to break open the blister unitwith dry hands by peeling the foil back toexpose the tablet. Stress the importance ofnot pushing tablet through the foilbecause this could damage the tablet.Once patient has removed tablet, sheshould place immediately on her tongue,where it will dissolve within seconds. Tellpatient not to chew orally disintegratingtablet or attempt to spit it out of hermouth.• Urge patient to avoid alcohol because ofits additive CNS effects.• Caution diabetic patient to monitor bloodglucose level closely because risperidonemay increase it.rivastigminetartrateExelon, Exelon PatchClass and CategoryChemical class: Carbamate derivativeTherapeutic class: AntidementiaPregnancy category: BIndications and Dosages To treat mild to moderate Alzheimer’stypedementiaCAPSULES , ORAL SOLUTIONAdults. Initial: 1.5 mg b.i.d. Dosageincreased by 3 mg daily every 2 wk, asneeded. Maximum: 12 mg daily.TRANSDERMALAdults. Initial: 4.6 mg/24 hr. After 4 wk,increased to 9.5 mg/24 hr. To treat mild to moderate dementia inParkinson’s diseaseCAPSULES , ORAL SOLUTIONAdults. Initial: 1.5 mg b.i.d. Dosageincreased by 3 mg daily every 4 wk, asneeded. Maximum: 12 mg daily.TRANSDERMALAdults. Initial: 4.6 mg/24 hr. After 4 wk,increased to 9.5 mg/24 hr. To convert patient from oral to transdermalrivastigmine therapyTRANSDERMALAdults. If total oral dosage was less than

6 mg daily, use 4.6 mg/24 hr, with firsttransdermal patch applied the day after thelast oral dose. If total oral dosage was 6 to12 mg daily, use 9.5 mg/24 hr, with firsttransdermal patch applied the day after thelast oral dose.DOSAGE ADJUSTMENT If patient developsadverse effects (such as nausea or vomiting)during oral therapy, treatment should bestopped for several doses, as prescribed,restarted at lowest dose, and increased by3 mg daily every 2 wk, as needed. If patientdevelops adverse effects during transdermaltherapy, treatment should be discontinnuedfor several days and restarted at same ornext lower dose level.Mechanism of ActionMay slow the decline of cognitive functionin patients with Alzheimer’s disease byincreasing acetylcholine concentration atcholinergic transmission sites. This actionprolongs and exaggerates the effects ofacetylcholine that are otherwise blocked bytoxic levels of anticholinergics. The cognitivedecline in these patients is partiallyrelated to cholinergic deficits along neuronalpathways projecting from the basalforebrain to the cerebral cortex and hippocampusthat are involved in memory,attention, learning, and cognition.ContraindicationsHypersensitivity to carbamate derivatives,rivastigmine, or their componentsInteractionsDRUGSanticholinergics: Possibly decreased effectivenessof anticholinergicsbethanechol, succinylcholine: Possibly synergisticeffectsAdverse ReactionsCNS: Aggression, anxiety, asthenia, confusion,depression, dizziness, extrapyramidalmovements, fatigue, fever, hallucinations,headache, insomnia, malaise, parkinsonism,seizures, somnolence, tremorCV: HypertensionEENT: RhinitisGI: Abdominal pain, anorexia, constipation,diarrhea, flatulence, indigestion, nausea,vomitingGU: UTISKIN: Increased sweating, reaction at patchrivastigmine tartrate 915application site (pruritus, redness, swelling)Other: Dehydration, flulike symptoms,weight lossNursing ConsiderationsWARNING Be aware that rivastigmineshould be started at lowest recommendeddosage and adjusted to effective maintenancedosage because initial therapy athigh dosage can cause serious adverse GIreactions, including anorexia, nausea, andweight loss. Also, higher than recommendedstarting dosage may cause severe vomitingand possibly esophageal rupture. Iftreatment is interrupted for longer thanseveral days, expect to restart at lowest recommendeddosage.• Be aware that drug shouldn't be stoppedabruptly because doing so may increasebehavioral disturbances and precipitate afurther decline in cognitive function.• Monitor respiratory status of patients withpulmonary disease, including asthma,chronic bronchitis, and emphysema,because rivastigmine has a weak affinityfor peripheral cholinesterase, which mayincrease bronchoconstriction andbronchial secretions.• Monitor patient for adequate urine outputbecause cholinomimetics, such as rivastigmine,may induce or exacerbate urinarytract or bladder obstruction.• Monitor patients with Parkinson’s diseasefor exaggerated parkinsonian symptoms,which may result from drug’s increasedcholinergic effects on CNS.PATIENT TEACHING• Explain to patient and family that rivastigminecan’t cure Alzheimer’s or Parkinson’sdisease but may slow the progressive deteriorationof memory and improvepatient’s ability to perform activities ofdaily living.• Teach patient and family how to administeroral solution, if prescribed, emphasizingneed to use the oral dosing syringeprovided. Explain that dose may be swalloweddirectly from the syringe or mixedinto a small glass of water, cold fruit juice,or soda; stirred; and then drunk.• Explain that oral drug should be takenwith food to reduce adverse GI effects.• For transdermal patch, instruct patient orcaregiver to apply it to clean, dry, hairless,QRS

916rizatriptan benzoateintact skin in a location, such as the back,that won’t be rubbed by tight clothing andwon’t be affected by lotion, cream, orpowder. Tell patient to remove the oldpatch before applying a new one and touse a new application site daily. Cautionagainst using the same site within 14 days.• To apply transdermal patch, tell patient topress patch firmly against skin until theedges stick well. Reassure patient thatpatch may be worn while swimming orbathing.• Instruct a family member to supervisepatient’s use of rivastigmine.• Urge caregiver to contact prescriber and towithhold drug if patient stops taking it formore than several days.rizatriptan benzoateMaxalt, Maxalt-MLTClass and CategoryChemical class: Selective 5-hydroxytryptamineTherapeutic class: AntimigrainePregnancy category: CIndications and Dosages To relieve acute migraine headacheDISINTEGRATING TABLETS, TABLETSAdults. 5 to 10 mg when migraineheadache starts; repeated every 2 hr, p.r.n.Maximum: 30 mg daily.DOSAGE ADJUSTMENT For patients takingpropranolol, initial dosage reduced to 5 mg,then repeated every 2 hr, p.r.n., up to maximumof 15 mg daily.Mechanism of ActionBinds to selective 5-hydroxytryptaminereceptor sites on cerebral blood vessels,causing vessels to constrict. This maydecrease the characteristic pulsing sensationand thus relieve the pain of migraineheadaches. Rizatriptan also may relieve painby inhibiting the release of proinflammatoryneuropeptides and reducing transmissionof trigeminal nerve impulses from sensorynerve endings during a migraineattack.ContraindicationsBasilar or hemiplegic migraine, hypersensitivityto rizatriptan or its components,ischemic coronary artery disease, uncontrolledhypertension, use within 14 days ofMAO inhibitor therapy, use within 24 hoursof other serotonin-receptor agonists orergotamine-containing or ergot-type drugsInteractionsDRUGSergot-containing drugs: Prolonged vasospasticreactionsMAO inhibitors, propranolol: Increasedblood rizatriptan levelselective serotonin-reuptake inhibitors:Increased risk of weakness, hyperreflexia,and lack of coordinationserotonin-receptor agonists: Additive vasospasticeffectsAdverse ReactionsCNS: Altered temperature sensation, anxiety,asthenia, ataxia, chills, confusion,depression, disorientation, dizziness, dreamdisturbances, drowsiness, euphoria, fatigue,hangover, headache, hypoesthesia, insomnia,mental impairment, nervousness,paresthesia, somnolence, tremor, vertigoCV: Arrhythmias, such as bradycardia andtachycardia; chest pain; hot flashes; hypertension;palpitationsEENT: Blurred vision; burning eyes; dryeyes, mouth, and throat; earache; eye painor irritation; lacrimation; nasal congestionand irritation; pharyngeal edema; pharyngitis;tinnitus; tongue swellingGI: Abdominal distention, constipation,diarrhea, dysphagia, flatulence, heartburn,indigestion, nausea, thirst, vomitingGU: Menstrual irregularities, polyuria, urinaryfrequencyMS: Arthralgia; dysarthria; muscle spasms,stiffness, or weakness; myalgiaRESP: Dyspnea, upper respiratory tractinfection, wheezingSKIN: Diaphoresis, flushing, pruritus, rash,urticariaOther: Angioedema, dehydration, facialedemaNursing Considerations• Use rizatriptan cautiously in patients withrenal or hepatic dysfunction because ofimpaired drug metabolism or excretion.Monitor patient’s BUN and serum creatininelevels and liver function test results,as appropriate.• Also use cautiously in patients with

peripheral vascular disease because drugmay cause vasospastic reactions, leading tovascular and colonic ischemia withabdominal pain and bloody diarrhea.Assess peripheral circulation and bowelsounds frequently during therapy.• Assess patient’s cardiovascular status andinstitute continuous ECG monitoring, asordered, immediately after giving rizatriptanin patients with cardiovascular riskfactors because of possible asymptomaticcardiac ischemia.• Monitor blood pressure regularly inpatients with hypertension because rizatriptanmay increase blood pressure.PATIENT TEACHING• Instruct patient taking rizatriptan disintegratingtablets to remove tablet from blisterpack with dry hands just before taking,to place tablet on tongue, and to allow itto dissolve and be swallowed with saliva.• Advise phenylketonuric patient not to usedisintegrating tablet form because it containsphenylalanine.• Instruct patient to seek emergency careimmediately if cardiac symptoms, such aschest pain, occur after administration.• Caution patient about possible adverseCNS reactions, and advise her to avoidpotentially hazardous activities untildrug’s CNS effects are known.romiplostimNplateClass and CategoryChemical class: Fc-peptide fusion proteinTherapeutic class: Platelet productionenhancerPregnancy category: CIndications and Dosages To treat thrombocytopenia in patientswith chronic immune (idiopathic)thrombocytopenic purpura (ITP) whohave had an insufficient response tocorticosteroids, immunoglobulins, orsplenectomySUBCUTANEOUS INJECTIONAdults. Initial: 1 mcg/kg based on actualbody weight, followed by weekly dosesadjusted in increments of 1 mcg/kg to keepplatelet count at or above 50 10 9 /L.romiplostim 917Maximum: 10 mcg/kg weekly.DOSAGE ADJUSTMENT If platelet count isless than 50 10 9 /L, dosage increased by1 mcg/kg. If platelet count exceeds 200 10 9 /L for 2 consecutive weeks, dosagereduced by 1 mcg/kg. If platelet countexceeds 400 10 9 /L, dose held until counthas fallen to less than 200 10 9 /L and thenresumed at a weekly dosage reduced by1 mcg/kg.Route Onset Peak DurationSubQ Unknown 7–50 hr UnknownMechanism of ActionIncreases platelet production by bindingand activating the thrombopoietin receptorin the same manner as endogenous thrombopoietinto prevent bleeding.ContraindicationsHypersensitivity to romiplostim or its componentsAdverse ReactionsCNS: Dizziness, headache, insomnia, paresthesiaCV: ThrombosisGI: Abdominal pain, dyspepsiaHEME: Bone marrow reticulin depositionMS: Arthralgia, extremity or shoulder pain,myalgiaOther: Antibody formation to romiplostimNursing Considerations• Be aware that romiplostim can be administeredonly by prescribers or healthcareproviders under their direction who areenrolled in the NEXUS program.• Romiplostim therapy is used to reduce therisk of bleeding and not as a therapy tonormalize platelet counts.• Be aware that romiplostim may increasepatient’s risk for hematologic malignancies.• Obtain a CBC, including platelet countand peripheral blood smears, before startingtherapy, weekly until dosage is stable,monthly throughout therapy, and for atleast 2 weeks after stopping therapy, asordered. Detection of peripheral blood cellabnormalities may require a bone marrowexamination to identify specific abnormality.• Expect dosage to be adjusted based onQRS

918ropinirole hydrochlorideweekly platelet count response because, ifdosage is too high, thrombotic and thromboemboliccomplications may occur..• Reconstitute drug using only preservativefreesterile water for injection, adding0.72 ml to 250-mcg vial or 1.2 ml to 500-mcg vial. Gently swirl and invert vial todissolve powder, which normally occurswithin 2 minutes. Don’t shake or agitatevigorously. Protect reconstituted drugfrom light.• To determine amount of reconstituteddrug to administer, first identify patient’stotal dose in micrograms based on actualbody weight. For example, a patient startingtherapy at 1 mcg/kg who weighs 75 kgwill receive 75 mcg. Then, divide orderedmicrogram dose by concentration ofreconstituted drug solution (500 mcg/ml).For example, a 75-mcg dose divided by500 mcg/ml will result in 0.15 ml of drugbeing administered. Discard any unusedportion, and don’t administer more thanone dose from a vial because reconstituteddrug can only be stored 24 hours, anddrug is given only weekly.• Administer drug using a syringe that contains0.01-ml graduations to ensure accuratedosage because volume to be administeredmay be quite small.• Be aware that drug may be given withother ITP therapies, such as corticosteroids,danazol, azathioprine, I.V.immunoglobulin and anti-D immunoglobulin.• Expect therapy to be discontinued after4 weeks at maximum dosage if plateletcount doesn’t increase enough to preventserious bleeding or if patient develops newor worsening abnormalities or cytopenias.• Monitor patient closely for bleeding afterdrug has been discontinued becausethromboyctopenia may occur at greaterseverity than when therapy was started.PATIENT TEACHING• Inform patient about increased risk ofhematologic malignancies before startingromiplostim therapy.• Stress importance of weekly blood tests toensure accurate dosing and early detectionof serious blood adverse reactions.• Urge patient to take precautions to preventbleeding and to avoid aspirin,NSAIDs, and other drugs that mayincrease bleeding risk.• Instruct patient to seek emergency careimmediately if unusual signs and symptomsoccur that suggest a blood clot, suchas shortness of breath, anxiety, change inskin color or mental status, or developmentof abnormal sensory or motor function.• When therapy ends, warn patient to reportany serious or prolonged bleedingepisodes because additional therapy maybe needed to control bleeding.ropinirolehydrochlorideRequipClass and CategoryChemical class: Non-ergot alkaloiddopamine agonistTherapeutic class: AntidyskineticPregnancy category: CIndications and Dosages To treat signs and symptoms ofParkinson’s diseaseTABLETSAdults. Initial: 0.25 mg t.i.d. Dosage titratedupward every wk according to the followingschedule: 0.25 mg t.i.d. in wk 1;0.5 mg t.i.d. in wk 2; 0.75 mg t.i.d. in wk 3;1 mg t.i.d. in wk 4. After wk 4, dosageincreased by 1.5 mg daily every wk up to9 mg daily, then by 3 mg/day up to 24 mgdaily. Maximum: 24 mg/day.E.R. TABLETSAdults. Initial: 2 mg once daily for 1 to2 wk, increased, as needed, in increments of2 mg/day at 1 wk or longer intervals.Maximum: 24 mg/day. To treat moderate to severe primaryrestless legs syndromeTABLETSAdults. Initial: 0.25 mg 1 to 3 hr beforebedtime. Dosage increased after 2 days to0.5 mg and then to 1 mg at the end of thefirst wk. If needed, dosage further increasedin 0.5-mg increments every wk. Maximum:4 mg daily.Mechanism of ActionDirectly stimulates postsynaptic dopamine

type 2 (D 2 ) receptors within the brain andacts as an agonist at peripheral D 2 receptors.These actions inhibit the firing of striatalcholinergic neurons, thus helping tocontrol alterations in voluntary musclemovement (such as tremors and rigidity)associated with Parkinson’s disease.ContraindicationsHypersensitivity to ropinirole or its componentsInteractionsDRUGScarbamazepine, cimetidine, ciprofloxacin,clarithromycin, diltiazem, enoxacin, erythromycin,fluvoxamine, mexiletine, norfloxacin,omeprazole, phenobarbital, phenytoin,rifampin, ritonavir, troleandomycin: Altereddrug clearance and increased blood level ofropinirolechlorprothixene, domperidone, droperidol,haloperidol, metoclopramide, phenothiazines,thiothixene: Possibly decreased effectivenessof ropiniroleCNS depressants: Additive effectsethinyl estradiol: Possibly reduced clearanceof ropiniroleACTIVITIESalcohol use: Additive effectsAdverse ReactionsCNS: Asthenia, confusion, dizziness, fallingasleep during activities of daily living,fatigue, hallucinations, headache, hypoesthesia,malaise, neuralgia, paresthesia,rigors, somnolence, syncope, transientischemic attack, vertigoCV: Acute coronary syndrome, angina,bradycardia, cardiac failure, chest pain,hypertension, MI, orthostatic hypotension,palpitations, peripheral edema, sick sinussyndrome, tachycardiaEENT: Abnormal vision, dry mouth, nasalcongestion, nasopharyngitis, rhinitis,toothacheGI: Abdominal pain, constipation, diarrhea,dyspepsia, gastric hemorrhage, gastroenteritis,indigestion, intestinal obstruction,ischemic hepatitis, nausea, pancreatitis,vomitingGU: Elevated BUN level, erectile dysfunction,UTIHEME: AnemiaMS: Arthralgia; arthritis; exacerbation ofropinirole hydrochloride 919restless leg syndrome in the early-morninghours; limb pain; muscle cramps, spasms,or stiffness; myalgia; neck pain; osteoarthritis;tendinitisRESP: Asthma, bronchitis, cough, upperrespiratory tract infectionSKIN: Diaphoresis, flushing, hot flashes,night sweats, rashOther: Influenza, intense urges to performcertain activities (such as gambling or sex),viral infection, weight lossNursing ConsiderationsWARNING Expect to reassess patient forexcessive sedation periodically duringtherapy. Excessive, acute drowsiness mayarise as late as 1 year after starting therapy.• When ropinirole is given as adjunct to levodopa,expect concurrent dosage of levodopato be gradually decreased as tolerated.• Expect to stop ropinirole gradually over7 days, as follows: over first 4 days, reducefrom t.i.d to b.i.d.; during last 3 days,reduce to once daily, followed by completewithdrawal of drug.WARNING Watch for altered mental statusduring drug withdrawal. Rapid dosereduction may lead to a symptom complexresembling neuroleptic malignant syndromethat includes fever, muscle rigidity,altered level of consciousness, and autonomicinstability.• Watch for orthostatic hypotension, especiallyin patient with early Parkinson’s disease.Orthostatic hypotension can occurmore than 4 weeks after start of therapy orafter a dosage reduction because ropinirolemay impair systemic regulation ofblood pressure.• Monitor patient for hallucinations, especiallyif patient has Parkinson’s disease, iselderly, or takes levodopa.• Monitor patient for worsening of preexistingdyskinesia; ropinirole may potentiatedopaminergic adverse effects of levodopa.• Avoid giving CNS depressants, sleep aids,and other CNS-interacting drugs duringropinirole therapy because they increasethe risk of somnolence.• Assess patient for skin changes regularlybecause risk of melanoma is higher inpatients with Parkinson’s disease. It isn’tclear whether this results from disease ordrugs used to treat it.QRS

920rosiglitazone maleatePATIENT TEACHING• Inform patient with Parkinson’s diseasethat ropinirole helps to improve musclecontrol and movement but doesn’t cureParkinson’s disease.• Encourage patient to take ropinirole withfood to decrease risk of adverse GI effects.• Caution patient to avoid hazardous activitiesuntil CNS effects of drug—includingsedation—are known.• If patient falls asleep during normal activities,advise her to notify prescriber.• Urge patient to avoid consuming alcoholand other sedating drugs (such as sleepaids) during therapy because they mayincrease drug’s CNS depressant effects.• If patient has restless legs syndrome,explain that symptoms might appear inearly morning during ropinirole therapyand could be worse or spread to otherlimbs. Urge patient to notify prescriber ifthis occurs.• Instruct patient to change positions slowlyto minimize effect on blood pressure.• Urge patient to have regular skin examinationsby a dermatologist or other qualifiedhealth professional.• Advise patient to notify prescriber aboutintense urges (as for gambling or sex)because dosage may need to be reduced ordrug discontinued.rosiglitazonemaleateAvandiaClass and CategoryChemical class: ThiazolidinedioneTherapeutic class: Antidiabetic drugPregnancy category: CIndications and Dosages To achieve glucose control in type 2 diabetesmellitus as monotherapy or incombination with metforminTABLETSAdults. Initial: 4 mg once daily or 2 mgb.i.d., increased to 8 mg once daily or 4 mgb.i.d. if glucose control is inadequate after12 wk. Maximum: 8 mg daily. To achieve glucose control in type 2 diabetesmellitus in combination withinsulin therapyTABLETSAdults. 4 mg daily with no change ininsulin dosage. Insulin dosage decreased by10% to 25% if hypoglycemia occurs or fastingplasma concentrations decrease to lessthan 100 mg/dl with combination therapy.Mechanism of ActionIncreases tissue sensitivity to insulin. Thisperoxisome proliferator-activated receptoragonist regulates the transcription ofinsulin-responsive genes found in key targettissues, such as adipose tissue, skeletal muscle,and the liver. Enhanced tissue sensi-tivityto insulin lowers the blood glucose level.ContraindicationsHypersensitivity to rosiglitazone or its components,New York Heart Association(NYHA) class III or IV heart failureInteractionsDRUGSCYP2C8 inducers, such as rifampin: Possiblydecreased effects of rosiglitazoneCYP2C8 inhibitors, such as gemfibrozil:Possibly increased effects of rosiglitazoneAdverse ReactionsCNS: Fatigue, headacheCV: Angina, congestive heart failure,edema, hypertension, myocardial ischemiaor infarctionEENT: Blurred vision, decreased visualacuity, macular edema, nasopharyngitis,sinusitisENDO: Hyperglycemia, hypoglycemiaGI: Diarrhea, elevated liver enzymes, hepatotoxicityHEME: AnemiaMS: Arthralgia, back pain, fracture(women)RESP: Dyspnea, upper respiratory tractinfectionSKIN: Pruritus, rash, Stevens-Johnson syndrome,urticariaOther: Anaphylaxis, angioedema, weightgainNursing Considerations• Give rosiglitazone cautiously in patientswith edema, heart failure, or hepaticimpairment because of potential adversereactions.• Be aware that drug isn’t recommended for

osuvastatin calcium 921patients with symptomatic heart failure.• Evaluate patient’s liver function beforestarting drug and periodically throughouttherapy, as ordered. Notify prescriberabout abnormalities, such as nausea, vomiting,abdominal pain, fatigue, anorexia,and dark urine. Drug may need to bestopped.WARNING Monitor patient for evidence ofcongestive heart failure—such as shortnessof breath, rapid weight gain, or edema—because rosiglitazone can cause fluidretention that may lead to or worsen heartfailure. Notify prescriber immediately ifthe patient’s cardiac status deteriorates,and expect to stop the drug, as ordered.• Monitor fasting glucose and glycosylatedhemoglobin A 1c levels periodically, asordered, to evaluate rosiglitazone effectiveness.• Be aware that drug is effective only in thepresence of endogenous insulin.PATIENT TEACHING• Stress the need to follow an exercise programand a diet control program duringrosiglitazone therapy.• Advise patient to notify prescriber immediatelyif she has shortness of breath, fluidretention, or sudden weight gain becausedrug may need to be discontinued.• Instruct patient to have liver functiontests, as prescribed, about every 2 monthsfor first year and then annually.• Inform premenopausal, anovulatorypatient that drug may induce ovulation,increasing risk of pregnancy.• Urge women to take precautions againstfalling; drug increases risk of fractures.rosuvastatincalciumCrestorClass and CategoryChemical class: HMG-CoA reductaseinhibitorTherapeutic class: AntihyperlipidemicPregnancy category: XIndications and Dosages To treat hyperlipidemia, mixed dyslipidemia,hypertriglyceridemia, and primarydysbetalipoproteinemia (Type IIIhyperlipoproteinemia); to slow the progressionof atherosclerosisTABLETSAdults with LDL-C level of 190 mg/dl orbelow. Initial: 10 mg daily, increased every2 to 4 wk, as needed. Maximum: 40 mgdaily.Adults with LDL-C level greater than190 mg/dl. Initial: 20 mg daily, increasedevery 2 to 4 wk, as needed. Maximum:40 mg daily. To treat homozygous familial hypercholesterolemiaTABLETSAdults. Initial: 20 mg daily, increased every2 to 4 wk, as needed. Maximum: 40 mgdaily. To treat heterozygous familial hypercholesterolemiaTABLETSChildren age 10 and over and adolescentsat least 1 year post-menarche. 5 to 20 mgdaily, increased q 4 wk, as needed.Maximum: 20 mg daily.DOSAGE ADJUSTMENT For patients takingcyclosporine, dosage shouldn’t exceed 5 mgdaily. For Asian patients, initial dosageshould be limited to 5 mg daily. Forpatients taking gemfibrozil or combinedlopinavir and ritonavir, 10 mg daily. Forpatients with severe renal impairment (creatinineclearance greater than 30 ml/min/1.73 m 2 ) who aren’t having hemodialysis,dosage should start at 5 mg daily but notexceed 10 mg daily. For patients takingniacin or fenofbrate, dosage reductionshould be considered.Route Onset Peak DurationP.O. Unknown 3–5 hr UnknownMechanism of ActionCholesterol and triglycerides circulate in theblood as part of lipoprotein complexes.Rosuvastatin inhibits the enzyme 3-hydroxy-3-methylglutaryl-coenzyme A(HMG-CoA) reductase. This inhibitionreduces lipid levels by increasing the numberof hepatic low-density-lipoprotein(LDL) receptors on the cell surface toincrease uptake and catabolism of LDL. Italso inhibits hepatic synthesis of very-lowdensitylipoprotein (VLDL), which decreas-QRS

922Indications and Dosages As adjunct treatment of seizures associatedwith Lennox-Gastaut syndromeTABLETSAdults. Initial: 200 to 400 mg b.i.d.,increased in daily increments of 200 to400 mg b.i.d. every 2 days until reaching1,600 mg b.i.d. Maximum: 1,600 mg b.i.d.Children age 4 and over. Initial: 5 mg/kgb.i.d., increased in daily increments of5 mg/kg b.i.d. every 2 days until reaching22.5 mg/kg b.i.d. or 1600 mg b.i.d.,whichever is less.DOSAGE ADJUSTMENT For patients undergoingdialysis, dosage may need to beincreased. For patients also receiving valrufinamidees the total number of VLDL and LDL particles.ContraindicationsActive liver disease, breast-feeding, hypersensitivityto rosuvastatin or its components,pregnancy, unexplained persistentelevations of serum transaminase levelsInteractionsDRUGSantacids: Decreased blood rosuvastatin levelif given within 2 hours of rosuvastatincyclosporine, gemfibrozil, lopinavir/ritonavir,niacin, other lipid-lowering drugs: Increasedrosuvastatin level and risk of myopathyoral contraceptives: Increased blood ethinylestradiol and norgestrel levelswarfarin: Increased INRAdverse ReactionsCNS: Asthenia, depression, dizziness, headache,hypertonia, insomnia, memory loss,paresthesiaCV: Chest pain, hypertension, peripheraledemaEENT: Pharyngitis, rhinitis, sinusitisENDO: Thyroid function abnormalitiesGI: Abdominal pain, constipation, diarrhea,elevated liver function test results, gastroenteritis,hepatic failure, hepatitis, jaundice,nausea, pancreatitisGU: Acute renal failure, proteinuria, UTIMS: Arthralgia, arthritis, back pain, myalgia,myopathy, rhabdomyolysisRESP: Bronchitis, increased coughSKIN: Rash, urticariaOther: Angioedema, flulike symptoms, generalizedpain, infectionNursing Considerations• Use rosuvastatin cautiously in patientswho consume large quantities of alcoholor have a history of liver disease becausedrug is contraindicated in patients withactive liver disease or unexplained persistentelevations of transaminase levels.• Also use cautiously in patients with riskfactors for myopathy, such as renal impairment,advanced age, and hypothyroidism.• Obtain baseline liver function test resultsand expect to monitor them every3 months for abnormal elevations. Notifyprescriber if elevations occur. If ALT orAST levels increase to more than threetimes the normal range, expect dosage tobe reduced or drug discontinued.• Monitor serum lipoprotein level, asordered, to evaluate response to therapy.• Expect rosuvastatin to be temporarilywithheld if patient develops any conditionthat may be related to myopathy or thatpredisposes her to renal failure, such assepsis, hypotension, major surgery, trauma,uncontrolled seizures, or severe metabolic,endocrine, or electrolyte disorders.• Notify prescriber if proteinuria or hematuriaappears on patient’s routine urinalysisbecause rosuvastatin dosage may needto be reduced.PATIENT TEACHING• Encourage patient to follow a low-fat, lowcholesteroldiet.• Tell patient to wait at least 2 hours aftertaking rosuvastatin before taking antacids.• Instruct patient to notify prescriber immediatelyabout muscle pain, tenderness, orweakness, especially if accompanied bymalaise or fever.• Tell woman of childbearing age about theneed to use reliable contraceptive methodwhile taking drug. Instruct her to notifyprescriber at once if she suspects she maybe pregnant.rufinamideBanzelClass and CategoryChemical class: Triazole derivativeTherapeutic class: AnticonvulsantPregnancy category: C

proate, initial dosage reduced to less than400 mg daily.Route Onset Peak DurationP.O. Unknown 4–6 hr UnknownMechanism of ActionUnknown, although rufinamide is knownto slow sodium channel recovery from inactivationafter a prolonged prepulse and tolimit repetitive firing of sodium-dependentaction potentials in neurons in the brain.These actions may help limit seizure activity.ContraindicationsFamilial short-QT syndrome, hypersensitivityto rufinamide or its componentsInteractionsDRUGScontraceptives containing ethinyl estradioland norethindrone: Decreased effectivenessof the oral contraceptivephenytoin: Increased plasma phenytoin leveland risk of adverse reactionsvalproate: Increased plasma rufinamidelevel and risk of adverse reactionsACTIVITIESalcohol use: Increased CNS effectsAdverse ReactionsCNS: Aggression, anxiety, ataxia, attentiondisturbance, dizziness, fatigue, headache,hyperactivity, seizures, somnolence, statusepilepticus, suicidal ideation, tremor, vertigoCV: First-degree AV block, right bundlebranch blockEENT: SinusitisENDO: Blurred vision, diplopia,nasopharyngitis, nystagmusGI: Abdominal pain, anorexia, constipation,dyspepsia, nausea, vomitingGU: Dysuria, enuresis, hematuria, incontinence,nephrolithiasis, pollakiuria, polyuriaHEME: Anemia, leukopenia, lymphadenopathy,neutropenia, thrombocytopeniaMS: Back painRESP: BronchitisSKIN: Pruritus, rashOther: Multi-organ hypersensitivityNursing Considerations• Administer rufinamide with food becauseabsorption is increased.• Monitor patient’s QT interval regularly, asordered, because rufinamide may shortenthe QT interval and possibly predisposepatient to ventricular fibrillation if theinterval falls below 300 msec.WARNING Watch closely for multi-organhypersensitivity, especially if patient developsa rash. Although uncommon, it maycause serious adverse effects, such asurticaria, facial edema, fever, elevatedeosinophils or liver enzymes, hematuria,stupor, lymphadenopathy and severe hepatitis,in addition to rash. Notify prescriberat once if such changes appear, and expectto stop drug and provide supportive care.• Watch closely for suicidal tendencies, especiallywhen therapy starts and dosagechanges and particularly in children andadolescents.• To stop therapy, expect to taper dosage tominimize adverse effects rather than stoppingabruptly.PATIENT TEACHING• Make sure patient receives medicationguide describing drug use and possiblesuicidal tendencies.• Instruct patient to take drug exactly asprescribed and to take each dose withfood. If patient has trouble swallowingtablets, tell him they may be crushed.• Inform woman that rufinamide decreaseseffectiveness of contraceptives containingethinyl estradiol and norethindrone. Tellher to use a different contraceptive duringtherapy and to contact prescriber immediatelyif she thinks she’s pregnant.• Tell patient to report a rash accompaniedby fever or other symptoms immediately.• Warn family or caregiver to watch patientfor suicidal tendencies, especially whentherapy starts or dosage changes, and particularlyif patient is a child or adolescent.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Caution patient not to stop taking drugabruptly. Explain that gradual taperinghelps to avoid withdrawal symptoms.• Explain that alcohol consumption mayintensify drug effects.salmeterolxinafoateSerevent Diskussalmeterol xinafoate 923QRS

924PATIENT TEACHING• Advise patient who is using salmeterol toprevent asthma-induced bronchospasm totake doses 12 hours apart for optimumeffect. Caution against using drug morethan every 12 hours.• Teach patient how to use the diskus byinstructing him to slide the lever onlyonce when preparing dose to avoid wastingdoses. Advise him to exhale immediatelybefore using the diskus and then toplace mouthpiece to his lips and inhalethrough his mouth, not his nose. Then heshould remove mouthpiece from hismouth, hold his breath for at least 10 secsalmeterolxinafoateClass and CategoryChemical class: Sympathomimetic amineTherapeutic class: BronchodilatorPregnancy category: CIndications and Dosages To prevent asthma-induced bronchospasmORAL INHALATION POWDERAdults and children age 4 and over.1 inhalation (50 mcg) every 12 hr. To prevent COPD-induced bronchospasmORAL INHALATION POWDERAdults. 1 inhalation (50 mcg) every 12 hr. To prevent exercise-induced bronchospasmORAL INHALATION POWDERAdults and children age 4 and over.1 inhalation (50 mcg) at least 30 min beforeexercise.Route Onset Peak DurationInhalation 10–20 min 3–4 hr 12 hrMechanism of ActionAttaches to beta 2 receptors on bronchial cellmembranes, stimulating the intracellularenzyme adenylate cyclase to convert adenosinetriphosphate to cAMP. The resultingincrease in intracellular cAMP level relaxesbronchial smooth-muscle cells, stabilizesmast cells, and inhibits histamine release.ContraindicationsHypersensitivity to salmeterol or its componentsInteractionsDRUGSatazanavir, clarithromycin, indinavir, itraconazole,ketoconazole, nefazodone, nelfinavir,ritonavir, saquinavir, telithromycin:Possibly increased risk of adverse cardiovasculareffectsbeta blockers: Mutual inhibition of therapeuticeffectsloop or thiazide diuretics: Increased risk ofhypokalemia and potentially life-threateningarrhythmiasMAO inhibitors, tricyclic antidepressants:Potentiated adverse vascular effects, such ashypertensive crisisAdverse ReactionsCNS: Dizziness, fever, headache, nervousness,paresthesia, tremorCV: Palpitations, tachycardiaEENT: Dry mouth, nose, and throat; sinusproblemsGI: NauseaMS: ArthralgiaRESP: Cough, paradoxical bronchospasmSKIN: Contact dermatitis, eczema, rash,urticariaOther: Angioedema, generalized aches andpainsNursing Considerations• Be aware that salmeterol shouldn’t be usedto relieve bronchospasm quickly becauseof its prolonged onset of action and thatpatients already taking drug twice dailyshouldn’t take additional doses for exercise-inducedbronchospasm.WARNING Be aware that a recent study suggeststhat asthma-related deaths mayincrease in asthmatics receiving salmeterol.Monitor this patient populationclosely throughout salmeterol therapy, andnotify prescriber immediately of anychanges in patient’s respiratory status.• Watch for arrhythmias and changes inblood pressure after use in patients withcardiovascular disorders, includingischemic cardiac disease, hypertension,and arrhythmias, because of drug’s betaadrenergiceffects.• Be aware that Serevent Diskus delivers fulldose of salmeterol in only one inhalation.WARNING Stop salmeterol immediately andnotify prescriber if patient develops paradoxicalbronchospasm. Risk is greatestwith first use of a new canister or vial usedas an inhalant.

onds, and exhale slowly.• Advise patient to rinse mouth with waterafter each dose to minimize dry mouth.• Advise patient to discard diskus 6 weeksafter removing it from overwrap or whendose indicator reads zero.• Instruct patient to notify prescriber if heneeds four or more oral inhalations ofrapid-acting inhaled bronchodilator a dayfor 2 or more consecutive days, or if heuses more than one canister of rapid-actingbronchodilator in an 8-week period.• Caution patient not to use other drugs totreat his underlying respiratory conditionwithout consulting prescriber and to let allprescribers know that he takes salmeterol.salsalate(salicylsalicylic acid)Amigesic, Anaflex 750, Argesic-SA,Disalcid, Marthritic, Mono-Gesic,Salflex, SalsitabClass and CategoryChemical class: Salicylic acid esterTherapeutic class: Analgesic, antiinflammatoryPregnancy category: CIndications and Dosages To relieve symptoms of rheumatoid arthritisand related rheumatic disordersCAPSULESAdults and adolescents. Initial: 1 g t.i.d.;dosage then titrated, as needed.TABLETSAdults and adolescents. Initial: 0.5 to 1 gb.i.d. or t.i.d.; dosage then titrated, as needed.Route Onset Peak DurationP.O. Unknown 2–3 wk UnknownMechanism of ActionExerts peripherally induced analgesic andanti-inflammatory effects by blocking painimpulses and inhibiting prostaglandin synthesis.ContraindicationsBleeding disorders; hypersensitivity toNSAIDs, salicylates, or their componentssalsalate 925InteractionsDRUGSacetaminophen: Increased risk of renal dysfunctionwith prolonged use of both drugsanticoagulants, thrombolytics: Increased riskand severity of GI bleedingantiemetics: Masked symptoms of salicylateinducedototoxicitybismuth subsalicylate: Increased risk of salicylatetoxicity with large doses of salsalatecefamandole, cefoperazone, cefotetan, plateletaggregation inhibitors, plicamycin, valproicacid: Possibly hypoprothrombinemiacorticosteroids: Possibly decreased blood salsalatelevel; additive therapeutic effectswhen both drugs are used to treat arthritisfurosemide: Increased risk of ototoxicity andsalicylate toxicityhydantoins: Possibly decreased hydantoinmetabolism, leading to toxicityinsulin, oral antidiabetic drugs: Potentiatedhypoglycemic effectlaxatives (cellulose-containing): Possiblyreduced salsalate effectiveness due toimpaired absorptionmethotrexate: Increased risk of methotrexatetoxicityNSAIDs: Increased risk of adverse GI effectsototoxic drugs, vancomycin: Increased risk ofototoxicityprobenecid, sulfinpyrazone: Decreased uricosuriceffectstopical salicylic acid, other salicylates:Increased risk of salicylate toxicity if significantquantities are absorbedurinary acidifiers (ammonium chloride,ascorbic acid, potassium or sodium phosphates):Decreased salicylate excretion, possiblyleading to salicylate toxicityurinary alkalizers (antacids [long-term highdoseuse], carbonic anhydrase inhibitors, citrates,sodium bicarbonate): Increased salicylateexcretion, leading to reduced effectivenessand shortened half-life; increased riskof salicylate toxicity with carbonic anhydraseinhibitor–induced metabolic acidosisvitamin K: Increased vitamin K requirementsACTIVITIESalcohol use: Increased risk of GI bleedingAdverse ReactionsCNS: CNS depression, confusion, dizziness,drowsiness, fever, headache, lassitudeQRS

926sapropterin dihydrochlorideEENT: Hearing loss, tinnitus, visionchangesGI: Anorexia, diarrhea, epigastric discomfort,GI bleeding, heartburn, hepatotoxicity,indigestion, nausea, thirst, vomitingHEME: Hemolytic anemia, leukopenia,prolonged bleeding time, thrombocytopeniaSKIN: Diaphoresis, purpura, rash, urticariaOther: Angioedema, Reye’s syndromeNursing Considerations• Avoid using salsalate in patients withhypoprothrombinemia or vitamin K deficiencybecause drug’s hypoprothrombinemiceffect may precipitate bleeding.• Monitor hepatic and renal function, asappropriate, during long-term therapy.• Assess for signs and symptoms of GIbleeding, such as abdominal pain or black,tarry stools, especially in patient with pepticulcer disease.• Assess for symptoms of ototoxicity, suchas ringing or roaring in ears.PATIENT TEACHING• Instruct patient to take salsalate with foodor a full glass of water and to remainupright for 1 hour after administration toprevent drug from lodging in esophagusand causing irritation.• Inform patient that therapeutic responsemay not occur for 2 to 3 weeks.• Urge patient to notify prescriber immediatelyof abdominal pain or black, tarrystools; these symptoms may indicate GIbleeding or drug toxicity.sapropterindihydrochlorideKuvanClass and CategoryChemical class: Synthetic tetrahydrobiopterinsaltTherapeutic class: Phenylalanine reducerPregnancy category: CIndications and Dosages To reduce blood phenylalanine level inpatients with hyperphenylalaninemiafrom tetrahydrobiopterin-responsivephenylketonuria, with phenylalaninerestricteddietTABLETSAdults and children age 4 and over. Initial:10 mg/kg daily with dosage increased ordecreased after 1 wk based on response andthen periodically adjusted, as needed.Expect to discontinue drug if levels fail toincrease after 1 mo of therapy at 20mg/kg/day. Maintenance: 5 to 20 mg/kgdaily. Maximum: 20 mg/kg daily.Mechanism of ActionAs a synthetic form of tetrahydrobiopterin,the cofactor of the enzyme phenylalaninehydroxylase (PAH), sapropterin hydroxylatesphenylalanine to form tyrosine. Thisimproves the oxidative metabolism ofphenylalanine, which decreases bloodphenylalanine.ContraindicationsHypersensitivity to sapropterin or its componentsInteractionsDRUGSfolate metabolism inhibitors, such asmethotrexate: Possibly decreased effectivenessof sapropterinlevodopa: Possibly increased risk of irritability,over stimulation or seizuressildenafil, tadalafil, vardenafil: Possiblyadditive vasorelaxation effect leading tohypotensionAdverse ReactionsCNS: Agitation, dizziness, fever, headache,irritability, over stimulation, seizuresCV: MI, peripheral edemaEENT: Nasal congestion, pharyngolaryngealpain, rhinorrheaGI: Abdominal pain, diarrhea, elevated liverenzymes, gastrointestinal bleeding, nausea,vomitingGU: PolyurinaHEME: Bleeding, neutropeniaMS: ArthralgiaRESP: Cough, respiratory failure, upperrespiratory infectionSKIN: RashNursing Considerations• Use cautiously in patients with hepaticimpairment because impaired phenylalaninemetabolism may be linked to hepaticdamage.• Administer drug at same time each day.

• Dissolve tablets in 4 to 8 ounces of wateror apple juice, which may take a few minutes.Stirring or crushing tablets will hastenprocess. Know that tablets may notdissolve completely. Give solution within15 minutes with food. If there are particlesleft in glass after administration, add morewater or apple juice and have patientdrink again to ensure a complete dose.• Monitor patient’s blood phenylalaninelevel regularly, as ordered.• Expect drug to be discontinued if patient’sblood phenylalanine level doesn’t decreaseafter 1 month at maximum dosage.• Continue to restrict dietary phenylalanineintake.PATIENT TEACHING• Tell patient to dissolve tablets in 4 to8 ounces water or apple juice, which maytake a few minutes. Advise him to stir orcrush tablets to hasten process and todrink solution within 15 minutes of dissolving.Explain that tablets may not completelydissolve but that solution is alrightto drink with particles floating in solution.After drinking solution, tell him to addmore water or apple juice if any particlesare clinging to glass and drink again.• Stress to patient or caregiver importanceof continuing dietary restriction of phenylalanineintake.• Stress continued need for periodic bloodtests to determine drug effectiveness.• Tell patient to a missed dose as soon as heremembers, unless it’s almost time for thenext dose. Warn patient not to take morethan 1 dose per day.saxagliptinmonohydrateOnglyzaClass and CategoryChemical class: Dipeptidyl peptidase-4inhibitorTherapeutic class: AntidiabeticPregnancy category: BIndications and Dosages To improve blood glucose control in type2 diabetes mellitus as adjunct to dietand exercisesaxagliptin monohydrate 927TABLETSAdults. 2.5 mg or 5 mg once dailyDOSAGE ADJUSTMENT For patients withmoderate or severe renal impairment (creatinineclearance 50 ml/min/1.73 m 2 or less),patients with end-stage renal disease,patients having hemodialysis, and patientsreceiving strong CYP3A4/5 inhibitors,dosage shouldn’t exceed 2.5 mg once daily.Route Onset Peak DurationP.O. Unknown 2 hr 24 hrMechanism of ActionIncretin hormones, such as glucosedependentinsulintropic polypeptide (GIP)and glucagons-like peptide-1 (GLP-1), arereleased into bloodstream from small intestinein response to meals. Upon arrival atthe pancreas, they stimulate pancreatic betacells to release insulin. GLP-1 also reducesglucagon secretion from pancreatic alphacells, which reduces hepatic glucose production.Incretin hormones become inactivatedwithin minutes of release by theenzyme, dipeptidyl peptidase-4. Saxagliptininhibits this enzyme, thereby slowing inactivationof incretin hormones, which providesmore time for them to increaseinsulin levels and blunt glucagon secretion.More insulin and less hepatic glucose productionwork together to lower blood glucoselevels.ContraindicationsHypersensitivity to saxagliptin or its componentsInteractionsDRUGSaprepitant, diltiazem, erythromycin, fluconazole,fosamprenavir, verapamil: Possiblyincreased plasma saxagliptin levelatazanavir, clarithromycin, indinavir, itraconazole,ketoconazole, nefazodone, nelfinavir,ritonavir, saquinavir, telithromycin:Increased plasma saxagliptin levelsulfonylureas: Increased risk of hypoglycemiaFOODSgrapefruit juice: Possibly increased plasmasaxagliptin levelsAdverse ReactionsCNS: HeadacheEENT: Sinusitis, nasopharyngitisQRS

928scopolamineENDO: HypoglycemiaGI: Abdominal pain, gastroenteritis, vomitingGU: Elevated plasma creatinine level, UTIHEME: LymphopeniaRESP: Upper respiratory tract infectionSKIN: Rash, urticariaOther: Peripheral edema, facial edemaNursing Considerations• Saxagliptin shouldn’t be used to treat type1 diabetes mellitus or diabetic ketoacidosis.It hasn’t been studied with insulin.• Obtain a serum creatinine level, asordered, before starting saxagliptin therapyand then periodically thereafter tomonitor patient’s renal function.• Monitor patient’s blood glucose level andhemoglobin A 1C to assess effectiveness ofsaxagliptin therapy.• Watch for hypoglycemia in patients takingantidiabetics, such as sulfonylureas. Expectdosage of insulin secretagogues (such assulfonylureas) to be reduced to reduce riskof hypoglycemia.PATIENT TEACHING• Stress that saxagliptin isn’t a replacementfor diet and exercise therapy.• Explain importance of self-monitoringglucose levels during saxagliptin therapy.• Teach patient to recognize hypoglycemiaand how to treat it if it should occur. Urgehim to carry glucose with him at all timesin case hypoglycemia occurs.• Instruct patient to notify prescriber iffever, trauma, infection, illness, surgery, orother stress occurs because blood glucosecontrol may be altered requiring temporaryinsulin therapy.scopolaminehydrobromidescopolaminetransdermalsystemTransderm-Scōp, Transderm-V (CAN)Class and CategoryChemical class: Belladonna alkaloid,tertiary amineTherapeutic class: Anesthesia adjunct, anticholinergic,antiemetic, antispasmodic,anti-vertigoPregnancy category: CIndications and Dosages To treat biliary tract disorders, enuresis,nausea and vomiting, and nocturiaI.V., I.M., OR SUBCUTANEOUS INJECTION(HYDROBROMIDE)Adults and adolescents. 300 to 600 mcg(0.3 to 0.6 mg) as a single dose.Children. 6 mcg (0.006 mg)/kg as a singledose. To prevent excessive salivation and respiratorytract secretions during anesthesiaI.M. INJECTION (HYDROBROMIDE)Adults and adolescents. 0.2 to 0.6 mg 30 to60 min before induction of anesthesia.Children ages 8 to 12. 0.3 mg 45 to 60 minbefore induction of anesthesia.Children ages 3 to 8. 0.2 mg 45 to 60 minbefore induction of anesthesia.Children ages 7 months to 3 years. 0.15 mg45 to 60 min before induction of anesthesia.Infants ages 4 to 7 months. 0.1 mg 45 to60 min before induction of anesthesia. As adjunct to anesthesia to induce sleepand calmnessI.V., I.M., OR SUBCUTANEOUS INJECTION(HYDROBROMIDE)Adults and adolescents. 0.6 mg t.i.d. orq.i.d. As adjunct to anesthesia to induce amnesiaI.V., I.M., OR SUBCUTANEOUS INJECTION(HYDROBROMIDE)Adults and adolescents. 0.32 to 0.65 mg. To prevent nausea, vomiting, and vertigoassociated with motion sicknessTRANSDERMAL SYSTEMAdults and adolescents. 1 U.S. transdermalsystem (0.5 mg) applied behind ear for 3-day period, beginning at least 4 hr beforeantiemetic effect is required. Or, 1 Canadiantransdermal system (1 mg) appliedbehind ear for 3-day period, beginning atleast 12 hr before antiemetic effect isrequired.DOSAGE ADJUSTMENT Dosage reductionpossible for elderly patients because of theirincreased sensitivity to scopolamine.

ContraindicationsAngle-closure glaucoma; hemorrhage withhemodynamic instability; hepatic dysfunction;hypersensitivity to barbiturates,scopolamine, other belladonna alkaloids, ortheir components; ileus; intestinal atony;myasthenia gravis; myocardial ischemia;obstructive GI disease, such as pyloricstenosis; obstructive uropathy, as in prostatichyperplasia; renal impairment; tachycardia;toxic megacolon; ulcerative colitisRoute Onset Peak DurationI.V., I.M., 30 min 1–2 hr 4–6 hrSubQ*I.V.† 10 min 50–80 min 2 hrI.M.‡ 15–30 Unknown 4 hrminTrans- 4 hr Unknown 72 hrdermalMechanism of ActionCompetitively inhibits acetylcholine atautonomic postganglionic cholinergicreceptors. Because the most sensitive receptorsare in the salivary, bronchial, and sweatglands, this action reduces secretions fromthese glands. Scopolamine reduces GIsmooth-muscle tone; decreases gastricsecretions and GI motility; reduces bladderdetrusor muscle tone; reduces nasal, oropharyngeal,and bronchial secretions; anddecreases airway resistance by relaxingsmooth muscles in the bronchi and bronchioles.Scopolamine also blocks neural pathwaysin the inner ear to relieve motion sicknessand depresses the cerebral cortex toproduce sedation and hypnotic effects.InteractionsDRUGSadsorbent antidiarrheals, antacids:Decreased absorption and therapeuticeffects of scopolamineanticholinergics (other): Possibly intensifiedanticholinergic effectsantimyasthenics: Possibly reduced intestinalmotilityCNS depressants: Possibly potentiated* For inhibition of saliva.† For amnesia.‡ For antiemesis.scopolamine 929effects of either drug, resulting in additivesedationcyclopropane: Increased risk of ventriculararrhythmias (with I.V. scopolamine)haloperidol: Decreased antipsychotic effectof haloperidolketoconazole: Decreased ketoconazoleabsorptionlorazepam (parenteral): Possibly hallucinations,irrational behavior, and sedationmetoclopramide: Possibly antagonized effectof metoclopramide on GI motilityopioid analgesics: Increased risk of severeconstipation and ileuspotassium chloride: Possibly increased severityof potassium chloride–induced GIlesionsurinary alkalizers (antacids, carbonic anhydraseinhibitors, citrates, sodium bicarbonate):Delayed excretion of scopolamine,possibly leading to increased therapeuticand adverse effectsACTIVITIESalcohol use: Additive CNS effectsAdverse ReactionsCNS: Dizziness, drowsiness, euphoria,insomnia, memory loss, paradoxical stimulationCV: Palpitations, tachycardiaEENT: Blurred vision; dry eyes, mouth,nose, and throat; mydriasisGI: Constipation, dysphagiaGU: Urinary hesitancy, urine retentionSKIN: Decreased sweating, dry skin, flushingOther: Injection site irritation or rednessNursing Considerations• For I.V. injection, dilute scopolamine withsterile water for injection.• Assess for bladder distention and monitorurine output because drug’s antimuscariniceffects can cause urine retention.• Monitor for pain. In presence of pain,drug may act as a stimulant and producedelirium if used without morphine ormeperidine.• Monitor heart rate for transient tachycardia,which may occur with high doses ofdrug. Rate should return to normal within30 minutes.PATIENT TEACHING• Instruct patient to apply scopolaminetransdermal patch on hairless area behindQRS

930InteractionsDRUGSacetaminophen, adrenocorticoids, beta blockers,chloramphenicol, cyclosporine, dacarbazine,digoxin, disopyramide, estrogens, metronidazole,oral anticoagulants, oral contraceptives,quinidine, thyroid hormones, tricyclicantidepressants: Decreased effectiveness ofthese drugsaddictive drugs: Increased risk of addictioncalcium channel blockers: Possibly excessivehypotensioncarbamazepine, succinimide anticonvulsants:Decreased blood levels and increased eliminationof these drugscarbonic anhydrase inhibitors: Increased riskof osteopeniaCNS depressants: Increased CNS depressanteffectscyclophosphamide: Increased risk of leukopenicactivity and reduced half-life of cyclophosphamidedivalproex sodium, valproic acid: IncreasedCNS depression and neurologic toxicitydoxycycline, fenoprofen: Increased eliminationof these drugsgeneral anesthetics (enflurane, halothane,methoxyflurane): Increased risk of hepatotoxicity;increased risk of nephrotoxicity(with methoxyflurane)griseofulvin: Decreased griseofulvin absorptionguanadrel, guanethidine: Possibly increasedorthostatic hypotensionhaloperidol: Possibly altered pattern or frequencyof seizures, decreased bloodhaloperidol levelketamine: Increased risk of hypotension orrespiratory depression (when secobarbital isused as preanesthetic)leucovorin (large doses): Decreased anticonvulsanteffect of secobarbitalloxapine, phenothiazines, thioxanthenes:Possibly lowered seizure thresholdMAO inhibitors: Possibly prolonged CNSdepressant effects of secobarbitalmaprotiline: Increased CNS depressanteffect; possibly lowered seizure thresholdand decreased anticonvulsant effect withhigh doses of maprotilinemethylphenidate: Increased risk of barbitusecobarbitalsodiumear and to wash hands thoroughly withsoap and water before and after applying.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to avoid alcohol while takingoral forms of scopolamine.• If patient complains of dry eyes, suggestlubricating drops.secobarbital sodiumNovosecobarb (CAN), SeconalClass, Category, and ScheduleChemical class: BarbiturateTherapeutic class: Sedative-hypnoticPregnancy category: DControlled substance schedule: IIIndications and Dosages To induce sedation before surgeryCAPSULESAdults. 200 to 300 mg 1 to 2 hr before surgery.Children. 2 to 6 mg/kg 1 to 2 hr before surgery.Maximum: 100 mg. To provide short-term treatment ofinsomniaCAPSULESAdults. 100 mg at bedtime. To relieve apprehension, daytime anxiety,and tensionCAPSULESAdults. 30 to 50 mg t.i.d. or q.i.d.Children. 2 mg/kg t.i.d.DOSAGE ADJUSTMENT Reduced dosagerequired for elderly or debilitated patientsand those with renal or hepatic dysfunction.Route Onset Peak DurationP.O. 10–15 min 15–30 min 1–4 hrMechanism of ActionInhibits upward conduction of nerveimpulses to the reticular formation of thebrain, thereby disrupting impulse transmissionto the cortex. This action depresses theCNS, producing drowsiness, hypnosis, andsedation.ContraindicationsHistory of barbiturate addiction; hypersensitivityto secobarbital, other barbiturates,or their components; nephritis; porphyria;severe hepatic or respiratory impairment

ate toxicitymexiletine: Decreased blood mexiletine levelphenylbutazone: Decreased effectiveness ofsecobarbitalposterior pituitary hormones: Increased riskof arrhythmias and coronary insufficiencyprimidone: Increased sedative effect ofeither drug, change in seizure patternvitamin D: Decreased vitamin D effectsxanthines (aminophylline, oxtriphylline,theophylline): Increased metabolism of xanthines(except dyphylline), decreased hypnoticeffect of secobarbitalFOODScaffeine: Increased caffeine metabolism,decreased hypnotic effect of secobarbitalACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Anxiety, clumsiness, confusion,depression, dizziness, drowsiness, hangover,headache, insomnia, irritability, lethargy,nervousness, nightmares, paradoxical stimulation,syncopeCV: HypotensionEENT: LaryngospasmGI: Anorexia, constipation, nausea, vomitingMS: Arthralgia, muscle weaknessRESP: Apnea, bronchospasm, respiratorydepressionSKIN: JaundiceOther: Drug dependence, weight lossNursing Considerations• Be aware that prolonged use of secobarbitalmay lead to tolerance and physical andpsychological dependence.WARNING To avoid withdrawal symptoms,expect to taper drug after long-term therapy.Withdrawal symptoms usually appear8 to 12 hours after stopping drug and mayinclude anxiety, insomnia, muscle twitching,nausea, orthostatic hypotension, vomiting,weakness, and weight loss. Severesymptoms may include delirium, hallucinations,and seizures. Generalized tonicclonicseizures may occur within 16 hoursor up to 5 days after last dose.• Assess patient for signs and symptoms ofbarbiturate toxicity, including dyspnea,severe confusion, and severe drowsiness.Notify prescriber immediately if theyappear because barbiturate toxicity may belife-threatening.selegiline 931• Expect prescriber to provide patient withthe least possible quantity of secobarbitalto minimize the risk of acute or chronicoverdosage. For patients who aredepressed, suicidal, or drug-dependent orwho have a history of drug abuse, instituteprecautions to prevent drug hoarding andoverdosage.PATIENT TEACHING• Instruct patient to take secobarbital exactlyas prescribed because of the risk ofaddiction.• Inform patient that taking drug with foodmay reduce adverse GI effects.• Advise patient to avoid alcohol and caffeineand potentially hazardous activitiesduring therapy.• Inform patient about possible hangovereffect.• If patient takes an oral contraceptive, recommendusing an additional form ofbirth control during therapy.• Caution patient not to stop taking drugabruptly.• Instruct patient to notify prescriber ofbone pain, muscle weakness, or unexplainedweight loss during therapy.selegilinehydrochlorideApo-Selegiline (CAN), Carbex, Eldepryl,Gen-Selegiline (CAN), Novo-Selegiline(CAN), Nu-Selegiline (CAN), SDDeprenyl (CAN), Selegiline-5 (CAN),Zelaparselegilinetransdermal systemEmsamClass and CategoryChemical class: Phenethylamine derivativeTherapeutic class: Antidepressant (Emsam),antidyskineticPregnancy category: CIndications and Dosages As adjunct to carbidopa-levodopa therapyto treat Parkinson’s diseaseCAPSULES , TABLETSAdults. 10 mg once daily, or 5 mg b.i.d.QRS

932selegilinewith breakfast and lunch.DOSAGE ADJUSTMENT For patient withlevodopa-induced adverse effects, 2.5 mgq.i.d. As adjunct to carbidopa-levodopa therapyto treat Parkinson’s disease inpatients whose response to therapy hasdeterioratedORALLY DISINTEGRATING TABLETS (ZELAPAR)Adults. Initial: 1.25 mg once daily beforebreakfast for at least 6 wk; then increased to2.5 mg once daily, if needed. To treat depressionTRANSDERMAL SYSTEM (EMSAM)Adults. Initial: 6 mg/24 hr with patchapplied daily to upper torso, upper thigh, orouter surface of upper arm. Increased every2 wk in increments of 3 mg/24 hr, as needed.Maximum: 12 mg/24 hr.Mechanism of ActionReduces dopamine metabolism by noncompetitivelyinhibiting the brain enzymemonoamine oxidase type B. This increasesthe amount of dopamine available to relievesymptoms of parkinsonism. Selegiline’smetabolites may also enhance dopaminetransmission by inhibiting its reuptake atsynapses.ContraindicationsHypersensitivity to selegiline or its components;pheochromocytoma; use within14 days of meperidine; use within 10 daysof general anesthesia; use with carbamazepine,oxcarbazepine, selective serotoninreuptake inhibitors (fluoxetine,paroxetine, sertraline), dual serotonin andnorephinephrine reuptake inhibitors(duloxetine, venlafaxine), tricyclic antidepressants(amitriptyline, bupropion,imipramine), analgesics (tramadol,propoxyphene), dextromethorphan; usewith St. John’s wort, mirtazapine, cyclobenzaprine,oral selegline, other MAOinhibitors, sympathomimetic amines(Emsam only)InteractionsDRUGScarbamazepine, oxcarbazepine: Increasedblood selegiline levelfluoxetine, fluvoxamine, nefazodone, paroxetine,sertraline, venlafaxine: Increased risk ofadverse reactions similar to those of serotoninsyndrome (confusion, hypomania,restlessness, myoclonus), autonomic instability,delirium, muscle rigidity, and severeagitationlevodopa: Increased risk of confusion, dyskinesia,hallucinations, nausea, and orthostatichypotensionmeperidine, possibly other opioid agonists:Increased risk of diaphoresis, excitation,muscle rigidity, and severe hypertensionsympathomimetics: Increased risk of severehypertensiontricyclic antidepressants: Possibly seriousCNS reactions, including decreased level ofconsciousness, hyperpyrexia, hypertension,muscle rigidity, seizures, and syncopeFOODScaffeine: Increased risk of hypertensionfoods that contain tyramine or other highpressoramines: Increased risk of suddenand severe hypertensionACTIVITIESalcohol use: Increased risk of hypertensionAdverse ReactionsCNS: Anxiety, chills, confusion, dizziness,drowsiness, dyskinesia, euphoria, extrapyramidalreactions, fatigue, hallucinations,headache, insomnia, irritability, lethargy,memory loss, mood changes, nervousness,paresthesia, restlessness, suicidal ideation,syncope, tremor, weaknessCV: Arrhythmias, chest pain, hypertension,orthostatic hypotension, palpitations,peripheral edemaEENT: Altered taste, blepharospasm,blurred vision, burning lips or mouth,diplopia, dry mouth, pharyngitis, sinusitis,tinnitusGI: Abdominal pain, anorexia, constipation,diarrhea, GI bleeding, heartburn, nausea,vomitingGU: Dysuria, urinary hesitancy, urinaryurgency, urine retentionMS: Arthralgia, back and leg pain, musclefatigue and spasms, neck stiffnessRESP: AsthmaSKIN: Diaphoresis, photosensitivity, rashOther: Application site reactions (Emsam),intense urges to perform certain activities(such as gambling or sex)Nursing Considerations• Assess patient for mental status and moodchanges because selegiline can worsen

such conditions as dementia, severepsychosis, tardive dyskinesia, and tremor.Be especially alert for suicidal tendencies,particularly when therapy starts or dosagechanges.• Monitor patient who is also taking levodopafor levodopa-induced adverse reactions,including confusion, dyskinesia, hallucinations,nausea, and orthostatichypotension.• Monitor for decreased symptoms ofParkinson’s disease to evaluate drug’seffectiveness.• Be aware that drug can reactivate gastriculcers because it prevents breakdown ofgastric histamine. Assess for related signsand symptoms, such as abdominal pain.• Assess patient for skin changes regularlybecause risk of melanoma is increased inpatients with Parkinson’s disease. It isn’tclear whether increase results from diseaseor drugs used to treat it.PATIENT TEACHING• Caution patient to take only prescribedamount because increased dosage maycause severe adverse reactions.• Advise patient to avoid taking selegiline inthe late afternoon or evening because itmay interfere with sleep.• For orally disintegrating tablets, tellpatient to take it before breakfast withoutany liquid. Caution him not to push tabletthrough the foil on the blister pack butinstead to peel back the foil with dryhands and gently remove the tablet. Heshould then immediately place the tabletson top of his tongue and let it disintegrate.Advise him not to drink or ingest any foodfor 5 minutes before and after taking thedrug.• If patient will use transdermal form,explain how and where to apply patch,stressing need to rotate sites. Tell patient towash hands well after application and todispose of removed patch immediately.• Stress that only one patch may be worn ata time. If a patch falls off, tell patient toapply a new patch to a new site and toresume previous schedule.• Urge patient to avoid tyramine-rich foodsand beverages during and for 2 weeks afterstopping selegiline therapy unless patientis prescribed the lowest dosage of transdermalsystem (6 mg per 24 hours), whichsertraline hydrochloride 933doesn’t require diet modification. Reviewwhich foods are considered tyramine-rich.• Instruct patient to immediately reportsevere headache, neck stiffness, racingheart, palpitations, or other sudden orunusual symptoms.• Caution patient to avoid exposing transdermalpatch to sources of direct heat,such as heating pads, electric blankets,heat lamps, saunas, hot tubs, and prolongedsunlight exposure.• Tell patient not to cut transdermal patchinto smaller pieces.• Urge caregiver to monitor patient closelyfor suicidal tendencies, especially whentherapy starts or dosage changes.• Urge patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to change positions slowlyto minimize the effects of orthostatichypotension.• Suggest that patient elevate his legs whensitting to reduce ankle swelling.• Urge patient to avoid excessive sun exposure.• Instruct patient to notify prescriber ifsymptoms develop that could indicateoverdose, including muscle twitching andeye spasms.• Urge patient to notify prescriber if drymouth lasts longer than 2 weeks. Advisehim to have routine dental checkups.• Urge patient to have regular skin examinationsdone by a dermatologist or otherqualified health professional.• Advise patient to notify prescriber aboutintense urges (as for gambling or sex)because dosage may need to be reduced ordrug discontinued.sertralinehydrochlorideZoloftClass and CategoryChemical class: Naphthylamine derivativeTherapeutic class: Antidepressant, antiobsessant,antipanicPregnancy category: CIndications and Dosages To treat major depressionQRS

934sertraline hydrochlorideORAL CONCENTRATE, TABLETSAdults. Initial: 50 mg daily, increased afterseveral wk in increments of 50 mg dailyevery wk, as needed. Maximum: 200 mgdaily. To treat obsessive-compulsive disorderORAL CONCENTRATE, TABLETSAdults and adolescents. Initial: 50 mgdaily, increased after several wk in incrementsof 50 mg daily every wk, as needed.Maximum: 200 mg daily.Children ages 6 to 12. Initial: 25 mg daily,increased every wk, as needed. Maximum:200 mg daily. To treat panic disorder, with or withoutagoraphobia; to treat posttraumaticstress disorderORAL CONCENTRATE, TABLETSAdults. Initial: 25 mg daily, increased to50 mg daily after 1 wk; then increased by50 mg daily every wk, as needed.Maximum: 200 mg daily.DOSAGE ADJUSTMENT Initial dosage reductionrecommended for elderly patients andthose with hepatic impairment. To treat premenstrual dysphoric disorder(PMDD)ORAL CONCENTRATE, TABLETSAdult women. Initial: 50 mg daily in morningor evening throughout menstrual cycle;or, 50 mg daily in morning or evening duringluteal phase of menstrual cycle only.Dosage increased each menstrual cycle in50-mg increments up to 150 mg daily, oreach luteal phase up to 100 mg daily, asneeded. Once 100-mg daily dosage establishedfor luteal phase, each successive cyclerequires a 50-mg titration step for 3 days atthe beginning of each luteal phase.Maximum: 150 mg daily for dosingthroughout menstrual cycle, or 100 mgdaily for dosing during luteal phase only.Route Onset Peak DurationP.O. 2–4 wk* Unknown UnknownMechanism of ActionInhibits reuptake of the neurotransmitterserotonin by CNS neurons, thereby increasingthe amount of serotonin available innerve synapses. An elevated serotonin level* For antidepressant and antipanic effects;for antiobsessant effect, longer than 4 wk.may result in elevated mood and reduceddepression. This action may also relievesymptoms of other psychiatric conditionsattributed to serotonin deficiency.ContraindicationsConcurrent use of disulfiram (oral concentrate)or pimozide; hypersensitivity to sertralineor its components; use within 14days of an MAO inhibitorInteractionsDRUGSaspirin, NSAIDs, warfarin: Increased anticoagulantactivity and risk of bleedingastemizole, terfenadine: Possibly increasedblood levels of these drugs, leading toincreased risk of arrhythmiascimetidine: Increased sertraline half-lifeMAO inhibitors: Possibly hyperpyretic episodes,hypertensive crisis, serotonin syndrome,and severe seizuresmoclobemide, serotonergics: Increased risk ofpotentially fatal serotonin syndromeserotonin and norepinephrine reuptakeinhibitors: Increased risk of bleeding, especiallyGI bleedingtolbutamide: Possibly hypoglycemiatricyclic antidepressants: Possibly impairedmetabolism of tricyclic antidepressants,resulting in increased risk of toxicityAdverse ReactionsCNS: Aggressiveness, agitation, anxiety, dizziness,drowsiness, fatigue, fever, headache,hyperkinesia, insomnia, nervousness, neurolepticmalignant syndrome–like reaction,paresthesia, serotonin syndrome, suicidalideation, tremor, weakness, yawningCV: PalpitationsEENT: Dry mouth, epistaxis, sinusitis,vision changesENDO: Syndrome of inappropriate ADHsecretionGI: Abdominal cramps, anorexia, constipation,diarrhea, flatulence, increasedappetite, indigestion, nausea, vomitingGU: Anorgasmia, decreased libido, ejaculationdisorders, impotence, urinary incontinenceSKIN: Diaphoresis, flushing, purpura, rashOther: Weight lossNursing Considerations• Monitor liver function test results andBUN and serum creatinine levels, as

appropriate, in patients with hepatic orrenal dysfunction.WARNING Monitor patient closely for evidenceof serotonin syndrome, such as agitation,hallucinations, coma, tachycardia,labile blood pressure, hyperthermia,hyperreflexia, incoordination, nausea,vomiting, and diarrhea. Serotonin syndromein its most severe form can resembleneuroleptic malignant syndrome,which includes hyperthermia, musclerigidity, autonomic instability, possiblyrapid changes in vital signs, and mentalstatus changes. Notify prescriber immediatelybecause serotonin syndrome reactionsthat resemble neuroleptic malignantsyndrome may be life-threatening. Be preparedto provide supportive care.• Monitor patient for hypo-osmolarity ofserum and urine and for hyponatremia,which may indicate sertraline-inducedsyndrome of inappropriate ADH secretion.• Be aware that effective antidepressanttherapy can promote development ofmania in predisposed people. If maniadevelops, notify prescriber immediatelyand expect to withhold sertraline.• Watch closely for suicidal tendencies, especiallywhen therapy starts and dosagechanges and especially in children andadolescents.• Monitor patient closely for evidence of GIbleeding, especially if patient takes a drugknown to cause it, such as aspirin, anNSAID, a serotonin or norepinephrinereuptake inhibitor, or warfarin.• When theray stops, expect to taper dosageto minimize adverse effects rather thanstopping drug abruptly.PATIENT TEACHINGWARNING Tell patient that sertralineincreases the risk of serotonin syndromeand reactions that resemble neurolepticmalignant syndrome, rare but seriouscomplications, when taken with someother drugs. Teach patient to recognizesigns and symptoms of serotonin syndromeand neuroleptic malignant syndrome,and advise him to notify prescriberimmediately if they occur.• Teach patient to dilute oral concentratebefore taking it. Tell him to use supplieddropper to remove prescribed amount andmix it with 4 oz (one-half cup) of water,ginger ale, lemon or lime soda, lemonade,or orange juice. Warn him not to mix oralconcentrate with anything else. Explainthat it’s normal for mixture to be slightlyhazy.• Tell patient to take dose immediately aftermixing it.• If patient has latex sensitivity, advise himto use an alternate dispenser because thesupplied dropper dispenser contains drynatural rubber.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Warn family or caregiver to watch patientclosely for evidence of suicidal thinking orbehavior, especially when therapy starts ordosage changes, and especially if patient isa child or adolescent.• Caution patient not to stop taking drugabruptly. Explain that gradual taperinghelps to avoid withdrawal symptoms.• Instruct female patients to notify prescriberif they are or could be pregnantand to discuss benefits and risks of continuingsertraline therapy throughout thepregnancy.• Advise patient to consult prescriber beforetaking any OTC product, especially aspirinproducts or NSAIDs.sevelamerhydrochlorideRenagelsevelamercarbonateRenvelaIndications and Dosages To lower serum phosphate level duringend-stage renal diseaseCAPSULES (RENAGEL)Adults. 2 capsules (806 mg) t.i.d. if serumphosphorus level is 6 to 7.5 mg/dl; 3 capsevelamer935Class and CategoryChemical class: PolyallylamineepichlorhydrinpolymerTherapeutic class: AntihyperphosphatemicPregnancy category: CQRS

936sibutramine hydrochloride monohydratesules (1,209 mg) t.i.d. if serum phosphoruslevel is 7.6 to 8.9 mg/dl; or 4 capsules(1,612 mg) t.i.d. if serum phosphorus levelis 9 mg/dl or more. Dosage increased ordecreased gradually by 1 capsule (403 mg)/meal, as needed. Maximum: 30 capsules(12.1 g) daily.TABLETS (RENVELA)Adults. 1 tablet (800 mg) t.i.d. with meals ifserum phosphorus level is 5.5 mg/dl to7.5 mg/dl; or 2 tablets (1,600 mg) if serumphosphorus level is 7.5 mg/dl or greater.Dosage increased or decreased gradually by1 tablet (800 mg)/meal at 2-wk intervals, asneeded.DOSAGE ADJUSTMENT For patients beingswitched from calcium acetate to sevelamercarbonate, 1 tablet of sevelamer (800 mg)can be substituted for every 1 tablet of calcium(667 mg) being taken.Mechanism of ActionInhibits phosphate absorption in the intestineby binding dietary phosphate, therebylowering serum phosphorus level.ContraindicationsFecal impaction, GI obstruction, hypersensitivityto sevelamer or its components,hypophosphatemia, ileusInteractionsDRUGSantiarrhythmics, anticonvulsants, digoxin,levothyroxine, liothyronine, quinolones, tetracyclines,theophylline, warfarin: Possiblyaltered absorption of these drugsphosphate salts, phosphorus salts:Neutralized therapeutic effects of sevelamerciprofloxacin: Decreased ciprofloxacin effectivenessAdverse ReactionsCNS: Headache, feverCV: Hypertension, hypotension, thrombosisEENT: NasopharyngitisGI: Abdominal pain, constipation (severe),diarrhea, fecal impaction, flatulence, ileus,indigestion, intestinal obstruction oir perforation,nausea, vomitingRESP: Bronchitis, dyspnea, increasedcough, upper respiratory tract infectionMS: Arthralgia, back or limb painSKIN: Pruritus, rashOther: InfectionNursing Considerations• Give other drugs at least 1 hour before or3 hours after sevelamer to prevent interaction.• Be aware that severe hypophosphatemiamay occur in patient with dysphagia,major GI tract surgery, or severe GI motilitydisorder (including severe constipation)because drug prevents phosphateabsorption.• Monitor blood pressure frequently.• Monitor serum phosphorus level to determinedrug’s effectiveness; monitor otherserum electrolyte levels, especially bicarbonateand chloride, to detect imbalances.PATIENT TEACHING• Tell patient to take drug with meals and toswallow capsules or tablets whole withwater and not to open, break, or chewthem.• Caution patient to take other drugs 1 hourbefore or 3 hours after sevelamer.• Review symptoms of thrombosis, andadvise patient to report them immediately.• Instruct patient to report severe or prolongedconstipation to prescriber becauseadditional treatment may be needed toprevent serious complications.sibutraminehydrochloridemonohydrateMeridiaClass, Category, and ScheduleChemical class: CyclobutanemethanamineTherapeutic class: AntiobesityPregnancy category: CControlled substance schedule: IVIndications and Dosages As adjunct to calorie-controlled diet tomanage obesityCAPSULESAdults. Initial: 10 mg daily, increased to15 mg daily after 4 wk if weight loss is inadequate.Maximum: 15 mg daily.DOSAGE ADJUSTMENT Reduction to 5 mgdaily may be needed if patient can’t tolerate10-mg dose.

Mechanism of ActionInhibits central reuptake of dopamine, norepinephrine,and serotonin, thereby suppressingappetite and lowering food intake,leading to weight loss.ContraindicationsAnorexia nervosa, concurrent use of othercentrally acting appetite suppressants, historyof cardiovascular disease, hypersensitivityto sibutramine or its components, usewithin 14 days of MAO inhibitor therapyInteractionsDRUGScertain decongestants and cough, cold, andallergy drugs; ephedrine; phenylpropanolamine;pseudoephedrine: Increased riskof elevated blood pressure or heart ratecertain opioid analgesics (dextromethorphan,fentanyl, meperidine, pentazocine), dihydroergotamine,lithium, MAO inhibitors, serotonergics,sumatriptan, tryptophan, zolmitriptan:Increased risk of serotonin syndromeerythromycin, ketoconazole: Possiblydecreased sibutramine clearancesibutramine hydrochloride monohydrate 937Adverse ReactionsCNS: Abnormal dreams, amnesia, anger,anxiety, confusion, depression, dizziness,drowsiness, gait dysfunction, Gilles de laTourette’s syndrome, headache, hypesthesia,impaired concentration, increased intraocularpressure, insomnia, mania, moodchanges, neuroleptic malignant syndrome,nervousness, nightmares, paresthesia, psychosis,serotonin syndrome, short termmemory loss, somnolence, speech disorder,stroke, suicidal ideation, transient ischemicattack, tremor, twitching, vertigoCV: Chest pain, edema, hypertension, MI,palpitations, tachycardiaEENT: Blurred vision, dry eyes or mouth,earache, epistaxis, nasal congestion, rhinitis,sinusitis, taste perversionGI: Abdominal pain, anorexia, constipation,diarrhea, gastritis, increased appetite, indigestion,nausea, thirst, vomitingGU: Decreased or increased libido, dysmenorrhea,impotence, urinary frequency, urineretention, UTI, vaginal candidiasisHEME: BleedingMS: Arthralgia, back or neck pain, myalgia,tenosynovitisSKIN: Acne, alopecia, dermatitis, diaphoresis,ecchymosis, flushing, photosensitivity,urticariaOther: Anaphylaxis, angioedema, flulikesymptomsNursing Considerations• Administer sibutramine cautiously inpatients with mild to moderate renalimpairment, and expect to not use it inpatients with severe renal impairment,including those with end-stage renal diseasereceiving hemodialysis.WARNING Use drug cautiously in patientswith a history of substance abuse, andwatch for signs of misuse.• Measure blood pressure and pulse ratebefore and during sibutramine therapy.Notify prescriber about sustained increases,and expect drug to be discontinued• Because serotonin release from nerve terminalshas been linked to cardiac valvedysfunction, assess for development ofthird heart sound.WARNING If patient takes drugs formigraine, notify prescriber immediately ifevidence of serotonin syndrome develops:agitation, anxiety, ataxia, chills, confusion,diaphoresis, disorientation, dysarthria,emesis, excitement, hemiballismus, hyperreflexia,hyperthermia, hypomania, lack ofcoordination, loss of consciousness,mydriasis, myoclonus, restlessness, tachycardia,tremor, and weakness.• Because drug decreases salivary flow, monitorpatient for adverse dental effects.WARNING Watch closely for evidence ofserotonin syndrome, such as agitation,hallucinations, coma, tachycardia, labileblood pressure, hyperthermia, hyperreflexia,incoordination, nausea, vomiting, anddiarrhea. In its most severe form, serotoninsyndrome can resemble neurolepticmalignant syndrome, which includeshyperthermia, muscle rigidity, autonomicinstability, possibly rapid changes in vitalsigns, and mental status changes. Notifyprescriber immediately because serotoninsyndrome reactions that resemble neurolepticmalignant syndrome may be lifethreatening.Be prepared to provide supportivecare.• Monitor patient closely for evidence ofsuicidal thinking or behavior, especiallywhen therapy starts or dosage changes.QRS

938sildenafil citrate• Monitor patient for weight loss to determinedrug effectiveness. Expect to discontinuedrug if patient has not lost at least5% of baseline body weight within thefirst 6 months of treatment.PATIENT TEACHING• Caution patient not to take sibutraminemore often than prescribed.• Teach patient how to measure his bloodpressure and pulse rate during therapy.• Explain that sibutramine is an adjunct toreduced-calorie diet, not a replacement forit.• Advise patient to report unusual bleedingor bruising.• Caution against taking OTC products thatcontain ephedrine because of theincreased risk of hypertension.• Urge patient to avoid potentially hazardousactivities until drug’s CNS effects areknown.• If patient reports dry mouth, suggestsugar-free hard candy or gum or a salivasubstitute.WARNING Tell patient to report any sudden,severe, or persistent symptoms at once.• Urge caregivers to monitor patient closelyfor evidence of suicidal tendencies, especiallywhen therapy starts or dosagechanges and to report concerns immediatelyto prescriber.sildenafil citrateRevatio, ViagraClass and CategoryChemical class: PyrazolopyrimidinonederivativeTherapeutic class: Antihypertensive (pulmonaryarterial), anti-impotencePregnancy category: BIndications and Dosages To treat erectile dysfunctionTABLETSAdults. 50 mg daily, taken 1 hr before sexualactivity; increased as prescribed, based onclinical response. Maximum: 100 mg daily.DOSAGE ADJUSTMENT Initially 25 mg forelderly patients, those with hepatic cirrhosisor creatinine clearance less than 30 ml/min/1.73 m 2 , and those taking potent cytochromeP-450 3A4 inhibitors or ritonavir.Dosage reduced to 25 mg if taken within4 hr of an alpha blocker. Maximum: 25 mg/48 hr. To treat pulmonary arterial hypertensionin order to improve exercise abilityand delay clinical worsening of conditionin patients classified as group 1 bythe World Health OrganizationTABLETSAdults. 20 mg t.i.d.I.V. INJECTIONAdults. 10 mg administered as bolus t.i.d.Route Onset Peak DurationP.O. In 30 min Unknown 4 hrMechanism of ActionEnhances the effect of nitric oxide releasedin the penis by stimulation. Nitric oxideincreases cGMP level, relaxes smooth muscle,and increases blood flow to the corpuscavernosum, thus producing an erection.ContraindicationsContinuous or intermittent nitrate therapy,hypersensitivity to sildenafil or componentsInteractionsDRUGSbarbiturates, bosentan, carabamazepine,efavirenza, nevirapine, phenytoin, rifabutin,rifampin: Altered plasma level of eitherdrugcimetidine, erythromycin, itraconazole,ketoconazole, mibefradil: Prolonged sildenafileffectdoxazosin and other alpha-blockers:Increased risk of symptomatic hypotensionnitrates: Profound hypotensionprotease inhibitors: Increased sildenafil effectrifampin: Decreased sildenafil effectFOODShigh-fat meals: Drug absorption delayed byup to 60 minutesAdverse ReactionsCNS: Cerebrovascular, intracerebral, orsubarachnoid hemorrhage; dizziness; headache;migraine; seizures; syncope; transientglobal amnesia, transient ischemic attackCV: Heart failure, hypertension, hypotension,myocardial infarction or ischemia,orthostatic hypotension, palpitations, suddencardiac death, tachycardia, ventriculararrhythmias

EENT: Blurred vision; change in color perception;diplopia; epistaxis; hearing loss;increased intraocular pressure; nasal congestion;nonarteritic anterior ischemic opticneuropathy; ocular burning, pressure, rednessor swelling; paramacular edema; photophobia;retinal vascular bleeding or disease;tinnitus, visual decrease or temporaryvision loss; vitreous detachmentENDO: Uncontrolled diabetes mellitusGI: Diarrhea, indigestionGU: Cystitis, dysuria, painful erection, priapism,UTIMS: Arthralgia, back painRESP: Pulmonary hemorrhage, upper respiratorytract infectionSKIN: Flushing, photosensitivityNursing Considerations• Use sildenafil cautiously in patients withrenal or hepatic dysfunction, elderlypatients, and men with penile abnormalitiesthat may predispose them to priapism.• Also use cautiously in patients with leftventricular outflow obstruction, such asaortic stenosis and idiopathic hypertrophicsubaortic stenosis, and those withseverely impaired autonomic control ofblood pressure because these conditionsincrease patient’s sensitivity to vasodilatorssuch as sildenafil.• Monitor patient’s blood pressure andheart rate and rhythm before and oftenduring therapy.• Monitor vision, especially in patients overage 50; who have diabetes, hypertension,coronary artery disease, or hyperlipidemia;or who smoke because sildenafil rarelymay cause nonarteritic anterior ischemicoptic neuropathy that may lead todecreased vision or permanent vision loss.PATIENT TEACHING• Explain that sildenafil used to treat erectiledysfunction may be taken up to 4 hoursbefore sexual activity but that taking it1 hour beforehand provides the mosteffective results.WARNING Warn patient not to take sildenafilif he also takes any form of organicnitrate, either continuously or intermittently,because profound hypotension anddeath could result. Also caution patienttaking sildenafil for erectile dysfunctionnot to take more than 25 mg within4 hours of an alpha blocker, such as doxazosin,because symptomatic orthostatichypotension can occur.• Tell patient to stop taking drug and contactprescriber if vision decreases suddenlyin one or both eyes or if he has a loss ofhearing, possibly with tinnitus and dizziness.• Advise patient taking sildenafil for erectiledysfunction to seek sexual counseling toenhance the drug’s effects.• To avoid possible penile damage and permanentloss of erectile function, urgepatient to notify prescriber immediately iferection is painful or lasts longer than 4hours.• Instruct diabetic patient to monitor hisblood glucose level frequently becausedrug may affect glucose control.silodosinRapafloContraindicationsHypersensitivity to silodosin and its comsilodosin939Class and CategoryChemical class: Highly selective alpha 1 -adrenergic receptor blockerTherapeutic class: Benign prostatic antihyperplasiaagentPregnancy category: BIndications and Dosages To treat symptomatic benign prostatichyperplasiaCAPSULESAdult men. 8 mg daily. Maximum: 8 mgdaily.DOSAGE ADJUSTMENT For patients withmoderate renal impairment (creatinineclearance between 30 and 50 ml/min),dosage reduced to 4 mg daily.Mechanism of ActionBinds to postsynaptic alpha 1 adrenoreceptorslocated in the prostate gland,bladder base and neck, and prostatic capsuleand urethra. Blocking action at theseadrenoreceptor sites causes relaxation ofsmooth muscle in the local area, whichimproves urine flow and reduces otherbenign prostatic hyperplasia symptoms.QRS

940simvastatinponents, severe hepatic insufficiency(Child-Pugh score 10 or above), severerenal insufficiency (creatinine clearance lessthan 30 ml/min/1.73 m 2 ), use with strongCYP3A4 inhibitors such as clarithromycin,ketoconazole, itraconazole, and ritonavirInteractionsDRUGSalpha blockers: Possibly increased effectsand risk of adverse reactionsantihypertensives: Increased risk of dizzinessand orthostatic hypotensioncyclosporin, CYP3A4 inhibitors such as clarithromycin,diltiazem, erythromycin, itraconazole,ketoconazole, ritonavir: Possiblyincreased serum silodosin levels and risk ofadverse reactionsAdverse ReactionsCNS: Asthenia, dizziness, headache, insomnia,syncopeCV: Orthostatic hypotensionEENT: Nasal congestion, nasopharyngitis,rhinorrhea, sinusitisGI: Abdominal pain, diarrhea, elevated liverenzymes, impaired hepatic function, jaundiceGU: Elevated prostate specific antigen level,retrograde ejaculationSKIN: Purpura, toxic skin eruptionNursing Considerations• Use cautiously in patients with mild renalimpairment and mild or moderate hepaticimpairment. Patients with moderate renalimpairment need dosage adjustment.• Monitor patient’s blood pressure forreduction, especially if he takes an antihypertensivewith silodosin.PATIENT TEACHING• Instruct patient to take drug with a meal.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient planning cataract surgeryor other ocular procedure to tell ophthalmologistthat he takes silodosin or hastaken it in the past because of potentialadverse reactions.simvastatinZocorClass and CategoryChemical class: Synthetically derived fermentationproduct of Aspergillus terreusTherapeutic class: AntihyperlipidemicPregnancy category: XIndications and Dosages To treat hyperlipidemiaTABLETSAdults. Initial: 20 to 40 mg daily in theevening. Dosage adjusted at 4-wk intervals,as needed, to achieve target LDL-cholesterollevel. Maintenance: 5 to 80 mg daily.Maximum: 80 mg daily. To treat homozygous familial hypercholesterolemiaTABLETSAdults. 40 mg daily in the evening, or 80mg/day in 3 divided doses—20 mg, 20 mg,and 40 mg (in the evening). Dosage adjustedevery 4 wk, as needed, to achieve targetLDL-cholesterol level. Maintenance: 5 to40 mg/day. Maximum: 80 mg daily.DOSAGE ADJUSTMENT Patients taking cyclosporineor who have severe renal insufficiencyshould initially receive 5 mg simvastatindaily and be increased as needed to nomore than 10 mg daily. Maximum dosageof 10 mg daily should also not be exceededin patients who are also taking fibrates orniacin. To treat adolescent heterozygous familialhypercholesterolemiaTABLETSChildren ages 10 to 17 at least 1 year postmenarche.Initial: 10 mg daily in theevening. Adjusted every 4 wk, as needed, toachieve target LDL-cholesterol level.Maintenance: 10 to 40 mg daily. Maximum:40 mg daily.DOSAGE ADJUSTMENT For patients who takecyclosporine, initial dosage reduced to 5mg/day and maximum dosage reduced to10 mg/day. For elderly patients and thosewith renal impairment, initial dosagereduced to 5 mg daily. For patients whotake danazol, fibric-acid derivative lipidloweringdrugs, such as gemfibrozil, orlipid-lowering doses of niacin (1 g daily ormore), maximum dosage reduced to 10 mgdaily. For patients who take amiodarone orverapamil, maximum dosage shouldn’texceed 20 mg daily.Mechanism of ActionInterferes with the hepatic enzyme hydroxymethylglutaryl-coenzymeA reductase.

This action reduces the formation ofmevalonic acid, a cholesterol precursor,thus interrupting the pathway necessary forcholesterol synthesis. When the cholesterollevel declines in hepatic cells, LDLs are consumed,which in turn reduces the levels ofcirculating total cholesterol and serumtriglycerides.Route Onset Peak DurationP.O. 2 wk 4–6 wk UnknownContraindicationsActive hepatic disease; breast-feeding; concurrentuse with clarithromycin, erythromycin,more than 1 quart of grapefruitjuice daily, HIV protease inhibitors, itraconazole,ketoconazole, nefazodone, ortelithromycin; hypersensitivity to simvastatinor its components; pregnancyInteractionsDRUGSamiodarone, antiretroviral proteaseinhibitors (amprenavir, indinavir, nelfinavir,ritonavir, saquinavir), clarithromycin,cyclosporine, danazol, gemfibrozil and otherfibrates, itraconazole, ketoconazole, erythromycin,nefazodone, niacin (1 g daily ormore), telithromycin, verapamil: Increasedrisk of myopathy or rhabdomyolysisazole antifungals, cyclosporine, gemfibrozil,immunosuppressants, macrolide antibiotics(including erythromycin), niacin, verapamil:Increased risk of acute renal failurebile acid sequestrants, cholestyramine,colestipol: Decreased simvastatin bioavailabilitydigoxin: Possibly slight elevation in blooddigoxin leveldiltiazem, verapamil: Possibly increasedblood simvastatin level, increased risk ofmyopathyoral anticoagulants: Increased bleeding orprolonged PTFOODSgrapefruit juice (1 or more quarts daily):Possibly increased blood simvastatin levelAdverse ReactionsCNS: Asthenia, dizziness, fatigue, headacheCV: Chest painEENT: Cataracts, rhinitisGI: Abdominal pain, constipation, diarrhea,elevated liver function test results, flatulence,heartburn, hepatic failure, indigestion,nausea, pancreatitis, vomitingMS: Myalgia, myopathy, rhabdomyolysisRESP: Upper respiratory tract infectionSKIN: Eczema, pruritus, rashNursing Considerations• Use simvastatin cautiously in elderlypatients and those with renal or hepaticimpairment.• Give drug 1 hour before or 4 hours aftergiving bile acid sequestrant, cholestyramine,or colestipol.• Expect to monitor liver function testresults every 3 to 6 months for abnormalelevations.• Monitor serum lipoprotein level, asordered, to evaluate response to therapy.PATIENT TEACHING• Urge patient to take drug in the evening.• Urge patient to follow low-fat, cholesterolloweringdiet.• Urge patient to notify prescriber immediatelyabout muscle pain, tenderness, orweakness and other symptoms of myopathy.• Inform female patient of childbearing ageof need to use reliable contraceptivemethod while taking drug. Instruct her tonotify prescriber at once if she suspectspregnancy.• Advise patient to avoid grapefruit juice todecrease risk of drug toxicity.sirolimus(rapamycin)Rapamunesirolimus 941Class and CategoryChemical class: Macrocyclic lactoneTherapeutic class: ImmunosuppressantPregnancy category: CIndications and Dosages To prevent rejection of kidney transplantationORAL SOLUTIONAdults and adolescents over age 13 weighing40 kg (88 lb) or more. Initial: 6-mgloading dose. Maintenance: 2 mg daily.Adolescents over age 13 weighing less than40 kg. Initial: 3-mg/m 2 loading dose.Maintenance: 1 mg/m 2 daily.QRS

942sirolimusDOSAGE ADJUSTMENT Maintenance dosagereduced by one-third for patients withimpaired hepatic function. Maintenancedosage increased by as much as 400% forpatients discontinuing concomitantcyclosporine therapy in order to maintainblood sirolimus trough level of 12 to24 nanograms/ml.Route Onset Peak DurationP.O. Unknown Unknown Up to 6 moafter discontinuationMechanism of ActionInhibits activation and proliferation ofT lymphocytes and antibody production.Sirolimus also inhibits cell cycle progressionfrom the G1 to the S phase, possibly byinhibiting a key regulatory kinase believedto suppress cytokine-driven T-cell proliferation.ContraindicationsHypersensitivity to sirolimus or its components,malignancyInteractionsDRUGSaminoglycosides, amphotericin B, cyclosporine:Possibly impaired renal functionbromocriptine, cimetidine, cisapride, clarithromycin,clotrimazole, cyclosporine, danazol,diltiazem, erythromycin, fluconazole,indinavir, itraconazole, ketoconazole, metoclopramide,nicardipine, ritonavir, troleandomycin,verapamil: Possibly increasedblood sirolimus level and toxicitycalcineurin inhibitors, corticosteroids:Increased risk of deteriorating renal function,serum lipid abnormalities, and UTIcarbamazepine, phenobarbital, phenytoin,rifabutin, rifapentine, St. John’s wort:Possibly decreased blood sirolimus levelHMG-CoA reductase inhibitors: Increasedrisk of rhabdomyolysis when administeredconcurrently with sirolimus andcyclosporinerifampin: Significantly increased sirolimusclearancevaccines (killed virus): Possibly decreasedimmune response to vaccinesvaccines (live virus): Increased risk of contractingdisease from live virusFOODSgrapefruit juice: Possibly decreased metabolismof sirolimushigh-fat diet: Reduced rate of sirolimusabsorptionAdverse ReactionsCNS: Asthenia, fever, headache, insomnia,tremorCV: Atrial fibrillation, chest pain, hyperlipidemia,hypersensitivity vasculitis, hypertension,pericardial effusion, peripheral edemaENDO: HyperglycemiaGI: Abdominal pain, constipation, diarrhea,elevated liver enzymes, hepatotoxicity, nausea,vomitingGU: Azoospermia, BK viral nephritis, elevatedserum creatinine level, nephrotic syndrome,proteinuria, UTIHEME: Anemia, lymphoma, neutropenia,pancytopenia, thrombocytopeniaMS: Arthralgia, low back or flank pain,joint abnormalityRESP: Dyspnea on exertion, interstitial lungdisease, pleural effusion, pulmonary hemorrhageSKIN: Acne, exfoliative dermatitis, rashOther: Anaphylaxis; angioedema; delayedwound healing; hypercholesterolemia;hypokalemia; hypophosphatemia; increasedsusceptibility to infection, including opportunisticinfections such as tuberculosis andactivation of latent viral infections; lymphedema;weight gain or lossNursing Considerations• Be aware that sirolimus isn’t recommendedin liver or lung transplant patients.• Use sirolimus cautiously in patients whoare receiving other drugs known toadversely affect renal function, such asaminoglycosides and amphotericin B;together, they may further decrease renalfunction.• Monitor patients with existing or recent(including recent exposure to) chickenpoxand patients with herpes zoster for worseningsymptoms because they have anincreased risk of developing severe generalizeddisease while taking sirolimus.• Mix oral sirolimus with at least 2 oz(60 ml) of water or orange juice in a glassor plastic container. Don’t dilute drug ingrapefruit juice or any other liquid.• Stir well and have patient drink solution

immediately. Then rinse glass with at least4 oz (120 ml) of additional liquid, stirwell, and have patient drink that liquid tomake sure that all of drug is taken.• Give initial dose as soon after transplantationas possible and daily dose 4 hoursafter cyclosporine, as prescribed.• Monitor whole blood sirolimus concentrations,as ordered, in patients receivingconcentrated form of drug, patientsweighing less than 40 kg (88 lb), patientswith hepatic impairment, and thosereceiving potent CYP3A4 inducers orinhibitors concurrently.• When using trough level to determinedrug’s effectiveness, keep in mind thatdosage adjustment should be made onlyafter other factors are taken into account,such as signs, symptoms, and tissue biopsyfindings. Keep in mind that interpretationmethods vary among laboratories and valuesaren’t interchangeable.• Monitor serum creatinine level, asordered, because BK virus associatednephropathy has occurred with sirolimustherapy. In addition, patients receivingsirolimus and cyclosporine may developimpaired renal function. Notify prescriberof any increases in serum creatinine levelbecause sirolimus or cyclosporine dosagemay need to be adjusted or drug discontinued.• Monitor patient for urinary protein excretion,as ordered. If protein appears inurine, sirolimus may be discontinued.• Monitor patient for signs and symptomsof infection and check CBC results, asordered, to detect sirolimus-induced blooddyscrasias or changes in neutrophil count,which may indicate infection.• For patients with hyperlipidemia, be preparedto institute dietary changes, an exerciseprogram, or a lipid-lowering drug regimenif blood cholesterol or triglyceridelevels increase because drug may aggravatehyperlipidemia.PATIENT TEACHING• Advise patient to take sirolimus consistentlyeither with or without food (but notfood high in fat) to prevent changes inabsorption rate.• Instruct patient to take daily dose with atleast 2 oz (60 ml) of water or orange juice.Caution him not to dilute drug in grapefruitjuice or any other liquid. Advise himto stir mixture well and drink immediately,then to add at least another 4 oz(120 ml) of liquid to empty container, stirmixture again, and drink that liquid toensure that he has swallowed all of drug.• Urge patient to avoid people with colds,flu, or other infections because immunosuppressionmakes him more vulnerable.• Instruct patient not to take live vaccines,such as measles, mumps, rubella, oralpolio, bacille Calmette-Guérin, yellowfever, varicella, and TY21a typhoid, duringsirolimus therapy.• Advise patient to keep follow-up appointmentsfor blood tests, as ordered.sitagliptinJanuviaMechanism of ActionInhibits the dipeptidyl peptidase-4 enzymeto slow inactivation of incretin hormones.These hormones are released by the intestinethroughout the day but increase inresponse to a meal. When blood glucoselevel is normal or increased, incretin horsitagliptin943Class and CategoryChemical class: Beta amino acid derivativeTherapeutic class: AntidiabeticPregnancy category: CIndications and Dosages To achieve control of glucose level intype 2 diabetes mellitus as monotherapyor with metformin or other thiazolidinedionesTABLETSAdults. 100 mg once daily.DOSAGE ADJUSTMENT For patients withmoderate renal insufficiency (creatinineclearance 30 to 50 ml/min/1.73 m 2 ), dosagereduced to 50 mg once daily; for patientswith severe renal insufficiency (creatinineclearance less than 30 ml/min/1.73 m 2 ) orend-stage renal disease requiring hemodialysisor peritoneal dialysis, dosage reducedto 25 mg once daily.Route Onset Peak DurationP.O. Unknown 1–4 hr UnknownQRS

944sodium bicarbonatemones increase insulin synthesis and releasefrom pancreatic beta cells. One type ofincretin hormone, glucagon-like peptide(GLP-1) also lowers glucagon secretionfrom pancreatic alpha cells which reduceshepatic glucose production. These combinedactions decrease blood glucose levelin type 2 diabetes.ContraindicationsDiabetic ketoacidosis, hypersensitivity tositagliptin or its components, type 1 diabetesInteractionsDRUGSACE inhibitors, disopyramide, fibric acidderivatives, fluoxetine, sulfonylureas: Possiblyincreased hypoglycemic effectsbeta blockers: Possibly prolonged hypoglycemiaor promotion of hyperglycemiadigoxin: Slightly increased plasma digoxinlevelestrogens, oral contraceptives, phenytoin,progestines, thiazide diuretics, triamterene:Possibly decreased hypoglycemic effectsAdverse ReactionsCNS: HeadacheEENT: NasopharyngitisGI: Abdominal pain, acute pancreatitis,diarrhea, elevated hepatic enzymes, nausea,vomitingRESP: Upper respiratory tract infectionSKIN: Cutaneous vasculitis, rash, Stevens-Johnson syndrome, urticariaOther: Anaphylaxis, angioedemaNursing Considerations• Assess patient’s renal function before startingsitagliptin therapy, as ordered, andperiodically thereafter. In moderate tosevere renal dysfunction, dosage will bereduced.• Monitor patient for hypersensitivity reactionsthat, although uncommon, may besevere. If present, notify prescriber andexpect sitagliptin to be discontinued.• Monitor patient’s blood glucose level, asordered, to determine effectiveness of sitagliptintherapy.PATIENT TEACHING• Stress the need to follow an exercise programand a diet control program duringsitagliptin therapy.• Advise patient to notify prescriber immediatelyif she has trouble breathing, hives,rash, or swelling.• Inform patient that periodic blood testswill be done to determine effectiveness ofdrug and assess kidney function.• Teach patient how to monitor blood glucoselevel and when to report changes.• Caution patient that taking other drugs inaddition to sitagliptin to control his diabetesmay lead to hypoglycemia. Reviewsigns, symptoms, and appropriate prescribedtreatment with him.• Instruct patient to contact prescriber if hedevelops other illnesses, such as infection,or experiences trauma or surgery becausehis diabetes medication may need adjustment.• Advise patient to carry identification indicatingthat she has diabetes.• Instruct patient to stop taking sitagliptinand report persistent severe abdominalpain, possibly radiating to the back andaccompanied by vomiting.sodium bicarbonateArm and Hammer Pure Baking Soda,Bell/ans, Citrocarbonate, Soda MintClass and CategoryChemical class: ElectrolyteTherapeutic class: Antacid, electrolytereplenisher, systemic and urinary alkalizerPregnancy category: CIndications and Dosages To treat hyperacidityEFFERVESCENT POWDERAdults and adolescents. 3.9 to 10 g in aglass of water after meals. Maximum: 19.5 gdaily.Children ages 6 to 12. 1 to 1.9 g in a glass ofwater after meals.ORAL POWDERAdults and adolescents. One-half tsp in aglass of water every 2 hr, p.r.n. Maximum:4 tsp daily in patients up to age 60.TABLETSAdults and adolescents. 325 mg to 2 g dailyto q.i.d., p.r.n. Maximum: 16 g daily.Children ages 6 to 12. 520 mg, repeatedonce after 30 min, p.r.n. To provide urinary alkalization

ORAL POWDERAdults and adolescents. 1 tsp in a glass ofwater every 4 hr. Maximum: 4 tsp daily inpatients up to age 60.TABLETSAdults and adolescents. Initial: 4 g, then1 to 2 g every 4 hr. Maximum: 16 g daily.Children. 23 to 230 mg/kg daily, adjustedp.r.n.I.V. INFUSIONAdults and children. 2 to 5 mEq/kg over4 to 8 hr. To treat metabolic acidosis during cardiacarrestI.V. INJECTIONAdults and children. Initial: 1 mEq/kg, followedby 0.5 mEq/kg every 10 min whilearrest continues. To treat less urgent forms of metabolicacidosisI.V. INFUSIONAdults and children. 2 to 5 mEq/kg over4 to 8 hr.DOSAGE ADJUSTMENT Dosage reductionpossible for elderly patients because of agerelatedrenal impairment.Mechanism of ActionIncreases plasma bicarbonate level, buffersexcess hydrogen ions, and raises blood pH,thereby reversing metabolic acidosis.Sodium bicarbonate also increases theexcretion of free bicarbonate ions in urine,raising urine pH; increased alkalinity ofurine may help to dissolve uric acid calculi.In addition, it relieves symptoms of hyperacidityby neutralizing or buffering existingstomach acid, thereby increasing the pH ofstomach contents.IncompatibilitiesDon’t admix I.V. form of sodium bicarbonatein same solution or administer throughsame I.V. line as other drugs because precipitatemay form.ContraindicationsHypocalcemia in which alkalosis may leadto tetany; hypochloremic alkalosis secondaryto vomiting, diuretics, or nasogastricsuction; preexisting metabolic or respiratoryalkalosissodium bicarbonate 945InteractionsDRUGSamphetamines, quinidine: Decreased urinaryexcretion of these drugs, possiblyresulting in toxicityanticholinergics: Decreased anticholinergicabsorption and effectivenesscalcium-containing products: Increased riskof milk-alkali syndromechlorpropamide, lithium, salicylates, tetracyclines:Increased renal excretion anddecreased absorption of these drugsciprofloxacin, norfloxacin, ofloxacin:Decreased solubility of these drugs, leadingto crystalluria and nephrotoxicitycitrates: Increased risk of systemic alkalosis;increased risk of calcium calculus formationand hypernatremia in patients withhistory of uric acid calculidigoxin: Possibly elevated digoxin levelenteric-coated drugs: Increased risk of gastricor duodenal irritation from rapidremoval of enteric coatingephedrine: Increased ephedrine half-life andduration of actionH 2 -receptor antagonists, iron supplements orpreparations, ketoconazole: Decreasedabsorption of these drugsmecamylamine: Decreased excretion andprolonged effect of mecamylaminemethenamine: Decreased methenamineeffectivenessmexiletine: Possibly mexiletine toxicitypotassium supplements: Decreased serumpotassium levelsucralfate: Interference with binding ofsucralfate to gastric mucosaurinary acidifiers (ammonium chloride,ascorbic acid, potassium and sodium phosphates):Counteracted effects of urinaryacidifiersFOODSdairy products: Increased risk of milk-alkalisyndrome with prolonged use of sodiumbicarbonateAdverse ReactionsCNS: Mental or mood changesCV: Irregular heartbeat, peripheral edema(with large doses), weak pulseEENT: Dry mouthGI: Abdominal cramps, thirstMS: Muscle spasms, myalgiaSKIN: Extravasation with necrosis, tissuesloughing, or ulcerationNursing Considerations• Monitor sodium intake of patient takingQRS

946sodium ferric gluconatesodium bicarbonate because effervescentpowder contains 700.6 mg of sodium/3.9 g; oral powder contains 952 mg ofsodium/tsp; and tablets contain 325 mg/3.9-mEq tablet, 520 mg/6.2-mEq tablet,and 650 mg/7.7-mEq tablet.• For I.V. infusion, dilute drug with normalsaline solution, D 5 W, or other standardelectrolyte solution before administration.• Avoid rapid I.V. infusion, which can causesevere alkalosis. Be aware that during cardiacarrest, risk of death from acidosismay outweigh risks of rapid infusion.• Monitor urine pH, as ordered, to determinedrug’s effectiveness as urine alkalizer.• If patient on long-term sodium bicarbonatetherapy is consuming calcium or milk,watch for milk-alkali syndrome, characterizedby anorexia, confusion, headache,hypercalcemia, metabolic acidosis, nausea,renal insufficiency, and vomiting.• Be aware that parenteral forms are hypertonicand that increased sodium intakecan produce edema and weight gain.• Assess I.V. site often for evidence ofextravasation. If it occurs, notify prescriberat once and remove I.V. catheter.Elevate the limb, apply warm compresses,and expect prescriber to administer a localinjection of hyaluronidase or lidocaine.PATIENT TEACHING• Advise patient not to take sodiumbicarbonate with large amounts of dairyproducts or for longer than 2 weeks,unless directed by prescriber.• Caution patient not to take more drugthan prescribed to avoid adverse reactions.• Direct patient not to take drug within2 hours of other oral drugs.• Advise patient to avoid taking other prescribedor OTC drugs without prescriber’sapproval because many drugs interactwith sodium bicarbonate.sodium ferricgluconate(contains 62.5 mg elemental iron per 5 ml)FerrlecitClass and CategoryChemical class: Iron salt, mineralTherapeutic class: AntianemicPregnancy category: BIndications and Dosages To treat iron deficiency anemia inpatients receiving long-term hemodialysisand erythropoietinI.V. INFUSION OR INJECTIONAdults. 125 mg of elemental iron. Usual:Minimum cumulative dose of 1 g elementaliron given over eight sequential dialysistreatments. Dosage repeated at lowestdosage needed to maintain target levels ofhemoglobin and hematocrit and acceptablelimits of blood iron level.Mechanism of ActionActs to replenish iron stores lost duringhemodialysis as a result of increased bloodloss or increased iron utilization from epoetintherapy. Iron is an essential componentof hemoglobin, myoglobin, and severalenzymes, including cytochromes, catalase,and peroxidase, and is needed for catecholaminemetabolism and normal neutrophilfunction. Sodium ferric gluconatealso normalizes RBC production by bindingwith hemoglobin or being stored as ferritinin reticuloendothelial cells of the liver,spleen, and bone marrow.IncompatibilitiesDon’t mix sodium ferric gluconate withother drugs or parenteral nutrition solutionsfor I.V. infusion.ContraindicationsAnemia other than iron deficiency, hypersensitivityto iron salts or their components,iron overloadInteractionsDRUGSoral iron preparations: Possibly reducedabsorption of oral iron supplementsAdverse ReactionsCNS: Asthenia, dizziness, fatigue, fever,headache, hypertonia, nervousness, paresthesia,syncopeCV: Chest pain, generalized edema, hypertension,hypotension, tachycardiaEENT: Dry mouthGI: Abdominal pain, diarrhea, nausea,vomitingHEME: HemorrhageMS: Back pain, leg cramps

RESP: Cough, dyspnea, upper respiratorytract infection, wheezingSKIN: Diaphoresis, pruritusOther: Anaphylaxis, generalized pain,hyperkalemia, hypersensitivity, infusion orinjection site reactionNursing Considerations• To reconstitute sodium ferric gluconatefor I.V. infusion, dilute prescribed dosagein 100 ml of normal saline solution immediatelybefore infusion. Infuse over 1 hour.Discard any unused diluted solution.• Inspect drug for particles and discolorationbefore administration and discard ifpresent.• Give undiluted drug by slow I.V. injectionat up to 12.5 mg/min, not to exceed125 mg per injection.• Be aware that most patients need a minimumcumulative dose of 1 gram of elementaliron administered over eightsequential dialysis treatments.WARNING Assess patient for evidence ofallergic reaction, including chills, facialflushing, pruritus, and rash, and of ahypersensitivity reaction, includingdiaphoresis, dyspnea, nausea, severe lowerback pain, vomiting, and wheezing.Discontinue drug and notify prescriberimmediately if patient develops an allergicor hypersensitivity reaction, and be preparedto provide emergency interventions.WARNING Assess blood pressure often afterdrug administration because hypotensionmay occur and may be related to infusionrate or total cumulative dose. Avoid rapidinfusion, and be prepared to provide I.V.fluids for volume expansion.• Expect to monitor blood hemoglobinlevel, hematocrit, serum ferritin level, andtransferrin saturation, as ordered, before,during, and after sodium ferric gluconatetherapy. Make sure serum iron level is tested48 hours after last dose. To prevent irontoxicity, notify prescriber and expect toend therapy if blood iron level is normalor elevated.• Assess patient for possible iron overload,characterized by bleeding in GI tract andlungs, decreased activity, pale conjunctivae,and sedation.PATIENT TEACHING• Warn patient not to take any oral ironsodium phenylbutyrate 947preparations during sodium ferric gluconatetherapy without first consultingprescriber.• Inform patient that symptoms of irondeficiency may include decreased stamina,learning problems, shortness of breath,and fatigue.sodiumphenylbutyrateBuphenylClass and CategoryChemical class: Phenylacetate prodrugTherapeutic class: AntihyperammonemicPregnancy category: CIndications and Dosages As adjunct to treat urea cycle disordersin combination with low-protein dietPOWDER, TABLETSAdults and children weighing more than20 kg (44 lb). 9.9 to 13 g/m 2 daily in 4 to6 divided doses with meals.Children weighing up to 20 kg. 450 to600 mg/kg daily in 4 to 6 divided doseswith meals.Mechanism of ActionProvides alternate pathway for eliminatingwaste nitrogen by forming phenylacetate,an active metabolite that conjugates withglutamine to produce phenylacetylglutamine,which is excreted by the kidneys.ContraindicationsAcute hyperammonemia, hypersensitivityto sodium phenylbutyrate or its componentsInteractionsDRUGScorticosteroids: Increased serum ammonialevelhaloperidol, valproate: Increased risk ofhyperammonemiaprobenecid: Decreased excretion of conjugatedproduct of sodium phenylbutyrateAdverse ReactionsCNS: Depression, disorientation, fatigue,headache, light-headedness, memory loss,syncopeCV: ArrhythmiasQRS

948sodium polystyrene sulfonateEENT: Hypoacusis, taste perversionGI: Abdominal pain, anorexia, constipation,elevated liver function test results, gastritis,nausea, peptic ulcer, rectal bleeding, vomitingGU: Amenorrhea, menstrual irregularitiesHEME: Anemia, aplastic anemia, leukocytosis,leukopenia, thrombocytopeniaSKIN: RashOther: Body odor, hyperchloremia, hypoalbuminemia,hypophosphatemia, metabolicacidosis, metabolic alkalosis, weight gainNursing Considerations• Mix powder form of sodium phenylbutyratewith food or liquid, but not withacidic beverages such as coffee and tea.• Be aware that drug shouldn’t be used totreat acute hyperammonemia, which is amedical emergency.• Monitor patient with history of heart failureor severe renal failure for fluid retentionbecause of drug’s sodium content.PATIENT TEACHING• Instruct patient to take sodium phenylbutyratewith meals but not to mix it withacidic beverages such as coffee and tea.• Advise patient to comply with follow-uplaboratory tests, as prescribed.• Urge patient to notify prescriber immediatelyabout changes in body odor becausethey may signal metabolic imbalance.sodium polystyrenesulfonateKayexalate, K-Exit (CAN), Kionex,PMS-Sodium Polystyrene Sulfonate(CAN), SPS SuspensionClass and CategoryChemical class: Sulfonated cation-exchangeresinTherapeutic class: AntihyperkalemicPregnancy category: CIndications and Dosages To treat hyperkalemiaORAL POWDER, SUSPENSIONAdults. 15 g (4 level tsp) once daily to q.i.d.Maximum: 40 g q.i.d.Children. 1 g/kg/dose, as needed.RECTAL POWDER, SUSPENSIONAdults. 25 to 100 g as retention enema, asneeded.Children. 1 g/kg/dose as retention enema,as needed.Route Onset Peak DurationP.O. 2–12 hr Unknown UnknownMechanism of ActionReleases sodium ions in exchange for othercations in intestines. Resin enters largeintestine and releases sodium ions inexchange for hydrogen ions. As the resinmoves through the intestines, hydrogenions are then exchanged for potassium ions,which are in greater concentration. Boundresin leaves the body in feces, carryingpotassium and other ions with it, therebyreducing serum potassium level.ContraindicationsHypersensitivity to sodium polystyrene sulfonateor its components, hypokalemia,obstructive bowel disease, reduced intestinalmotility in neonates, oral administrationin neonatesInteractionsDRUGSantacids, laxatives: Increased risk of metabolicalkalosispotassium-sparing diuretics, potassium supplements:Increased risk of fluid retentionAdverse ReactionsCV: Peripheral edemaGI: Abdominal cramps, anorexia, colonicnecrosis, constipation, epigastric pain, fecalimpaction, GI bleeding, indigestion,ischemic colitis, nausea, perforation, vomitingGU: Decreased urine outputOther: Hypernatremia, hypocalcemia,hypokalemia, weight gainNursing Considerations• Use sodium polystyrene sulfonate cautiouslyin patients with heart failure,hypertension, or marked edema.• Be aware that drug is available as powderedresin or as solution that containssorbitol to facilitate movement of resinthrough intestines. As a result, patient mayexperience abdominal cramps, diarrhea,nausea, and vomiting.• Because the drug doesn’t take effect for

several hours, be aware that it’s inappropriatefor treating acute, life-threateninghyperkalemia.• If patient has hypokalemia or hypocalcemia,notify prescriber immediately andexpect to withhold drug because it reducespotassium and calcium levels. Evidence ofhypokalemia includes abdominal cramps,acidic urine, anorexia, drowsiness, ECGchanges, hypotension, hypoventilation,muscle weakness, and tachycardia.Evidence of hypocalcemia includesabdominal pain, agitation, anxiety, ECGchanges, hypotension, muscle twitching,psychosis, seizures, and tetany.• To give powdered resin as oral suspension,mix powder in water, syrup, or food andgive promptly, being sure to follow fullaspiration precautions (such as keepingpatient in an upright position while givingdrug). If needed, administer through gastricfeeding tube.• Precede rectal administration with acleansing enema, as ordered.• When giving rectally, suspend powderedresin in 100 ml of aqueous solutionwarmed to body temperature, in bag connectedto soft, large (French 28) catheter.Have patient lie on his left side with hislower leg straight and upper leg flexed orwith his knees to his chest. Gently insertthe tube into the rectum and well into thesigmoid colon. The solution should flowinto the colon by way of gravity and beretained for 30 to 60 minutes or longer, ifpossible. After patient is unable to retainthe solution any longer, administer a nonsodium-containingcleansing enema, asprescribed.• Use of sorbitol with sodium polystyrenesulfonate isn’t recommended because ofincreased risk of colonic necrosis andother serious GI effects, such as bleeding,ischemic colitis, and perforation.• After administration, assess for constipationand fecal impaction.PATIENT TEACHING• Instruct patient not to mix oral form ofsodium polystyrene sulfonate with foodsand liquids high in potassium content,such as bananas and orange juice.• If patient will self-administer rectal solution,teach the correct technique and bodyposition. Remind him to let the solutionflow into the colon by gravity and toretain it for at least 30 to 60 minutes,longer if possible.• Advise patient to notify prescriber immediatelyabout abdominal cramps, nausea,and vomiting.sodiumthiosalicylateRexolate, Tusalsodium thiosalicylate 949Class and CategoryChemical class: Salicylic acid derivativeTherapeutic class: Analgesic, antiinflammatoryPregnancy category: Not ratedIndications and Dosages To relieve symptoms of acute goutI.V. OR I.M. INJECTIONAdults. Initial: 100 mg every 3 to 4 hr for2 days; then 100 mg daily. To relieve pain from musculoskeletalconditionsI.V. OR I.M. INJECTIONAdults. 50 to 100 mg daily or every otherday. To relieve symptoms of osteoarthritisI.V. OR I.M. INJECTIONAdults. 100 mg 3 times/wk for several wk,then once/wk, usually up to a total dosageof 2.5 g. After 1 to 2 wk, another course oftreatment may be given. To treat rheumatic feverI.V. OR I.M. INJECTIONAdults. Initial: 100 to 150 mg every 4 to8 hr for 3 days, then 100 mg b.i.d.Mechanism of ActionExerts peripherally induced analgesic andanti-inflammatory effects by blocking painimpulses and inhibiting prostaglandin synthesis.ContraindicationsGI bleeding; hemophilia; hemorrhage;hypersensitivity to sodium thiosalicylate,NSAIDs, or their components; Reye’s syndromeInteractionsDRUGSACE inhibitors, beta blockers: DecreasedQRS

950ContraindicationsGastric retention, hypersensitivity to solifesolifenacinsuccinateantihypertensive effect of these drugsactivated charcoal: Decreased sodium thiosalicylateabsorptionantacids, urinary alkalizers: Increased excretionof sodium thiosalicylate, leading toreduced drug effectiveness and shortenedhalf-lifecarbonic anhydrase inhibitors (such as acetazolamide):Increased risk of salicylate toxicity;possibly displacement of acetazolamidefrom protein-binding sites, resultingin toxicitycorticosteroids: Possibly increased sodiumthiosalicylate excretioninsulin, oral antidiabetic drugs: Altered glucosecontrol (with large sodium thiosalicylatedoses)loop diuretics: Possibly decreased effectivenessof loop diuretics in patients with renalor hepatic impairmentmethotrexate: Increased risk of methotrexatetoxicitynizatidine: Increased blood sodium thiosalicylatelevelprobenecid, sulfinpyrazone: Decreased uricosuriceffectsspironolactone: Possibly inhibited diureticeffect of spironolactoneurinary acidifiers (including ammoniumchloride, ascorbic acid, methionine):Decreased sodium thiosalicylate excretion,possibly leading to salicylate toxicityACTIVITIESalcohol use: Increased risk of gastrointestinalulcerationAdverse ReactionsGI: Anorexia, diarrhea, GI bleeding, heartburn,hepatotoxicity, indigestion, nausea,thirst, vomitingHEME: Leukopenia, platelet dysfunction,prolonged bleeding time, thrombocytopeniaRESP: BronchospasmSKIN: Rash, urticariaOther: AngioedemaNursing Considerations• Use drug cautiously in patients with asthma,chronic urticaria, or nasal polypsbecause these patients are more prone tohypersensitivity.• Expect to monitor hepatic and renal functionduring long-term drug therapy.• After repeated use or large doses, look forsigns of salicylate toxicity: CNS depression,confusion, diaphoresis, diarrhea, difficultyhearing, dizziness, headache, hyperventilation,lassitude, tinnitus, and vomiting.• Be aware that tinnitus usually means thatthe blood sodium thiosalicylate level hasreached or exceeded the upper limit fortherapeutic effects.PATIENT TEACHING• Instruct patient to notify prescriber immediatelyabout bleeding or symptoms of salicylatetoxicity.solifenacinsuccinateVESIcareClass and CategoryChemical class: Muscarinic receptorantagonistTherapeutic class: Bladder antispasmodicPregnancy category: CIndications and Dosages To treat overactive urinary bladder withsymptoms of urge incontinence, urgency,and frequencyTABLETSAdults. 5 mg daily; if tolerated well,increased to 10 mg daily.DOSAGE ADJUSTMENT For patients withsevere renal impairment or moderatehepatic impairment or patients taking ketoconazoleor other potent CYP3A4inhibitors, dosage limited to 5 mg daily.Route Onset Peak DurationP.O. Unknown 3–8 hr UnknownMechanism of ActionAntagonizes the effect of acetylcholine onmuscarinic receptors in detrusor muscle,decreasing the muscle spasms that causeinappropriate bladder emptying. Thisaction increases bladder capacity and volume,which relieves the sensation ofurgency and frequency and enhances bladdercontrol.

nacin or its components, uncontrolledangle-closure glaucoma, urine retentionInteractionsDRUGSketoconazole, other potent CYP3A4inhibitors: Possibly decreased metabolism ofsolifenacin and increased risk of adverseeffectsAdverse ReactionsCNS: Confusion, depression, dizziness,fatigue, hallucinations, headacheCV: Hypertension, prolonged QT interval,peripheral edema, torsades de pointesEENT: Blurred vision, dry eyes or mouth,pharyngitisGI: Abdominal pain, constipation, indigestion,nausea, vomitingGU: UTI, uriney retentionRESP: CoughRESP: Pruritus, rash, urticariaOther: Angioedema, influenzaNursing Considerations• Use cautiously in patients with ulcerativecolitis, intestinal atony, or myastheniagravis because solifenacin may decrease GImotility; in patients with significant bladderoutflow obstruction because solifenacinmay cause urine retention; inpatients with hepatic impairment becausesolifenacin is metabolized in the liver; andin patients with renal impairment becausesolifenacin excretion may be impaired.• Monitor elderly patients, especially thoseage 75 and over, for adverse reactionsbecause they’re at increased risk for solifenacin-inducedadverse reactions.PATIENT TEACHING• Instruct patient to take solifenacin with afull glass of water and to swallow thetablet whole.• Caution patient to avoid exertion in awarm or hot environment because sweatingmay be delayed, which could increasebody temperature and increase risk ofheatstroke.• Advise patient to avoid potentially hazardousactivities until drug’s CNS effectsare known.• Inform patient that alcohol may causedrowsiness, and urge patient to limit oravoid alcoholic beverages while takingsolifenacin.somatropin 951somatropinAccretropin, Genotropin, Humatrope,Norditropin, Nutropin, Nutropin AQ,Omnitrope, Saizen, Serostim,Tev-TropinClass and CategoryChemical class: Recombinant DNA productTherapeutic class: Growth hormonePregnancy category: B (Serostim) or C(Genotropin, Humatrope, Norditropin,Nutropin, Nutropin AQ, Saizen)Indications and Dosages To treat growth failure caused by growthhormone deficiencySUBCUTANEOUS INJECTION (NUTROPIN,NUTROPIN AQ)Adults. 0.3 mg (0.9 international units)/kg/wk.SUBCUTANEOUS INJECTION (SAIZEN)Adults. Initial: 0.005 mg/kg daily, increasedafter 4 wk by no more than 0.01 mg/kgdaily, as needed.I.M. OR SUBCUTANEOUS INJECTION (HUMATROPE,NUTROPIN, SAIZEN)Children. 0.18 to 0.3 mg (0.54 to 0.9 internationalunits)/kg/wk, divided into equaldoses given daily or every other day over6 to 7 days.SUBCUTANEOUS INJECTION (NORDITROPIN)Adults. Initial: 0.004 mg/kg daily, increasedafter 6 wk by no more than 0.016 mg/kgdaily, as needed.SUBCUTANEOUS INJECTION (GENOTROPIN,NORDITROPIN)Children. 0.16 to 0.24 mg (0.48 to0.72 international units)/kg/wk, dividedinto equal doses given daily over 6 to7 days.SUBCUTANEOUS INJECTION (TEV-TROPIN)Children. Up to 0.1 mg/kg three times/wk.SUBCUTANEOUS INJECTION (OMNITROPE)Adults. Initial: 0.04 mg/kg/wk divided into7 daily doses and increased at 4- to 8-wkintervals, as needed. Maximum: 0.08 mg/kg/wk. Or, 0.15 to 0.30 mg/day.Children. 0.16 to 0.24 mg/kg/wk dividedinto 6 to 7 daily doses.SUBCUTANEOUS INJECTION (ACCRETROPIN)Children. 0.18 to 0.3 mg/kg/wk dividedinto 6 to 7 daily doses.QRS

952somatropin To treat growth failure caused by chronicrenal insufficiencySUBCUTANEOUS INJECTION (NUTROPIN,NUTROPIN AQ)Children. Up to 0.35 mg (1.05 internationalunits)/kg/wk, divided into equal dosesgiven daily. To treat growth failure caused byTurner’s syndromeSUBCUTANEOUS INJECTION (NUTROPIN,NUTROPIN AQ)Adults and children. Up to 0.375 mg(1.125 international units)/kg/wk, dividedinto equal doses given daily or every otherday over 7 days.SUBCUTANEOUS INJECTION (NORDITROPIN)Adults and children. Up to 0.067 mg/kg/day.SUBCUTANEOUS INJECTION (ACCRETROPIN)Children. 0.36 mg/kg/wk divided into 6 to7 daily doses. To treat short stature or growth failurein children with short staturehomeobox-containing gene (SHOX)deficiency whose epiphyses are not closedSUBCUTANEOUS INJECTION (HUMATROPE)Children. 0.35 mg/kg weekly divided intoequal daily doses. To provide long-term treatment ofgrowth failure in children born small forgestational age and no catch-up growthby age 2SUBCUTANEOUS INJECTION (GENOTROPIN)Children. 0.48 mg/kg/wk, divided intoequal doses and administered daily over6 to 7 days.SUBCUTANEOUS INJECTION (HUMATROPE)Children. Up to 0.47 mg/kg/wk, dividedinto equal doses and administered dailyover 6 to 7 days.SUBCUTANEOUS INJECTION (NORDITROPIN)Children. Up to 0.067 mg/kg/day. To treat growth factor failure due toPrader-Willi syndromeSUBCUTANEOUS INJECTION (GENOTROPIN)Children. 0.24 mg/kg/wk. To treat AIDS-related cachexia orweight lossSUBCUTANEOUS INJECTION (SEROSTIM)Adults weighing more than 55 kg (121 lb).6 mg at bedtime.Adults weighing 45 to 55 kg (99 to 121 lb).5 mg at bedtime.Adults weighing 35 to 45 kg (77 to 99 lb).4 mg at bedtime.Adults weighing less than 35 kg. 0.1 mg/kgat bedtime.DOSAGE ADJUSTMENT For patients atincreased risk for adverse effects related toSerostim, 0.1 mg/kg every other day. Forelderly patients, regardless of type of somatropinprescribed, lower starting dose andsmaller dosage titration recommended.Route Onset Peak DurationI.M., Unknown Unknown 12–48 hrSubQMechanism of ActionIncreases production of somatomedins (orinsulin-like growth factor) in the liver andother tissues, which mediates somatropin’sanabolic and growth-promoting effects.The drug binds to specific receptorsthroughout the body, stimulating aminoacid transport; DNA, RNA, and proteinsynthesis; cell proliferation; and growth ofbone and soft tissue.Somatropin also decreases insulin cellreceptor sensitivity, thereby increasingblood glucose level; stimulates triglyceridehydrolysis in adipose tissue and hepatic glucoseoutput; and aids bone growth by promotinga positive calcium balance andretention of sodium and potassium.ContraindicationsActive neoplasia; active proliferative orsevere nonproliferative diabetic retinopathy;acute critical illness due to complicationsfollowing open-heart surgery, abdominalsurgery, or multiple trauma; acute respiratoryfailure; cancer; closed epiphyses;hypersensitivity to somatropin, its components,or benzyl alcohol; Prader-Willi syndromecoupled with severe obesity, historyof upper airway obstruction or sleep apnea,or severe respiratory impairmentInteractionsDRUGSanabolic steroids, androgens, estrogens, thyroidhormones: Possibly accelerated epiphysealclosureanticonvulsants, corticosteroids, cyclosporine,sex steroids: Possibly altered clearance ofthese drugs, increasing risk of adverseeffectscorticosteroids, corticotropin: Inhibitedgrowth response to somatropin; decreased

esponse of corticosteroids or corticotropinoral estrogens: Decreased somatropin effectivenessAdverse ReactionsCNS: Depression, dizziness, fatigue,headache, hypoesthesia, insomnia, intracranialhypertension or tumor, paresthesia,weaknessCV: Chest pain, edema, hypertriglyceridemiaEENT: Otitis, papilledema, rhinitis, sinusitis,tonsillitis, vision changes, worsening ofdiabetic retinopathyENDO: Breast pain, edema, tenderness, ormass; gynecomastia; hyperglycemia;hypothyroidismGI: Nausea, pancreatitis, vomitingGU: UTIHEME: EosinophiliaMS: Arthralgia; back, bone, joint, or legpain; carpal tunnel syndrome; myalgia; progressionof existing scoliosis; slipped capitalfemoral epiphysis (children)RESP: Upper respiratory tract infectionSKIN: Increased growth of nevi, rashOther: Elevated serum alkaline phosphatase,inorganic phosphorus, and parathyroidhormone levels; flulike symptoms;injection site inflammation, lipoatrophyNursing Considerations• Be aware that somatropin shouldn’t beused in patients with malignancy andshould be stopped if patient is diagnosedwith malignancy. Cancer treatment mustbe completed with evidence of remissionbefore somatropin can be started orrestarted.• Make sure patient with Prader-Willi syndromehas been evaluated for upper airwayobstruction and sleep apnea beforestarting somatropin because of increasedrisk of respiratory arrest. Notify prescriberimmediately and expect to stop drug ifpatient starts snoring, snoring increases,or other evidence of upper airwayobstruction develops.• Make sure patient has a funduscopic eyeexamination before starting and periodicallythroughout somatropin therapy torule out papilledema.• Use cautiously in elderly patients becausethey’re more prone to adverse reactions tosomatropin. Expect initial dosage to besomatropin 953lower and dosage adjustment more gradualto minimize adverse effects.• Reconstitute somatropin according topackage directions. (Nutropin AQ andforms available in cartridges, such asNorditropin NordiFlex, don’t requirereconstitution.) In general, swirl vial gentlyrather than shaking it to dissolve contents.• Don’t reconstitute with diluent containingbenzyl alcohol if drug will be given toneonate. Don’t use diluent supplied forHumatrope for patients sensitive toMetacresol or glycerin; use sterile water forinjection.• Store Nutropin AQ vials and cartridgesrefrigerated in a dark place.• Remember to rotate injection sites toavoid tissue atrophy at injection site.WARNING Although uncommon, intracranialhypertension is possible. Monitorpatient for such signs and symptoms asheadache, nausea, papilledema, visionchanges, and vomiting, especially duringfirst 8 weeks of therapy. If intrancranialhypertension occurs, notify prescriber,expect to discontinue drug, and providesupportive care, as needed.• Because somatropin is a protein, monitorpatient for local or systemic allergic reaction.• Monitor patient’s blood glucose levelbecause somatropin may decrease insulinsensitivity, especially at higher does.• Monitor patient’s thyroid function andobtain periodic test results, as ordered,because untreated hypothyroidsm mayinterfere with somatropin, especially inchildren.• Assess patient’s skin regularly for changesthat suggest skin malignancy.PATIENT TEACHING• Instruct diabetic patient who takes insulinto monitor blood glucose level frequently;somatropin may induce insulin resistance.• Inform parents of a child with Turner’ssyndrome about increased risk of earinfections.• Advise family or cargiver to observepatient for limping, which may indicate aslipped epiphysis.• Teach patient or caregiver how to measureand administer drug at home using eitherpen device or vial, syringe, and needle.QRS

954sotalol hydrochloridesotalolhydrochlorideBetapace, Betapace AF, Sotacor (CAN)Class and CategoryChemical class: MethanesulfonanilideTherapeutic class: Class III antiarrhythmicPregnancy category: BIndications and Dosages To treat life-threatening ventriculararrhythmiasTABLETSAdults. Initial: 80 mg b.i.d. Maintenance:160 to 320 mg daily in divided doses b.i.d.or t.i.d. Maximum: 640 mg daily.DOSAGE ADJUSTMENT If creatinine clearanceis 30 to 60 ml/min/1.73 m 2 , dosage intervalextended to every 24 hr; if creatinine clearanceis less than 30 ml/min/1.73 m 2 , dosageinterval extended to every 36 to 48 hr,according to response; if creatinine clearanceless than 10 ml/min/1.73 m 2 , dosageadjusted as prescribed. To maintain normal sinus rhythm inpatients with highly symptomatic atrialfibrillation who are currently in sinusrhythmTABLETSAdults. Initial: If creatinine clearance is40 to 60 ml/min/1.73 m 2 , give 80 mg daily;if creatinine clearance exceeds 60 ml/min/1.73 m 2 , give 80 mg b.i.d. Maintenance:After at least 3 days (five or six doses givendaily), if 80-mg dose is tolerated and QTinterval less than 500 msec, dosage maintainedand patient discharged. Or hospitalizedpatient monitored closely to determinemaintenance dosage while increasing to120 mg b.i.d. for 3 days (five or six doses ifdaily dosing). Maximum: 160 mg b.i.d. ifcreatinine clearance exceeds 60 ml/min/1.73 m 2 .DOSAGE ADJUSTMENT If 80-mg once ortwice daily doesn’t reduce frequency of atrialfibrillation relapses and is tolerated withoutexcessive QT-interval prolongation(greater than 520 msec), dosage increasedto 120 mg once or twice daily, dependingon creatinine clearance. If 120-mg dosedoesn’t reduce frequency of early relapseand is tolerated using same criteria, dosageincreased to 160 mg once or twice daily,depending on creatinine clearance.DOSAGE ADJUSTMENT If QT interval is520 msec or more, dosage reduced until itreturns to less than 520 msec. If QT intervalexceeds 520 msec with lowest maintenancedosage of 80 mg, drug stopped. If renalfunction deteriorates, daily dose reduced byhalf and given daily.Route Onset Peak DurationP.O. Unknown 2–3 hr UnknownMechanism of ActionCombines class II and class III antiarrhythmicactivity to increase sinus cycle length.This beta blocker decreases AV nodal conductionand increases AV nodal refractoriness.Suppression of SA node automaticityand AV node conductivity decreases atrialand ventricular ectopy.ContraindicationsAsthma, atrial arrhythmias (if baseline QTinterval exceeds 450 msec or creatinineclearance is less than 40 ml/min/1.73 m 2 ),cardiogenic shock, congenital or acquiredQT syndromes, COPD, heart failure (unlessit results from tachyarrhythmia that’s treatableby sotalol), hypersensitivity to sotalolor its components, second- or third-degreeAV block without functioning pacemaker,sinus bradycardiaInteractionsDRUGSallergen immunotherapy, allergenic extractsfor skin testing: Increased risk of serious systemicadverse reaction or anaphylaxisamiodarone: Additive depressant effect onconduction, negative inotropic effectanesthetics (hydrocarbon inhalation):Increased risk of myocardial depression andhypotensionantacids: Altered sotalol effectivenessastemizole, class I antiarrhythmics, phenothiazines,terfenadine, tricyclic antidepressants:Prolonged QT interval, life-threateningtorsades de pointesbeta blockers (other): Additive beta blockadebeta 2 -receptor stimulants: Decreased effectivenessof these drugscalcium channel blockers, clonidine, diazoxide,guanabenz, reserpine and other antihypertensives:Additive antihypertensive

effect and, possibly, other beta-blockingeffectscimetidine: Possibly impaired sotalol clearanceglucagon: Possibly blunted hyperglycemicresponseinsulin, oral antidiabetic drugs: Impairedglucose control, increased risk of hyperglycemialidocaine: Decreased lidocaine clearance,increased risk of lidocaine toxicityMAO inhibitors: Increased risk of significanthypertensionneuromuscular blockers: Possibly potentiatedand prolonged neuromuscular blockadephenothiazines: Increased blood levels ofboth drugspropafenone: Increased blood level and halflifeof sotalolsympathomimetics, xanthines: Possiblymutual inhibition of therapeutic effectsAdverse ReactionsCNS: Anxiety, depression, dizziness, drowsiness,fatigue, insomnia, lethargy, nervousness,weaknessCV: AV conduction disorders, bradycardia,heart failure, hypotension, peripheral vascularinsufficiencyEENT: Nasal congestionENDO: Hyperglycemia, hypoglycemiaGI: Abdominal pain, constipation, diarrhea,nausea, vomitingGU: Sexual dysfunctionMS: Muscle weaknessRESP: Bronchospasm, dyspnea, wheezingNursing Considerations• Expect to obtain baseline creatinine clearanceand QT interval before startingsotalol.• Monitor blood pressure, apical and radialpulses, fluid intake and output, dailyweight, respiratory rate, and circulation inlimbs before and during sotalol therapy.• If prescriber is stopping amiodarone, beaware that sotalol shouldn’t be starteduntil QT interval has returned to baselinebecause of possible adverse cardiac effects.• Be aware that stopping sotalol abruptlymay cause life-threatening reactions.• Monitor serum electrolyte levels becausedrug can increase risk of torsades depointes in patients with electrolyte imbalances,especially hypokalemia or hypomagnesemia.• Assess carefully if patient has diabetesmellitus or thyrotoxicosis because theymay mask hypoglycemia and hyperthyroidism.PATIENT TEACHING• Advise patient to notify prescriber immediatelyif he has difficulty breathing.• Urge patient to consult prescriber beforetaking OTC drugs, especially cold remedies,which may decrease sotalol’s effectiveness.• Urge patient to avoid hazardous activitiesuntil drug’s CNS effects are known.sparfloxacinZagamClass and CategoryChemical class: FluoroquinoloneTherapeutic class: AntibioticPregnancy category: Csparfloxacin 955Indications and Dosages To treat community-acquired pneumoniacaused by Chlamydia pneumoniae,Haemophilus influenzae, H. parainfluenzae,Moraxella catarrhalis,Mycoplasma pneumoniae, or Streptococcuspneumoniae and acute bacterialexacerbations of chronic bronchitiscaused by C. pneumoniae, Enterobactercloacae, H. influenzae, H. parainfluenzae,Klebsiella pneumoniae, M.catarrhalis, Staphylococcus aureus, orS. pneumoniaeTABLETSAdults. 400 mg on day 1, followed by200 mg/day for 10 days.DOSAGE ADJUSTMENT For patients with creatinineclearance less than 50 ml/min/1.73 m 2 , 400 mg on day 1 and then dosinginterval extended to 200 mg every 48 hr for9 days.Mechanism of ActionCauses bacterial cells to die by inhibitingthe enzyme DNA gyrase, which is responsiblefor unwinding and supercoiling bacterialDNA before it replicates.ContraindicationsHistory of photosensitivity, hypersensitivityQRS

956spectinomycin hydrochlorideto quinolone derivatives, job or lifestyle thatprecludes compliance with measures to preventphototoxicity, prolonged QTc intervalor use of drugs that can prolong QTc intervalInteractionsDRUGSaluminum-, calcium-, or magnesiumcontainingantacids; ferrous sulfate;magnesium-containing laxatives; sucralfate;zinc: Decreased bioavailability ofsparfloxacinamiodarone, astemizole, bepridil, cisapride,class IA antiarrhythmics (disopyramide,quinidine, procainamide), class III antiarrhythmics(ibutilide, sotalol), erythromycin,pentamidine, phenothiazines, terfenadine,tricyclic antidepressants, other drugsthat can prolong QTc interval: Possiblyprolonged QTc interval and torsades depointesAdverse ReactionsCNS: Asthenia, cerebral thrombosis, dizziness,drowsiness, headache, insomnia, lightheadedness,nervousness, seizures, somnolenceCV: Cardiopulmonary arrest, embolism,prolonged QTc interval, torsades depointes, vasodilationEENT: Laryngeal edema, taste perversionGI: Abdominal pain, diarrhea, hepaticnecrosis or failure, hepatitis, intestinal perforation,nausea, pseudomembranous colitis,vomitingGU: Acute renal failure, vaginal candidiasisHEME: Agranulocytosis, hemolytic anemia,pancytopenia, thrombocytopeniaMS: Rhabdomyolisis, tendinitis, tendonruptureRESP: Interstitial pneumonia, pulmonaryedemaSKIN: Photosensitivity, pruritus, rash,Stevens-Johnson syndrome, toxic epidermalnecrolysisOther: Acidosis, anaphylaxis, angioedema,squamous cell carcinomaNursing Considerations• Use sparfloxacin cautiously in patientswith known or suspected CNS disordersbecause of risk of seizures. Instituteseizure precautions according to facilitypolicy.• Monitor renal and liver function testresults, as appropriate, during prolongedtherapy.• Measure QTc interval regularly becausesparfloxacin has been found to increaseQTc interval and risk of torsades depointes.• Severe diarrhea may indicate pseudomembranouscolitis; give fluid, electrolyte, andprotein replacement, as ordered.PATIENT TEACHING• Urge patient to avoid potentially hazardousactivities until sparfloxacin’s CNSeffects are known.• Advise patient to notify prescriber at onceabout aching or throbbing tendon pain.• Instruct patient to wait 4 hours after takingsparfloxacin before taking antacidsthat contain aluminum, calcium, or magnesium;laxatives that contain magnesium;or vitamins that contain iron or zinc.• Caution patient to avoid exposure to sunlight,bright natural light, and othersources of ultraviolet light during therapyand for 5 days afterward. Urge him towear sunscreen and protective clothingwhen outdoors.• Urge patient to notify prescriber at firstsign of photosensitivity reaction (blistering,burning or swelling sensation, itching,rash, redness).spectinomycinhydrochlorideTrobicinClass and CategoryChemical class: Aminocyclitol, aminoglycosidederivativeTherapeutic class: AntibioticPregnancy category: Not ratedIndications and Dosages To treat acute endocervical, rectal, andurethral gonorrhea caused by susceptiblestrains of Neisseria gonorrhoeaeI.M. INJECTIONAdults and children weighing 45 kg (99 lb)or more. 2 g as a single dose, repeated asprescribed for adult if reinfection occurs oris strongly suspected. Maximum: 4 g foradults, 2 g for children.

Children weighing less than 45 kg (exceptinfants). 40 mg/kg as a single dose.Mechanism of ActionBinds to negatively charged sites on bacterialouter cell membrane, disrupting cellintegrity, and binds to bacterial ribosomalsubunits, inhibiting protein synthesis. Bothactions lead to bacterial cell death.ContraindicationsHypersensitivity to spectinomycin or itscomponentsAdverse ReactionsCNS: Dizziness, insomniaGI: Abdominal cramps, nausea, vomitingOther: Injection site painNursing Considerations• To reconstitute spectinomycin, add 3.2 mlbacteriostatic water for injection (withbenzyl alcohol) to each 2-g vial or 6.2 mlof diluent to each 4-g vial. Shake vial vigorouslybefore withdrawing dose.• Administer I.M. injection deep into largemuscle mass, preferably upper outer quadrantof gluteal muscle.PATIENT TEACHING• Tell patient he’ll be tested for syphilis atthe start of treatment and 3 months laterbecause spectinomycin treatment maymask or delay syphilis symptoms.• Explain risk factors for sexually transmitteddiseases, and teach correct condomuse.• Advise patient to encourage sexual partnerto be tested for gonorrhea.• Instruct patient to notify prescriber ifsigns and symptoms persist after a fewdays.spironolactoneAldactone, Novospiroton (CAN)Class and CategoryChemical class: Aldosterone antagonistTherapeutic class: Aldosterone antagonist,antihypertensive, diagnostic aid for primaryhyperaldosteronism, diureticPregnancy category: Not ratedIndications and Dosages To treat edema cause by heartfailure, hepatic cirrhosis, orspironolactone 957nephrotic syndromeTABLETSAdults. Initial: 25 to 200 mg daily in divideddoses b.i.d. to q.i.d. for at least 5 days.Maintenance: 75 to 400 mg daily in divideddoses b.i.d. to q.i.d. Maximum: 400 mgdaily.Children. Initial: 1 to 3 mg/kg daily as asingle dose or in divided doses b.i.d. toq.i.d. for at least 2 wk; adjusted, as needed,after 5 days. Maximum: 3 times initial dose. To treat hypertensionTABLETSAdults. Initial: 50 to 100 mg daily as a singledose or in divided doses b.i.d. to q.i.d.for at least 2 wk; gradually adjusted every2 wk, as needed, to control blood pressure,up to 200 mg daily. Maximum: 400 mgdaily.Children. Initial: 1 to 3 mg/kg daily as asingle dose or in divided doses b.i.d. toq.i.d. for at least 2 wk; adjusted, as needed,after 5 days. Maximum: 3 times initial dose. To aid in the diagnosis of primaryhyperaldosteronismTABLETSAdults. For long test, 400 mg daily in divideddoses b.i.d. to q.i.d. for 3 to 4 wk; forshort test, 400 mg daily in divided dosesb.i.d. to q.i.d. for 4 days. To treat primary hyperaldosteronismTABLETSAdults. 100 to 400 mg daily in divideddoses b.i.d. to q.i.d. before surgery.Maximum: 400 mg daily.DOSAGE ADJUSTMENT Long-term maintenancedosage decreased for patients at riskfor complications during surgery. To substitute as therapy for diureticinducedhypokalemiaTABLETSAdults. 25 to 100 mg daily as a single doseor in divided doses b.i.d. to q.i.d.Maximum: 400 mg daily.Route Onset Peak DurationP.O.* Unknown 2–3 days 2–3 daysContraindicationsAcute renal insufficiency, anuria, hyperkalemia,hypersensitivity to spironolactone orits components* For diuretic effect; others unknown.QRS

958spironolactoneMechanism of ActionNormally, aldosterone attaches to receptorson the walls of distal convolutedtubule cells, causing sodium (Na + ) andwater (H 2 0) reabsorption in the blood, asshown at left. Spironolactone competeswith aldosterone for these receptors,Bloodvesselthereby preventing sodium and waterreabsorption and causing their excretionthrough the distal convoluted tubules, asshown below right. Increased urinaryexcretion of sodium and water reducesblood volume and blood pressure.AldosteroneAldosteroneReceptorDistalconvolutedtubuleSpironolactoneNa Na + + Na Na + + Na Na + +Na Na + +H 2 O 2 HH 2 O 2 ONa Na + +H 2 O 2 H 2 O 2 H 2 O 2 InteractionsDRUGSACE inhibitors, cyclosporine, other potassium-sparingdiuretics, potassium-containingdrugs, potassium supplements: Increased riskof hyperkalemiadigoxin: Possibly increased half-life of digoxinexchange resins (sodium cycle), such as sodiumpolystyrene sulfonate: Increased risk ofhypokalemia and fluid retentionheparin, oral anticoagulants: Decreased anticoagulanteffect of these drugshypotension-producing drugs: Possiblypotentiated antihypertensive or diureticeffect of spironolactonelithium: Possibly lithium toxicityNSAIDs, sympathomimetics: Decreased antihypertensiveeffect of spironolactoneFOODSlow-salt milk, salt substitutes: Increased riskof hyperkalemiaAdverse ReactionsCNS: Dizziness, encephalopathy, fatigue,headacheEENT: Increased intraocular pressure, nasalcongestion, tinnitus, vision changesENDO: GynecomastiaGI: Abdominal pain, anorexia, constipation,diarrhea, flatulence, nausea, vomitingGU: ImpotenceHEME: Aplastic anemia, neutropeniaRESP: Cough, dyspneaMS: Arthralgia, back and leg pain, muscleweakness, myalgiaOther: HyperkalemiaNursing Considerations• Be aware that for children or patients whohave trouble swallowing, pharmacist maycrush spironolactone tablets, mix with flavoredsyrup, and dispense as a suspension.It’s stable 1 month when refrigerated.• In diagnosing primary aldosteronism, testis considered positive if patient’s serumpotassium level rises when spironolactoneis given and falls when it’s discontinued.• Expect to evaluate patient’s serum potassiumlevel 1 week after spiraonolactonetherapy begins, after each dosage adjustment,monthly for the first 3 months,quarterly for 1 year, and then every 6months thereafter or as ordered. Notifyprescriber if level exceeds 5 mEq/L orpatient’s renal function deteriorates(serum creatinine level exceeding 4 mg/dl). If patient has severe heart failure, followclosely because hyperkalemia may befatal in such patients.• Evaluate spironolactone’s effectiveness byassessing blood pressure and edema.

• Stop drug for several days, as prescribed,before patient undergoes adrenal veincatheterization to measure serum aldosteronelevel and plasma renin activity.PATIENT TEACHING• Instruct patient to take spironolactonewith meals or milk.• If patient can’t swallow tablets, mentionthat pharmacist can crush and mix themwith a flavored syrup as a suspension.• Teach patient who takes spironolactonefor hypertension how to measure hisblood pressure. Urge him to monitor itregularly and report pressure greater than140 mm Hg systolic or 90 mm Hg diastolicto prescriber.• Caution patient that he may experiencedizziness during spironolactone therapy iffluid balance is altered.streptokinaseKabikinase, StreptaseClass and CategoryChemical class: Purified beta-hemolyticStreptococcus filtrateTherapeutic class: ThrombolyticPregnancy category: CIndications and Dosages To lyse coronary artery thrombiI.V. INFUSIONAdults. 1,500,000 international units within60 min of event.INTRACORONARY INFUSIONAdults. 20,000-international unit bolus, followedby 2,000 international units/min for60 min for total dose of 140,000 internationalunits. To lyse acute arterial thromboembolismor thrombosis, acute pulmonary embolism,or deep vein thrombosisI.V. INFUSIONAdults. 250,000-international unit bolusover 30 min, followed by 100,000 internationalunits/hr for 24 to 72 hr. To clear an occluded arteriovenouscannulaI.V. INJECTIONAdults. 100,000 to 250,000 internationalunits instilled slowly into each occludedlumen.streptokinase 959Mechanism of ActionBinds to fibrin in thrombus and convertstrapped plasminogen to plasmin. Plasminbreaks down fibrin, fibrinogen, and otherclotting factors, thereby dissolving thethrombus.Route Onset Peak DurationI.V. Immediate 20–120 4 hrminIncompatibilitiesDon’t mix streptokinase in the same syringeor give through the same I.V. line as otherdrugs.ContraindicationsActive internal bleeding, AV malformationor aneurysm, bleeding diathesis, history ofstroke or intracranial or intraspinal surgerywithin the previous 2 months, hypersensitivityto streptokinase or its components,intracranial cancer, severe uncontrolledhypertensionInteractionsDRUGSanticoagulants, enoxaparin, heparin,NSAIDs, platelet aggregation inhibitors:Increased risk of bleedingantifibrinolytics: Antagonized effects of bothdrugsantihypertensives: Increased risk of severehypotension, especially when streptokinaseis administered rapidly to treat coronaryartery occlusioncefamandole, cefoperazone, cefotetan, plicamycin,valproic acid: Possibly hypoprothrombinemiaand increased risk of severehemorrhagecorticosteroids, ethacrynic acid, salicylates:Possibly GI ulceration or bleedingAdverse ReactionsCNS: Chills, feverCV: Arrhythmias, hypotensionHEME: Unusual bleeding or bruisingNursing Considerations• Obtain hematocrit, platelet count, APTT,PT, and INR, as ordered, before givingstreptokinase.• To prevent foaming, don’t shake drug duringreconstitution.• Check requently for bleeding at I.V. siteQRS

960streptomycin sulfateand for blood in urine and stool. Performneurologic assessment to detect intracranialbleeding.• If serious spontaneous bleeding (not controlledby local pressure) occurs, stopstreptokinase infusion immediately andnotify prescriber.• Monitor heart rate and rhythm by continuousECG, as ordered.• Treat fever with acetaminophen, as prescribed,rather than aspirin to reduce therisk of bleeding.PATIENT TEACHING• Explain to patient that he’ll be on bed restduring streptokinase therapy.• Inform patient that minor bleeding mayoccur at arterial puncture or surgical sites.Reassure him that appropriate care measureswill be taken if bleeding occurs.• Advise patient to wear or carry medicalalert identification stating that he takesstreptokinase.• Inform patient that if he experiences chestpain within 12 months of therapy, heshould notify health care providers that hehas received streptokinase because repeatedadministration within 12 months maybe ineffective.streptomycin sulfateClass and CategoryChemical class: AminoglycosideTherapeutic class: AntibioticPregnancy category: DIndications and Dosages To treat gram-negative bacillary bacteremia,meningeal infections, pneumonia,systemic infections, and UTI causedby susceptible strains of Aerobacteraerogenes, Brucella, Calymmatobacteriumgranulomatis, Enterococcusfaecalis, Escherichia coli, Haemophilusducreyi, H. influenzae, Klebsiella pneumoniae,and ProteusI.M. INJECTIONAdults. 1 to 2 g daily in divided doses every6 to 12 hr. Maximum: 2 g daily.Children. 20 to 40 mg/kg daily in divideddoses every 6 to 12 hr. As adjunct to treat endocarditis causedby Streptococcus viridans or E. faecalisI.M. INJECTIONAdults. 1 g b.i.d. for 1 wk (S. viridans) or2wk (E. faecalis) with a penicillin. Then,500 mg b.i.d. for 1 wk (S. viridans) or 4 wk(E. faecalis). As adjunct to treat tuberculosis causedby Mycobacterium tuberculosisI.M. INJECTIONAdults. 1 g daily with other antibiotics;dosage reduced to 1 g 2 or 3 times/wk, asappropriate and prescribed. Maximum: 2 gdaily.Children. 20 mg/kg daily with other antibiotics.Maximum: 1 g daily.DOSAGE ADJUSTMENT For elderly patients,dosage decreased to 500 to 750 mg daily incombination with other antibiotics. To treat plague caused by Yersinia pestisI.M. INJECTIONAdults. 2 g daily in 2 equally divided dosesfor at least 10 days.Children. 30 mg/kg daily in divided dosesb.i.d. or t.i.d. for 10 days. To treat tularemia caused by FrancisellatularensisI.M. INJECTIONAdults. 1 to 2 g daily in divided doses for7 to 14 days.DOSAGE ADJUSTMENT If creatinine clearanceis 50 to 80 ml/min/1.73 m 2 , dosage reducedto 7.5 mg/kg I.M. every 24 hr; if 10 to49 ml/min/1.73 m 2 , 7.5 mg/kg I.M. every24 to 72 hr; if less than 10 ml/min/1.73 m 2 ,7.5 mg/kg I.M. every 72 to 96 hr.Mechanism of ActionBinds to negatively charged sites on thebacteria’s outer cell membrane, disruptingcell integrity. Streptomycin also binds tobacterial ribosomal subunits and inhibitsprotein synthesis. Both actions lead to bacterialcell death.IncompatibilitiesDon’t mix streptomycin in same solution oradminister through same I.V. line as otherantibiotics.ContraindicationsHypersensitivity to streptomycin or otheraminoglycosidesInteractionsDRUGSantimyasthenics: Possibly decreased effect ofantimyasthenics on skeletal muscle

eta-lactam antibiotics: Inactivation ofstreptomycincapreomycin, other aminoglycosides:Increased potential for ototoxicity, nephrotoxicity,and neuromuscular blockadeindomethacin (I.V.): Decreased renal clearanceof streptomycin when given to prematureneonates, possibly leading to aminoglycosidetoxicitymethoxyflurane, polymyxins (parenteral):Increased risk of nephrotoxicity and neuromuscularblockadenephrotoxic and ototoxic drugs: Increasedrisk of nephrotoxicity and ototoxicityneuromuscular blockers: Increased neuromuscularblockadeAdverse ReactionsCNS: Clumsiness, dizziness, neurotoxicity,paresthesia, peripheral neuropathy, seizures,unsteadiness, vertigoEENT: Hearing loss, sensation of fullness inears, tinnitus, vision lossGI: Anorexia, nausea, thirst, vomitingGU: Decreased or increased urine output,nephrotoxicityMS: Muscle twitchingSKIN: Erythema, pruritus, rash, urticariaNursing Considerations• Use streptomycin cautiously in patientswith renal impairment. In severely uremicpatients, single dose can produce highblood level of drug for several days; cumulativeeffects may produce ototoxicity.• Expect prescriber to order baseline renalfunction studies and to assess cranialnerve VIII function (responsible for hearing)at start of streptomycin therapy toallow for later comparisons.• Monitor serum peak and trough levels, asordered, to ensure adequate but not toxicdrug level.• Be aware that streptomycin should begiven only by I.M. injection.• To reconstitute streptomycin, add between4.2 and 4.5 ml of sodium chloride forinjection or sterile water for injection toeach 1-g vial to provide a concentration of200 mg/ml, or add between 3.2 and 3.5 mlof diluent to each 5-g vial to provide aconcentration of 250 mg/ml. Alternatively,add 6.5 ml of diluent to each 5-g vial toprovide a concentration of 500 mg/ml.• Don’t give more than 500 mg/ml.InteractionsDRUGSaluminum-containing drugs (such as antsucralfate961• Rotate injection sites to prevent sterileabscess formation.PATIENT TEACHING• Advise patient to refrigerate streptomycinsolution at 36° to 46° F (2° to 8° C).• Inform patient that treatment for tuberculosislasts at least 1 year.• Urge patient to notify prescriber if he hasfullness or ringing in ears, hearing loss, orvertigo.sucralfateApo-sucralfate (CAN), Carafate,Sulcrate (CAN), Sulcrate SuspensionPlus (CAN)Class and CategoryChemical class: Disulfated disaccharide, aluminumsaltTherapeutic class: AntiulcerPregnancy category: BIndications and Dosages To prevent duodenal ulcerTABLETSAdults and adolescents. 1 g b.i.d. To treat active duodenal ulcerORAL SUSPENSIONAdults and adolescents. 1 g q.i.d. 1 hrbefore meals and at bedtime for 4 to 8 wk,possibly less. Or, 2 g b.i.d. on empty stomachon waking and at bedtime for 4 to8 wk, possibly less.TABLETSAdults and adolescents. 1 g q.i.d. 1 hrbefore meals and at bedtime for 4 to 8 wk,possibly less.Mechanism of ActionMay react with hydrochloric acid in thestomach to form a complex that buffersacid. The complex adheres electrostaticallyto proteins on the ulcer’s surface and createsa protective barrier at the ulcer site.Sucralfate also inhibits back-diffusion ofhydrogen ions and adsorbs pepsin and bileacids, actions that promote healing of anexisting duodenal ulcer and prevent ulcerformation.QRS

962sulfadiazineacids, antidiarrheals, buffered aspirin withaluminum, and vaginal douches): Possiblyaluminum toxicity in patients with renalfailureantacids: Possibly interference with bindingof sucralfate to GI mucosacimetidine, ciprofloxacin, digoxin, norfloxacin,ofloxacin, phenytoin, ranitidine, tetracycline,theophylline: Decreased bioavailabilityof these drugsAdverse ReactionsCNS: Dizziness, drowsiness, light-headednessEENT: Dry mouthGI: Constipation, diarrhea, indigestion,nausea, vomitingMS: Back painSKIN: Pruritus, rash, urticariaNursing Considerations• Use sucralfate cautiously in patients withchronic renal failure because of increasedrisk of aluminum toxicity.• Administer drug to patient when he hasan empty stomach.PATIENT TEACHING• Instruct patient to take sucralfate on anempty stomach at least 1 hour beforemeals and at bedtime.• Advise patient not to take antacids within30 minutes of sucralfate.• Caution patient to check with prescriberbefore taking another drug within 2 hoursof sucralfate.sulfadiazineClass and CategoryChemical class: SulfonamideTherapeutic class: Antibiotic, antiprotozoalPregnancy category: CIndications and Dosages To treat asymptomatic carriers ofmeningitisTABLETSAdults and adolescents. 1 g every 12 hr for2 days.Children ages 1 to 12. 500 mg every 12 hrfor 2 days.Children ages 2 to 12 months. 500 mg dailyfor 2 days. To prevent recurrent rheumatic feverTABLETSAdults and adolescents. 500 mg daily (forpatients weighing less than 30 kg [66 lb]) to1 g daily (for patients weighing 30 kg ormore). To treat inclusive nocardiosisTABLETSAdults and adolescents. 4 to 8 g daily for atleast 6 wk. As adjunct to treat toxoplasmosis inpatients with AIDSTABLETSAdults and adolescents. 1 to 2 g every 6 hr,with 50 to 100 mg daily of pyrimethamineand 10 to 25 mg daily of leucovorin.Children age 2 months and over. 50 mg/kgb.i.d. for 12 mo, together with 2 mg/kgdaily of pyrimethamine for 2 days, then1 mg/kg/day of pyrimethamine for 2 to6 mo, then 1 mg/kg daily of pyrimethamine3 times/wk for remainder of 12 mo; inaddition, 5 mg of leucovorin given 3 times/wk for 12 mo. Maximum: 6 g daily. To treat toxoplasmosis in pregnantwomen after week 16 of gestationTABLETSAdults. 1 g every 6 hr, together with 25 mgdaily of pyrimethamine and 5 to 15 mgdaily of leucovorin.Mechanism of ActionInhibits para-aminobenzoic acid, a bacterialenzyme responsible for synthesizing folicacid, which susceptible bacteria require forgrowth. By inactivating bacteria, sulfadiazineprevents or alleviates infection.ContraindicationsBreastfeeding; hypersensitivity to sulfadiazine,its components, or other chemicallyrelated drugs, such as sulfonamides; pregnancyat termInteractionsDRUGSbone marrow depressants: Increased risk ofleukopenic or thrombocytopenic effectscyclosporine: Decreased blood cyclosporinelevel, increased risk of nephrotoxicityestrogen-containing oral contraceptives:Increased risk of breakthrough bleedingand pregnancyhemolytics: Increased risk of adverse effectshepatotoxic drugs: Increased risk of hepatotoxicity

hydantoins, oral anticoagulants, oral antidiabeticdrugs: Increased or prolonged effectsof these drugs, possibly toxicityindomethacin, probenecid, salicylates:Increased blood level of free sulfadiazinecaused by displacement from plasmaprotein–binding sitesmethotrexate: Increased risk of leukopenicor thrombocytopenic effects of methotrexatephenylbutazone, sulfinpyrazone: Increasedblood sulfadiazine leveluricosuric drugs: Potentiated uricosuricactionAdverse ReactionsCNS: Dizziness, fatigue, fever, headache,lethargy, weaknessEENT: PharyngitisGI: Anorexia, diarrhea, dysphagia, nausea,vomitingGU: CrystalluriaHEME: Agranulocytosis, aplastic anemia,hemolytic anemia, leukopenia, thrombocytopenia,unusual bleeding or bruisingMS: Arthralgia, myalgiaSKIN: Blisters, erythema, jaundice, pallor,photosensitivity, pruritus, rashOther: Drug-induced feverNursing Considerations• Use sulfadiazine cautiously in patientswith blood dyscrasias or megaloblasticanemia from folate deficiency becausedrug may cause blood dyscrasias; in thosewith G6PD deficiency because hemolysismay occur; in those with hepatic or renalimpairment because of increased risk oftoxicity; and in those with porphyriabecause drug may precipitate an acuteattack.• Obtain blood sample for CBC and bodytissue or fluid specimen for culture andsensitivity tests, as ordered, before givingdrug. Expect first dose to be given beforeresults are available.WARNING Monitor patient for druginducedfever, which may develop 7 to10 days after starting sulfadiazine therapy.Signs and symptoms may include abdominalpain, anorexia, ataxia, depression, diarrhea,headache, insomnia, nausea, peripheralneuropathy, tinnitus, and vomiting.• Monitor fluid intake and output duringtherapy. Altered fluid balance may increaserisk of crystalluria.• Frequently monitor blood glucose level,and assess for signs and symptoms ofhypoglycemia in patients who take an oralantidiabetic drug. Be prepared to respondif hypoglycemia develops.PATIENT TEACHING• Instruct patient to take sulfadiazine exactlyas prescribed and to complete the fullcourse even if he feels better.• Advise patient to take drug with a fullglass of water and to drink plenty of fluidsduring therapy.• Urge patient to notify prescriber if urineturns reddish brown; this may indicatecrystalluria.• Inform patient about possible dizziness,and urge him to avoid potentially hazardousactivities until drug’s CNS effects areknown.• Advise patient to avoid prolonged exposureto sunlight and to wear sunscreen andprotective clothing when outdoors.• Urge patient who takes oral contraceptivesto use an additional method of birth controlduring therapy.• Advise patient who takes an oral antidiabeticdrug to check his blood glucose levelfrequently because of the increased risk ofhypoglycemia during therapy.sulfamethizoleThiosulfil ForteClass and CategoryChemical class: SulfonamideTherapeutic class: AntibioticPregnancy category: Csulfamethizole 963Indications and Dosages To treat cystitis and other UTIs causedby Enterobacter species, Escherichiacoli, Klebsiella species, Proteus mirabilis,P. vulgaris, or StaphylococcusaureusTABLETSAdults. 0.5 to 1 g every 6 to 8 hr.Children age 2 months and over. 7.5 to11.25 mg/kg every 6 hr.DOSAGE ADJUSTMENT Dosage usuallyreduced for patients with impaired renalfunction.QRS

964sulfamethizoleMechanism of ActionInhibits para-aminobenzoic acid, a bacterialenzyme responsible for synthesizing folicacid, which susceptible bacteria require forgrowth. By inactivating bacteria, sulfamethizoleprevents or alleviates infection.ContraindicationsBreastfeeding; hypersensitivity to sulfamethizole,its components, or other chemicallyrelated drugs, such as sulfonamides;pregnancy at termInteractionsDRUGSbone marrow depressants: Increased risk ofleukopenic or thrombocytopenic effectscyclosporine: Decreased blood cyclosporinelevel, increased risk of nephrotoxicityestrogen-containing oral contraceptives:Increased risk of breakthrough bleedingand pregnancyhemolytics: Increased risk of adverse effectshepatotoxic drugs: Increased risk of hepatotoxicityhydantoins, oral anticoagulants, oral antidiabeticdrugs: Increased or prolonged effectsof these drugs, possibly toxicityindomethacin, probenecid, salicylates:Increased blood level of free sulfamethizolecaused by displacement from plasmaprotein–binding sitesmethotrexate: Increased risk of leukopenicor thrombocytopenic effects of methotrexatephenylbutazone, sulfinpyrazone: Increasedblood sulfamethizole leveluricosuric drugs: Potentiated uricosuricactionAdverse ReactionsCNS: Dizziness, fatigue, fever, headache,lethargy, weaknessEENT: PharyngitisGI: Anorexia, diarrhea, dysphagia, nausea,vomitingGU: CrystalluriaHEME: Agranulocytosis, aplastic anemia,hemolytic anemia, leukopenia,thrombocytopenia, unusual bleeding orbruisingMS: Arthralgia, myalgiaSKIN: Blisters, erythema, jaundice, pallor,photosensitivity, pruritus, rashOther: Drug-induced feverNursing Considerations• Use sulfamethizole cautiously in patientswith blood dyscrasias or megaloblasticanemia from folate deficiency becausedrug may cause blood dyscrasias; in thosewith G6PD deficiency because hemolysismay occur; in those with hepatic or renalimpairment because of increased risk oftoxicity; and in those with porphyriabecause drug may precipitate an acuteattack.• Obtain blood sample for CBC and bodytissue or fluid specimen for culture andsensitivity tests, as ordered, before givingdrug. Expect first dose to be given beforeresults are available.WARNING Monitor patient for druginducedfever, which may develop 7 to10 days after sulfamethizole starts. Signsand symptoms include abdominal pain,anorexia, ataxia, depression, diarrhea,headache, insomnia, nausea, peripheralneuropathy, tinnitus, and vomiting.• Monitor fluid intake and output duringtherapy. Altered fluid balance may increaserisk of crystalluria.• Frequently monitor blood glucose leveland assess for signs and symptoms ofhypoglycemia in patients who take an oralantidiabetic drug. Be prepared to respondif hypoglycemia develops.PATIENT TEACHING• Instruct patient to take sulfamethizoleexactly as prescribed and to complete thefull course even if he feels better.• Advise patient to take drug with a fullglass of water and to drink plenty of fluidsduring therapy.• Urge patient to notify prescriber if urineturns reddish brown; this may indicatecrystalluria.• Inform patient about possible dizziness,and urge him to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to avoid prolonged exposureto sunlight and to wear sunscreen andprotective clothing when outdoors.• Urge patient who takes oral contraceptivesto use an additional method of birth controlduring therapy.• Advise patient who takes an oral antidiabeticdrug to check his blood glucose levelfrequently because of the increased risk ofhypoglycemia during therapy.

sulfamethoxazoleApo-Sulfamethoxazole (CAN),Gantanol, UrobakClass and CategoryChemical class: SulfonamideTherapeutic class: Antibiotic, antiprotozoalPregnancy category: CIndications and Dosages To treat chlamydial conjunctivitis;malaria (as adjunct to quinine sulfateand pyrimethamine); toxoplasmosis(as adjunct to pyrimethamine); andUTI, including pyelonephritis andcystitis, caused by susceptible organismsTABLETSAdults. Initial: 2 g, followed by 1 g every8 to 12 hr.Children age 2 months and over. Initial:50 to 60 mg/kg, then 25 to 30 mg/kg every12 hr. Maximum: 2 g for initial dose,75 mg/kg daily for subsequent doses.DOSAGE ADJUSTMENT Dosage reductionusually needed for patients with impairedrenal function. To treat uncomplicated urethritis,cervicitis, and proctitis caused byChlamydia trachomatisTABLETSAdults. 1 g every 12 hr for 10 days.DOSAGE ADJUSTMENT For patients with creatinineclearance of 10 to 30 ml/min/1.73 m 2 , recommended dose reduced by50% or dosing interval extended; for creatinineclearance of less than 10 ml/min/1.73 m 2 , recommended dose reduced by75% or dosing interval extended, as prescribed.Mechanism of ActionInhibits para-aminobenzoic acid, a bacterialenzyme responsible for synthesizing folicacid, which susceptible bacteria require forgrowth. By inactivating bacteria, sulfamethoxazoleprevents or alleviates infection.ContraindicationsBreastfeeding; hypersensitivity to sulfamethoxazole,its components, or otherchemically related drugs, such as sulfonamides;pregnancy at termsulfamethoxazole 965InteractionsDRUGSbone marrow depressants: Increased risk ofleukopenic or thrombocytopenic effectscyclosporine: Decreased blood cyclosporinelevel, increased risk of nephrotoxicityestrogen-containing oral contraceptives:Increased risk of breakthrough bleedingand pregnancyhemolytics: Increased risk of adverse effectshepatotoxic drugs: Increased risk of hepatotoxicityhydantoins, oral anticoagulants, oral antidiabeticdrugs: Increased or prolonged effectsof these drugs, possibly toxicityindomethacin, probenecid, salicylates:Increased blood level of free sulfamethoxazolecaused by displacement from plasmaprotein-binding sitesmethotrexate: Increased risk of leukopenicor thrombocytopenic effects of methotrexatephenylbutazone, sulfinpyrazone: Increasedblood sulfamethoxazole leveluricosuric drugs: Potentiated uricosuricactionAdverse ReactionsCNS: Dizziness, fatigue, fever, headache,lethargy, weaknessEENT: PharyngitisGI: Anorexia, diarrhea, dysphagia, nausea,vomitingGU: CrystalluriaHEME: Agranulocytosis, aplastic anemia,hemolytic anemia, leukopenia, thrombocytopenia,unusual bleeding or bruisingMS: Arthralgia, myalgiaSKIN: Blisters, erythema, jaundice, pallor,photosensitivity, pruritus, rashOther: Drug-induced feverNursing Considerations• Use sulfamethoxazole cautiously inpatients with blood dyscrasias or megaloblasticanemia from folate deficiencybecause drug may cause blood dyscrasias;in those with G6PD deficiency becausehemolysis may occur; in those with hepaticor renal impairment because ofincreased risk of toxicity; and in thosewith porphyria because drug may precipitatean acute attack.• Obtain blood sample for CBC and bodytissue or fluid specimen for culture andQRS

966sulfasalazinesensitivity tests, as ordered, before givingdrug. Expect first dose to be given beforeresults are available.WARNING Monitor patient for druginducedfever, which may develop 7 to10 days after sulfamethoxazole starts. Signsand symptoms include abdominal pain,anorexia, ataxia, depression, diarrhea,headache, insomnia, nausea, peripheralneuropathy, tinnitus, and vomiting.• Monitor fluid intake and output duringtherapy. Altered fluid balance may increaserisk of crystalluria.• Frequently monitor blood glucose leveland assess for signs and symptoms ofhypoglycemia in patients who take an oralantidiabetic drug. Be prepared to respondif hypogly-cemia develops.PATIENT TEACHING• Instruct patient to take sulfamethoxazoleexactly as prescribed and to complete thefull course even if he feels better.• Advise patient to take drug with a fullglass of water and to drink plenty of fluidsduring therapy.• Urge patient to notify prescriber if urineturns reddish brown; this may indicatecrystalluria.• Inform patient about possible dizziness,and urge him to avoid potentially hazardousactivities until drug’s CNS effectsare known.• Advise patient to avoid prolonged exposureto sunlight and to wear sunscreen andprotective clothing when outdoors.• Urge patient who takes oral contraceptivesto use an additional method of birth controlduring therapy.• Advise patient who takes an oral antidiabeticdrug to check his blood glucose levelfrequently because of increased risk ofhypoglycemia during therapy.sulfasalazineAlti-Sulfasalazine (CAN), Azulfidine,Azulfidine EN-Tabs, PMS-Sulfasalazine(CAN), PMS-Sulfasalazine E.C. (CAN),Salazopyrin EN-Tabs (CAN), S.A.S.-500(CAN), S.A.S. Enteric-500 (CAN)Class and CategoryChemical class: Salicylate, sulfonamideTherapeutic class: Anti-inflammatory, antirheumatic,immunomodulatorPregnancy category: BIndications and Dosages To treat inflammatory bowel diseases,such as ulcerative colitis, and to maintainor prolong remissionDELAYED-RELEASE TABLETS, TABLETSAdults and adolescents. Initial: 500 to1,000 mg every 6 to 8 hr. Or 500 mg every6 to 12 hr to decrease adverse GI reactions.Maintenance: 500 mg every 6 hr.Children over age 6. Initial: 6.7 to 10 mg/kgevery 4 hr, 10 to 15 mg/kg every 6 hr, or13.3 to 20 mg/kg every 8 hr. Maintenance:7.5 mg/kg every 6 hr. To treat rheumatoid arthritisDELAYED-RELEASE TABLETS, TABLETSAdults. Initial: 500 to 1,000 mg daily duringwk 1, increased by 500 mg daily everywk, as needed, up to 2,000 mg daily individed doses. If no response after 12 wk,increased to 3,000 mg daily. Maintenance:1,000 mg every 12 hr. Maximum: 3,000 mgdaily. To treat juvenile rheumatoid arthritis inpatients who have not responded to salicylatesor other NSAIDsDELAYED-RELEASE TABLETSChildren ages 6 to 16. 30 to 50 mg/kg dailyin divided doses b.i.d. Maximum: 2 g daily.Mechanism of ActionAs a prodrug of sulfapyridine and 5-aminosalicylicacid (mesalamine), delivers moresulfapyridine and mesalamine to the colonthan either metabolite could provide alone.Sulfapyridine provides antibacterial actionalong the intestinal wall; mesalamineinhibits cyclooxygenase, thereby decreasingthe production of arachidonic acid metabolitesand reducing colonic inflammation.ContraindicationsHypersensitivity to salicylates, sulfasalazine,sulfonamides, chemically related drugs, ortheir components; intestinal or urinaryobstruction; porphyriaInteractionsDRUGSbone marrow depressants: Increased leukopenicand thrombocytopenic effects of bothdrugsdigoxin: Possibly inhibited absorption and

decreased blood level of digoxinfolic acid (vitamin B 9 ): Decreased folic acidabsorptionhepatotoxic drugs: Increased risk of hepatotoxicityhydantoins, oral anticoagulants, oral antidiabeticdrugs: Increased, prolonged, or toxiceffects of these drugsmethotrexate, phenylbutazone, sulfinpyrazone:Possibly potentiated effects of thesedrugsAdverse ReactionsCNS: Ataxia, chills, depression, fatigue,fever, Guillain-Barré syndrome, headache,insomnia, meningitis, peripheral neuropathy,seizures, vertigo, weaknessCV: Pericarditis, vasculitisEENT: Hearing loss, orange-yellow tears,pharyngitis, tinnitusGI: Abdominal pain, anorexia, cirrhosis,diarrhea, elevated liver enzymes, hepatitis,hepatotoxicity, indigestion, jaundice, nausea,pancreatitis, ulcerative colitis exacerbation,vomitingGU: Crystalluria, decreased ejaculatory volume,male infertility, nephritis, nephroticsyndrome, orange-yellow urine, toxicnephrosisHEME: Agranulocytosis, aplastic anemia,Heinz body or hemolytic anemia, leukopenia,neutropenia, thrombocytopenia,unusual bleeding or bruisingMS: Arthralgia, rhabdomyolysisRESP: Cyanosis, idiopathic pulmonaryfibrosis, lymphocytic interstitial pneumonitis,pleuritisSKIN: Alopecia, drug rash with eosinophiliaand systemic symptoms (DRESS), erythemamultiforme, exfoliative dermatitis,epidermal necrolysis, photosensitivity, pruritus,purpura, rash, Stevens-Johnson syndrome,toxic epidermal necrolysis, urticariaOTHER: Anaphylaxis, lupus erythematosuslikesyndrome, serum sickness syndromeNursing Considerations• Monitor CBC, liver function test results,and BUN and serum creatinine levelsbefore and periodically during prolongedsulfasalazine therapy.• Be aware that sulfasalazine doses over 4 gor a blood level over 50 mcg/ml increasesthe risk of adverse and toxic reactions.• Monitor fluid intake and output and urinecolor, pH, and consistency. Acidic urinemay require alkalization to prevent crystalluria.PATIENT TEACHING• Instruct patient to take sulfasalazine withmeals, milk, or an antacid to decrease GIdistress, and to swallow tablets whole.• Advise patient to prevent crystalluria bytaking drug with a full glass of water anddrinking at least 64 oz of fluid per day.• Instruct patient and family to administerdrug around the clock.• Inform patient that symptom relief maytake 2 to 5 days for ulcerative colitis and4 to 12 weeks for rheumatoid arthritis.• Alert patient that drug may turn urine andskin orange-yellow.• Advise contact lens wearer to considerwearing glasses during therapy becausedrug can permanently stain contact lensesyellow.• Instruct patient to avoid prolonged sunexposure and to wear protective clothingand sunscreen when outdoors.• Advise patient to brush with a soft-bristledtoothbrush and to use dental floss andtoothpicks gently because leukopenic andthrombocytopenic drug effects increaserisk of infection and gingival bleeding.• Urge patient to return for laboratory testsand follow-up visits to monitor drug’seffect.• Instruct patient to report sore throat,fever, paleness, skin discoloration, or jaundice.These may be signs of serious adverseeffects. Explain that prescriber may ordertests to determine their cause and thatdrug may be discontinued until test resultsare known.sulfinpyrazonesulfinpyrazone 967Anturane, Apo-Sulfinpyrazone (CAN),Novopyrazone (CAN)Class and CategoryChemical class: Pyrazalone derivativeTherapeutic class: Antigout, uricosuricPregnancy category: Not ratedIndications and Dosages To treat chronic or intermittent goutyarthritisQRS

968sulfinpyrazoneCAPSULES , TABLETSAdults. Initial: 100 to 200 mg b.i.d.,increased by 200 mg daily every 2 to 4 days,if needed. Maintenance: 100 to 200 mgb.i.d. Maximum: 400 mg b.i.d. during wk 1;then 200 to 400 mg b.i.d. until serum uratelevel is controlled.Route Onset Peak DurationP.O. Unknown Unknown 4–10 hrMechanism of ActionInhibits renal tubular reabsorption of uricacid, thereby increasing uric acid excretionand decreasing serum urate level. Decreasedserum urate level prevents urate deposition,tophus formation, and chronic jointchanges. It also helps resolve existing uratedeposits and eventually reduces the numberof gouty arthritis attacks.ContraindicationsActive peptic ulcer disease, blooddyscrasias, hypersensitivity to sulfinpyrazoneor its components, symptoms of GIinflammation or ulcerationInteractionsDRUGSacetaminophen: Increased risk of hepatotoxicity,decreased acetaminophen effectsaminosalicylate sodium: Increased bloodlevel and prolonged duration of this drug,possibly leading to toxicityantineoplastics: Increased risk of uric acidnephropathybismuth subsalicylate and other salicylates:Decreased sulfinpyrazone effectscefamandole, cefoperazone, cefotetan, moxalactam,plicamycin, valproic acid: Possiblyhypoprothrombinemia, increased risk ofsevere hemorrhagediazoxide, mecamylamine, pyrazinamide:Possibly increased serum uric acid levelhydantoins: Increased blood hydantoinlevel, possibly leading to hydantoin toxicityniacin: Possibly decreased uricosuric effectof sulfinpyrazonenitrofurantoin: Decreased nitrofurantoineffectiveness, possibly nitrofurantoin toxicityNSAIDs, oral anticoagulants, platelet aggregationinhibitors, thrombolytics: Increasedrisk of bleedingoral antidiabetic drugs: Increased risk ofhypoglycemiaprobenecid: Increased sulfinpyrazone effectstheophylline: Possibly decreased blood theophyllinelevelverapamil: Increased clearance anddecreased bioavailability of verapamilACTIVITIESalcohol use: Possibly increased serum uricacid levelAdverse ReactionsCNS: DizzinessEENT: TinnitusGI: Abdominal pain, epigastric discomfort,GI bleeding, indigestion, nausea, vomitingGU: Dysuria, flank pain, hematuria, renalcalculi, renal colic, renal failureHEME: Agranulocytosis, anemia, aplasticanemia, leukopenia, thrombocytopeniaMS: Arthralgia, gouty arthritis (acuteattack)RESP: Bronchospasm, dyspnea, wheezingSKIN: Erythema, rashNursing Considerations• Expect to start with full maintenance dose,as ordered, for patient being switched tosulfinpyrazone from another uricosuric.• Monitor serum uric acid level periodically,as ordered, to evaluate drug effectiveness.• Assess for signs of acute gouty arthritis,especially during first few months ofsulfinpyrazone therapy.PATIENT TEACHING• Instruct patient to take sulfinpyrazonewith food, milk, or an antacid to preventGI distress.• Stress the importance of taking drug everyday, even when feeling better, to preventacute gouty arthritis attacks.• Inform patient that acute gouty arthritismay worsen during initial therapy butshould improve as treatment continues.Explain that he may not experience drug’sfull therapeutic effect for 6 months.• If an acute gouty arthritis attack occurs,advise patient to seek additional treatmentbut to continue taking sulfinpyrazone, asprescribed, to help prevent exacerbation.• Advise patient to drink at least 80 oz offluids per day to decrease the risk of renalcalculus formation.• Instruct patient to consult prescriberbefore taking OTC products that contain

aspirin or acetaminophen.• Advise patient to avoid alcohol while takingsulfinpyrazone.• Encourage patient to return for orderedfollow-up laboratory tests to check forblood dyscrasias.sulfisoxazoleApo-Sulfisoxazole (CAN), Gantrisin,Novo-Soxazole (CAN), Sulfizole (CAN)sulfisoxazole acetylGantrisinClass and CategoryChemical class: SulfonamideTherapeutic class: Antibiotic, antiprotozoalPregnancy category: CIndications and Dosages To treat nocardiosis; plague; malaria (asadjunct to quinine sulfate and pyrimethamine);and UTI, including pyelonephritisand cystitis, caused by susceptibleorganismsORAL SUSPENSION, ORAL SYRUP, TABLETSAdults and adolescents. Initial: 2 to 4 gdaily in divided doses. Maintenance: 4 to 8 gdaily in divided doses every 4 to 6 hr.Maximum: 8 g daily.Children over age 2 months. Initial: 75 mg/kg, followed by 120 to 150 mg/kg daily individed doses every 4 to 6 hr. Maximum:6 g daily. To treat uncomplicated cystitis in womenORAL SUSPENSION, ORAL SYRUP, TABLETSAdults. 2 g as a single dose. To treat acute or recurrent otitis mediain combination with erythromycin inpenicillin-allergic patientsORAL SUSPENSION, ORAL SYRUP, TABLETSChildren. 150 mg of sulfisoxazole/kg dailyand 50 mg of erythromycin/kg daily individed doses q.i.d. To treat lymphogranuloma venereumORAL SUSPENSION, ORAL SYRUP, TABLETSAdults. 500 mg every 6 hr for 21 days. To treat uncomplicated urethritis, cervicitis,or proctitis caused by ChlamydiatrachomatisORAL SUSPENSION, ORAL SYRUP, TABLETSAdults. 500 mg every 6 hr.sulfisoxazole 969DOSAGE ADJUSTMENT For patients withrenal impairment, dosing interval changedto every 8 to 24 hr, as prescribed.Mechanism of ActionInhibits para-aminobenzoic acid, a bacterialenzyme responsible for synthesizing folicacid, which susceptible bacteria require forgrowth. By inactivating bacteria, sulfisoxazoleprevents or alleviates infection.ContraindicationsBreast-feeding; hypersensitivity to sulfisoxazole,other chemically related drugs, such assulfonamides, or their components; pregnancyat termInteractionsDRUGSbone marrow depressants, methotrexate:Increased risk of leukopenia or thrombocytopeniacyclosporine: Increased risk of nephrotoxicitydiuretics: Increased incidence of thrombocytopenicpurpurahemolytics (such as doxapram and methyldopa):Increased risk of toxic reactionhepatotoxic drugs (such as amiodarone):Increased risk of hepatotoxicityhydantoins, oral anticoagulants, oral antidiabeticdrugs: Increased or prolonged effectsof these drugs, possibly toxicityindomethacin, probenecid, salicylates:Increased blood sulfisoxazole leveloral contraceptives: Increased risk of breakthroughbleeding with long-term sulfisoxazoleusephenylbutazone, sulfinpyrazone: Risk ofincreased blood sulfisoxazole levelthiopental: Increased anesthetic effect ofthiopentaltolbutamide: Prolonged half-life of tolbutamideuricosurics: Potentiated uricosuric actionAdverse ReactionsCNS: Dizziness, fatigue, fever, headache,lethargy, weaknessEENT: PharyngitisGI: Anorexia, diarrhea, dysphagia, nausea,vomitingGU: CrystalluriaHEME: Agranulocytosis, aplastic anemia,hemolytic anemia, leukopenia, thrombocytopenia,unusual bleeding or bruisingMS: Arthralgia, myalgiaQRS

970sulindacSKIN: Blisters, erythema, jaundice, pallor,photosensitivity, pruritus, rashOther: Drug-induced feverNursing Considerations• Use sulfisoxazole cautiously in patientswith blood dyscrasias or megaloblasticanemia from folate deficiency becausedrug may cause blood dyscrasias; in thosewith G6PD deficiency because hemolysismay occur; in those with hepatic or renalimpairment because of increased risk oftoxicity; and in those with porphyriabecause drug may precipitate acute attack.• Obtain blood sample for CBC and tissueor fluid specimen for culture and sensitivitytesting, as ordered, before beginningsulfisoxazole therapy. Expect to give firstdose before results are available.WARNING Expect prescriber to discontinuesulfisoxazole if patient exhibits signs ofblood dyscrasias, including fever, jaundice,maculopapular or other rash, pallor,pharyngitis, or purpura.• Monitor CBC often, as appropriate, duringtreatment for signs of adverse reactions.• Closely monitor patients with AIDS, whoare at increased risk for adverse reactions.WARNING Monitor patient for druginducedfever, which may develop 7 to10 days after sulfisoxazole starts. Signs andsymptoms include abdominal pain,anorexia, ataxia, depression, diarrhea,headache, insomnia, nausea, peripheralneuropathy, tinnitus, and vomiting.• Monitor fluid intake and output. Unlesscontraindicated, provide sufficient fluidsto maintain a daily urine output of at least1,200 ml.• For otitis media caused by Haemophilusinfluenzae, expect to give drug with erythromycin,as prescribed.• Frequently monitor blood glucose leveland assess for signs of hypoglycemia inpatients who take oral antidiabetic drugs.PATIENT TEACHING• Instruct patient to take sulfisoxazole exactlyas prescribed and to complete the fullcourse of therapy even if he feels better.• Advise patient to take drug with a fullglass of water.• Inform patient that tablet may be chewedor crushed and mixed with liquid to easeswallowing.• Advise patient to shake oral suspensionwell before use and to measure oral suspensionor syrup dose with calibrateddevice to ensure accuracy.• Inform patient that oral suspension orsyrup form of drug may be stored at roomtemperature.• Advise patient to drink 2 to 3 L of fluiddaily to maintain hydration, unless contraindicated.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient who takes an oral antidiabeticto check her blood glucose leveloften because of the risk of hypoglycemia.• Advise patient to avoid prolonged exposureto sunlight and to use sunscreen andwear protective clothing when outdoors.sulindacApo-Sulin (CAN), Clinoril, Novo-Sundac (CAN)Class and CategoryChemical class: Pyrroleacetic acid derivativeTherapeutic class: Antigout, antiinflammatory,antirheumaticPregnancy category: Not ratedIndications and Dosages To decrease pain and inflammation inankylosing spondylitis, acute attacks ofgout or pseudogout, bursitis, moderatelypainful arthralgia, osteoarthritis, rheumatoidarthritis, and tendinitisTABLETSAdults and adolescents over age 14. Initial:150 to 200 mg b.i.d., adjusted based onpatient’s response. Maximum: 200 mg b.i.d. To relieve symptoms of acute gouty arthritis,acute subacromial bursitis, andsupraspinatus tendinitisTABLETSAdults and adolescents over age 14. 200 mgb.i.d. for 7 to 14 days; decreased to lowesteffective dosage after satisfactory responseoccurs.DOSAGE ADJUSTMENT For elderly patients,dosage reduced to 50% of usual adultdosage, if needed.Mechanism of ActionMay block the activity of cyclooxygenase,

an enzyme needed to synthesizeprostaglandins, which mediate the inflammatoryresponse and cause local vasodilation,swelling, and pain. By blockingcyclooxygenase and inhibitingprostaglandins, this NSAID reduces inflammatorysymptoms and pain.Route Onset Peak DurationP.O. In 1 wk* 2–3 wk* UnknownContraindicationsAngioedema, asthma, bronchospasm, nasalpolyps, rhinitis, or urticaria induced byaspirin, iodides, or other NSAIDsInteractionsDRUGSacetaminophen, cyclosporine, gold compounds,nephrotoxic drugs: Increased risk ofadverse renal effectsantacids: Decreased blood level and effectsof sulindacantihypertensives: Risk of decreased antihypertensiveeffectaspirin, salicylates: Decreased sulindaceffects, increased risk of GI hemorrhagebone marrow depressants: Increased risk ofleukopenia and thrombocytopeniacefamandole, cefoperazone, cefotetan, colchicine,oral anticoagulants, plicamycin, thrombolytics,valproic acid: Increased risk ofbleedingcimetidine, ranitidine: Increased bioavailabilityof both drugsdigoxin: Increased blood digoxin level andrisk of digitalis toxicitydimethyl sulfoxide (DMSO): Decreasedsulindac effectiveness, possibly peripheralneuropathy with topical application ofDMSOdiuretics: Possibly decreased loop diureticeffects and increased thiazide diureticeffectsglucocorticoids, other NSAIDs, potassiumsupplements: Increased risk of adverse GIeffectshydantoins: Increased blood hydantoin leveland risk of phenytoin toxicityinsulin, oral antidiabetic drugs: Increasedrisk of hypoglycemia* For antirheumatic effects; unknown forantigout or anti-inflammatory effects.Nursing Considerations• Use sulindac with extreme caution inpatients with a history of ulcer disease orGI bleeding because NSAIDs such assulindac increase risk of GI bleeding andulceration. Expect to use sulindac for theshortest time possible in these patients.• Be aware that serious GI tract ulceration,bleeding, and perforation may occur withoutwarning symptoms. Elderly patientsare at greater risk. To minimize risk, givedrug with food. If GI distress occurs, withsulindac971lithium: Possibly increased blood level andtoxic effects of lithiummethotrexate: Decreased methotrexateexcretion, possibly leading to toxicityplatelet aggregation inhibitors: Increased riskof bleeding, additive effects of these drugsprobenecid: Increased blood level andadverse and toxic effects of sulindacACTIVITIESalcohol use: Increased risk of adverse GIeffects, including GI bleedingAdverse ReactionsCNS: Aseptic meningitis, cerebral hemorrhage,chills, drowsiness, fever, headache,ischemic stroke, malaise, nervousness, transientischemic attackCV: Deep vein thrombosis, edema, heartfailure, hypertension, MI, palpitations,peripheral edema, vasculitisEENT: TinnitusENDO: HypoglycemiaGI: Abdominal cramps or pain, anorexia,constipation, diarrhea, esophageal irritation,flatulence, gastritis, gastrointestinalbleeding or ulceration, hepatic failure, hepatitis,hepatotoxicity, indigestion, jaundice,liver failure, nausea, perforation of stomachor intestines, vomitingGU: Acute renal failure, decreased urineoutput, interstitial nephritis, nephrotic syndrome,polyuria, proteinuriaHEME: Agranulocytosis, aplastic anemia,leukopenia, pancytopeniaRESP: Bronchial spasm, dyspnea, pulmonaryedema, wheezingSKIN: Diaphoresis, erythema multiforme,exfoliative dermatitis, maculopapular rash,pruritus, purpura, Stevens-Johnson syndrome,toxic epidermal necrolysis, urticariaOther: Anaphylaxis, angioedema, facialedema, hypersensitivity syndromeQRS

972sulindachold drug and notify prescriber at once.• Use sulindac cautiously in patients withhypertension, and monitor blood pressureclosely throughout therapy. Drug maycause hypertension or worsen it.WARNING Monitor patient closely forthrombotic events, including MI andstroke, because NSAIDs increase the risk.• If patient has systemic lupus erythematosusand mixed connective tissue disease,monitor him closely because sulindacincreases the risk of aseptic meningitis.WARNING If patient has bone marrow suppressionor is receiving antineoplastic drugtherapy, monitor laboratory results(including WBC count), and watch forevidence of infection because anti-inflammatoryand antipyretic actions of sulindacmay mask signs and symptoms, such asfever and pain.• Especially if patient is elderly or takingsulindac long-term, watch for less commonbut serious adverse GI reactions,including anorexia, constipation, diverticulitis,dysphagia, esophagitis, gastritis, gastroenteritis,gastroesophageal reflux disease,hemorrhoids, hiatal hernia, melena,stomatitis, and vomiting.• Monitor liver function test results because,in rare cases, elevated levels may progressto severe hepatic reactions, including fatalhepatitis, liver necrosis, and hepatic failure.• Watch BUN and serum creatinine levels inelderly patients; those with heart failure,impaired renal function, or hepatic dysfunction;and those taking diuretics orACE inhibitors; because drug may causerenal failure.• Monitor CBC for decreased hemoglobinand hematocrit because drug may worsenanemia.• Assess patient’s skin routinely for rash orother signs of hypersensitivity reactionbecause sulindac and other NSAIDs maycause serious skin reactions without warning,even in patients with no history ofNSAID hypersensitivity. Stop drug at firstsign of reaction, and notify prescriber.WARNING Monitor patient for adventitiousbreath sounds and dyspnea; sulindac maycause fluid retention, which may precipitateheart failure in susceptible patients.• Expect patient to undergo audiometricexaminations before and periodically duringprolonged therapy, as ordered.• Monitor patient for evidence of hypersensitivitysyndrome, which could becomelife-threatening. Report multiple occurringand multi-organ adverse reactions to prescriberand expect drug to be discontinued.Be prepared to provide emergencysupportive care, as ordered.PATIENT TEACHING• Instruct patient to take sulindac exactly asprescribed. Explain that higher doses don’tincrease effectiveness and may increaserisk of adverse reactions.• Advise patient to crush tablet and mixwith food, if needed, to aid in swallowing.• Instruct patient to take drug with orimmediately after meals to decrease GIdistress, to take with a full glass of water,and to remain upright for 20 to 30 minutesafter administration to prevent drugfrom lodging in esophagus and causingesophageal irritation.• Urge patient to notify prescriber immediatelyof chills, fever, rash, or sweating,which may indicate hypersensitivity.• Advise patient to consult prescriber beforeusing acetaminophen, alcohol, aspirin,other NSAIDs, or any OTC drugs duringsulindac therapy.• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Explain the need for periodic physicalexaminations and laboratory tests duringprolonged therapy to monitor drug effectiveness.• Inform patient that sulindac may increasethe risk of serious adverse cardiovascularreactions; urge patient to seek immediatemedical attention if signs or symptomsarise, such as chest pain, shortness ofbreath, weakness, and slurring of speech.• Tell patient that sulindac also may increasethe risk of serious adverse GI reactions;stress the need to seek immediate medicalattention for such signs and symptoms asepigastric or abdominal pain, indigestion,black or tarry stools, or vomiting blood ormaterial that looks like coffee grounds.• Alert patient to the possibility of rare butserious hypersensitivity reactions. Urgehim to seek immediate medical attentionfor rash, blisters, itching, fever, or otherindications of hypersensitivity.

sumatriptansuccinateImitrexClass and CategoryChemical class: Serotonin 5-HT 1 -receptoragonistTherapeutic class: AntimigrainePregnancy category: CIndications and Dosages To relieve acute migraine attacks, withor without aura, or cluster headachesTABLETSAdults. 25 to 100 mg as a single dose assoon as possible after onset of symptoms,repeated every 2 hr, as needed and prescribed.Maximum: 300 mg daily.DOSAGE ADJUSTMENT For patients withhepatic dysfunction, 50 mg is maximumsingle dose.SUBCUTANEOUS INJECTIONAdults. Initial: 6 mg, repeated after 1 or2 hr, if needed. Maximum: 2 (6-mg) injections/24hr. If migraine symptoms returnafter initial subcutaneous injection, 50 mgP.O. every 2 hr up to 200 mg daily.NASAL SPRAYAdults. 1 or 2 sprays (5 or 10 mg) into onenostril as a single dose or 1 spray (20 mg)into one nostril as a single dose. One additionaldose may be taken if another attackoccurs after at least 2 hr. Maximum: 40 mgdaily.Route Onset Peak DurationP.O. In 30 min 2–4 hr Up to 24 hrSubQ In 10 min 1–2 hr Up to 24 hrNasal In 15 min Unknown Up to 24 hrMechanism of ActionMay stimulate 5-HT 1 receptors, causingselective vasoconstriction of inflamed anddilated cranial blood vessels in carotid circulation,thus decreasing carotid arterialblood flow and relieving acute migraines.ContraindicationsBasilar or hemiplegic migraine, cardiovasculardisease, concurrent use of ergotamine-containingdrugs, hypersensitivity tosumatriptan succinate 973sumatriptan or its components, ischemicheart disease, Prinzmetal’s angina, use within14 days of MAO inhibitor therapy, usewithin 24 hours of another serotonin5-HT 1 receptor agonistInteractionsDRUGSantidepressants, lithium: Increased risk ofserious adverse effectsergotamine-containing drugs: Possiblyadditive or prolonged vasoconstrictiveeffectsfluoxetine, fluvoxamine, paroxetine, sertraline:Possibly incoordination, hyperreflexia,and weaknessMAO inhibitors: Risk of decreased sumatriptanclearance, increased risk of seriousadverse effectsAdverse ReactionsCNS: Anxiety, atypical sensations, dizziness,drowsiness, fatigue, fever, headache,malaise, sedation, seizures, vertigo, weaknessCV: Arrhythmias; chest heaviness, pain,pressure, or tightness; coronary artery vasospasm;ECG changes; hypertension;hypotension; palpitationsEENT: Abnormal vision; nasal burning(P.O., subcutaneous); jaw or mouth discomfort;nasal irritation (nasal); nose orthroat discomfort; photophobia (P.O., subcutaneous);taste perversion (nasal); tonguenumbness or sorenessGI: Abdominal discomfort, dysphagiaMS: Jaw discomfort, muscle cramps, myalgia,neck pain or stiffnessSKIN: Dermatitis, diaphoresis, erythema,flushing, pallor, photosensitivity (P.O., subcutaneous),pruritus, rash, urticariaOther: Injection site burning, pain, andrednessNursing Considerations• Be aware that sumatriptan shouldn’t begiven to elderly patients because they’remore likely to have decreased hepaticfunction, coronary artery disease (CAD),and more pronounced blood pressureincreases.• Assess patient for chest pain, and monitorblood pressure in patients with CADbefore and for at least 1 hour after sumatriptanadministration.QRS

974sumatriptan succinate• Don’t give sumatriptan within 24 hours ofanother 5-HT 1 -receptor agonist, such asnaratriptan, rizatriptan, or zolmitriptan.• After nasal administration, rinse tip ofbottle with hot water (don’t suction waterinto bottle) and dry with a clean tissue.Replace cap after cleaning.• Inspect injection solution for particles anddiscoloration before administering.Discard solution if you detect thesechanges.• Be aware that drug shouldn’t be administeredI.V. because this may precipitatecoronary artery vasospasm.• Assess patients with risk factors for CADfor arrhythmias, chest pain, and othersigns of heart disease.• For patients with seizure disorder, instituteseizure precautions according to facilitypolicy because sumatriptan may lowerseizure threshold.PATIENT TEACHING• Advise patient to use sumatriptan as soonas possible after the onset of migrainesymptoms.• Urge patient to contact prescriber andavoid taking sumatriptan if headachesymptoms aren’t typical.• Remind patient not to exceed prescribeddaily dosage.• Advise patient to swallow tablets wholeand drink fluids to disguise unpleasanttaste.• Show patient suitable sites for subcutaneousinjection, and teach him how toload, administer, and discard autoinjector.Or, explain how to administer drug usingneedle-free drug delivery system, SumavelDosePro. (Snap off plastic tip, flip backlever into active position, and press end ofdevice to the skin of abdomen or thigh.)• Instruct patient to administer no morethan two subcutaneous doses in 24 hoursand not to take a second dose if first dosedoesn’t provide significant relief.• Inform patient that he may experienceburning, pain, and redness for 10 to 30minutes after subcutaneous injection.Suggest that he apply ice to relieve painand redness.• Teach patient how to use nasal form correctly.• To avoid cross-contamination, advisepatient not to use the same nasal containerfor more than one person.• Encourage patient to lie down in a dark,quiet room after taking drug to helprelieve migraine.• Instruct patient to seek emergency care forchest, jaw, or neck tightness after drug usebecause drug may cause coronary arteryvasospasm; subsequent doses may requireECG monitoring.• Urge patient to report palpitations or rashto prescriber.• Advise patient to avoid potentially hazardousactivities until drug’s CNS effects areknown.• Alert patient with seizure disorder thatdrug may lower seizure threshold.• Encourage yearly ophthalmologic examinationsfor patients who require prolongeddrug therapy.

tacrine hydrochloride 975tacrinehydrochloride(tetrahydroaminoacridine,THA)CognexTClass and CategoryChemical class: Monoamine acridineTherapeutic class: Dementia treatmentPregnancy category: CIndications and Dosages To treat mild to moderate Alzheimer’stypedementiaCAPSULESAdults. Initial: 10 mg q.i.d. for 4 wk,increased to 20 mg q.i.d. and adjusted every4 wk as prescribed. Maximum: 160 mg dailyin 4 divided doses.ContraindicationsHypersensitivity to tacrine, other acridinederivatives, or their components; jaundicefrom previous tacrine use; serum bilirubinlevel that exceeds 3 mg/dlInteractionsDRUGSanticholinergics: Decreased effects of bothdrugscholinergics, other cholinesterase inhibitors:Increased effects of these drugs and tacrine,possibly leading to toxicitycimetidine: Increased blood tacrine level,possibly leading to toxicityneuromuscular blockers: Prolonged or exaggeratedmuscle relaxationNSAIDs: Increased gastric acid secretion,possibly GI irritation and bleedingtheophylline: Increased blood theophyllinelevel, possibly leading to toxicityFOODSMechanism of ActionTacrine may relieve dementia in patientswith Alzheimer’s disease by increasing theacetylcholine level in the CNS. InAlzheimer’s disease, some cholinergicneurons lose their ability to function,which decreases the acetylcholine level.The remaining functioning cholinergicneurons release acetylcholine, but it’senzymatically broken down bycholinesterases into acetic acid and choline,as shown below left. Without acetylcholineto activate muscarinic (M) and nicotinic(N) receptors on postsynaptic cellmembranes, nerve transmission andexcitability decrease.Tacrine binds with and inhibits cholinesterases,making more intact acetylcholineavailable in cholinergic synapses, as shownbelow right. This prolongs and enhancesacetylcholine’s effects, which increasesnerve transmission and reduces symptomsof dementia.AcetylcholineCholinergicneuron neuronTCholinergicAcetylcholineTacrine Tacrinesynapse Cholinesterases CholinesterasesAcetic Acetic acid acidCholine CholineN receptor N M receptor M

976tacrolimusall foods: Reduced tacrine bioavailabilityACTIVITIESsmoking: Possibly decreased tacrine effectivenessAdverse ReactionsCNS: Agitation, anxiety, asthenia, ataxia,confusion, depression, dizziness, fatigue,hallucinations, headache, hostility, insomnia,seizures, somnolence, syncope, tremorCV: Arrhythmias, chest pain, conductiondisturbances, hypertension, hypotension,palpitations, peripheral edema, sick sinussyndromeEENT: RhinitisGI: Abdominal pain, anorexia, constipation,diarrhea, elevated liver function test results,flatulence, indigestion, nausea, vomitingGU: Bladder obstruction, urinary frequencyand incontinence, UTIMS: Back pain, muscle stiffness, myalgiaRESP: Asthma, cough, upper respiratorytract infection, wheezingSKIN: Flushing, jaundice, purpura, rashOther: Weight lossNursing Considerations• In patients with asthma, monitor forwheezing and increased mucus productionbecause tacrine may increase bronchoconstrictionand bronchial secretions.• Expect to monitor hepatic enzyme levels(specifically ALT), as ordered, every otherweek from at least week 4 to week 16 oftacrine therapy.• If patient has elevated serum ALT level,monitor her for signs and symptoms ofhepatitis, such as jaundice and rightupper-quadrantpain. ALT level shouldreturn to normal 4 to 6 weeks after therapystops.• Once ALT level returns to normal, expectto begin tacrine therapy again (starting at10 mg q.i.d.) as prescribed, and checkpatient’s hepatic enzyme levels weekly for16 weeks, monthly for 2 months, and thenevery 3 months thereafter, as ordered.• Monitor patient for bradyarrhythmias,conduction disturbances, and sick sinussyndrome because tacrine may have avagotonic effect on the heart rate.WARNING Be aware that tacrine’s cholinergiceffects may exacerbate seizures orparkinsonian symptoms.• Monitor patient’s urine output and assessfor abdominal distention and abnormalbowel sounds because drug’s cholinergiceffects may exacerbate conditions involvingurinary tract or GI obstruction orileus.• Be aware that patients with peptic ulcerdisease and those receiving NSAIDs are atincreased risk for developing diarrhea,nausea, and vomiting because tacrineincreases gastric acid secretion.• Assess patient for increased signs andsymptoms because drug becomes lesseffective as Alzheimer’s disease progressesand the number of intact cholinergic neuronsdeclines.PATIENT TEACHING• Instruct patient to take tacrine on anempty stomach, and advise caregiver tomake sure that the patient swallows thedrug.• If patient experiences GI distress, suggesttaking drug with meals. Mention thatdrug’s effects may be delayed.• Urge patient to seek assistance when walkingand changing position until drug’seffects are known. Instruct her to avoidpotentially hazardous activities during thisperiod.• Advise patient not to smoke because itdecreases drug’s effectiveness.• Caution patient not to stop taking drugabruptly. Doing so may impair cognitiveability.• Inform caregiver that tacrine will becomeless effective as Alzheimer’s disease progresses.• Urge caregiver to make sure patientreturns regularly for follow-up visits andlaboratory tests to monitor drug effectiveness.tacrolimusPrografClass and CategoryChemical class: MacrolideTherapeutic class: ImmunosuppressantPregnancy category: CIndications and Dosages To prevent organ rejection in patientsundergoing allogeneic liver, kidney, orheart transplantation

CAPSULESAdults having kidney transplantation.0.2 mg/kg/day given in two equally divideddoses every 12 hr beginning only after renalfunction has recovered (serum creatininelevel of 4 mg/dl or less).DOSAGE ADJUSTMENT Black patients mayneed higher doses after kidney transplantation.Adults having liver transplantation.0.10 to 0.15 mg/kg/day given in two equallydivided doses every 12 hr. Administer 6 hrafter transplantation.Adults having heart transplantation.0.075 mg/kg/day given in two equally divideddoses every 12 hr. Administer 6 hr aftertransplantation.Children having liver transplantation.0.15 to 0.20 mg/kg/day given in two equallydivided doses every 12 hr. Administer 6 hrafter transplantation.I.V. INFUSIONAdults having kidney or liver transplantation.0.03 to 0.05 mg/kg/day as a continuousinfusion beginning no sooner than 6 hrafter transplantation.Adults having heart transplantation.0.0187 to 0.025 mg/kg/day as a continuousinfusion beginning no sooner than 6 hrafter transplantation.Children having liver transplantation.0.03 to 0.05 mg/kg/day as a continuousinfusion beginning no sooner than 6 hrafter transplantation.DOSAGE ADJUSTMENT Therapy delayed upto 48 hours or longer in patients with postoperativeoliguria. For patients with hepaticor renal impairment, dosage kept at lowerend of range with possible need for furtherreduction.Mechanism of ActionInhibits T-lymphocyte activation, possiblyby binding to an intracellular protein,FKBP-12. This binding results in formationof a complex of tacrolimus-FKBP-12, calcium,calmodulin, and calcineurin, whichinhibits phosphatase activity of calcineurin.This inhibition may prevent dephosphorylationand translocation of nuclear factor ofactivated T-cells, a nuclear componentthought to initiate gene transcription forthe formation of lymphokines. The result isinhibition of T-lymphocyte activation,tacrolimus 977which produces immunosuppression.IncompatibilitiesDon’t store diluted drug in PVC containersbecause of increased instability oftacrolimus and possible extraction ofphthalates. Don’t mix or co-infusedtacrolimus with solutions of pH 9 orgreater, such as with acyclovir or ganciclovir,because of chemical instability oftacrolimus in alkaline media.ContraindicationsBreast-feeding, hypersensitivity to tacrolimusor its components, hypersensitivity topolyoxyl 60 hydrogenated castor oil (parenteralform), ocular exposure, within24 hours of cyclosporine therapyInteractionsDRUGSaminoglycosides, amphotericin B, cisplatin,cyclosporine, other nephrotoxic drugs:Increased risk of renal impairmentbromocriptine, chloramphenicol, cimetidine,cisapride, clarithromycin, clotrimazole,cyclosporine, danazol, diltiazem, erythromycin,ethinyl estradiol, fluconazole, ganciclovir,itraconazole, ketoconazole, lansoprazole,magnesium-aluminum-hydroxide, metoclopramide,methylprednisolone, nefazodone,nicardipine, nifedipine, nelfinavir, omeprazole,protease inhibitors, ritonavir, troleandomycin,verapamil, voriconazole: Possiblyincreased blood tacrolimus levelcarbamazepine, caspofungin, phenobarbital,phenytoin, rifabutin, rifampin, sirolimus, St.John’s wort: Possibly decreased blood tacrolimuslevelmycophenolic acid: Possibly increased plasmamycophenolic acid levelphenytoin: Possibly increased blood phenytoinlevelsirolimus: Increased risk of wound healingcomplications, renal dysfunction, andinsulin-dependent post-transplant diabetesmellitusvaccines (live or killed): Possibly suppressedimmune response and increased adverseeffects of vaccineFOODSgrapefruit juice: Possibly increased bloodtacrolimus trough levels in liver transplantpatientshigh-fat foods: Decreased absorption ofT

978tacrolimusoral tacrolimusAdverse ReactionsCNS: Asthenia, fever, dizziness, headache,hemiparesis, insomnia, jittery feeling,leukoencephalopathy, mental changes,mutism, neurotoxicity, paresthesia, posteriorreversible encephalopathy syndrome,progressive multifocal leukoencephalopathy,seizures, speech disorder, stroke, syncope,tremorCV: Atrial and ventricular arrhythmias, cardiacarrest, chest pain, hypercholesterolemia,hyperlipemia, hypertension, hypertriglyceridemia,myocardial hypertrophy orischemia, MI, pericardial effusion, peripheraledema, QT-interval prolongation, torsadesde pointes, venous thrombosisEENT: Blindness, cortical blindness, deafness,hearing loss, photophobiaENDO: Cushingoid features, diabetes mellitus,hot flashes, hyperglycemiaGI: Abdominal pain, anorexia, ascites, bileduct stenosis, colitis, constipation, diarrhea,dyspepsia, enterocolitis, gastric ulcer, gastroenteritis,gastroesophageal reflux disease,hepatic impairment or toxicity, impairedgastric emptying, nausea, pancreatitis,venoocclusive liver disease, vomitingGU: Acute renal failure, BK virus nephropathy,elevated creatinine and BUN levels,hemorrhagic cystitis, hemolytic-uremicsyndrome, micturition abnormality,nephrotoxicity, oliguria, renal impairment,UTIHEME: Anemia, decreased platelet count,disseminated intravascular coagulation,leukocytosis, neutropenia, pancytopenia,thrombocytopeniaMS: Arthralgia, back painRESP: Acute respiratory distress syndrome,atelectasis, bronchitis, cough increase, dyspnea,interstitial lung disease, lung infiltration,pleural effusion, respiratory distress orfailureSKIN: Flushing, malignancy, pruritus, rash,Stevens-Johnson syndrome, toxic epidermalnecrolysisOther: Anaphylaxis, cytomegalovirus infection,hyperkalemia, hypokalemia, hypomagnesemia,hypophosphatemia, impairedwound healing, lymphoproliferative ormalignant disorders, multi-organ failure,opportunistic infections (including activationof latent viral infections), primarygraft dysfunction, weight lossNursing Considerations• Don’t start tacrolimus therapy within24 hours of cyclosporine, and vice versa. Iftacrolimus or cyclosporine blood levels areelevated beyond 24 hours of either drugbeing discontinued, the other drug shouldnot be started until elevation is resolved.• Be aware that I.V. tacrolimus therapyshould only be given if patient can’t tolerateoral tacrolimus. Patient should beswitched to oral therapy as soon as possible.• Expect to give drug with adrenal corticosteroidtherapy.• Dilute intravenous drug with normalsaline solution or 5% dextrose to 0.004 to0.02 mg/ml following manufacturer guidelines.Once diluted, drug should be storedin glass or polyethylene containers (notPVC, because of decreased stability andpossible extraction of phthalates). Discardafter 24 hours if not used.• When converting patient from parenteralto oral therapy after heart transplantation,expect to give oral form 8 to 12 hours afterinfusion is discontinued.• Be aware that children having liver transplantationusually need higher doses oftacrolimus than adults.WARNING Closely monitor patient for anaphylaxisat least during first 30 minutes ofI.V. administration. Make sure emergencyequipment and drugs, such as aqueoussolution of epinephrine and oxygen, areimmediately available.• Monitor patient’s blood tacrolimus troughlevels regularly, as ordered. Higher troughlevels increase risk of toxicity.• Monitor blood pressure, especially inpatients with history of hypertension,because drug can worsen this condition.• Monitor results of liver and renal functiontests, as ordered, to detect signs ofdecreased function.• Tacrolimus may increase serum cholesterol,lipid, and triglyceride levels.• Monitor patient’s blood glucose levelclosely because tacrolimus may causepost-transplant diabetes mellitus with theneed for insulin therapy, especially inblack and Hispanic patients.

tadalafil 979• Monitor patient’s serum potassium level,as ordered, because drug can alter it.• Watch for evidence of neurotoxicity, especiallyin patients receiving high doses ofdrug. Evidence of encephalopathy includesheadache, impaired consciousness, loss ofmotor function, psychiatric disturbance,seizures, and tremors.PATIENT TEACHING• Advise patient to take oral doses 12 hoursapart at same time each day.• Instruct patient to take capsules on anempty stomach.• Tell patient to avoid consuming grapefruitjuice while taking tacrolimus.• Advise patient not to stop taking drugwithout consulting prescriber.• Instruct patient not to receive virus vaccinesduring therapy. Urge him to avoidpeople who have received such vaccines orto wear a protective mask when he’saround them.• Caution patient to avoid having contactwith people who have infections duringtherapy because tacrolimus causesimmunosuppression.• Stress importance of having repeated laboratorytests while taking tacrolimus, andurge compliance.• Inform patient that tacrolimus therapymay result in insulin-dependent diabetes.Tell him to report frequent urination or anincrease in thirst, hunger, or fatigue.• Instruct patient to limit exposure to directsunlight and to wear protective clothingand use sunscreen when exposure can’t beavoided.tadalafilAdcirca, CialisClass and CategoryChemical class: Phosphodiesterase inhibitorTherapeutic class: Anti-impotencePregnancy category: BIndications and Dosages To treat erectile dysfunctionTABLETSAdults. Initial: 10 mg daily taken 1 hrbefore sexual activity; dosage decreased to5 mg or increased to 20 mg, as prescribed,based on clinical response. Maximum:20 mg daily. Or, 2.5 mg once daily,increased to 5 mg once daily, if needed.DOSAGE ADJUSTMENT For patients takingpotent CYP3A4 inhibitors such as itraconazole,ketoconazole, or ritonavir, dosageshouldn’t exceed 10 mg every 72 hr. Forpatients with moderate to severe renalinsufficiency who take drug on an as-neededbasis, dosage shouldn’t exceed 5 mgdaily. For patients with mild to moderatehepatic impairment who take drug on anas-needed basis, dosage shouldn’t exceed10 mg daily. For patients who take drugonce daily, no dosage adjustment is neededwith mild to moderate hepatic or renalimpairment; once daily dosing not recommendedfor use with severe hepatic or renalimpairment. To treat pulmonary arterial hypertensionin order to improve exercise abilityin patients classified as group 1 by theWorld Health OrganizationTABLETS (ADCIRCA)Adults. 40 mg once daily.DOSAGE ADJUSTMENT For patients withmild to moderate hepatic or renal impairmentor who have already taken ritonavirfor at least 1 week, initial dosage of 20 mgonce daily and then increased as tolerated.For patient already taking tadalafil andbeing prescribed ritonavir, tadalafil temporarilydiscontinued for at least 24 hoursbefore ritonavir starts. Then, after at least1 week of ritonavir, tadalafil restarted at20 mg once daily and then increased to40 mg once daily, as tolerated.Route Onset Peak DurationP.O. Unknown 30 min– Unknown6 hrMechanism of ActionEnhances the effect of nitric oxide releasedin the penis during sexual stimulation.Nitric oxide activates the enzyme guanylatecyclase, which causes increased levels ofcGMP in the corpus cavernosum. This leadsto increased blood flow to the penis, thusproducing an erection.ContraindicationsContinuous or intermittent nitrate therapy,hypersensitivity to tadalafil or its compo-T

980tadalafilnents, retinitis pigmentosaInteractionsDRUGScarbamazepine, phenytoin, phenobarbitol:Possibly decreased tadalafil effectsdoxazosin, tamsulosin and other alphablockers: Increased risk of symptomatichypotensionerythromycin, itraconazole, ketoconazole,ritonavir: Prolonged tadalafil effectsnitrates: Profound hypotensionprotease inhibitors (other than ritonavir):Possibly prolonged tadalafil effectsrifampin: Decreased tadalafil effectsFOODSgrapefruit juice: Possibly prolonged tadalafileffectsACTIVITIESalcohol use: Potentiated blood pressure loweringeffectsAdverse ReactionsCNS: Asthenia, dizziness, fatigue, headache,hypesthesia, insomnia, migraine, paresthesia,seizures, somnolence, stroke, syncope,transient global amnesia, vertigoCV: Angina pectoris, chest pain, hypotension,hypertension, MI, postural hypotension,palpitations, sudden cardiac death,tachycardiaEENT: Blurred vision, changes in colorvision, conjunctivitis, dry mouth, epistaxis,eyelid swelling, eye pain, hearing loss,increased lacrimation, nasal congestion,nasopharyngitis, nonarteritic anteriorishcemic optic neuropathy, pharyngitis,retinal artery or vein occlusion, visual fielddefectsGI: Abnormal liver function studies, diarrhea,dysphagia, dyspepsia, esophagitis, gastroesophagealreflux, gastritis, increasedgamma-glutamyl transpeptidase levels, nausea,upper abdominal pain, vomitingGU: Priapism, spontaneous penile erection,UTIMS: Arthralgia, back or neck pain, extremitypain, myalgiaRESP: Bronchitis, cough, dyspnea, upperrespiratory tract infectionSKIN: Diaphoresis, exfoliative dermatitis,flushing, pruritus, rash, Stevens-Johnsonsyndrome, urticariaOther: Facial edema, flulike symptoms,hypersensitivity reactionsNursing Considerations• Know that patients with hereditary degenerativeretinal disorders, including retinitispigmentosa, should not receive tadalafilbecause of the risk of serious ophthalmicadverse reactions.• Patients with severe hepatic or renalimpairment should not receive tadalafilbecause its effects in these patients areunknown.• Use tadalafil cautiously in patients withleft ventricular outflow obstruction, suchas aortic stenosis and idiopathic hypertrophicsubaortic stenosis, and those withseverely impaired autonomic control ofblood pressure because these conditionsincrease sensitivity to vasodilators such astadalafil.• Use tadalafil cautiously in patients withconditions that may predispose them topriapism, such as sickle cell anemia, multiplemyeloma, leukemia, or penile deformities(such as angulation, cavernosal fibrosis,or Peyronie’s disease).• Monitor blood pressure and heart rate andrhythm before and during therapy.PATIENT TEACHING• Explain that, when used as needed to treaterectile dysfunction, tadalafil should betaken 1 hour before sexual activity to providethe most effective results. Alternatively,if the patient chooses to take asmaller dose of tadalfil daily, encouragehim to take it at about the same timeevery day regardless of the timing of sexualactivity.WARNING Tell patient not to take tadalafil ifhe takes any form of organic nitrate, eithercontinuously or intermittently, becauseprofound hypotension and death couldresult. Tell him to seek immediate medicalattention if he has a sudden loss of visionor hearing.• If patient takes tadalafil to treat erectiledysfunction, advise him to obtain sexualcounseling to help enhance the drug’seffects.• To avoid possible penile damage and permanentloss of erectile function, urgepatient to notify prescriber immediately iferection is painful or lasts longer than4 hours.• Advise patient to limit alcohol consumptionwhile taking tadalafil.

tamoxifen citrateApo-Tamox (CAN), Gen-Tamoxifen(CAN), Nolvadex, Novo-Tamoxifen(CAN), Tamofen (CAN), Tamone (CAN)Class and CategoryChemical class: Triphenylethylene derivativeTherapeutic class: Nonsteroidal antiestrogenagent, partial estrogen agonistPregnancy category: DIndications and Dosages To treat metastatic breast cancer in menand women; to treat node-negativebreast cancer in women, or node-positivebreast cancer in postmenopausalwomen, after total or segmental mastectomy,axillary dissection, and breastirradiationTABLETSAdults. 20 to 40 mg daily. Dosages greaterthan 20 mg administered b.i.d. To reduce the risk of invasive breast cancerin women with ductal carcinoma insitu (DCIS) after surgery and radiation,to reduce the risk of breast cancer inwomen at high riskTABLETSAdults. 20 mg daily for 5 yr.Mechanism of ActionMay block the effects of estrogen on breasttissue by competing with estrogen for estrogen-receptorbinding sites. Estrogen maystimulate the growth of cancer cells.ContraindicationsHypersensitivity to tamoxifen or its components;women at high risk for breast cancerand women with ductal carcinoma in situand a history of deep vein thrombosis orpulmonary embolus or who needcoumarin-type anticoagulant therapy; usewith anastrozole therapyInteractionsDRUGSbromocriptine: Possibly increased bloodtamoxifen levelestrogens: Possibly altered therapeutic effectof tamoxifenwarfarin and other coumarin-type anticoagulants:Increased anticoagulant effect ofthese drugstamoxifen citrate 981Adverse ReactionsCNS: Confusion, depression, dizziness,fatigue, headache, light-headedness, somnolence,stroke, weaknessCV: Edema, hyperlipidemia, thrombosisEENT: Keratopathy, ocular toxicity (includingcataracts), optic neuritis, retinopathyGI: Elevated liver function test results,hepatotoxicity, nausea, vomitingGU: Endometrial cancer, endometrialhyperplasia, endometrial polyps, genitalitching, menstrual irregularities, ovariancysts, uterine malignancies, vaginal discharge(females); impotence, decreasedlibido (males)HEME: Anemia, leukopenia, thrombocytopeniaMS: Transient bone or tumor painRESP: Pulmonary embolismSKIN: Bullous pemphigoid, dry skin, erythemamultiforme, rash, Stevens-Johnsonsyndrome, thinning hairOther: Angioedema, hot flashes, hypercalcemia,weight gainNursing ConsiderationsWARNING Make sure that patient has beeninformed about serious or potentially lifethreateningadverse effects associated withtamoxifen before therapy begins. Be awarethat women with ductal carcinoma in situand those at high risk for breast cancer aremore likely to develop uterine cancer,stroke, or pulmonary emboli than othersreceiving tamoxifen.• If patient is premenopausal, begin drugtherapy in the middle of menstruation; ifpatient’s menstrual cycles are irregular,verify that she has had a negative pregnancytest before therapy starts.• Expect patient to undergo an ophthalmicexamination before and periodically duringtamoxifen therapy. Also expect tomonitor patient for adverse ocular reactions,such as cataracts.• Assess patient for signs and symptoms ofthromboembolic events, such as shortnessof breath, leg pain, and change in mentalstatus.• Periodically monitor patient’s platelet andWBC counts, cholesterol and triglyceridelevels, and liver function test results, asordered.• Monitor blood calcium level and assessT

982tamsulosin hydrochloridepatient for signs and symptoms of hypercalcemia,such as nausea, vomiting, andthirst; tamoxifen may cause hypercalcemiain breast cancer patients with bone metastasiswithin a few weeks of starting treatment.• Store tamoxifen in a closed, light-resistantcontainer at room temperature.PATIENT TEACHING• Advise patient to swallow tamoxifen tabletwhole with water.• Instruct premenopausal patient to use anonhormonal form of contraception, suchas a condom or diaphragm, during tamoxifentherapy. Emphasize that she shouldn’tbecome pregnant while taking drug andfor 2 months afterward. Advise her tonotify prescriber at once if she becomespregnant during therapy.• Inform patient of the most common sideeffects—hot flashes, vaginal discharge, andirregular menses.• Urge patient to immediately notify prescriberif she notices a rash, itching, difficultybreathing, or facial swelling becausethey may signify a hypersensitivity reaction.• Advise patient to notify prescriber if sheexperiences leg pain or calf swelling duringtamoxifen therapy because they mayindicate a blood clot.• Instruct patient to report signs of hepatotoxicity,such as tiredness, nausea, yellowskin, and flulike symptoms.• Advise patient to have regular gynecologicexmainations and to notoify prescriberabout abnormal symptoms, includingabdominal or pelvic pain, new breastlumps, and unusual vaginal discharge orbleeding.• Urge patients who take tamoxifen for prophylaxisto have regular mammogramsbecause tamoxifen doesn’t prevent all cancers.• Stress the importance of taking tamoxifenregularly. Urge patient to consult prescriberif adverse reactions, such as nauseaand vomiting, are interfering with dosageschedule. These symptoms may be a signof hypercalcemia.• Inform women who wish to breast-feedthat tamoxifen my appear in breast milkand cause serious adverse effects in theinfant.tamsulosinhydrochlorideFlomaxClass and CategoryChemical class: SulfamoylphenethylaminederivativeTherapeutic class: Benign prostatic hyperplasia(BPH) treatmentPregnancy category: BIndications and Dosages To treat BPHCAPSULESAdults. Initial: 0.4 mg daily 30 min p.c. for2 to 4 wk, increased to 0.8 mg daily if noresponse to initial dosage. Maximum:0.8 mg daily.Mechanism of ActionBlocks alpha 1 -adrenergic receptors in theprostate. This action inhibits smoothmusclecontraction in the prostate, prostaticcapsule, prostatic urethra, and bladderneck, which improves the rate of urine flowand reduces symptoms of BPH.ContraindicationsHypersensitivity to tamsulosin, quinazolines,or their componentsInteractionsDRUGSalpha blockers: Additive effects of bothdrugscimetidine: Risk of decreased tamsulosinclearanceCYP2D6 inhibitors (such as fluoxetine,paroxetine, terbinafine), CYP3A4 inhibitors(such as erythromycin, ketoconazole):Possibly increased plasma tamsulosin levelphosphodiesterase-5 inhibitors: Increasedrisk of hypotensionAdverse ReactionsCNS: Asthenia, dizziness, drowsiness, headache,insomnia, syncope, vertigoCV: Chest pain, orthostatic hypotensionEENT: Amblyopia, diplopia, intraoperativefloppy iris syndrome, pharyngitis, rhinitisGI: Diarrhea, nauseaGU: Decreased libido, ejaculation disorders,priapismMS: Back pain

RESP: Respiratory impairmentSKIN: Pruritus, rash, urticariaOther: AngioedemaNursing Considerations• Be aware that prostate cancer should beruled out before tamsulosin therapybegins.• Give drug about 30 minutes after the samemeal each day.• If patient takes drug on an empty stomach,monitor his blood pressure because ofthe increased risk of orthostatic hypotension.• If patient doesn’t take drug for severaldays, resume therapy at 0.4 mg/dose, asprescribed.PATIENT TEACHING• Instruct patient not to open, crush, orchew tamsulosin capsules and to take drugabout 30 minutes after the same meal eachday.• Instruct patient to notify prescriber if hemisses several days of therapy, and cautionhim against restarting drug at previousdosage.• Advise patient to avoid potentially hazardousactivities until drug’s CNS effectsare known. Mention the need for cautionif dosage is increased.• Advise patient to change position slowly,especially after initial dose and eachdosage increase, to minimize effects oforthostatic hypotension.tapentadolNucyntaClass, Category, and ScheduleChemical class: Mu-opioid agonistTherapeutic class: Centrally acting syntheticanalgesicPregnancy category: CControlled substance schedule: IIIndications and Dosages To relieve moderate to severe acute painTABLETSAdults. 50 mg to 100 mg repeated every4 to 6 hr, as needed. Maximum: 700 mg onfirst day; 600 mg daily thereafterDOSAGE ADJUSTMENT On first day of therapy,second dose may be given as soon astapentadol 9831 hour after first dose, if needed. Forpatients with moderate hepatic impairment(Child-Pugh Class B), dosage should notexceed 50 mg for each episode, and intervalsbetween doses should be at least8 hours.Route Onset Peak DurationP.O. Unknown 1 hr 4 hrMechanism of ActionBinds with and activates opioid receptors(mainly mu receptors) in brain and spinalcord and inhibits norepinephrine reuptaketo produce analgesia.ContraindicationsAcute or severe bronchial asthma, hypercapniaor significant respiratory depressionnot monitored or without available resuscitationequipment, hypersensitivity to tapentadolor its components, paralytic ileus,within 14 days of MAO inhibitor therapyInteractionsDRUGSCNS depressants: Increased risk of CNSdepressionMAO inhibitors: Possibly hyperpyreticepisodes, hypertensive crisis, serotonin syndrome,and severe seizuresserotonergics: Increased risk of potentiallyfatal serotonin syndromeACTIVITIESalcohol use: Increased risk of CNS depressionAdverse ReactionsCNS: Abnormal dreams, anxiety, confusion,dizziness, fatigue, headache, insomnia,lethargy, seizure, serotonin syndrome, somnolence,syncope, tremorCV: HypotensionEENT: Dry mouth, nasopharyngitisENDO: Hot flashGI: Constipation, dyspepsia, nausea, vomitingGU: Anorexia, UTIMS: ArthralgiaRESP: Respiratory depression, upper respiratoryinfectionSKIN: Diaphoresis, pruritis, rash, urticariaOther: Hypersensitivity reactions, physicalor psychological dependence, withdrawalT

984telavancinNursing Considerations• Be aware that tapentadol isn’t recommendedfor patients with severe renalimpairment (creatinine clearance less than30 ml/min/1.73 m 2 ) or severe hepatic dysfunction(Child-Pugh Class C).• Use tapentadol cautiously in patients withhypoxia, hypercapnia, or decreased respiratoryreserve such as may occur in asthma,COPD, cor pulmonale, severe obesity,sleep apnea syndrome, myxedema, kyphoscoliosis,CNS depression, or coma. Alsouse cautiously in patients with head injuryor conditions in which increased intracranialpressure may occur because drug mayobscure the signs and symptoms. Also usecautiously in patients with mild to moderaterenal or hepatic dysfunction and inpatients with biliary tract disease, includingacute pancreatitis, because drug maycause spasm of the sphincter of Oddi.• Expect to begin tapentadol therapy atlower doses in elderly patients because ofage-related decreased renal and hepaticfunction.• Monitor patient’s respiratory rate, depth,and effort during tapentadol therapybecause drug may cause respiratorydepression, especially in elderly or debilitatedpatients and in those who have conditionsaccompanied by hypoxia, hypercapnia,or upper airway obstruction. Ifrespiratory rate drops below 10 breathsper minute, notify prescriber, expect drugto be discontinued, and provide neededsupportive care, which may include anopioid antagonist such as naloxone, asordered.• Monitor patient for evidence of physicaland psychological dependence.WARNING Watch patient closely for evidenceof serotonin syndrome, which canbe life-threatening. Report mental statuschanges (agitation, hallucinations, coma),autonomic instability (tachycardia, labileblood pressure, hyperthermia), neuromuscularabnormalities (hyperreflexia, incoordination)or GI disturbances (nausea,vomiting or diarrhea).• Don’t stop tapentadol abruptly if used ona regular basis because withdrawal symptomsmay occur.• Be aware that tapentadol shouldn’t be usedduring or just before labor and delivery.PATIENT TEACHING• Instruct patient to take tapentadol exactlyas prescribed and not to adjust dose orfrequency without consulting prescriber.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Caution patient to avoid alcohol or otherCNS depressants while taking tapentadol.• Advise patient who has been taking tapentadolregularly not to stop taking itabruptly but rather to taper drug usegradually and based on prescriber instructionsto reduce the risk of withdrawalsymptoms.telavancinVibativClass and CategoryChemical class: LipoglycopeptideTherapeutic class: AntibacterialPregnancy category: CIndications and Dosages To treat complicated skin and skin structureinfections caused by gram-positiveorganisms (Staphylococcus aureus,Streptococcus pyogenes, Streptococcusagalactiae, Streptococcus anginosusgroup [includes S. anginosus, S. intermedius,and S. constellatus], orEnterococcus faecalis (vancomycinsusceptibleisolates only)I.V. INFUSIONAdults. 10 mg/kg administered over 60 minevery 24 hours for 7 to 14 daysDOSAGE ADJUSTMENT For patients with creatinineclearance ot 30 to 50 ml/min/1.73 m 2 , dosage reduced to 7.5 mg/kg every24 hours. For patient with creatinine clearanceof at least 10 but less than 30 ml/min/1.73 m 2 , 10 mg/kg every 48 hours.Route Onset Peak DurationI.V. Unknown 1–2 hr 24 hrMechanism of ActionInhibits cell wall synthesis and alters thepermeability of bacterial membranes, causingcell wall lysis and cell death. Telavancinis a lipoglycopeptide antibacterial that’s asynthetic derivative of vancomycin.

IncompatibilitiesDon’t mix telavancin with other drugs orIV solutions containing additives. If administrationmust be through the same IV line,flush the line with 5% dextrose injection,0.9% sodium chloride injection, or lactatedRinger’s injection before and after infusingtelavancin.ContraindicationsHypersensitivity to telavancin or its componentsInteractionsDRUGSACE inhibitors, loop diuretics, NSAIDs:Increased risk of nephrotoxicitydrugs known to prolong the QT interval, suchas clarithromycin, disopyramide, erythromycin,quindine: Increased risk of prolongedQT intervalAdverse ReactionsCNS: Dizziness, rigorsCV: Prolonged QT intervalEENT: Taste disturbanceGI: Abdominal pain, anorexia, diarrhea,Clostridium difficile–associated diarrhea,nausea, vomitingGU: Elevated creatinine level, foamy urine,nephrotoxicity such as renal failure, impairment,or insufficiencySKIN: Pruritus, rashOther: Infusion-related reactions such aserythema or painNursing Considerations• Know that telavancin isn’t recommendedfor patients with congenital long-QT syndrome,uncompensated heart failure, orsevere left ventricular hypertrophy or whocurrently have a prolonged QT intervalbecause it may prolong the QT interval,causing life-threatening complications.• Use cautiously in patients taking drugsknown to prolong the QT interval becauseof increased the risk of a prolonged QTinterval.• Make sure woman of childbearing age hasa negative pregnancy test result beforestarting telavancin because of risk of fetalharm.• Obtain baseline serum creatinine levelbefore telavancin therapy starts, and monitorit throughout therapy, as ordered,because drug may cause nephrotoxicity,telavancin 985especially in patients with pre-existingrenal disease, diabetes mellitus, congestiveheart failure, or hypertension and inpatients taking such nephrotoxic drugs asNSAIDs, ACE inhibitors, and loop diuretics.If renal function declines, notify prescriberand expect to discontinue telavancin.• Dilute a 250-mg vial with 15 ml or a 750-mg vial with 45 ml of a diluent such as 5%dextrose injection, sterile water for injection,or 0.9% sodium chloride injection toobtain a solution of 15 mg/ml. Whenready to administer drug, further dilutedoses of 150 mg to 800 mg in 100 to250 ml of 5% dextrose injection, 0.9%sodium chloride injection, or lactatedRinger’s injection before infusion. Dosesless than 150 mg or greater than 800 mgshould be further diluted in a volume thatyields a final concentration of 0.6 to0.8 mg/ml.• Infuse telavancin over 60 minutes becausemore rapid infusion may cause a reactionlike red-man syndrome, which causesflushing of upper body, urticaria, pruritus,or rash. If present, stop or slow infusion toresolve.• Use telavancin within 4 hours of the timeit is reconstituted in the vial (including itstransfer to an infusion bag for furtherdilution) if kept at room temperature and72 hours if refrigerated. Discard if timelimit exceeds these parameters.• Monitor patient for diarrhea, which mayrange from mild to severe and may occurup to 2 months after antibiotic is discontinued.Report diarrhea and, if C. difficileis suspected, expect telavancin to be discontinued.Provide supportive care, suchas fluid and electrolyte replacement, proteinsupplementation, antibiotic therapyto treat C. difficile, and possibly surgicalintervention, as needed.• Be aware that while telavancin doesn’tinterfere with coagulation, it does interferewith certain tests used to monitor coagulation,such as PT, INR, APTT, activatedclotting time, and coagualtion-based factorXa tests. Collect blood samples forcoagulation tests as close as possible toadministration of next dose of telavancinto minimize interference.PATIENT TEACHINGT

986telithromycin• Instruct women of childbearing age to useeffective contraception during telavancintherapy.• Caution patient that diarrhea may occurup to 2 months after antibiotic has beendiscontinued and to report any persistentor severe episodes to prescriber.• Warn patient that drug may cause urine tobe foamy and taste to be altered.• Advise patient to alert all prescribers thathe takes telavancin because some drugsmay interact with it, causing seriousadverse effects.telithromycinKetekClass and CategoryChemical class: Semisynthetic ketolideTherapeutic class: AntibioticPregnancy category: CIndications and Dosages To treat mild to moderate communityacquiredpneumonia caused byStreptococcus pneumoniae, Haemophilusinfluenzae, Moraxella catarrhalis,Chlamydophila pneumoniae, orMycoplasma pneumoniaeTABLETSAdults. 800 mg daily P.O. for 7 to 10 days.Route Onset Peak DurationP.O. Unknown 1 hr UnknownMechanism of ActionBinds to domains II and V of the 50S ribosomalsubunit in many aerobic, anaerobic,gram-positive, and gram-negative bacteriaof the respiratory tract. Telithromycin mayalso inhibit the assembly of nascent ribosomalunits. These actions inhibit RNAdependentprotein synthesis in bacterialcells, causing them to die.ContraindicationsCisapride or pimozide therapy; history ofhepatitis or jaundice associated with use oftelithromycin or any macrolide antibiotic;hypersensitivity to telithromycin, macrolideantibiotics, or their components; myastheniagravisInteractionsDRUGSatorvastatin, lovastatin, midazolam,pimozide, simvastatin: Possibly increasedblood levels of these drugscisapride, dofetilide, procainamide, quinidine:Increased risk of prolonged QT intervalitraconazole, ketoconazole: Increased bloodlevel of telithromycinoral anticoagulants: Possibly potentiatedeffects of oral anticoagulantsrifampin: Decreased blood level of telithromycinsotalol: Decreased sotalol absorptiontheophylline: Increased risk of adverse GIreactionsAdverse ReactionsCNS: Dizziness, fatigue, headache, insomnia,somnolence, transient loss of consciousness,vertigoCV: Atrial arrhythmias, prolonged QTinterval, torsades de pointesEENT: Blurred vision, difficulty focusingeyes, diplopia, dry mouth, glossitis, oralcandidiasis, stomatitisGI: Abdominal distention or pain, anorexia,constipation, diarrhea, elevated liver functiontest results, flatulence, fulminant hepatitis,gastroenteritis, gastritis, hepatic failureor necrosis, hepatitis, nausea, pseudomembranouscolitis, taste perversion, vomitingGU: Vaginal candidiasis, vaginitis, vaginosis(fungal)HEME: Increased platelet countMS: Exacerbated myasthenia gravis, musclecrampsRESP: Acute respiratory failureSKIN: Diaphoresis, rashOther: Angioedema, anaphylaxisNursing Considerations• Be aware that telithromycin therapyshouldn’t be used in patients who havecongenital prolonged QT interval or ongoingproarrhythmic conditions (such asuncorrected hypokalemia or hypomagnesemia,or serious bradycardia) or in thosereceiving concurrent therapy with class IAor class III antiarrhythmics becausetelithromycin increases the risk of QTintervalprolongation, which may lead toventricular arrhythmias, including torsadesde pointes.

• Before administering the first telithromycindose, expect to obtain respiratoryspecimens for culture and sensitivity testing.• Monitor patient closely for diarrhea,which may indicate pseudomembranouscolitis. If it occurs, notify prescriber andexpect to withhold drug and give fluids,electrolytes, protein, and an antibioticeffective against Clostridium difficile.WARNING Monitor patient’s liver studiesfor abnormalities, and assess patient forevidence of liver dysfunction, such asfatigue, malaise, anorexia, nausea, jaundice,acholic stools, and liver tenderness,because telithromycin may cause potentiallylife-threatening acute hepatic failureand severe liver damage.PATIENT TEACHING• Stress need to take drug for prescribedduration even if patient feels better beforeprescription is finished.• Caution patient to avoid hazardous activitiesuntil drug’s CNS and visual effects areknown. Explain that telithromycin cancause trouble focusing eyes, especially forfirst 30 minutes after a dose.• Instruct patient to notify prescriber ifvisual disturbances occur, and tell her toavoid quick changes in viewing near anddistant objects.• Tell patient to alert prescriber if she faintsbecause drug may alter heart rhythm.• Caution patient to notify prescriberimmediately about fatigue, malaise,anorexia, nausea, abdominal tenderness,yellow skin, or changes in stool appearance.telmisartanMicardisClass and CategoryChemical class: Nonpeptide angiotensin IIantagonistTherapeutic class: AntihypertensivePregnancy category: C (first trimester), D(later trimesters)Indications and Dosages To manage hypertension, alone or withother antihypertensivestelmisartan 987TABLETSAdults. Initial: 40 mg daily. Maintenance:20 to 80 mg daily. Maximum: 80 mg daily. To reduce risk of MI, stroke, or deathfrom cardiovascular causes in patients athigh risk who are unable to take ACEinhibitorsTABLETSAdults age 55 and over. 80 mg once daily.Route Onset Peak DurationP.O. Unknown In 4 wk UnknownMechanism of ActionBlocks angiotensin II from binding toreceptor sites in many tissues, includingvascular smooth muscle and adrenal glands.This action inhibits the vasoconstrictiveand aldosterone-secreting effects ofangiotensin II, which reduces blood pressure.ContraindicationsHypersensitivity to telmisartan or its componentsInteractionsDRUGSdigoxin: Increased peak blood digoxin leveland risk of digitalis toxicitydiuretics, other antihypertensives: Enhancedhypotensive effectlithium: Increased serum lithium levels andtoxicityramipril: Increased serum ramipril level;decreased telmisartan levelAdverse ReactionsCNS: Asthenia, dizziness, fatigue, headache,syncope, weaknessCV: Atrial fibrillation, bradycardia, chestpain, congestive heart failure, hypertension,hypotension, MI, orthostatic hypotension,peripheral edemaEENT: Pharyngitis, sinusitisGI: Abdominal pain, diarrhea, elevated liverenzyme levels, indigestion, nausea, vomitingGU: Acute renal failure, erectile dysfunction,renal dysfunction, UTIHEME: Anemia, eosinophilia, thrombocytopeniaMS: Back pain, leg or muscle cramps, myalgia,tendon pain, tendinitis, tenosynovitisRESP: ACE cough, upper respiratory tractinfectionT

988temazepamSKIN: Diaphoresis, erythema, urticariaOther: Anaphylaxis, angioedema, elevateduric acid level, flulike symptoms, hyperkalemia,hypovolemiaNursing Considerations• Give telmisartan cautiously to patientswith dehydration or hyponatremia.• Expect prescriber to add a diuretic to regimenif patient’s blood pressure isn’t wellcontrolled by telmisartan.• Check patient’s blood pressure regularly.Be prepared to treat symptomatichypotension by placing patient in supineposition and giving normal saline solution,as ordered.• Monitor BUN and serum creatinine levelsand urine output in patients withimpaired renal function because they’re atincreased risk for oliguria, progressiveazotemia, and possibly acute renal failure.• Monitor liver function test results, asappropriate, and assess for evidence ofdrug toxicity in patients with severe hepaticdisease because they’re at increased riskfor toxicity from increased drug accumulation.• Avoid using telmisartan in pregnantwomen during second and third trimestersbecause drug can increase the risk of fetalharm.PATIENT TEACHING• Advise patient to avoid hazardous activitiesuntil telmisartan’s CNS effects areknown.• Instruct patient to change position slowlyto minimize effects of orthostatic hypotension.• Urge patient to immediately notify prescriberabout diarrhea, dizziness, severenausea, or vomiting.• Instruct patient to consult prescriberbefore taking any new drug.• Advise patient to drink adequate amountsof fluid during hot weather and whenexercising.• Advise female patients of childbearing ageto notify presciber immediately aboutknown or suspected pregnancy.temazepamApo-Temazepam (CAN), Novo-Temazepam (CAN), RestorilClass, Category, and ScheduleChemical class: BenzodiazepineTherapeutic class: Sedative-hypnoticPregnancy category: XControlled substance schedule: IVIndications and Dosages To provide short-term management ofinsomniaCAPSULESAdults. 7.5 to 30 mg 30 min before at bedtime.Maximum: 30 mg daily.DOSAGE ADJUSTMENT For elderly ordebilitated patients, 7.5 mg 30 min beforebedtime. Maximum: 15 mg daily.Mechanism of ActionMay potentiate the effects of gammaaminobutyricacid (GABA) and otherinhibitory neurotransmitters by binding tospecific benzodiazepine receptor sites inlimbic and cortical areas of the CNS. Bybinding to these receptor sites, temazepamincreases GABA’s inhibitory effects andblocks cortical and limbic arousal.ContraindicationsHypersensitivity to temazepam, other benzodiazepines,or their components; pregnancyInteractionsDRUGSantihistamines (such as brompheniramine,carbinoxamine, chlorpheniramine, clemastine,cyproheptadine, diphenhydramine, trimeprazine),anxiolytics, barbiturates, generalanesthetics, opioid analgesics, phenothiazines,promethazine, sedative-hypnotics, tramadol,tricyclic antidepressants: Increased sedationor respiratory depressionclozapine: Risk of respiratory depression orarrestdigoxin: Increased risk of elevated blooddigoxin level and digitalis toxicityflumazenil: Increased risk of withdrawalsymptomslevodopa: Possibly decreased levodopaeffectsoral contraceptives: Decreased response totemazepamphenytoin: Possibly phenytoin toxicityprobenecid: Increased response totemazepamzidovudine: Possibly zidovudine toxicityACTIVITIES

alcohol use: Increased CNS depression andrisk of apneasmoking: Increased temazepam clearanceAdverse ReactionsCNS: Aggressiveness, anxiety (in daytime),ataxia, complex behaviors (such as sleepdriving), confusion, decreased concentration,depression, dizziness, drowsiness,euphoria, fatigue, headache, insomnia,nightmares, slurred speech, suicidalideation, syncope, talkativeness, tremor,vertigo, wakefulness during last third ofnightCV: Palpitations, tachycardiaEENT: Abnormal or blurred vision,increased salivation, throat tightnessGI: Abdominal pain, constipation, diarrhea,hepatic dysfunction, nausea, thirst, vomitingGU: Decreased libidoHEME: Agranulocytosis, anemia, leukopenia,neutropenia, thrombocytopeniaMS: Muscle spasm or weaknessRESP: Dyspnea, increased bronchial secretionsSKIN: Diaphoresis, flushing, jaundice, pruritus,rashOther: Anaphylaxis, angioedema, physicaland psychological dependenceNursing Considerations• Use temazepam cautiously in patients witha history of depression or suicidalthoughts.WARNING Monitor patient closely for evidenceof hypersensitivity reaction, such asdyspnea, throat tightness, nausea, vomiting,and swelling. If present, discontinuetemazepam immediately, notify prescriber,and provide supportive care.• Watch patient closely for suicidal tendencies,particularly when therapy starts anddosage changes, because depression mayworsen temporarily during these timesand could lead to suicidal ideation.WARNING Monitor patient for evidence ofphysical and psychological dependenceduring therapy.• Implement safety precautions, accordingto facility policy, especially in elderlypatients, because they’re more sensitive todrug’s CNS effects.• Assess patients with respiratory depression,severe COPD, or sleep apnea for signs ofventilatory failure.• Be aware that temazepam can aggravateacute intermittent porphyria, myastheniagravis, and severe renal impairment.• Be aware that temazepam may cause worseningpsychosis or deterioration of cognitionor coordination in patients with latestageParkinson’s disease.• Be aware that drug shouldn’t be discontinuedabruptly, even after only 1 to 2 weeksof therapy, because doing so may causeseizures or withdrawal symptoms, such asinsomnia, irritability, and nervousness.PATIENT TEACHING• Instruct patient to take temazepam exactlyas prescribed and not to stop or changedosage without consulting prescriber.• Explain the risks associated with abruptcessation, including abdominal cramps,acute sense of hearing, confusion, depression,nausea, numbness, perceptual disturbances,photophobia, sweating, tachycardia,tingling, trembling, and vomiting.• Advise patient to avoid consuming alcoholbecause it increases drug’s sedative effectsand the risk of such abnormal behaviorsas sleep driving.• Caution patient about possible drowsiness.Advise her to avoid potentially hazardousactivities until drug’s CNS effects areknown.• Urge patient to notify prescriber immediatelyabout excessive drowsiness, nausea,and known or suspected pregnancy.• Instruct patient to stop taking temazepamand seek emergency care if she experiencesdifficulty breathing, throat tightness, nausea,vomiting, or abnormally swelling.• Advise patient that drug may cause abnormalbehaviors during sleep, such as drivinga car, eating, talking on the phone, orhaving sex without any recall of the event.If family notices any such behavior orpatient sees evidence of such behaviorupon awakening, the prescriber should benotified.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes.tenecteplaseTNKasetenecteplase 989T

990tenecteplaseClass and CategoryChemical class: Purified glycoproteinTherapeutic class: ThrombolyticPregnancy category: CIndications and Dosages To reduce mortality associated withacute MII.V. INJECTIONAdults. Single bolus administered over5 sec in individualized dosage based onpatient’s weight, as follows: 30 mg (6 ml)for patients weighing less than 60 kg(132 lb); 35 mg (7 ml) for patients weighing60 to 69 kg (132 to 152 lb); 40 mg(8 ml) for patients weighing 70 to 79 kg(154 to 174 lb); 45 mg (9 ml) for patientsweighing 80 to 89 kg (176 to 196 lb); 50 mg(10 ml) for patients weighing 90 kg (198 lb)or more. Maximum: 50 mg total dose.Mechanism of ActionBinds to fibrin and converts plasminogen toplasmin. Plasmin breaks down fibrin, fibrinogen,and other clotting factors, resultingin dissolution of a coronary arterythrombus.IncompatibilitiesDon’t administer tenecteplase through anI.V. line containing dextrose because precipitationmay occur.ContraindicationsActive internal bleeding, aneurysm, arteriovenousmalformation, bleeding disorders,brain tumor, history of cerebrovascularaccident, hypersensitivity to tenecteplase orits components, intracranial or intraspinalsurgery or trauma within past 2 months,severe uncontrolled hypertensionInteractionsDRUGSabciximab, aspirin, clopidogrel, dipyridamole,heparin, oral anticoagulants, ticlopidine:Possibly increased risk of bleedingAdverse ReactionsCNS: Intracranial hemorrhageEENT: Epistaxis, gingival bleeding, pharyngealbleedingGI: GI and retroperitoneal bleedingGU: Genitourinary bleeding, prolonged orheavy menstrual bleedingHEME: HematomaRESP: HemoptysisSKIN: Bleeding at puncture sites, surgicalincision sites, or venous cutdown sitesNursing ConsiderationsWARNING Reconstitute tenecteplase forinjection immediately before use becausedrug contains no antibacterial preservatives.If reconstituted drug isn’t usedimmediately, refrigerate vial at 36° to 46° F(2° to 8° C). Discard solution if not usedwithin 8 hours.• To reconstitute and administer drug, usesupplied 10-ml syringe with dual cannuladevice. Withdraw 10 ml of supplied (preservative-free)sterile water for injectioninto syringe, and inject entire contentsinto vial containing tenecteplase dry powder,directing stream of diluent into powder.Gently swirl—don’t shake—vial untilcontents are completely dissolved. If slightfoaming occurs during reconstitution,allow drug to stand undisturbed for a fewminutes to allow large bubbles to dissipate.Then withdraw prescribed dose oftenecteplase from reconstituted drug invial, using supplied syringe. Make surethat reconstituted preparation is a colorlessto pale yellow transparent solution.Discard any unused solution.• Give drug as a single I.V. bolus over 5 seconds.Although supplied syringe is intendedfor use with needleless I.V. systems, beaware that it is also compatible with a conventionalneedle. Follow manufacturer’sdirections for use with each system. Flushany dextrose-containing I.V. lines withsaline solution before and after administeringtenecteplase.WARNING Monitor patient for evidence ofGI bleeding, including bloody or black,tarry stools; bloody or coffee-ground vomitus;and severe stomach pain. Notify prescriberimmediately if any of these signs orsymptoms develops.• Assess tenecteplase injection site for signsand symptoms of hematoma, includingdeep, dark purple bruises under skin anditching, pain, redness, or swelling. Alsomonitor patient for superficial bleeding,delayed bleeding at puncture sites, andbleeding from surgical incisions.• Assess for signs and symptoms of intracranialbleeding (such as decreased level ofconsciousness), retroperitoneal bleeding

(such as abdominal pain or swelling andback pain), genitourinary bleeding (suchas hematuria), or respiratory tract bleeding(such as hemoptysis). Notify prescriberimmediately if patient developsany of these signs or symptoms.• If serious bleeding (not controllable bylocal pressure) occurs, expect to discontinueconcomitant heparin or oralantiplatelet therapy immediately.• If possible, avoid I.M. injections andnonessential handling of patient for firstfew hours after drug administration.• If arterial puncture becomes necessaryduring first few hours after tenecteplaseadministration, expect to use an upperextremity that’s accessible to manual compression.Apply pressure for at least30 minutes after procedure, use a pressuredressing, and frequently monitor puncturesite for signs of bleeding.PATIENT TEACHING• Advise patient to immediately report anybleeding, including from nose or gums.• Instruct patient to limit physical activityduring tenecteplase administration toreduce the risk of injury or bleeding.terazosinhydrochlorideHytrinClass and CategoryChemical class: Quinazoline derivativeTherapeutic class: Antihypertensive, benignprostatic hyperplasia (BPH) treatmentPregnancy category: CIndications and Dosages To manage hypertensionCAPSULESAdults. Initial: 1 mg at bedtime.Maintenance: 1 to 5 mg daily as a singledose or in divided doses every 12 hr.Maximum: 20 mg daily. To treat symptomatic BPHCAPSULESAdults. Initial: 1 mg at bedtime, increasedin increments to 2 mg, 5 mg, and then10 mg, as prescribed, based on symptomimprovement and urine flow rate.Maintenance: 5 to 10 mg daily as a singleterazosin hydrochloride 991dose or in divided doses every 12 hr.Maximum: 20 mg daily.Route Onset Peak DurationP.O. 15 min 2–3 hr 24 hrMechanism of ActionBlocks postsynaptic alpha 1 -adrenergicreceptors in many tissues, including vascularsmooth muscle, the bladder neck, andthe prostate. This action promotes vasodilation,which reduces blood pressure andimproves urine flow.ContraindicationsHypersensitivity to terazosin, other quinazolines,or their componentsInteractionsDRUGSclonidine: Possibly decreased clonidineeffectsdiuretics, other antihypertensives: Additivehypotensive effectdopamine: Risk of decreased terazosineffects and antagonized vasoconstrictiveeffect of dopamine (in high doses)epinephrine: Risk of decreased terazosineffects, possibly severe hypotension andtachycardiaindomethacin, other NSAIDS: Altered terazosineffects related to sodium and fluidretentionmethoxamine, phenylephrine: Decreasedvasopressor effects, and shortened durationof action of these drugsphosphodiesterase-5 inhibitors, verapamil:Additive blood pressure–lowering effectsand symptomatic hypotensionsympathomimetics: Decreased terazosineffectsAdverse ReactionsCNS: Asthenia, dizziness, headache, lethargy,nervousness, paresthesia, somnolence,syncope, vertigoCV: Chest pain, hypotension, orthostatichypotension, palpitations, peripheraledema, sinus tachycardiaEENT: Blurred vision, dry mouth, intraoperativefloppy iris syndrome, nasal congestion,sinusitisGI: Constipation, diarrhea, nausea, vomitingMS: Arthralgia, back painT

992terbinafine hydrochlorideOther: Flulike symptoms, weight gainNursing Considerations• Be aware that prostate cancer should beruled out before giving terazosin for BPH.• Expect prescriber to reduce terazosindosage if a diuretic or another antihypertensiveis added to patient’s regimen.• Monitor blood pressure 2 to 3 hours afterinitial dose because of possible first-dosehypotension and again after 24 hours toevaluate patient’s response.• If patient requires administration by feedingtube, place capsule in 60 ml of warmtap water. Stir until capsule shell dissolvesand liquid contents are released into water(5 to 10 minutes).• Be aware that elderly patients may haveexaggerated hypotension and otheradverse reactions.PATIENT TEACHING• Instruct patient to take terazosin at thesame time each night.• Explain possible first-dose hypotension.Advise patient to change position and riseslowly to prevent syncope early in therapy.Suggest sitting or lying down if dizzinessor light-headedness occurs.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Instruct patient to notify prescriber if shemisses several doses in a row; caution heragainst resuming therapy at previousdose.• Inform patient that drug may take 2 to6 weeks to improve urinary hesitancy.• Advise patient to avoid alcohol use, prolongedstanding, and excessive exercise orexposure to hot weather because theseactivities can worsen orthostatic hypotension.• Stress the importance of regular follow-upvisits with prescriber to evaluate patient’sresponse to drug.terbinafinehydrochlorideLamisilClass and CategoryChemical class: Allylamine derivativeTherapeutic class: AntifungalPregnancy category: BIndications and Dosages To treat onychomycosis of fingernailsand toenailsTABLETSAdults and adolescents. 125 mg b.i.d. or250 mg daily for 6 to 12 wk.DOSAGE ADJUSTMENT For patients with stablechronic hepatic dysfunction or renaldysfunction (creatinine clearance less than50 ml/min/1.73 m 2 or serum creatininegreater than 3.4 mg/dl), dosage reduced by50%.Mechanism of ActionInhibits the conversion of squalene monooxygenaseto squalene epoxidase, a keyenzyme in fungal biosynthesis. The resultingsqualene accumulation weakens cellmembranes and creates a deficiency ofergosterol, the fungal membrane componentnecessary for normal fungal growth.ContraindicationsHypersensitivity to terbinafine or its componentsInteractionsDRUGSbeta blockers, MAO inhibitors (type B), selectiveserotonin reuptake inhibitors, tricyclicantidepressants: Possibly increased bloodlevels of these drugscimetidine, other hepatic enzyme inhibitors:Significantly decreased terbinafine clearance,possibly increased adverse reactionshepatotoxic drugs: Increased risk of hepatotoxicityrifampin: Increased clearance and decreasedeffectiveness of terbinafineFOODScaffeine: Decreased caffeine clearanceACTIVITIESalcohol use: Increased risk of severe hepatitisAdverse ReactionsCNS: HeadacheEENT: Taste perversionGI: Abdominal pain, anorexia, diarrhea,elevated liver function test results, flatulence,hepatic failure, indigestion, nausea,vomitingSKIN: Cutaneous lupus erythematosus,

pruritus, rash, urticariaOther: Angioedema, systemic lupus erythematosusNursing Considerations• Because terbinafine has been linked toserious adverse hepatic effects, expect tosend nail specimens for laboratory testingto confirm onychomycosis before startingtherapy.• Be aware that drug shouldn’t be given topatients with chronic or active hepatic diseaseor renal impairment.• Monitor patient for hepatic failure(anorexia, dark urine, fatigue, jaundice,nausea, pale stools, right upper abdominalpain, and vomiting). Expect to stop drugand obtain liver function tests if theseproblems develop.PATIENT TEACHING• Instruct patient to space terbinafine dosesevenly if taking drug more than once aday.• Stress the need to complete the full courseof terbinafine therapy to prevent relapse ofinfection.• Discourage consumption of alcohol duringtherapy.• Tell patient to contact prescriber if onychomycosisdoesn’t improve in a fewweeks.terbutaline sulfateBrethaire, Brethine, Bricanyl, BricanylTurbuhaler (CAN)Class and CategoryChemical class: Sympathomimetic amineTherapeutic class: BronchodilatorPregnancy category: BIndications and Dosages To prevent or reverse bronchospasmfrom asthma, bronchitis, or emphysemaTABLETS (BRETHINE, BRICANYL)Adults and adolescents age 15 and over.2.5 to 5 mg t.i.d. at 6-hr intervals whileawake. Maximum: 15 mg daily.Children ages 12 to 15. 2.5 mg t.i.d. at 6-hrintervals while awake. Maximum: 7.5 mgdaily.Children ages 6 to 11. 50 to 75 mcg/kg t.i.d.at 6-hr intervals while awake. Maximum:terbutaline sulfate 993150 mcg/kg/dose or 5 mg daily.SUBCUTANEOUS INJECTION (BRICANYL)Adults and children age 12 and over.Initial: 0.25 mg, repeated in 15 to 30 min asprescribed. Maximum: 0.5 mg/4-hr period.Children ages 6 to 12. 5 to 10 mcg (0.005 to0.01 mg)/kg every 15 to 20 min, up to3 doses. Maximum: 400 mcg (0.4 mg)/dose.INHALATION AEROSOL (BRETHAIRE)Adults and children. 2 inhalations(400 mcg) every 4 to 6 hr, as needed and asprescribed.INHALATION AEROSOL (BRICANYL TURBUHALER)Adults and children. 1 inhalation(500 mcg), repeated after 5 min, as neededand as prescribed. Maximum: 6 inhalationsdaily.Route Onset Peak DurationP.O. 30–90 2–3 hr 4–8 hrminSubQ 15–30 30–60 min 1.5–4 hrminInhalation In 5 min 30–90 min 3–6 hrMechanism of ActionStimulates beta 2 -adrenergic receptors in thelungs, which is believed to increase productionof cAMP. The increased cAMP levelrelaxes bronchial smooth muscles, therebyincreasing bronchial airflow and relievingbronchospasm.ContraindicationsHypersensitivity to terbutaline, other sympathomimeticamines, or their componentsInteractionsDRUGSantihypertensives, diuretics: Decreased antihypertensiveeffectbeta blockers: Mutual inhibition of therapeuticeffects, increased risk of bronchospasmCNS stimulants: Additive CNS stimulation,possibly resulting in adverse effectsdigoxin: Increased risk of arrhythmias, possiblydigitalis toxicityhalogenated anesthetics: Possibly ventriculararrhythmiasMAO inhibitors: Possibly potentiated actionof terbutaline; headache, hyperpyrexia,hypertension, possible hypertensive crisismaprotiline, tricyclic antidepressants:T

994teriparatidePossibly potentiated action of terbutalinenitrates: Decreased effectiveness of nitratesritodrine: Increased effects of either drugand potential for adverse effectssympathomimetics: Increased CNS stimulationand risk of adverse cardiovasculareffects, including prolonged QT intervalthyroid hormones: Increased effects of eitherdrug, risk of coronary insufficiency inpatients with coronary artery diseasexanthines (theophylline): Increased CNSstimulation and other additive toxic effectsFOODScaffeine: Increased CNS stimulation andother additive toxic effectsAdverse ReactionsCNS: Anxiety, dizziness, drowsiness, headache,insomnia, light-headedness, nervousness,restlessness, tremor, weaknessCV: Chest pain, irregular heartbeat, palpitations,tachycardiaEENT: Dry mouth, taste perversionENDO: HyperglycemiaGI: Heartburn, nausea, vomitingMS: Muscle spasmsRESP: DyspneaSKIN: Diaphoresis, flushing, rashNursing Considerations• Use terbutaline cautiously in patients withcardiovascular disease because drug canadversely affect cardiovascular function.Monitor patient’s heart rate and rhythmand blood pressure, and assess for chestpain.• For subcutaneous use, inject into lateraldeltoid area.• Assess patient’s respiratory rate, depth,and quality; oxygen saturation; and activitytolerance at regular intervals becausecontinuous use of beta 2 -agonists for12 months or longer accelerates thedecline in pulmonary function.PATIENT TEACHING• Teach patient how to use terbutaline aerosolinhaler or give subcutaneous injection,as needed.• Instruct patient not to increase dose orfrequency without consulting prescriber.• Urge patient to seek immediate medicalattention if symptoms worsen.• Inform patient that she may experiencetransient nervousness or tremors duringterbutaline therapy.teriparatideForteoClass and CategoryChemical class: Recombinant humanparathyroid hormone (PTH)Therapeutic class: Bone growth and densityregulatorPregnancy category: CIndications and Dosages To treat osteoporosis in postmenopausalwomen and primary or hypogonadalosteoporosis in men at high risk for fracture;to treat men and women with glucocorticoid-inducedosteoporosis at highrisk for fractureSUBCUTANEOUS INJECTIONAdults. 20 mcg daily for up to 2 yr.Route Onset Peak DurationSubQ 2 hr 4–6 hr 16–24 hrContraindicationsHypersensitivity to teriparatide or its componentsInteractionsDRUGSdigitalis glycosides: Possibly increased risk ofdigitalis toxicityAdverse ReactionsCNS: Asthenia, depression, dizziness, headache,insomnia, paresthesia, syncope, vertigoCV: Angina pectoris, chest pain, hypertension,transient orthostatic hypotensionEENT: Pharyngitis, rhinitis, taste perversion,tooth disorderENDO: Transient hypoparathyroidismGI: Constipation, diarrhea, indigestion,vomitingMS: Arthralgia, muscle cramps or spasms inback or leg, neck painRESP: Cough, dyspnea, pneumoniaSKIN: Diaphoresis, pruritus, rash, urticariaOther: Angioedema, generalized pain,injection site reactions (erythema, localizedbruising, minor bleeding, pain, pruritus,swelling), transient hypercalcemia orhypocalcemiaNursing ConsiderationsWARNING Be aware that teriparatide

teriparatide 995Mechanism of ActionTeriparatide, which contains recombinantPTH, stimulates new bone growth andincreases bone density. In a patient withosteoporosis, bone density and mass arediminished by an imbalance betweenbone destruction and formation.Normally, osteoclasts break down andresorb bone, leaving behind a cavity in asection of bone. Then bone-buildingcells, called osteoblasts, line the walls ofthe cavity and stimulate new bone formation.PTH stimulates these actions byattaching to receptors on osteoclasts andosteoblasts, as shown below.Teriparatide binds to cell-surfacereceptors on osteoblasts and preferentiallystimulates osteoblastic over osteoclasticactivity. Also, the drug increases theamount of circulating calcium availablefor bone formation by increasing theintestinal absorption of calcium andphosphate, thus enhancing the rate ofcalcium resorption from bone, increasingthe reabsorption of calcium, and inhibitingthe reabsorption of phosphate in thekidneys. These actions stimulate newbone formation and increase bone densityto reduce osteoporotic bone changes.shouldn’t be used to treat patients at riskfor osteosarcoma (such as those withPaget’s disease or a metabolic bone diseaseother than osteoporosis), unexplained elevationsof alkaline phosphatase, open epiphyses,or prior skeletal radiation ormalignancy.WARNING Be aware that patients withhypercalcemia shouldn’t receive teriparatidebecause drug may worsen hypercalcemia.• Use drug cautiously in patients with activeor recent urolithiasis because drug couldworsen this condition.• Monitor patient closely for allergic reactionsbecause teriparatide is a peptideagent.• Monitor patient’s blood calcium level, andnotify prescriber of any elevation; in persistenthypercalcemia, the drug may needto be stopped.• Monitor patient’s blood pressure duringthe first several doses of drug therapybecause of a risk of transient orthostatichypotension. If this occurs, place patientin a reclining position and alert prescriber.PATIENT TEACHING• Teach patient how to administer teriparatideby subcutaneous injection and how toproperly use the delivery pen device anddispose of needles. Advise her not to sharepen device with others.• Inform patient that each delivery pen canbe used for up to 28 days after the firstinjection but then should be discardedeven if it still contains solution.• Instruct patient to store the delivery penin the refrigerator and to recap it whennot in use to protect it from damage andlight.• Tell patient that delivery pen may be usedimmediately after removal from refrigera-T

996tetracycline hydrochloridetor and should be put back in refrigeratoras soon as the injection is given.• Instruct patient to inject drug into thighor abdominal wall and to rotate injectionsites.• Caution patient to administer drug in aroom where she can immediately sit or liedown if light-headedness or palpitationsoccur. Advise her to notify prescriber ifthese symptoms persist or worsen.• Instruct patient to notify prescriber ofpersistent symptoms of hypercalcemia,such as nausea, vomiting, constipation,lethargy, and muscle weakness.• Caution patient about potential developingosteosarcoma.tetracyclinehydrochlorideAchromycin, Achromycin V, Apo-Tetra(CAN), Novo-Tetra (CAN), Nu-Tetra(CAN), Panmycin, Robitet, Sumycin,Tetracap, Tetracyn, Tetracyn 500Class and CategoryChemical class: Chlortetracycline derivativeTherapeutic class: AntibioticPregnancy category: DIndications and Dosages To treat actinomycosis caused by susceptibleorganismsCAPSULES, ORAL SUSPENSION, TABLETSAdults and adolescents. 250 to 500 mgevery 6 hr or 500 to 1,000 mg every 12 hr.Maximum: 4 g daily.Children age 8 and over. 6.25 to 12.5 mg/kgevery 6 hr or 12.5 to 25 mg/kg every 12 hr. To treat acne vulgarisCAPSULES, ORAL SUSPENSION, TABLETSAdults and adolescents. Initial: 500 to2,000 mg daily in divided doses untilimprovement occurs (usually in 3 wk); thendosage reduced gradually. Maintenance:125 to 1,000 mg daily. Maximum: 4 g daily. To treat brucellosis caused by susceptibleorganismsCAPSULES, ORAL SUSPENSION, TABLETSAdults and adolescents. 500 mg every 6 hrfor 3 wk, given with 1 g of streptomycinI.M. every 12 hr in week 1 and daily inweek 2. Maximum: 4 g daily.Children ages 8 to 12. 6.25 to 12.5 mg/kgevery 6 hr, or 12.5 to 25 mg/kg every 12 hr. To treat gonorrhea caused by NeisseriagonorrhoeaeCAPSULES, ORAL SUSPENSION, TABLETSAdults and adolescents. 1,500 mg, then500 mg every 6 hr for 5 days. Maximum: 4 gdaily. To treat syphilis caused by TreponemapallidumCAPSULES, ORAL SUSPENSION, TABLETSAdults and adolescents. 500 mg every 6 hrfor 15 days (for early syphilis) or 30 days(for late syphilis). Maximum: 4 g daily.Children ages 9 to 12. 6.25 to 12.5 mg/kgevery 6 hr, or 12.5 to 25 mg/kg every 12 hr. To treat uncomplicated endocervical,rectal, or urethral infections caused byChlamydia trachomatisCAPSULES, ORAL SUSPENSION, TABLETSAdults and adolescents. 500 mg q.i.d. for atleast 7 days. Maximum: 4 g daily.DOSAGE ADJUSTMENT For patients withrenal impairment, dosage possibly reducedbecause of extended half-life.Mechanism of ActionExerts a bacteriostatic effect against a widevariety of gram-positive and gram-negativeorganisms by passing through the bacteriallipid bilayer, where it binds reversibly to 30Sribosomal subunits. Bound tetracyclineblocks the binding of aminoacyl transferRNA to messenger RNA, thus inhibiting bacterialprotein synthesis.ContraindicationsHypersensitivity to tetracycline or its componentsInteractionsDRUGSaluminum-, calcium-, or magnesium-containingantacids; iron supplements (oral);magnesium-containing laxatives; magnesiumsalicylate; multivitamins (containing manganeseor zinc salts); sodium bicarbonate:Possibly impaired absorption of oral tetracyclineand formation of nonabsorbablecomplexescholestyramine, colestipol: Possibly impairedabsorption of oral tetracyclinedigoxin: Possibly increased digoxin levelmethoxyflurane: Possibly nephrotoxicityoral contraceptives (containing estrogen):

Possibly reduced contraceptive reliabilityand increased risk of breakthrough bleeding(with long-term tetracycline use)penicillins: Possibly decreased bactericidaleffect of penicillinsvitamin A: Possibly benign intracranialhypertensionFOODSdairy products and other foods: Possiblyimpaired absorption of oral tetracyclineAdverse ReactionsCNS: Dizziness, light-headedness, unsteadinessEENT: Darkened or discolored tongue,enamel hypoplasia, oral candidiasis, toothdiscoloration (in children)GI: Abdominal pain, diarrhea, hepatotoxicity,nausea, rectal candidiasis, vomitingGU: Vaginal candidiasisSKIN: PhotosensitivityNursing Considerations• Avoid giving tetracycline to children underage 8 because drug may cause permanentbrown or yellow tooth discoloration andenamel hypoplasia.• Be aware that tooth discoloration andenamel hypoplasia may occur in breastfeedinginfants, along with inhibition oflinear skeletal growth, oral and vaginalcandidiasis, and photosensitivity.• To reduce the risk of esophageal irritationor ulceration, avoid bedtime dosing oftetracycline for patient with esophagealobstruction or compression.• Assess for photosensitivity, which candevelop within a few minutes or up to severalhours after exposure to sunlight orother ultraviolet (UV) light. Effects maylast for 1 to 2 days after discontinuation ofdrug.• Be aware that citric acid in tetracyclinepreparations may accelerate drug deteriorationand that using outdated drug maycause Fanconi’s syndrome, characterizedby multiple defects in renal tubular function.Symptoms include acidosis, bicarbonatewasting, glycosuria, hypokalemia,osteomalacia, and phosphaturia.PATIENT TEACHING• Instruct patient to take oral tetracycline atleast 1 hour before meals or 2 hours aftermeals because dairy products and somefoods may interfere with absorption.• Advise patient to take each dose with a fullglass of water while in an upright positionto avoid esophageal or GI irritation.• Instruct patient taking oral suspension toshake container well before measuringdose and to use a calibrated measuringdevice.• Advise patient to avoid taking other drugs,including OTC antacids and other preparations,within 3 hours of oral tetracycline.• Urge patient to complete entire course oftetracycline therapy even if she feels better.• Caution her to avoid direct sunlight or UVlight and to wear sunscreen when outdoors.• Advise women who use oral contraceptivescontaining estrogen to use anothermethod of contraception while takingtetracycline because contraceptives may beless effective.• Stress the need to discard outdated tetracyclinebecause of the risk of toxic effects.• Encourage patient to take safety precautionsif she experiences dizziness or otheradverse CNS reactions.thalidomideThalomidthalidomide 997Class and CategoryChemical class: Glutamic-acid derivativeTherapeutic class: Anti-inflammatory,immuno-modulatorPregnancy category: XIndications and Dosages To treat acute cutaneous erythemanodosum leprosumCAPSULESAdults and adolescents. 100 to 400 mgdaily at bedtime or at least 1 hr after theevening meal. Usual: 200 mg.DOSAGE ADJUSTMENT For patients weighingless than 50 kg (110 lb), dosage started at100 mg. To prevent or suppress recurrence ofcutaneous erythema nodosum leprosumCAPSULESAdults and adolescents. Minimum dosagenecessary to control reaction; dosagetapered every 3 to 6 mo in increments of50 mg every 2 to 4 wk, as prescribed.T

998Nursing Considerations• Be aware that all patients receiving thalidomidemust complete an informed consentform and participate in a confidentialmonitoring registry. Thalidomide may beobtained only through physicians andpharmacies registered in the System forThalidomide Education and PrescribingSafety (STEPS) Program, a comprehensivesafety program designed to prevent fetalexposure to thalidomide. Thalidomidemay be dispensed only in original packagingand in no more than a 28-day supply.Prescriptions older than 7 days may not befilled.• Be aware that female patients of childbearingage must use two contraceptive methodsduring therapy. Pregnancy testingmust be performed 24 hours before startingthalidomide, weekly during firstmonth of therapy, then monthly thereafterin women with regular menstrual cycles orevery 2 weeks in women with irregularmenstrual cycles.WARNING Be aware that thalidomideshouldn’t be given to pregnant patient. Asingle dose may cause severe birth defectsor fetal death.• Assess patient’s medication history for useof carbamazepine, griseofulvin, HIV-proteaseinhibitors, modafinil, penicillins,phenytoin, rifabutin, rifampin, and theherbal remedy St. John’s wort. These productscan decrease the effectiveness of hormonalcontraceptives during thalidomidetherapy.WARNING Monitor patient closely for evithalidomideMechanism of ActionSuppresses the production of tumor necrosisfactor-alpha, which reduces neutrophilsand CD4 T cells in erythema nodosum leprosumlesions, thus preventing or controllingsymptoms.ContraindicationsHypersensitivity to thalidomide or its components;men, regardless of history ofvasectomy, who refuse to wear latex condomduring intercourse with women ofchildbearing age; pregnancy; women ofchildbearing age who aren’t using two reliablecontraceptive methods or aren’tabstaining from heterosexual intercourseInteractionsDRUGSantihistamines, anxiolytics, barbiturates,chlorpromazine, CNS depressants, hypnotics,opioid analgesics, reserpine, sedatives:Increased CNS depressionchloramphenicol, cisplatin, dapsone, didanosine,ethambutol, ethionamide, hydralazine,isoniazid, lithium, metronidazole, nitrofurantoin,nitrous oxide, other drugs associatedwith peripheral neuropathy, phenytoin,stavudine, vincristine, zalcitabine: Increasedrisk of peripheral neuropathyACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Agitation, anxiety, asthenia, chills,confusion, depression, dizziness, drowsiness,fatigue, fever, headache, insomnia,lethargy, loss of consciousness, malaise,mood changes, nervousness, paresthesia,peripheral neuropathy, seizures, somnolence,status epilepticus, stupor, syncope,tremor, vertigoCV: Arrhythmias, bradycardia, embolism,hyperlipidemia, hypertension, orthostatichypotension, peripheral edema, tachycardia,thrombosisEENT: Dry mouth, oral candidiasis,pharyngitis, rhinitis, sinusitis, tooth painENDO: HypothyroidismGI: Abdominal pain, anorexia, constipation,diarrhea, elevated liver function test results,flatulence, hepatic dysfunction, increasedappetite, intestinal perforation, nausea,vomitingGU: Albuminuria, elevated creatinine level,hematuria, impotenceHEME: Anemia, decreased platelets count,leukopenia, neutropenia, prolonged PTMS: Arthralgia, back or bone pain, muscleweakness, myalgia, neck pain or rigidityRESP: Cough, dyspnea, pleural effusion,pulmonary embolismSKIN: Acne, dermatitis, diaphoresis, dryness,erythema multiforme, photosensitivity,pruritus, rashOther: Facial edema, hypercalcemia, hyperkalemia,hypocalcemia, hypokalemia,hyponatremia, increased alkaline phosphataselevel, lymphadenopathy, pain (generalized),tumor lysis syndrome, weight lossor gain

dence of a venous thromboembolic event(shortness of breath, chest pain, or arm orleg swelling). Notify prescriber immediatelyand expect to assist with diagnosticstudies to confirm suspicions and providetreatment, as ordered.• To minimize sedative effect, give thalidomidein divided doses t.i.d. or q.i.d., asprescribed, with larger dose in theevening.• Assess for early signs of peripheralneuropathy (muscle cramps, numbnessand tingling in toes and fingers, pain orsuperficial sensory loss in feet or hands) inpatients receiving long-term thalidomidetherapy. Early detection and drug discontinuation,as pre-scribed, prevents furtherdamage and increases the chance forreversal.• Expect to stop thalidomide if absoluteneutrophil count is less than 750/mm 3 .Routine monitoring of WBC count is recommendedevery other week for first3 months of treatment in HIV-positiveand other immunosuppressed patientsand monthly in immunocompetentpatients.PATIENT TEACHING• Instruct patient to have thalidomide prescriptionfilled promptly because prescriptionsmore than 7 days old may not befilled.• Urge patient to take drug exactly as prescribed.• Inform female patient that drug will harma fetus, and stress the need to avoid pregnancy.Tell her that pregnancy tests willbe done before and frequently duringtherapy.• Instruct female patient to abstain fromsexual intercourse or to use two reliablemethods of birth control simultaneously,starting 4 weeks before drug therapy andcontinuing for up to 4 weeks after therapyhas been completed. One contraceptivemethod must be highly effective, such asan intrauterine device, oral contraceptive,or tubal ligation; the other may be a cervicalcap, diaphragm, or latex condom.WARNING Inform male patient, even onewho has had a vasectomy, that he must usebarrier contraception (latex condom)when having sexual intercourse with awoman of childbearing age.Indications and Dosages As loading dose to treat reversible airwayobstruction in patients not currentlyreceiving theophyllineCAPSULES, ELIXIR, ORAL SOLUTION, SYRUP,TABLETSAdults and children. 5 mg/kg as a singledose.I.V. INFUSIONAdults and children. 5 mg/kg infused over20 to 30 min. As partial loading dose to treat reversibleairway obstruction in patients currentlyreceiving theophyllineCAPSULES, ELIXIR, ORAL SOLUTION, SYRUP,TABLETS, I.V. INFUSIONAdults and children. Individualized dosagebased on blood theophylline level, as pretheophylline999• Caution patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Suggest changing positions slowly to minimizeeffects of orthostatic hypotension.• Instruct patient to immediately reportsigns of peripheral neuropathy, includingnumbness, pain, or tingling in feet andhands.• Inform HIV-positive patient of the needfor viral-load testing after first and thirdmonths of therapy and then every3 months.• Urge patient to avoid using alcohol anddonating blood or sperm during therapy.theophyllineAerolate, Aerolate III, Aerolate Jr.,Aerolate Sr., Apo-Theo LA (CAN),Asmalix, Elixophyllin, Lanophyllin,PMS Theophylline (CAN),Pulmophylline (CAN), Quibron-TDividose, Quibron-T/SR Dividose,Respbid, Slo-Bid Gyrocaps, Slo-Phyllin,Theo-24, Theo-SR (CAN), TheobidDuracaps, Theochron, Theoclear,Theoclear LA, Theo-Dur, Theolair,Theolair-SR, Theovent Long-Acting, T-Phyl, Truxophyllin, Uni-Dur, UniphylClass and CategoryChemical class: Xanthine derivativeTherapeutic class: BronchodilatorPregnancy category: CT

1000imum of 400 mg daily in equally divideddoses every 8 to 12 hr; after 3 more days, iftolerated, dosage increased to 20 mg/kgdaily up to maximum of 600 mg daily inequally divided doses every 8 to 12 hr.Dosages above 600 mg daily are based onblood theophylline level and clinicalresponse.ORAL SOLUTION, SYRUPAdults and children weighing more than45 kg. Initial: 300 mg daily in equally divideddoses every 6 to 8 hr; after 3 days, if tolerated,increased to 400 mg daily in divideddoses every 6 to 8 hr; after 3 more days, iftolerated, increased to 600 mg daily individed doses every 6 to 8 hr. Dosagesabove 600 mg daily are based on bloodtheophylline level and clinical response.Children age 1 and over weighing 45 kg orless. Initial: 12 to 14 mg/kg daily up tomaximum of 300 mg daily in equally divideddoses every 4 to 6 hr; after 3 days, if tolerated,increased to 16 mg/kg up to a maximumof 400 mg daily in equally divideddoses every 4 to 6 hr; after 3 more days, iftolerated, dosage increased to 20 mg/kgdaily up to maximum of 600 mg daily inequally divided doses every 4 to 6 hr.Dosages above 600 mg daily are based onblood theophylline level and clinicalresponse.Full-term infants ages 26 to 52 weeks.Dosage individualized in mg/kg daily, asprescribed, and administered in equallydivided doses every 6 hr.Full-term infants up to age 26 weeks.Dosage individualized in mg/kg daily, asprescribed, and administered in equallydivided doses every 8 hr.Premature infants age 24 days and over.1.5 mg/kg every 12 hr.Premature infants under age 24 days.1 mg/kg every 12 hr.I.V. INFUSIONAdults and adolescents age 16 and over.0.4 mg/kg/hr for nonsmokers, 0.7 mg/kg/hrfor smokers.DOSAGE ADJUSTMENT For elderly patientsand adults with cardiac decompensation,cor pulmonale, or hepatic impairment, I.V.dosage reduced to 0.2 mg/kg/hr.Children ages 9 to 16. 0.7 mg/kg/hr.Children ages 1 to 9. 0.8 mg/kg/hr.Full-term infants up to age 1. Dosage inditheophyllinescribed. Loading dose based on principlethat 0.5 mg/kg of theophylline will producea 1-mcg/ml increase in blood theophyllinelevel. To provide maintenance treatment ofreversible airway obstruction associatedwith asthma or COPDCAPSULES, TABLETSAdults and children weighing more than45 kg (99 lb). Initial: 300 mg daily in equallydivided doses every 6 to 8 hr; after3 days, if tolerated, increased to 400 mgdaily in divided doses every 6 to 8 hr; after3 more days, if tolerated, increased to600 mg daily in divided doses every 6 to8 hr. Dosages above 600 mg daily are basedon blood theophylline level and clinicalresponse.Children age 1 and over weighing 45 kg orless. Initial: 12 to 14 mg/kg daily up tomaximum of 300 mg daily in equally divideddoses every 4 to 6 hr; after 3 days, if tolerated,increased to 16 mg/kg up to maximumof 400 mg daily in equally divideddoses every 4 to 6 hr; after 3 more days, iftolerated, 20 mg/kg daily up to maximumof 600 mg daily in equally divided dosesevery 4 to 6 hr. Dosages above 600 mg dailyare based on blood theophylline level andclinical response.ELIXIRAdults. Initial: 300 mg daily in equallydivided doses every 6 to 8 hr; after 3 days, iftolerated, increased to 400 mg daily individed doses every 6 to 8 hr; after 3 moredays, if tolerated, increased to 600 mg dailyin divided doses every 6 to 8 hr. Dosagesabove 600 mg daily are based on bloodtheophylline level and clinical response.E.R. CAPSULES OR TABLETSAdults and children weighing 45 kg ormore. Initial: 300 mg daily in equally divideddoses every 8 to 12 hr; after 3 days, iftolerated, increased to 400 mg daily individed doses every 8 to 12 hr; after 3 moredays, if tolerated, increased to 600 mg dailyin divided doses every 8 to 12 hr. Dosagesabove 600 mg daily are based on bloodtheophylline level and clinical response.Children age 1 and over weighing less than45 kg. Initial: 12 to 14 mg/kg daily up tomaximum of 300 mg daily in equally divideddoses every 8 to 12 hr; after 3 days, iftolerated, increased to 16 mg/kg up to max-

vidualized in mg/kg daily as prescribed.Mechanism of ActionInhibits phosphodiesterase enzymes, causingbronchodilation. Normally, theseenzymes inactivate cAMP and cGMP, whichare responsible for bronchial smoothmusclerelaxation. Theophylline also maycause calcium translocation, antagonizeprostaglandins and adenosine receptors,stimulate catecholamines, and inhibitcGMP metabolism.IncompatibilitiesDon’t mix parenteral theophylline solutionwith any additives. Don’t infuse theophyllinethrough same I.V. line asHetastarch (Hespan), a colloidal plasmavolume expander, which is incompatiblewith theophylline.ContraindicationsHypersensitivity to theophylline or its components,peptic ulcer disease, uncontrolledseizure disorderInteractionsDRUGSadenosine: Decreased adenosine effectivenessallopurinol, cimetidine, ciprofloxacin, clarithromycin,disulfiram, enoxacin, erythromycin,fluvoxamine, interferon alpha (humanrecombinant), methotrexate, mexiletine, pentoxifylline,propafenone, propranolol, tacrine,thiabendazole, ticlopidine, troleandomycin,verapamil: Increased blood theophyllinelevel and risk of toxicityaminoglutethimide, carbamazepine, isoproterenol(I.V.), moricizine, oral contraceptives(containing estrogen), phenobarbital, phenytoin,rifampin: Decreased blood theophyllinelevel and possibly drug effectivenessbenzodiazepines: Possibly reversal of benzodiazepinesedationbeta blockers: Possibly decreased bronchodilatoreffect of theophyllineephedrine: Increased adverse effects, includinginsomnia, nausea, and nervousnesshalothane anesthetics: Increased risk of ventriculararrhythmiasketamine: Lowered seizure thresholdlithium: Decreased lithium effectivenessneuromuscular blockers: Possibly antagonizedneuromuscular blockadetheophylline 1001sucralfate: Decreased absorption of oraltheophyllineFOODShigh-carbohydrate, low-protein diet: Possiblydecreased theophylline eliminationlow-carbohydrate, high-protein diet; dailyintake of charbroiled beef: Possibly increasedtheophylline eliminationACTIVITIESalcohol use: Increased blood theophyllinelevel and risk of toxicitysmoking: Increased drug clearance,decreased drug effectivenessAdverse ReactionsCNS: Agitation, anxiety (I.V. form), behavioralchanges, confusion, disorientation,headache, insomnia, nervousness, seizures,tremorCV: Hypotension, tachycardia, ventriculararrhythmiasENDO: HyperglycemiaGI: Abdominal pain, diarrhea, heartburn,nausea, vomitingGU: Increased urine outputOther: HypercalcemiaNursing Considerations• Be aware that ideal body weight is used tocalculate theophylline dosages becausedrug doesn’t bind well in body fat.• Be aware that E.R. capsules and tabletsshouldn’t be used for oral loading doses.• Infuse theophylline loading dose, bolus,or intermittent infusion at a rate thatdoesn’t exceed 25 mg/min.• Administer continuous theophylline infusionwith rate-controlled infusion device.• Monitor blood theophylline level, asordered, to gauge therapeutic level anddetect toxicity.• Frequently assess heart rate and rhythmbecause theophylline can exacerbate existingarrhythmias.• Be especially alert for signs of toxicity inpatient with acute pulmonary edema,hypothyroidism, influenza vaccination,prolonged fever, sepsis with multipleorgan failure, shock, or viral pulmonaryinfection because of decreased drug clearance.• Monitor blood theophylline level inpatients with uncorrected acidemiabecause they have an increased risk of toxicity.T

1002thiethylperazine maleate• Expect patient with cystic fibrosis orhyperthyroidism to have increased theophyllineclearance and decreased drugeffectiveness. Monitor blood theophyllinelevel, as ordered.• Suspect toxicity if patient experiencesvomiting, and be prepared to obtain bloodtheophylline level.PATIENT TEACHING• Instruct patient to swallow theophyllinetablets whole and not to chew or crushthem, unless scored for breaking.• Explain that patient may open capsulesand mix contents with soft food but thatshe shouldn’t chew or crush granules.• Instruct patient to take drug with a fullglass of water on an empty stomach (30 to60 minutes before meals or 2 hours aftermeals). However, suggest that she takedrug with food or antacids if GI distressoccurs.• Encourage patient to take drug at the sametimes every day.• Advise patient to notify prescriber if shedevelops a fever, makes a significantdietary change, or starts or stops smokingor taking other drugs because these factorsmay alter blood theophylline level.• Tell female patient to notify prescriber ifshe is or cold be pregnant.thiethylperazinemaleateTorecanClass and CategoryChemical class: Piperazine phenothiazineTherapeutic class: AntiemeticPregnancy category: Not ratedIndications and Dosages To treat nausea and vomitingTABLETS, I.M. INJECTION, SUPPOSITORIESAdults and adolescents. 10 mg once dailyto t.i.d. Maximum: 30 mg daily.Route Onset Peak DurationP.O. 30–60 min Unknown 4 hrMechanism of ActionRelieves nausea and vomiting by centrallyblocking dopamine receptors in the medullarychemoreceptor trigger zone.ContraindicationsBreast-feeding; coma; hypersensitivity tothiethylperazine, sulfites, tartrazine dye, ortheir components; jaundice; severe CNSdepressionInteractionsDRUGSaluminum- or magnesium-containing antacids,antidiarrheals (adsorbent): Decreasedabsorption of thiethylperazineanticonvulsants (including barbiturates):Lowered seizure thresholdantihistamines, tricyclic antidepressants:Additive CNS and GI effects, including ileusand severe constipationantihypertensives: Enhanced hypotensiveeffect of both drugsantimuscarinics (including antiparkinsoniandrugs, MAO inhibitors, meperidine, and phenothiazines):Additive GI effects, includingileus and severe constipationappetite suppressants: Decreased anorecticeffectbarbiturates, benzodiazepines, CNS depressants,general anesthetics, opioid analgesics:Additive CNS effectsbeta blockers: Increased blood levels of bothdrugs; additive hypotensive effects; possiblyarrhythmias, irreversible retinopathy, andtardive dyskinesiabromocriptine: Possibly decreased effectivenessof bromocriptinehepatotoxic drugs: Increased risk of hepatotoxicitylevodopa: Decreased effectiveness of levodopalithium: Possibly acute encephalopathymethoxsalen, porfimer: Possibly increasedphotosensitivitymetrizamide: Increased risk of seizuresototoxic drugs: Possibly masked symptomsof ototoxicity (dizziness, tinnitus, and vertigo)phenytoin: Increased risk of phenytoin toxicityquinidine: Possibly adverse cardiac effectsriboflavin: Increased requirements for riboflavinsympathomimetics: Reduced vasopressorresponse and duration of action ofsympathomimetics

tramadol: Additive CNS effects, increasedrisk of seizuresACTIVITIESalcohol use: Additive CNS effectsAdverse ReactionsCNS: Confusion, dizziness, EEG abnormalities,extrapyramidal reactions (dystonia,pseudoparkinsonism), sedationCV: ECG changes, hypotension, orthostatichypotension, tachycardiaEENT: Blurred vision, dry mouthENDO: GynecomastiaGI: Constipation, increased appetiteGU: Darkened urine, ejaculation disorders,menstrual irregularities, urine retentionHEME: Agranulocytosis, leukopenia (transient)SKIN: Contact dermatitis, photosensitivityOther: Weight gainthiethylperazine maleate 1003Nursing Considerations• Avoid using thiethylperazine in patientswith neurologic impairment because drugcan disrupt central temperature regulation.• Avoid inadvertent I.V. administration ofthiethylperazine; injection is for I.M.administration only.• Keep patient in recumbent position for30 to 60 minutes after I.M. injection tominimize the risk of hypotension.• Be aware that parenteral preparations containsulfites and that tablets contain tartrazinedye.• Moisten suppository with water or watersolublelubricant before insertion. If suppositoryhas softened excessively, chill for30 minutes or run under cold water beforeremoving wrapper.• Avoid skin contact with drug to preventcontact dermatitis.• Because thiethylperazine may cause reactionsfrom anticholinergic effects andadrenergic blockade, assess for blurredvision, constipation, dry mouth, impotence,urine retention (from cholinergicactivity) and priapism (from alphaadrenergicblockade).• During prolonged therapy, assess for visualdisturbances because drug may causecorneal keratopathy and retinal discoloration(pigmentary retinopathy).WARNING Be aware that thiethylperazinemay cause neuroleptic malignant syndrome,a rare but extremely serious reactioncharacterized by cardiovascular instability,decreased level of consciousness,extrapyramidal effects, and hyperpyrexia.• Monitor CBC with differential, as ordered,because drug may worsen existing blooddyscrasias, such as agranulocytosis, neutropenia,and thrombocytopenia, inpatients with bone marrow suppression.Be aware that drug may worsen angleclosureglaucoma, encephalopathy, organicor traumatic brain damage, or tardivedyskinesia.• When possible, avoid combining thiethylperazinewith CNS depressants becausethese drugs may potentiate thiethylperazine’seffects.• Monitor patient with cardiac disease forexaggerated cardiovascular reactions.• Implement seizure precautions and monitorfor seizures in patients with knownseizure disorder because drug may lowerseizure threshold.• Implement safety precautions, accordingto facility policy, for elderly patients. Theymay be especially sensitive to drug’s sedativeand extrapyramidal effects.• Be prepared to discontinue drug 48 hoursbefore myelography and to resume drug24 to 48 hours afterward to minimize therisk of seizures.• Be aware that photosensitivity may turnpatient’s skin yellow-brown, gray, or purplebecause of hyperpigmentation.• Be aware that drug shouldn’t be given topregnant patient because it may causejaundice and extrapyramidal symptoms inher neonate.PATIENT TEACHING• Instruct patient to stay recumbent for1 hour after taking thiethylperazine tominimize effects of orthostatic hypotension.• Advise patient to notify prescriber immediatelyabout adverse CNS reactions,decreased urine output, or vision changes.• Urge patient to avoid alcohol use andpotentially hazardous activities duringtherapy.• Encourage patient to avoid excessive sunexposure and to use sunscreen when she’soutdoors.• Advise patient on long-term therapy tohave periodic eye examinations to detectpossible eye disorders.T

1004thiopental sodiumthiopental sodiumPentothalClass, Category, and ScheduleChemical class: BarbiturateTherapeutic class: Anticonvulsant, sedativehypnoticPregnancy category: CControlled substance: Schedule IIIIndications and Dosages To control seizures from anesthesia orother causesI.V. INJECTIONAdults. Initial: 75 to 125 mg (3 to 5 ml of2.5% solution) as soon as possible afteronset of seizure. Maximum: 250 mg givenover 10 min. To facilitate narcoanalysisI.V. INFUSION OR INJECTIONAdults. Dosage individualized based onpatient’s age, condition, sex, and weight;injected at 100 mg/min (4 ml/min of 2.5%solution) with patient counting backwardsfrom 100. Expect to discontinue injectiononce patient becomes confused with hercounting but is still awake. Or, use 0.2%concentration in D 5 W for injection andinfuse at 50 ml/min. To treat cerebral hypertensionI.V. INFUSION OR INJECTIONAdults. 1.5 to 3.5 mg/kg, repeated as needed,to reduce elevated intracranial pressure(ICP).Route Onset Peak DurationI.V. 10–40 sec Unknown 10–30 minMechanism of ActionDepresses the CNS and may inhibit ascendingtransmission of impulses in the reticularformation. Thiopental may enhance ormimic inhibitory action of gamma-aminobutyricacid, thereby causing anticonvulsanteffect and producing sedation and hypnosis.Thiopental may reduce ICP by increasingcerebral vascular resistance, whichdecreases cerebral blood flow and volume.IncompatibilitiesDon’t mix thiopental with acidic I.V. drugsor solutions, succinylcholine, or tubocurarine.ContraindicationsHistory of porphyria; hypersensitivity tothiopental, its components, or other barbituratesInteractionsDRUGSclonidine, CNS depressants, guanabenz, magnesiumsulfate, methyldopa, metyrosine, pargyline,rauwolfia alkaloids: Additive CNSdepressant effectsdiazoxide, diuretics, guanadrel, guanethidine,mecamylamine, trimethaphan: Possiblyadditive hypotensive effectketamine: Increased risk of hypotension orrespiratory depression; possibly counteredhypnotic effect of thiopentalphenothiazines: Possibly increased CNSdepression or excitation, increasedhypotensive effectACTIVITIESalcohol use: Additive CNS depressant effectsAdverse ReactionsCNS: Agitation, anxiety, seizuresCV: Bradycardia, hypotension, shock, tachycardia,thrombophlebitisGI: HiccupsRESP: Apnea, bronchospasm, cough, laryngospasm,respiratory depression, wheezingSKIN: Hives, itching, rash, rednessOther: AngioedemaNursing Considerations• Before administering thiopental, expect topremedicate patient with an anticholinergic,such as atropine or glycopyrrolate, tominimize secretions.• Be prepared to administer a test dose of25 to 75 mg (1 to 3 ml of 2.5% solution)to determine tolerance or sensitivity.Expect to observe patient for at least1 minute after administering test dose.• Dilute drug with a compatible I.V. solutionbefore administering, such as D 5 Wfor injection, normal saline solution forinjection, or sterile water for injection. Beaware that sterile water for injectionshouldn’t be used to prepare 0.2% or 0.4%solution because it would result in a hypotonicsolution and cause hemolysis.• To prepare 0.2% solution, dilute 1 g ofthiopental with 500 ml of compatible diluentto produce a final concentration of2 mg/ml.

• To prepare 0.4% solution, dilute 1 g thiopentalwith 250 ml compatible diluent or2 g thiopental with 500 ml compatiblediluent to produce a final concentration of4 mg/ml.• To prepare 2.5% solution, dilute 1 g ofthiopental with 40 ml of compatible diluentor 5 g of thiopental with 200 ml ofcompatible diluent to produce a final concentrationof 25 mg/ml.• Inspect solution for particles beforeadministration. Use solution within24 hours of reconstitution, and discardunused portion after 24 hours.• Monitor patient’s blood and tissue oxygenationand vital signs during I.V.administration. Keep emergency equipmentand drugs nearby in case respiratorydepression occurs.• If patient has a history of CV disease orhypotension, monitor her for CV depressanteffects, such as bradycardia, hypotension,or shock.• In patient with a history of seizures, instituteseizure precautions according to facilityprotocol.• Monitor respiratory rate, rhythm, andquality for signs of respiratory depressionin debilitated patient or one with a historyof respiratory disease.• Monitor patient’s neurologic status everyhour, or as ordered, in patient withincreased ICP.PATIENT TEACHING• Explain the need for frequent hemodynamicmonitoring.• Advise patient to use caution when drivingor performing tasks that require alertnessfor at least 24 hours after receivingthiopental.• Instruct patient not to consume alcohol orother CNS depressants for at least 24hours after thiopental administration(unless prescribed) because they increasethe effects of thiopental.• Instruct patient to report persistentdrowsiness, rash, severe dizziness, or skinlesions to prescriber.thioridazineMellaril (CAN), Mellaril-S, Novo-Ridazine (CAN)thioridazine 1005thioridazinehydrochlorideApo-Thioridazine (CAN), Mellaril,Mellaril Concentrate, Novo-Ridazine(CAN), PMS ThioridazineClass and CategoryChemical class: Piperidine phenothiazineTherapeutic class: Antipsychotic drugPregnancy category: Not ratedIndications and Dosages To treat schizophrenia in patients unresponsiveto other antipsychotic drugsORAL SOLUTION, ORAL SUSPENSION, TABLETSAdults and adolescents. Initial: 50 to100 mg t.i.d., gradually increased, as neededand tolerated. Maintenance: 200 to 800 mgdaily in two to four divided doses.Maximum: 800 mg daily.Children ages 2 to 12. Initial: 0.5 mg/kgdaily in divided doses, gradually increased,as needed and tolerated. Maximum: 3 mg/kg daily.Route Onset Peak DurationP.O. Up to 6 wk– Unknownseveral wk 6 moMechanism of ActionDepresses areas of the brain that controlactivity and aggression, including the cerebralcortex, hypothalamus, and limbic systemby blocking postsynaptic dopamine 2(D 2 ) receptors. Drug may relieve anxiety byindirectly reducing arousal and increasingfiltration of internal stimuli to the brainstem reticular activating system.ContraindicationsComa; concurrent use of drugs that inhibitthe metabolism of thioridazine, such as fluoxetine,fluvoxamine, paroxetine, pindolol,and propranolol; concurrent use of drugsthat prolong the QT interval; concurrentuse of high doses of a CNS depressant; historyof arrhythmias; hypersensitivity tothioridazine, other phenothiazines, or theircomponents; prolonged QT interval;reduced cytochrome P450 2D6 activity;severe CNS depression; severe hypertensiveor hypotensive cardiac diseaseT

1006thioridazineInteractionsDRUGSamantadine, antihistamines, antimuscarinics,clozapine, cyclobenzaprine, diphenoxylate,disopyramide, maprotilene:Additive anticholinergic effectsamiodarone, bepridil, cisapride, disopyramide,erythromycin, flecainide, grepafloxacin,ibutilide, pimozide, probucol, procainamide,quinidine, sotalol, sparfloxacin, tocainide:Possibly prolonged QT intervalamphetamine, chlorpromazine, dextroamphetamine:Possibly decreased effects ofthese drugs and thioridazineantacids, antidiarrheals (adsorbent), kaolin,rifabutin, rifampin, rifapentine: Reducedbioavailability of thioridazineanxiolytics, benzodiazepines, clonidine, dronabinol,guanabenz, guanfacine, opioid analgesics,phenothiazines, sedative-hypnotics:Possibly increased CNS effects or hypotensionbarbiturates, fosphenytoin, phenytoin, valproicacid: Increased CNS depression, loweredseizure thresholdbromocriptine: Possibly decreased effectivenessof bromocriptinecarbamazepine: Possibly decreased bloodthioridazine levelcharcoal: Reduced thioridazine absorptiondopamine, droperidol, haloperidol, metoclopramide,metyrosine: Possibly increasedadverse CNS effectsephedrine, epinephrine, norepinephrine,phenylephrine: Possibly severe hypotension,MI, or tachycardiafluoxetine, fluvoxamine, other cytochromeP450 2D6 inhibitors, paroxetine, pindolol:Inhibited metabolism of thioridazine, leadingto elevated blood thioridazine levelgeneral anesthetics: Possibly potentiatedCNS depressionguanadrel, guanethidine, methyldopa:Inhibited hypotensive effect of these drugslevodopa, pergolide, pramipexole, ropinirole:Possibly inhibited antiparkinsonianresponselithium (high doses): Risk of encephalopathicsyndrome (characterized by confusion,elevated liver function test results andfasting blood glucose level, extrapyramidalsymptoms, fever, lethargy, leukocytosis, andweakness)MAO inhibitors: Possibly exaggeratedextrapyramidal reactionsmethoxsalen, oral contraceptives, porfimer,sulfonamides, sulfonylureas, tetracyclines, thiazidediuretics, vitamin A analogues:Possibly increased photosensitivitypropranolol: Increased blood propranololand thioridazine levels, increased CNSeffects, hypotensiontramadol: Increased blood tramadol level,possibly increased risk of seizurestrazodone: Possibly additive hypotensionACTIVITIESalcohol use: Additive CNS effectsAdverse ReactionsCNS: Akathisia, altered temperature regulation,depression, dizziness, drowsiness,extrapyramidal reactions (dystonia,laryngospasm, motor restlessness,pseudoparkinsonism), headache, insomniaCV: ECG changes, hypertension, hypotension,prolonged QT interval, torsades depointes, ventricular tachycardiaEENT: Blurred vision, change in color perception,dry mouth, impaired night vision,mydriasis, photophobiaENDO: Breast engorgement, galactorrheaGI: Constipation, ileus, nauseaGU: Amenorrhea, decreased libido, ejaculationdisorders, impotence, menstrual irregularities,priapism, urine retentionHEME: Agranulocytosis, anemia, aplasticanemia, eosinophilia, leukocytosis, leukopenia,pancytopenia, thrombocytopeniaSKIN: Hyperpigmentation, jaundice, photosensitivityOther: Weight gainNursing ConsiderationsWARNING Expect to give thioridazine onlyif patient has failed to respond to therapywith at least two other antipsychotic drugsbecause thioridazine may prolong the QTinterval and has been associated with torsadesde pointes and sudden death.WARNING Thioridazine shouldn’t be usedto treat elderly patients with dementiarelatedpsychosis because drug increasesthe risk of death in these patients.• Obtain baseline and serial ECG tracingsand serum potassium levels, as ordered.Notify prescriber if QT interval is greaterthan 500 msec or if potassium level isabnormal, and expect to discontinue drugimmediately.

thioridazine 1007• Frequently monitor blood pressure andassess for chest pain in patients with heartdisease because thioridazine has causedhypotension and has precipitated anginaon occasion. Also monitor urine output inpatients with benign prostatic hyperplasiabecause drug can worsen urine retention.• Be aware that high doses and large dosagechanges in patient with a seizure disordermay lower seizure threshold. Institute seizureprecautions, as appropriate, accordingto facility policy.• Administer drug with food, milk, or a fullglass of water to minimize GI distress.• Measure oral suspension using calibratedmeasuring device. Dilute with 60 to120 ml of fruit juice, distilled water, oracidified tap water immediately beforeadministration.• Don’t give thioridazine oral suspensionwith carbamazepine oral suspension; arubbery orange precipitate may form instool.• To prevent contact dermatitis, don’t letoral solution come in contact with skin.• Administer antacid or adsorbent antidiarrhealat least 1 hour before or 2 hoursafter thioridazine.WARNING Be aware that thioridazine cancause neuroleptic malignant syndrome—most commonly in male patients. Signsand symptoms include altered level ofconsciousness, altered mental status, autonomicinstability (diaphoresis, hypotensionor hypertension, sinus tachycardia),hyperthermia, and severe extrapyramidaldysfunction. Acute renal failure, increasedserum creatine phosphokinase level, andleukocytosis also have occurred. Notifyprescriber immediately if such symptomsdevelop, and be prepared to discontinuetherapy.• Be aware that drug shouldn’t be discontinuedabruptly. Sudden withdrawal of thioridazinemay produce transient dizziness,nausea, tremor, and vomiting.• Assess for eye pain because drug’s anticholinergiceffects can worsen angle-closureglaucoma.• Promptly investigate and report blurredvision, defective color perception, orimpaired night vision because of the riskof pigmentary retinopathy.• Expect prescriber to discontinue thioridazineand order CBC if patient experiencessigns of infection. Also expect drug therapyto be stopped 48 hours before myelographyand resumed 24 to 48 hours afterward.• Monitor patient for signs and symptomsof tardive dyskinesia—such as uncontrollablemovements of the arms, face, orlegs—even after treatment stops. Notifyprescriber if they develop.PATIENT TEACHING• Instruct patient to take thioridazine exactlyas prescribed and not to stop takingdrug without consulting prescriberbecause of the risk of withdrawal symptoms.• Instruct patient to notify prescriber immediatelyif she develops unusual symptoms,such as dizziness, palpitations, and syncope,because they may indicate the presenceof torsades de pointes.• Advise patient not to take drug within2 hours of an antacid.• Caution patient to avoid alcohol use,which increases thioridazine’s sedativeeffects, and to avoid hazardous activities ifdrowsiness occurs.• Urge patient to notify prescriber immediatelyif she experiences blurred vision,defective color perception, difficulty withnighttime vision, excessive drowsiness,nausea, sore throat, or other signs of infection.Thioridazine treatment may be discontinued.• Advise female patient to use effective contraceptionwhile taking drug because itsfetal effects are unknown. Instruct her toinform prescriber immediately of knownor suspected pregnancy.• Because drug may alter temperature regulation,encourage patient to avoid exposureto extreme temperatures during therapy.• Advise patient to wear protective darkglasses to minimize the effects of adversevision reactions.• If patient requires long-term therapy,explain the risk of tardive dyskinesia, andurge her to notify prescriber immediatelyif she develops uncontrollable movementsof her arms, face, or legs.• Instruct patient to tell other prescribersthat she’s taking thioridazine before shetakes any new drug.T

1008thiothixenethiothixeneNavanethiothixenehydrochlorideNavane, Thiothixene HCl IntensolClass and CategoryChemical class: Thioxanthene derivativeTherapeutic class: AntipsychoticPregnancy category: Not ratedIndications and Dosages To treat psychotic disorders, such asacute psychosis, psychotic depression,and schizophreniaCAPSULES (THIOTHIXENE), ORAL SOLUTION(THIOTHIXENE HYDROCHLORIDE)Adults and children age 12 and over.Initial: 2 mg t.i.d. (for mild conditions) or5 mg b.i.d. (for more severe conditions),increased every wk, as needed. Usual: 10 to40 mg daily in divided doses. Maximum:60 mg daily (for severe conditions).DOSAGE ADJUSTMENT For elderly patients,lowest effective dosage used for maintenancetherapy; maximum dosage limited to30 mg/ day. For some patients, one dailydose possibly used for maintenance therapy.I.M. INJECTION (THIOTHIXENE HYDROCHLORIDE)Adults. Initial: 4 mg b.i.d. to q.i.d. Optimal:4 mg every 6 to 12 hr. Usual: 16 to 20 mgdaily in divided doses. Maximum: 30 mgdaily.Mechanism of ActionIncreases dopamine turnover by blockingpostsynaptic dopamine receptors in themesolimbic system. Eventually, dopamineneurotransmission decreases, resulting inantipsychotic effects.ContraindicationsBlood dyscrasias, coma, hypersensitivity tothiothixene or its components, Parkinson’sdisease, severe CNS depression, shock, useof quinidineInteractionsDRUGSamphetamines: Decreased effectiveness ofeither drugantacids, antidiarrheals (adsorbent): Possiblyreduced bioavailability of thiothixeneantihistamines, tricyclic antidepressants:Additive anticholinergic effects, causingsevere constipation, ileus, or increasedintraocular pressurebromocriptine: Possibly increased serumprolactin level and decreased effectivenessof bromocriptinecarbamazepine: Possibly decreased bloodthiothixene leveldopamine: Decreased vasoconstrictive effectof dopamine (in high doses)ephedrine, phenylephrine: Possibly reducedvasopressor responseepinephrine: Possibly epinephrine reversal,leading to severe hypotension, tachycardia,and possibly MIerythromycin: Increased adverse effects ofthiothixenegeneral anesthetics, opioid analgesics, tramadol:Additive CNS effects, increased riskof seizuresguanadrel, guanethidine: Possibly decreasedantihypertensive effect of these drugshypotensive drugs: Possibly excessive hypotensionlevodopa: Possibly reduced effectiveness oflevodopalithium: Possibly encephalopathic syndrome(with a blood level that exceeds 12 mEq/L)MAO inhibitors: Possibly exaggeratedextrapyramidal reactionsmetaraminol, methoxamine, norepinephrine:Possibly reduced vasopressor responsepergolide: Possibly reduced effectiveness ofpergolidepropranolol: Possibly seizures and increasedhypotensionquinidine: Additive orthostatic hypotension,possibly prolonged QT intervalACTIVITIESalcohol use: Additive CNS effects, increasedrisk of seizuressmoking: Possibly decreased blood thiothixenelevelAdverse ReactionsCNS: Agitation, akathisia, drowsiness, dystonia,fatigue, insomnia, light-headedness,neuroleptic malignant syndrome, paradoxicalexacerbation of psychotic disorder, restlessness,seizures, syncope, tardive dyskinesia,weaknessCV: ECG changes, edema, hypotension,

peripheral edema, tachycardiaEENT: Blurred vision, dry mouth, increasedsalivation, miosis, mydriasis, nasal congestion,retinopathyENDO: Breast engorgement, galactorrhea,hyperglycemia, hypoglycemiaGI: Anorexia, constipation, diarrhea, elevatedliver function test results, ileus, increasedappetite, nausea, vomitingGU: Amenorrhea, glycosuria, impotence,priapismHEME: Agranulocytosis, anemia,eosinophilia, hemolytic anemia, leukocytosis,leukopenia, neutropenia, pancytopenia,thrombocytopeniaSKIN: Contact dermatitis, decreased sweating,photosensitivity, pruritus, rashOther: Hyperuricemia, weight gainNursing ConsiderationsWARNING Thiothixene shouldn’t be used totreat elderly patients with dementia-relatedpsychosis because drug increases therisk of death in these patients.• Administer thiothixene capsules with foodor milk if needed to minimize GI distress.• Don’t give drug within 1 hr of an antacid.• Dilute oral solution with 60 to 120 ml offruit or tomato juice, milk, soup, water, ora carbonated beverage. Measure dose andadminister using a calibrated measuringdevice. Avoid spilling solution on skinbecause drug may cause contact dermatitis.• Avoid inadvertent I.V. delivery of thiothixene.It’s intended for I.M. use.• Be aware that I.M. administration usuallyis reserved for acute, severe agitation orfor patients who can’t take oral preparations.• Maintain patient in recumbent positionfor 30 minutes after I.M. injection to minimizeorthostatic hypotension.• Assess patient for early signs of potentiallyirreversible tardive dyskinesia, a syndromeof involuntary rhythmic movements of theface, jaw, mouth, or tongue.WARNING Be aware that drug can precipitateneuroleptic malignant syndrome, aserious condition characterized by alteredmental status, arrhythmias, diaphoresis,hyperpyrexia, muscle rigidity, and tachycardia,especially in patients with hyperthyroidismor thyrotoxicosis. Symptomsthiothixene 1009may be severe enough to cause life-threateningrespiratory depression.• Monitor patient’s serum calcium levelbecause hypocalcemia may lead to dystonicreactions.• Keep in mind that hypotension from thiothixenemay precipitate angina in patientswith known cardiac disease.WARNING Be aware that drug-inducedadverse CNS reactions may mimic or suppressneurologic evidence of CNS disorders,such as brain tumor, encephalitis, encephalopathy,meningitis, Reye’s syndrome,and tetanus.• Monitor for extrapyramidal symptoms—particularly dystonias—in children withacute illnesses, including CNS infections,dehydration, gastroenteritis, measles, orvaricella-zoster infections.• Monitor patient’s CBC, as ordered,because serious adverse hematologic reactionsmay occur, such as agranulocytosis,leukopenia, and neutropenia. More frequentmonitoring during first few monthsof thiothixene therapy is recommendedfor patients with a history of druginducedleukopenia or neutropenia orwho have had a significantly low WBCcount in the past. If abnormalities occurduring therapy, monitor patient for feveror other signs of infection, notify prescriber,and expect drug to be discontinuedif abnormalities are severe.• Implement seizure precautions in patientswith a history of seizures or EEG abnormalitiesbecause thiothixene can lower theseizure threshold.• Assess patient for eye pain because thiothixene’santicholinergic effects may worsenangle-closure glaucoma. Assess patientwith benign prostatic hyperplasia for urineretention.PATIENT TEACHING• Fully inform patient facing long-termthiothixene therapy about risk of developingtardive dyskinesia.• Advise patient to avoid exposure to sunlightor ultraviolet light, and to apply sunscreenwhen outdoors.• Urge patient to avoid smoking or to begina smoking cessation program while takingthiothixene.• Encourage patient to avoid extreme temperaturechanges during drug therapy toT

1010thyroid USPprevent hyperthermia or hypothermiacaused by decreased sweating.• Instruct patient to immediately report sorethroat or other signs of infection.thyroid USPArmour Thyroid, Thyrar, ThyroidStrong, WesthroidClass and CategoryChemical class: Porcine thyroid gland hormoneTherapeutic class: Thyroid hormonereplacementPregnancy category: AIndications and Dosages To treat hypothyroidism without myxedemaTABLETSAdults and children. Initial: 60 mg daily,increased by 30 mg daily every mo p.r.n.Maintenance: 60 to 120 mg daily. To treat hypothyroidism or myxedemain patients with cardiovascular diseaseTABLETSAdults. Initial: 15 mg daily; daily dosagedoubled every 2 wk, as indicated to achievedesired response, up to 180 mg daily.Maintenance: 60 to 180 mg daily. To treat congenital hypothyroidism (cretinism)or severe hypothyroidism in childrenand infantsTABLETSChildren and infants. Initial: 15 mg daily;daily dosage doubled every 2 wk, as indicatedto achieve desired response, up to180 mg daily. If desired response isn’tachieved, dosage further increased by 30 to60 mg daily. Maintenance: Individualized.Mechanism of ActionStimulates growth and maturation of tissues,increases energy expenditure, andaffects all enzyme actions through severalmechanisms. Thyroid hormone:• regulates cell differentiation and proliferation• aids in myelination of nerves and developmentof axonal and dendritic processesin the nervous system• enhances protein and carbohydratemetabolism by promoting metabolicprocess-es that increase gluconeogenesisand protein synthesis and facilitate themobilization of glycogen stores.ContraindicationsAcute MI not associated with hypothyroidism,hypersensitivity to thyroid USP or itscomponents, obesity treatment, untreatedthyrotoxicosisInteractionsDRUGSbarbiturates, carbamazepine, phenytoin,rifampin: Possibly increased catabolism ofthyroid hormonecholestyramine, colestipol: Decreased effectivenessof thyroid hormonecorticosteroids: Decreased metabolism ofcorticosteroidsestrogens: Possibly increased circulatingconcentrations of thyroxine-binding globulin,decreased effectiveness of thyroid hormoneinsulin, oral antidiabetic drugs: Possiblyaltered blood glucose controlketamine: Risk of marked hypertension andtachycardiaoral anticoagulants: Altered anticoagulanteffectsympathomimetics: Increased adverse cardiovasculareffectstricyclic antidepressants: Increased therapeuticand toxic effects of both drugsFOODSall foods: Possibly altered absorption of thyroidhormoneAdverse ReactionsCNS: Headache, insomnia, nervousness,tremorCV: Angina; arrhythmias, including atrialfibrillation and sinus tachycardia; palpitationsENDO: HyperthyroidismGI: Diarrhea, vomitingGU: Menstrual irregularitiesSKIN: Alopecia, diaphoresisOther: Heat intolerance, weight lossNursing Considerations• Avoid giving oral thyroid hormone withfood because it may alter drug absorption.• Don’t give thyroid hormone within5 hours of cholestyramine or colestipol.Giving them together can reduce hormoneabsorption.

WARNING Be aware that thyroid hormonetherapy can unmask or worsen adrenalinsufficiency, precipitate adrenal crisis inpatients with uncontrolled adrenal insufficiency,and increase the risk of arrhythmiasin patients with coronary artery disease.• Monitor blood glucose level often becausethyroid hormone therapy can unmask orexacerbate symptoms of other endocrinedisorders and also may alter antidiabeticdrug dosage requirements in patients withdiabetes mellitus. Be aware that withdrawalof thyroid hormone can precipitate ahypoglycemic response in susceptiblepatients.PATIENT TEACHING• Tell patient to take thyroid hormone on anempty stomach at the same time each day.• Advise her to inform prescriber immediatelyand seek medical attention if sheexperiences chest pain, nervousness, orsweating.• Instruct patient who uses cholestyramineor colestipol not to take these drugs within5 hours of thyroid dose.• Inform patient that full effects may not beevident for 1 to 3 weeks.• Instruct patient with diabetes mellitus tomonitor blood glucose level frequently.thyrotropin(thyroid-stimulatinghormone, TSH)Thytroparthyrotropin alfaThyrogenClass and CategoryChemical class: Recombinant glycoproteinof human TSHTherapeutic class: Diagnostic aidPregnancy category: CIndications and Dosages To provide diagnostic follow-up ofpatients with well-differentiated thyroidcarcinomaI.M. INJECTION (THYROTROPIN ALFA)Adults and adolescents age 16 and over.0.9 mg every 24 hr for 2 doses or everythyrotropin 101172 hr for 3 doses. Scanning or serum thyroglobulintesting performed 72 hr after lastinjection. To provide differential diagnosis of subclinicalhypothyroidism or low thyroidreserveI.M. OR SUBCUTANEOUS INJECTION(THYROTROPIN)Adults and adolescents age 16 and over.10 international units daily for 1 to 3 days,followed by radioactive iodine study 24 hrafter last injection. No response indicatesthyroid failure; substantial response indicatespituitary failure. To determine thyroid status in patientsreceiving thyroid hormone, to differentiatebetween primary and secondaryhypothyroidismI.M. OR SUBCUTANEOUS INJECTION(THYROTROPIN)Adults and adolescents age 16 and over.10 international units daily for 1 to 3 days. To aid in diagnosing thyroid carcinomaremnant after surgeryI.M. OR SUBCUTANEOUS INJECTION(THYROTROPIN)Adults and adolescents age 16 and over.10 international units daily for 3 to 7 days. As adjunct for radioiodine ablation ofthyroid tissue remnants in patients whohave undergone a near-total or totalthyroidectomy for well-differentiatedthyroid cancer and who have no evidenceof metastatic thyroid cancerI.M. INJECTION (THYROTROPIN ALPHA)Adults. 0.9 mg, followed by a second0.9 mg 24 hours later, followed by radioiodineadministration 24 hours later.Mechanism of ActionStimulates production of thyroglobulin byactive thyroid tissue and enhances uptake ofiodine, synthesis of thyroid precursor hormones(monoiodotyrosine, diiodotyrosine,and levothyroxine), and release of triiodothyronine(T 3 ) and thyroxine (T 4 )from the thyroid gland into systemic circulation.Thyrotropin also binds with thyroidcancer tissue and stimulates iodine uptakein radioactive iodine imaging to detect cancercells in euthyroid patients after neartotalor total thyroidectomy.ContraindicationsCoronary thrombosis, hypersensitivity toT

1012Adverse ReactionsCNS: Amnesia, anxiety, asthenia, ataxia,confusion, depression, dizziness, drowsitiagabinehydrochloridethyrotropin or its components, uncorrectedadrenal insufficiencyAdverse ReactionsCNS: Asthenia, fever, headache, paresthesiaENDO: HyperthyroidismGI: Nausea, vomitingRESP: Respiratory distressSKIN: Rash, urticariaOther: Flulike symptoms; sudden, rapid,painful enlargement of locally recurringpapillary carcinomaNursing ConsiderationsWARNING Be aware that thyrotropin canunmask or worsen adrenal insufficiency,precipitate adrenal crisis in patients withuncontrolled adrenal insufficiency, andincrease the risk of arrhythmias in patientswith coronary artery disease.• Reconstitute thyrotropin solution withmanufacturer-provided diluent, whichcontains no preservatives.• Administer I.M. thyrotropin injections tothe buttocks.WARNING Avoid inadvertent I.V. or intradermalinjection of thyrotropin. I.V.administration may result in severe reactions,including diaphoresis, hypotension,nausea, tachycardia, and vomiting.Intradermal injection may damage tissueat injection site.• Monitor patient closely, especially duringfirst 24 hours after drug administration,because patients have died (rarely) duringthis time.• Check for chest pain and increased heartrate, especially in patients with cardiac orcoronary artery disease, including angina,hypertension, and recent acute MI, and inpatients with residual thyroid tissue. Drugmay increase serum thyroid hormonelevel.PATIENT TEACHING• Advise patient to continue taking prescribedthyroid hormone replacementwhile receiving injections of thyrotropinalfa unless otherwise directed by prescriber.• If patient is scheduled for radioactiveiodine test, tell her to follow a low-iodinediet.• Inform patient that testing may take 5 to12 days to complete.tiagabinehydrochlorideGabitrilClass and CategoryChemical class: Nipecotic acid derivativeTherapeutic class: AnticonvulsantPregnancy category: CIndications and Dosages As adjunct to treat partial seizuresTABLETSAdults. Initial: 4 mg daily; increased by4 mg/wk up to 16 mg daily, then dosageincreased by 4 to 8 mg every wk untildesired response occurs. Usual: 32 to 56 mgdaily. Maximum: 56 mg daily in 2 to4 divided doses.Children ages 12 to 18. Initial: 4 mg dailyfor 1 wk, then increased by 4 to 8 mg/wkuntil desired response occurs. Maximum:32 mg daily in 2 to 4 divided doses.DOSAGE ADJUSTMENT For patients withimpaired hepatic function, dosage individualizedand reduced, or interval extended ifneeded, because of reduced drug clearance.Mechanism of ActionAppears to inhibit neuronal and glialuptake of gamma-aminobutyric acid(GABA), the major inhibitory neurotransmitterin the CNS. Tiagabine makes moreGABA available in the CNS to open chloridechannels in postsynaptic membranes,thereby leading to membrane hyperpolarizationand preventing transmission ofnerve impulses.ContraindicationsHypersensitivity to tiagabine or its componentsInteractionsDRUGSbenzodiazepines, CNS depressants: Possiblyadditive CNS depressioncarbamazepine, phenobarbital, phenytoin:Possibly decreased tiagabine effectivenessACTIVITIESalcohol use: Possibly additive CNS depression

ness, EEG abnormalities, hostility, impairedcognition, insomnia, light-headedness,paresthesia, seizures, status epilepticus, suicidalideation, tremor, weaknessEENT: Pharyngitis, stomatitisGI: Abdominal pain, diarrhea, increasedappetite, nausea, vomitingGU: UTIMS: DysarthriaSKIN: Ecchymosis, rashNursing Considerations• Give tiagabine with food.WARNING Expect to taper dosage gradually,as prescribed, because stopping drugabruptly may increase seizure frequency.• Take seizure precautions because tiagabinehas caused seizures and status epilepticusin patients with no history of seizures.• Watch patient closely for evidence of suicidaltendencies, especially when therapystarts or dosage changes, and report concernsat once.PATIENT TEACHING• Instruct patient to take drug with food.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.Also urge her to avoid alcohol use.• If patient takes a CNS depressant, explainthat drug may increase depressant effect.• Instruct patient not to stop takingtiagabine abruptly. Explain that prescriberusually tapers dosage over 4 weeks toreduce the risk of withdrawal seizures.• Urge caregivers to watch patient closely forevidence of suicidal tendencies, especiallywhen therapy starts or dosage changes,and to report concerns immediately.• Encourage woman who becomes pregnantwhile taking tiagabine to enroll in theNorth American antiepileptic drug pregnancyregistry by calling 1-888-233-2334.Explain that the registry is collectinginformation about the safety of antiepilepticdrugs during pregnancy.ticarcillin disodiumTicarClass and CategoryChemical class: PenicillinTherapeutic class: AntibioticPregnancy category: Bticarcillin disodium 1013Indications and Dosages To treat moderate to severe infections,such as bacteremia, diabetic foot ulcers,empyema, intra-abdominal infections,lower respiratory tract infections(including pneumonia), lung abscess,peritonitis, pulmonary infections due tocomplications of cystic fibrosis (includingbronchiectasis and pneumonia), septicemia,and skin and soft-tissue infections(including cellulitis) caused by susceptibleorganismsI.V. INFUSIONAdults and children. 200 to 300 mg/kgdaily in divided doses every 4 to 6 hr. Usual:3 g every 4 hr or 4 g every 6 hr. To treat uncomplicated UTII.V. INFUSION, I.M. INJECTIONAdults and children weighing 40 kg (88 lb)or more. 1 g every 6 hr.Children over age 1 month and weighingless than 40 kg. 50 to 100 mg/kg daily individed doses every 6 to 8 hr. To treat complicated UTII.V. INFUSIONAdults and children. 150 to 200 mg/kg inequally divided doses every 4 to 6 hr. Usual:3 g every 6 hr.DOSAGE ADJUSTMENT For patients withcreatinine clearance of 30 to 60 ml/min/1.73 m 2 , 2 g I.V. every 4 hr; with creatinineclearance of 10 to 30 ml/min/1.73 m 2 ,2 gI.V. every 8 hr; with creatinine clearance ofless than 10 ml/min/1.73 m 2 , 2 g I.V. every12 hr or 1 g I.M. every 6 hr.Mechanism of ActionInhibits bacterial cell wall synthesis bybinding to specific penicillin-binding proteinsinside the bacterial cell wall.Ultimately, this leads to cell wall lysis anddeath.IncompatibilitiesDon’t administer ticarcillin through thesame I.V. line as amikacin, gentamicin, ortobramycin. Don’t give within 1 hr ofaminoglycosides.ContraindicationsHypersensitivity to ticarcillin, penicillins, ortheir componentsInteractionsDRUGSaminoglycosides: Additive or synergisticT

1014ticlopidine hydrochlorideactivity against some bacteria, possiblymutual inactivationanticoagulants: Possibly interference withplatelet aggregation, prolonged PTmethotrexate: Prolonged blood methotrexatelevel, increased risk of methotrexate toxicityprobenecid: Prolonged blood ticarcillin levelAdverse ReactionsCV: Thrombophlebitis, vasculitisGI: Elevated liver function test results, nausea,pseudomembranous colitis, vomitingGU: ProteinuriaHEME: Anemia, eosinophilia, hemorrhage,leukopenia, neutropenia, prolonged bleedingtime, thrombocytopeniaSKIN: Erythema nodosum, exfoliative dermatitis,pruritus, rash, toxic epidermalnecrolysis, urticariaOther: Anaphylaxis, hypernatremia,hypokalemia, injection site pain, superinfectionNursing Considerations• Obtain body fluid or tissue samples forculture and sensitivity testing, as ordered.Review test results, if possible, before givingfirst dose of ticarcillin.• Don’t inject more than 2 g of drug at anyone I.M. injection site.• Reconstitute each gram of ticarcillin with4 ml of compatible diluent. Further dilutereconstituted I.V. solution to 10 to100 mg/ml with compatible I.V. solution.To minimize vein irritation, don’t exceedconcentration of 100 mg/ml. Concentrationsof 50 mg/ml or greater are preferred.Infuse appropriate I.V. dose over30 to 120 minutes.• Check for local injection site reaction,including thrombophlebitis, during therapy.• Be aware that ticarcillin may worsensymptoms in patients with a history of GIdisease or colitis.• For patients with renal impairment, takeseizure precautions, according to facilitypolicy, because of increased risk ofseizures.• Monitor patient closely for diarrhea,which may indicate pseudomembranouscolitis caused by Clostridium difficile. Ifdiarrhea occurs, notify prescriber andexpect to withhold ticarcillin and treatwith fluids, electrolytes, protein, and anantibiotic effective against C. difficile.• Also look for signs of superinfection, suchas oral candidiasis and rash in breast-feedinginfant.• Monitor serum electrolyte levels forhypernatremia due to drug’s high sodiumcontent and for hypokalemia due toincreased urinary potassium loss.WARNING Monitor patient’s platelet count,PT, and APTT because ticarcillin mayincrease bleeding time and, in rare cases,may induce thrombocytopenia.PATIENT TEACHING• Stress need to take full course of ticarcillinexactly as prescribed, even if feeling better.• Urge patient to report past allergies topenicillins and to notify prescriber at onceabout adverse reactions, including fever.• Advise patient to decrease sodium intaketo reduce the risk of electrolyte imbalance.• Instruct patient to report diarrhea that’ssevere or prolonged. Remind patient thatwatery or bloody stools can occur 2 ormore months after antibiotic therapy andcan be serious, requiring prompt treatment.ticlopidinehydrochlorideTiclidClass and CategoryChemical class: Thienopyridine derivativeTherapeutic class: Antithrombotic, plateletaggregation inhibitorPregnancy category: BIndications and Dosages To reduce the risk of initial thromboticstroke in patients who have experiencedtransient ischemic attack, to reduce therisk of recurrent stroke in patients whohave previously experienced thromboticstrokeTABLETSAdults. 250 mg b.i.d. As adjunct to reduce the risk of subacutestent thrombosis after successful coronarystent implantationTABLETSAdults. 250 mg b.i.d with antiplatelet doses

ticlopidine hydrochloride 1015Mechanism of ActionNormally, platelets don’t adhere to bloodvessel walls. However, when a thromboticstroke or other disorder damages bloodvessel walls, platelets are activated andadhere within seconds. Once activated,platelets release adenosine diphosphate(ADP). This causes fibrinogen to bind toglycoprotein IIb/IIIa (GP IIb/IIIa) receptorson the surface of activated plateletsand connect with other activatedplatelets. Then a thrombus forms.Ticlopidine inhibits the release ofADP from activated platelets, which preventsfibrinogen from binding to GPIIb/IIIa receptors on the surface of activatedplatelets, as shown below. Thisaction prevents platelets from aggregatingto form a thrombus, which preventsthrombosis of an implanted stent orrecurrence of stroke.FibrinogenTiclopidineGP IIb/IIIa receptorADPPlateletof aspirin for up to 30 days after successfulstent implantation.Route Onset Peak DurationP.O. 2–4 days 8–11 days 1–2 wkContraindicationsCoagulopathy, GI bleeding, hematologicdisorders related to hematopoiesis (includinghistory of thrombotic thrombocytopenicpurpura, neutropenia, and thrombocytopenia),hemophilia, hypersensitivity toticlopidine or its components, intracranialbleeding, retinal bleeding, severe hepaticdiseaseInteractionsDRUGSaluminum- and magnesium-containing antacids:Possibly decreased peak blood ticlopidinelevelantineoplastics, antithymocyte globulin,heparin, NSAIDs, oral anticoagulants,platelet aggregation inhibitors, salicylates,strontium-89 chloride, thrombolytics:Increased risk of bleedingcimetidine: Reduced clearance of ticlopidine,increased risk of adverse reactionscyclosporine, digoxin: Decreased blood leveland possibly reduced effects of these drugsporfimer: Decreased effectiveness of porfimerphotodynamic therapyxanthines (aminophylline, oxytriphylline,theophylline): Decreased theophylline clearance,increased risk of toxicityAdverse ReactionsCNS: DizzinessCV: Hypercholesterolemia, vasculitisEENT: TinnitusGI: Abdominal pain, anorexia, diarrhea,elevated liver function test results, flatulence,indigestion, nausea, vomitingHEME: Agranulocytosis, aplastic anemia,hemolysis, hemolytic anemia, neutropenia,pancytopenia, thrombocytopenia, thromboticthrombocytopenia, thromboticthrombocytopenic purpuraSKIN: Pruritus, purpura, rashOther: Hyponatremia, serum sicknesslikereactionNursing Considerations• Give ticlopidine with food to maximize GIT

1016tigecyclineabsorption and minimize any GI distress.• Avoid I.M. injections of other drugsbecause excessive bleeding, bruising, orhematoma may occur.• During first 3 months of therapy, monitorCBC every 2 weeks, as ordered (more frequentlyin patients with depressed neutrophilcount).• Be aware that ticlopidine therapy typicallyis used for patients with stroke or anincreased risk of stroke who can’t tolerateaspirin because of the risk of neutropeniaor agranulocytosis.WARNING Be aware that ticlopidine therapyirreversibly affects platelet aggregation.Expect prescriber to discontinue drug10 to 14 days before surgical procedures toprevent uncontrolled bleeding.• Monitor serum cholesterol level duringfirst month of ticlopidine therapy forexpected increase. Hypercholesterolemiamay persist for duration of treatment.PATIENT TEACHING• Urge patient to take ticlopidine with food.• Inform patient that she may be atincreased risk for infection because drugmay decrease WBC or platelet count, especiallyin first 3 months of therapy.• Advise patient to notify prescriber immediatelyif she has chills, fever, or sorethroat.• Urge patient to keep scheduled appointmentsfor blood tests to detect abnormalities.• Instruct patient to apply prolonged pressureto injured areas because bleeding maytake longer than usual to stop. Urge her toimmediately report to prescriber anyunusual bleeding or bruising.tigecyclineTygacilClass and CategoryChemical class: GlycylcyclineTherapeutic class: AntibioticPregnancy category: DIndications and Dosages To treat complicated skin and skin structureinfections caused by Escherichiacoli, Enterococcus faecalis (vancomycin-susceptibleisolates only),Staphylococcus aureus (methicillinsusceptibleand -resistant isolates),Streptococcus agalactiae, Streptococcusanginosus group (includes S. anginosus,S. intermedius, and S. constellatus),Streptococcus pyogenes, and Bacteroidesfragilis; to treat complicated intraabdominalinfections caused byCitrobacter freundii, Enterobactercloacae, E. coli, Klebsiella oxytoca,Klebsiella pneumoniae, Enterococcusfaecalis (vancomycin-suseptible isolatesonly), S. aureus (methicillin-susceptibleisolates only), S. anginosus group, B.fragilis, Bacteroides thetaiotaomicron,Bacteroides uniformis, Bacteroides vulgatus,Clostridium perfringens, andPeptostreptococcus micros; to treatcommunity-acquired bacterial pneumoniacaused by Streptococcus pneumoniae(penicillin-susceptible isolates),including cases with concurrent bacteremia,Haemophilus influenzae(beta-lactamase negative isolates), andLegionella pneumophilaI.V. INFUSIONAdults. Initial: 100 mg infused over 30 to60 min followed by 50 mg infused over30 to 60 min every 12 hr for 5 to 14 daysfor complicated skin and skin structureinfections and intra-abdominal infections(7 to 14 days for community-acquired bacterialpneumonia).DOSAGE ADJUSTMENT For patients withsevere hepatic impairment, initial dosage of100 mg should be followed by a reducedmaintenance dosage of 25 mg every 12 hr.Mechanism of ActionInhibits protein translation in bacteria bybinding to the 30S ribosomal subunit,which prevents binding of amino-acyltRNA molecules to the ribosome complex,thus interfering with protein synthesis.Through this bacteriostatic action, bacteriaare weakened.IncompatibilitiesDon’t give amphotericin B, chlorpromazine,methylprednisolone, or voriconazolesimultaneously through the same Y-site.ContraindicationsHypersensitivity to tigecycline or its components

Adverse ReactionsCNS: Asthenia, chills, dizziness, fever,headache, insomnia, somnolenceCV: Bradycardia, hypertension, hypotension,peripheral edema, phlebitis, septicshock, tachycardia, thrombophlebitis,vasodilationEENT: Dry mouth, taste perversionENDO: Hyperglycemia, hypoglycemiaGI: Abdominal pain, acute pancreatitis,anorexia, constipation, diarrhea, dyspepsia,elevated liver enzyme levels, hepatic dysfunctionor failure, jaundice, nausea, pancreatitis,pseudomembranous colitis, vomitingGU: Elevated BUN and creatinine levels,vaginal candidiasisHEME: Anemia, increased PT, leukocytosis,thrombocythemiaMS: Back painRESP: Increased cough, dyspneaSKIN: Diaphoresis, photosensitivity, pruritus,rashOther: Anaphylaxis, hypersensitivity reaction,hypocalcemia; hypokalemia; hyponatremia;hypoproteinemia; injection sitereaction, such as edema, phlebitis, inflammation,and paintigecycline 1017Nursing Considerations• Obtain body tissue and fluid samples forculture and sensitivity tests as orderedbefore giving first dose of tigecycline.Expect to begin drug therapy before testresults are known.• Avoid giving tigecycline to children underage 8 because drug may cause permanentbrown or yellow tooth discoloration andenamel hypoplasia.• Use tigecycline cautiously in patientshypersensitive to tetracycline antibioticsbecause glycylcycline antibiotics are structurallysimilar to tetracyclines.• Also use cautiously in patients with complicatedintra-abdominal infections secondaryto intestinal perforation because ofthe risk of septic shock.• Determine whether female patients couldbe pregnant before starting tigecyclinetherapy because the drug may cause harmto fetus.• Reconstitute each vial of tigecycline with5.3 ml of 0.9% sodium chloride injectionor 5% dextrose injection to achieve a concentrationof 10 mg/ml. Note that thecolor will be yellow to orange. If it’s not,the solution should be discarded.Immediately withdraw reconstituted solutionfrom the vial and add to a 100-ml I.V.bag for infusion. Drug may be stored inthe I.V. bag at room temperature for up to6 hours or refrigerated up to 24 hoursbefore use.• If the patient’s I.V. line is used to infuseother drugs, flush the line with either0.9% sodium chloride injection or 5%dextrose injection before and after tigecyclineinfusion.• Infuse tigecycline over 30 to 60 minutes.• Monitor patient closely for diarrhea,which may indicate pseudomembranouscolitis, which is known to occur withmany antibiotics. If diarrhea occurs duringtigecycline therapy, notify prescriberand expect to withhold drug. Expect totreat psuedomembranous colitis, if confirmed,with fluids, electrolytes, protein,and an antibiotic effective againstClostridium difficile.• Monitor patient for adverse reactions,keeping in mind the similarity betweentigecycline and tetracycline.• Assess patient for superinfection, such asvaginal candidiasis, that may result fromovergrowth of nonsusceptible organisms,including fungi. If signs of infection arepresent, notify prescriber and provide supportivecare, as prescribed.• Monitor patient’s liver function closely. Ifenzyme levels become elevated, notify prescriberbecause dosage may need to bedecreased or drug discontinued.• Be aware that adverse reactions may continueafter therapy stops.PATIENT TEACHING• Instruct patient to report adverse reactions,especially hypersensitivity reactions,such as a rash or itching, as well as diarrhea.• Tell patient to report discomfort at theinfusion site because the site may need tobe changed.• Urge patient to report diarrhea that’ssevere or prolonged. Remind patient thatwatery or bloody stools can occur 2 ormore months after antibiotic therapy andcan be serious, requiring prompt treatment.T

1018tiludronate disodiumtiludronatedisodium(contains 200 mg of tiludronic acid pertablet)SkelidClass and CategoryChemical class: AminobiphosphonateTherapeutic class: Bone resorption inhibitorPregnancy category: CIndications and Dosages To treat Paget’s disease in patients withserum alkaline phosphatase levels atleast twice the upper limit of normal,who are symptomatic or at risk forfuture complications of the diseaseTABLETSAdults. Initial: 400 mg of tiludronic aciddaily 2 hr before or after meals for 3 mo.Maximum: 400 mg of tiludronic acid daily.Mechanism of ActionReduces the activity of cells that cause boneloss and increases bone mass. Tiludronatemay act by inhibiting osteoclast activity onnewly formed bone resorption surfaces.This activity reduces the number of sites atwhich bone is remodeled. When bone formationexceeds bone resorption at theseremodeling sites, bone mass increases.Tiludronate may also inhibit bone destructionby binding to hydroxyapatite crystals,which give bone its rigidity.ContraindicationsCreatinine clearance less than 30ml/min/1.73 m 2 , esophageal abnormalitiesthat delay esophageal emptying, hypersensitivityto tiludronate or its componentsInteractionsDRUGSaluminum- or magnesium-containingantacids, mineral supplements (such as calcium,iron), salicylates, salicylate-containingcompounds: Decreased absorption of tiludronateindomethacin: Possibly increased bioavailabilityof tiludronateFOODSall foods and beverages (except plain water):Decreased absorption of tiludronateAdverse ReactionsCNS: Dizziness, headacheCV: Chest pain, edemaEENT: Cataracts, conjunctivitis, glaucoma,pharyngitis, rhinitisGI: Diarrhea, esophageal irritation andulceration, flatulence, indigestion, nausea,vomitingMS: Arthralgia, back pain, myalgia, osteonecrosisof jawRESP: Cough, upper respiratory tract infectionSKIN: RashOther: Flulike symptomsNursing Considerations• Be prepared to monitor serum calciumlevels before, during, and after tiludronatetherapy because drug may exacerbate suchconditions as hyperparathyroidism,hypocalcemia, and vitamin D deficiency.Ensure adequate dietary intake of calciumand vitamin D during and after treatment.If hypocalcemia occurs, expect to administera calcium supplement, as prescribed.WARNING Be aware that tiludronate mayirritate upper GI mucosa, causing suchadverse reactions as esophageal ulcer. Tohelp minimize these reactions, havepatient take drug with full glass of plainwater and remain upright for at least30 minutes.PATIENT TEACHING• Instruct patient to take drug with 6 to 8 ozof plain water on an empty stomach (atleast 2 hours before or after beverages,food, other drugs, or mineral supplements,including mineral water) becausefood and beverages may severely reducedrug’s effect. Also, advise her to remainupright for at least 30 minutes after takingdrug.• Advise patient not to chew or suck ontablet to reduce the risk of esophageal irritation.• Instruct patient to notify prescriber immediatelyif she develops signs or symptomsof esophageal irritation, such as troubleswallowing or worsening heartburn; thesemay indicate a serious esophageal disorder.• Caution patient not to take salicylatecontainingdrugs, such as aspirin, duringtiludronate therapy.

timolol maleateApo-Timol (CAN), Blocadren, Novo-Timol (CAN)Class and CategoryChemical class: Beta blockerTherapeutic class: Antihypertensive, MIprophylactic, vascular headache prophylacticPregnancy category: CIndications and Dosages To manage hypertensionTABLETSAdults. Initial: 10 mg b.i.d., increased everywk as prescribed. Maintenance: 20 to 40 mgdaily in divided doses. Maximum: 60 mgdaily. To provide long-term prophylaxisafter MITABLETSAdults. 10 mg b.i.d., beginning 1 to 4 wkafter MI and continuing for at least 2 yr. To prevent migraine headacheTABLETSAdults. Initial: 10 mg b.i.d. Maintenance:20 mg daily in divided doses. Maximum:30 mg daily; discontinued after 8 wk, asprescribed, if maximum dose is ineffective.Route Onset Peak DurationP.O. 30 min 1–2 hr 4–8 hrMechanism of ActionSelectively blocks alpha 1 and beta 2 receptorsin vascular smooth muscle and beta 1receptors in the heart. This reduces peripheralvascular resistance and blood pressureand relieves migraine headaches. Timolol’spotent beta blockade prevents the reflextachycardia that typically occurs with mostalpha blockers, and decreases cardiacexcitability, cardiac output, and myocardialoxygen demand, thus preventing MI.ContraindicationsAcute bronchospasm; asthma; cardiogenicshock; children; COPD (severe); heart failure;hypersensitivity to timolol, other betablockers, or their components; second- orthird-degree AV block; severe sinus bradycardiatimolol maleate 1019InteractionsDRUGSallergen immunotherapy, allergenic extractsfor skin testing: Increased risk of serious systemicadverse reactions or anaphylaxisamiodarone: Additive depressant effect oncardiac conduction, negative inotropiceffectanesthetics (hydrocarbon inhalation):Increased risk of myocardial depression andhypotensionbeta blockers: Additive beta blockade effectscalcium channel blockers, clonidine, diazoxide,guanabenz, reserpine, other hypotensionproducingdrugs: Additive hypotensive effectand, possibly, other beta blockade effectscimetidine: Possibly interference with timololclearanceestrogens: Decreased antihypertensive effectof timololfentanyl, fentanyl derivatives: Possiblyincreased risk of initial bradycardia afterinduction doses of fentanyl or derivative(with long-term timolol use)glucagon: Possibly blunted hyperglycemicresponseinsulin, oral antidiabetic drugs: Possiblymasking of tachycardia in response tohypoglycemia, impaired glucose controllidocaine: Decreased lidocaine clearance,increased risk of lidocaine toxicityMAO inhibitors: Increased risk of significanthypertensionneuromuscular blockers: Possibly potentiatedand prolonged action of these drugsNSAIDs: Possibly decreased hypotensiveeffectphenothiazines: Increased blood levels ofboth drugsphenytoin (parenteral): Additive cardiacdepressant effectsympathomimetics, xanthines: Possiblymutual inhibition of therapeutic effectsAdverse ReactionsCNS: Asthenia, decreased concentration,depression, dizziness, fatigue, fever, hallucinations,headache, insomnia, nervousness,nightmares, paresthesia, stroke, syncope,vertigoCV: Angina, arrhythmias, bradycardia, cardiacarrest, chest pain, edema, palpitations,Raynaud’s phenomenon, vasodilationEENT: Diplopia, dry eyes, eye irritation,T

1020tinidazoleptosis, tinnitus, vision changesENDO: Hyperglycemia, hypoglycemiaGI: Abdominal pain, diarrhea,hepatomegaly, indigestion, nausea, vomitingGU: Decreased libido, impotenceMS: Arthralgia, decreased tolerance to exercise,extremity pain, muscle weaknessRESP: Bronchospasm, cough, crackles, dyspneaSKIN: Alopecia, diaphoresis, hyperpigmentation,pruritus, purpura, rashOther: Anaphylaxis, weight lossNursing ConsiderationsWARNING Be aware that timolol may maskevidence of acute hypoglycemia in diabeticpatient. It also may mask certain signs ofhyperthyroidism, such as tachycardia.• Be aware that timolol may prolong hypoglycemiaby interfering with glycogenolysisor may promote hyperglycemia bydecreasing tissue sensitivity to insulin.• Monitor blood pressure and cardiac output,as appropriate, for patient with a historyof systolic heart failure or left ventriculardysfunction because timolol’s negativeinotropic effect can depress cardiacoutput.WARNING Timolol shouldn’t be discontinuedabruptly because this may produceMI, myocardial ischemia, severe hypertension,or ventricular arrhythmias, particularlyin patient with known cardiovasculardisease.• Expect varied drug effectiveness in elderlypatients; they may be less sensitive todrug’s antihypertensive effect or more sensitivebecause of reduced drug clearance.• Monitor for impaired circulation in elderlypatients with age-related peripheral vasculardisease or patients with Raynaud’sphenomenon. Such patients may experienceexacerbated symptoms fromincreased alpha stimulation. Elderlypatients also are at increased risk for betablocker–induced hypothermia.• If timolol worsens skin condition, such aspsoriasis, notify prescriber.PATIENT TEACHING• Instruct patient taking timolol to informprescriber of chest pain, fainting, lightheadedness,or shortness of breath, whichmay indicate the need for dosage change.• Caution patient not to stop taking drugabruptly. Timolol dosage must be taperedgradually under prescriber’s supervision.• Instruct patient with diabetes to monitorblood glucose level often during therapy.• Warn patient with psoriasis about possibleflare-ups of skin condition.tinidazoleTindamaxClass and CategoryChemical class: Synthetic nitroimidazoleTherapeutic class: AntiprotozoalPregnancy category: CIndications and Dosages To treat trichomoniasis caused byTrichomonas vaginalisTABLETSAdults. 2 g one time with food. To treat giardiasis caused by Giardiaduodenalis (G. lamblia)TABLETSAdults. 2 g one time with food.Children age 4 and over. 50 mg/kg (up to2 g) one time with food. To treat intestinal amebiasis caused byEntamoeba histolyticaTABLETSAdults. 2 g daily for 3 days with food.Children age 4 and over. 50 mg/kg (up to2 g) daily for 3 days with food. To treat amebic liver abscess caused byEntamoeba histolyticaTABLETSAdults. 2 g daily for 3 to 5 days with food.Children age 4 and over. 50 mg/kg (up to2 g) daily for 3 to 5 days with food.DOSAGE ADJUSTMENT For patients receivinghemodialysis, an additional dose equivalentto one-half the dose prescribed should begiven after the dialysis treatment on thedays dialysis is performed.Mechanism of ActionUndergoes intracellular chemical reductionduring anaerobic metabolism. After tinidazoleis reduced, it damages DNA’s helicalstructure and breaks its strands, whichinhibits bacterial nucleic acid synthesis andcauses cell death.

ContraindicationsBreast-feeding, hypersensitivity to tinidazoleor its components, treatment of trichomoniasisduring first trimester of pregnancyInteractionsDRUGScholestyramine: Possibly decreased bioavailabilityof tinidazolecimetidine, ketoconazole: Possibly delayedelimination and increased blood level oftinidazolecyclosporine, tacrolimus: Possibly increasedserum cyclosporine and tacrolimus levelsdisulfiram: Possibly combined toxicity,resulting in confusion and psychosisfluorouracil: Possibly decreased fluorouracilclearancelithium: Possibly increased serum lithiumlevelsoral anticoagulants: Possibly increased anticoagulanteffectoxytetracycline: Possibly diminished effect oftinidazolephenobarbital, phenytoin, rifampin: Possiblyincreased metabolism and decreased bloodlevel of tinidazoleACTIVITIESalcohol use: Possibly disulfiram-like effectsAdverse ReactionsCNS: Ataxia, dizziness, coma, confusion,depression, drowsiness, fatigue, fever, headache,insomnia, malaise, peripheral neuropathy,seizures, vertigo, weaknessCV: PalpitationsEENT: Dry mouth, excessive salivation,furry tongue, metallic or bitter taste, oralcandidiasis, pharyngitis, stomatitis, tonguediscolorationGI: Abdominal cramps, anorexia, constipation,diarrhea, epigastric discomfort, flatulence,hepatic abnormalities, indigestion,nausea, thirst, vomitingGU: Darkened urine, dysuria, increasedvaginal discharge, menorrhagia, UTI, vaginalcandidiasis or odor, vulvo-vaginal discomfortHEME: Reversible thrombocytopenia, transientleukopenia or neutropeniaMS: Arthralgia, arthritis, myalgia, pelvicpainRESP: Bronchospasm, dyspnea, upper respiratorytract infectiontinzaparin sodium 1021SKIN: Diaphoresis, erythema multiforme,flushing, pruritus, rash, Stevens-Johnsonsyndrome, urticariaOther: AngioedemaNursing Considerations• Use tinidazole cautiously in patients withCNS disease or blood dyscrasias becausetinidazole’s adverse effects may worsenthese disorders. Also use cautiously inpatients with hepatic impairment becausea chemically related drug has reducedelimination.• Take seizure precautions. If a seizure orother abnormal neurologic symptomsoccur, notify prescriber and expect to stopdrug.• Treat a patient diagnosed with trichomoniasisand her sexual partner with thesame dose of tinidazole and at the sametime, as ordered, because trichomoniasis isa sexually transmitted disease.• Monitor patient’s total WBC count anddifferential if retreatment with tinidazoleis needed because adverse hematologicreactions may occur with repeated use.PATIENT TEACHING• Tell patient to take tinidazole with food tominimize gastric discomfort.• Instruct patient unable to swallow tabletsto crush tinidazole and mix in artificialcherry syrup and then take with food.• Advise patient to avoid alcohol while takingtinidazole and for 3 days afterwardbecause alcohol can cause intense flushing.• Tell patient to alert prescriber before takingtinidazole if she thinks or knows she ispregnant because tinidazole crosses theplacental barrier during the first trimesterand its effects on the fetus are unknown.• Instruct breast-feeding patient not tobreast-feed during therapy and for 3 daysafter taking last dose.tinzaparin sodiumInnohepClass and CategoryChemical class: Low–molecular-weightheparinTherapeutic class: Anticoagulant, antithromboticPregnancy category: BT

1022tinzaparin sodiumIndications and Dosages As adjunct to treat pulmonary thromboembolismand acute symptomatic deepvein thrombosisSUBCUTANEOUS INJECTIONAdults. 175 anti-Xa international units/kgdaily for at least 6 days. Maximum:18,000 to 21,000 anti-Xa international unitsdaily.Route Onset Peak DurationSubQ 2–3 hr 4–6 hr 24 hrMechanism of ActionPotentiates the action of antithrombin III, acoagulation inhibitor. By binding withantithrombin III, tinzaparin rapidly bindswith and inactivates clotting factors (primarilyfibrin and factor Xa). Withoutthrombin, fibrinogen can’t convert to fibrinand clots can’t form.ContraindicationsActive major bleeding; heparin-inducedthrombocytopenia (current or past); hypersensitivityto tinzaparin or its components,other low–molecular-weight heparins, sulfites,benzyl alcohol, or pork productsInteractionsDRUGSalteplase, anistreplase, aspirin, dextran,dipyridamole, NSAIDs, oral anticoagulants,streptokinase, sulfinpyrazone, urokinase:Possibly increased risk of bleeding and riskof spinal or epidural hematomasAdverse ReactionsCNS: Confusion, dizziness, epidural orspinal hematoma, headache, insomnia,intracranial hemorrhage, paralysisCV: Angina, hypertension, hypotension,tachycardiaEENT: Epistaxis, gingival bleeding, pharyngealbleedingGI: Constipation, elevated liver functiontest results, GI and retroperitoneal bleeding,hematemesis, nausea, vomitingGU: Hematuria, genitourinary bleeding,prolonged or heavy menstrual bleeding, UTIHEME: Anemia, thrombocytopenia, unusualbruisingMS: Back painRESP: Dyspnea, hemoptysis, pulmonaryembolismSKIN: Bleeding at puncture sites, surgicalincision sites, or venous cutdown sites; rashOther: Injection site hematoma, includingitching, pain, redness, and swellingNursing Considerations• Use tinzaparin with extreme caution inpatients who are elderly and have renalinsufficiency because drug may increasethe risk of death.• Expect warfarin therapy to begin within1 to 3 days of tinzaparin use.• Monitor patient’s INR. Expect therapy tocontinue until INR reaches 2.0 for 2 consecutivedays.WARNING Monitor patient for evidnce ofGI bleeding, including bloody or black,tarry stools; bloody or coffee-ground vomitus;and severe stomach pain. Notify prescriberimmediately if patient developsany of these signs or symptoms.• Assess tinzaparin injection site for signsand symptoms of hematoma, includingdeep, dark purple bruises under skin anditching, pain, redness, or swelling.• Assess patient for evidence of intracranialbleeding (such as decreased level of consciousness),retroperitoneal bleeding (suchas abdominal pain or swelling and backpain), genitourinary bleeding (such ashematuria), or respiratory tract bleeding(such as hemoptysis). Notify prescriberimmediately about any of these signs orsymptoms.• If serious bleeding (not controllable bylocal pressure) occurs, expect to discontinueany concomitant warfarin or antiplateletdrugs immediately.• Expect to treat bleeding by administering1 mg of protamine sulfate 1% solution I.V.per 100 anti-Xa international units of tinzaparin,as prescribed.• If possible, avoid giving I.M. injections topatient receiving tinzaparin. If arterialpuncture becomes necessary during tinzaparintherapy, expect to apply pressureafter procedure and to monitor puncturesite frequently for signs of bleeding.• Monitor patient’s laboratory tests for elevatedliver enzyme levels. If significant elevationspersist or worsen, notify prescriberimmediately.WARNING Monitor patient receiving tinzaparinand epidural or spinal anesthesia or

when a spinal puncture is performedbecause spinal hematomas can occur,causing long-term or permanent paralysis.Watch for evidence of neurologic impairment,such as changes in sensory or motorfunction. If present, notify prescriberimmediately because urgent care is neededto minimize effects of hematoma. Use ofindwelling epidural catheters, concurentuse of other drugs that affect hemostatis, ahistory of traumatic or repeated epiduralor spinal punctures, or a history of spinaldeformity or spinal surgery increases therisk of spinal or epidural heamtomas inpatients receiving tinzaparin.PATIENT TEACHING• Advise patient who is receiving tinzaparinto immediately report any bleeding,including from nose or gums.• Instruct patient to limit physical activityduring tinzaparin administration toreduce the risk of injury or bleeding.• Urge female patient to notify prescriber ifshe is or could be pregnant.tioproninThiolaClass and CategoryChemical class: Thiol compoundTherapeutic class: AntiurolithicPregnancy category: CIndications and Dosages To prevent the formation of urinary cystinecalculiTABLETSAdults. 800 mg daily in 3 divided doses.Children over age 9. 15 mg/kg in 3 divideddoses.DOSAGE ADJUSTMENT For patients with ahistory of hypersensitivity to penicillamine,therapy initiated at a reduced dosage; laterdosage adjusted as prescribed, according tourine cystine level.Route Onset Peak DurationP.O. Rapid Unknown 8–10 hrMechanism of ActionInhibits the formation of urinary cystinecalculi by undergoing thiol-disulfidetiopronin; tiotropium bromide 1023exchange with cystine (cystine-cystinedisulfide) to form a water-soluble compound,tiopronin-cystine disulfide.ContraindicationsHistory of agranulocytosis, aplastic anemia,or thrombocytopenia; hypersensitivity totiopronin or its componentsInteractionsDRUGSbone marrow depressants: Increased risk ofadverse hematologic effectshepatotoxic drugs: Increased risk of hepatotoxiceffectsnephrotoxic drugs: Increased risk of nephrotoxiceffectsAdverse ReactionsCNS: Chills, feverCV: Peripheral edemaEENT: Laryngeal edema, stomatitisGU: Hematuria, proteinuriaHEME: Anemia, eosinophilia, leukopenia,thrombocytopeniaMS: ArthralgiaSKIN: Ecchymosis, jaundice, pruritus, rash,urticariaNursing Considerations• Watch for drug fever, which may occurduring first month of tiopronin therapy.• Be aware that drug may be stoppedtemporarily, then restarted at lower dose.• Expect to monitor urine cystine level sodosage can be adjusted to keep cystinelevel below 250 g/ml.PATIENT TEACHING• Instruct patient to take tiopronin on anempty stomach, 1 hour before or 2 hoursafter meals, for faster drug absorption.• Advise patient to drink at least 3 L of fluiddaily to maintain a urine output of at least2 L daily during therapy.• Urge patient to maintain a diet low inmethionine, which is an essential aminoacid found in eggs, cheese, fish, and milk.tiotropium bromideSpiriva HandiHalerClass and CategoryChemical class: Nonane bromide monohydrateT

1024tiotropium bromideTherapeutic class: Anticholingeric, bronchodilatorPregnancy category: CIndications and Dosages To prevent bronchospasm associatedwith COPD, including chronic bronchitisand emphysema; to reduce COPDexacerbationsAEROSOL CAPSULESAdults. 18 mcg (1 capsule) with 2 inhalationsonce daily using HandiHaler inhalationdeviceMechanism of ActionPrevents acetylcholine from attaching tomuscarinic receptors on membranes ofsmooth-muscle cells. By blocking acetylcholine’seffects in the bronchi and bronchioles,tiotropium relaxes smooth musclesand causes bronchodilation.ContraindicationsHypersensitivity to atropine or its derivatives,including ipratropium, tiotropium, ortheir componentsInteractionsDRUGSanticholinergics: Possibly increased anticholinergiceffectsAdverse ReactionsCNS: Depression, difficulty speaking, dizziness,paresthesia, strokeCV: Angina, atrial fibrillation, chest pain,hypercholesterolemia, palpitations, peripheraledema, supraventricular tachycardia,tachycardiaEENT: Applicaiton site irritation (glossitis,mouth ulceration, pharyngolaryngeal pain),blurred vision, cataract, dry mouth, epistaxis,eye pain, glaucoma, hoarseness, laryngitis,oral candidiasis, pharyngitis, rhinitis,sinusitis, stomatitis, throat irritation, visualhalosENDO: HyperglycemiaGI: Abdominal pain, constipation, dysphagia,gastroesophageal reflux, indigestion,intestinal obstruction, ileus, vomitingGU: Urinary difficulty, urine retention, UTIMS: Arthritis, leg or skeletal pain, myalgiaRESP: Cough, paradoxical bronchospasm,upper respiratory tract infectionSKIN: Pruritus, rash, urticariaOther: Allergic reaction, angioedema, candidiasis,flulike symptoms, infectionNursing Considerations• Use tiotropium cautiously in patients withangle-closure glaucoma, benign prostatichyperplasia, or bladder neck obstruction.WARNING Monitor patient closely after givingfirst dose of tiotropium for immediatehypersensitivity reactions, includingangioedema and paradoxical bronchospasm.If reaction occurs, notify prescriberand expect to stop tiotropium andprovide supportive care. Because atropineis of a similar structure, monitor patientshypersensitive to atropine closely whengiving tiotropium because of potential forsimilar hypersensitivity reactions. Also usetiotropium cautiously in patients whohave severe hypersensitivity to milk proteins.• Monitor patient’s renal function, asordered, especially in patients with moderateto severe renal impairment, becausetiotropium is excreted mainly by the kidneys.• Monitor patient’s pulmonary function, asordered, to evaluate the effectiveness oftio-tropium.PATIENT TEACHING• Caution patient not to use tiotropium totreat acute bronchospasm.• Instruct patient on the proper use of theHandiHaler inhalation device. Tell patientto place the capsule into the center chamberof the inhalation device and then topress and release the button on the side ofthe inhalation device to pierce the capsule.Then have the patient exhale completely,close her lips around the mouthpiece,inhale slowly and deeply, and hold herbreath for as long as is comfortable.• Alert patient that the HandiHaler deviceshould not be used for taking any otherdrug and that tiotropium must be takenonly using the device and never swallowed.• Tell patient not to expose capsules to airuntil ready for use. To remove a capsulefrom the blister pack, tell patient to openthe foil only as far as the stop line to avoidexposing the rest of the capsules in theblister pack to air. Instruct patient to discardcapsules if they are inadvertentlyexposed to air and won’t be used immediately.• Advise patient to keep powder out of her

eyes because it may irritate them or blurher vision.• Instruct patient to rinse her mouth aftereach treatment to help minimize throatdryness and irritation.• Advise patient to tell prescriber aboutdecreased response to tiotropium as wellas difficulty urinating, eye pain, palpitations,and vision changes.tirofibanhydrochlorideAggrastatClass and CategoryChemical class: Tyrosine derivativeTherapeutic class: Platelet aggregationinhibitorPregnancy category: BIndications and Dosages To treat acute coronary syndromeI.V. INFUSIONAdults. 0.4 mcg/kg/min for 30 min, followedby 0.1 mcg/kg/min.DOSAGE ADJUSTMENT For patients with creatinineclearance of less than 30 ml/min/1.73 m 2 , infusion rate reduced by one-half.Route Onset Peak DurationI.V. Immediate 30 min 4–8 hrMechanism of ActionBinds to glycoprotein IIb/IIIa receptor siteson the surface of activated platelets.Circulating fibrinogen can bind to thesereceptor sites and link platelets together,forming a clot that eventually blocks acoronary artery. By binding to receptorsites, tirofiban prevents the normal bindingof fibrinogen and other factors and inhibitsplatelet aggregation.IncompatibilitiesDon’t infuse tirofiban in same I.V. line withany drug other than atropine sulfate, dobutamine,dopamine, epinephrine hydrochloride,furosemide, heparin, lidocaine, midazolamhydrochloride, morphine sulfate,nitroglycerin, potassium chloride, propranololhydrochloride, or famotidine (Pepcidinjection).tirofiban hydrochloride 1025ContraindicationsAcute pericarditis; arteriovenous malformation;coagulopathy; stroke that occurredwithin previous 30 days or a history ofhemorrhagic stroke; GI or GU bleeding;hemophilia; history of thrombocytopeniaafter tirofiban use; hypersensitivity totirofiban or its components; intracranialaneurysm or mass, intracranial bleeding,retinal bleeding, aortic dissection, or anyevidence of active abnormal bleeding withinprevious 30 days; major surgery or traumawithin previous 6 weeks; severe uncontrolledhypertension (systolic blood pressureabove 180 mm Hg, diastolic bloodpressure above 110 mm Hg)InteractionsDRUGSantineoplastics, antithymocyte globulin,NSAIDs, oral anticoagulants, platelet aggregationinhibitors, strontium-89 chloride,thrombolytics: Increased risk of bleedinglevothyroxine, omeprazole: Increased rate oftirofiban clearanceporfimer: Decreased effectiveness of porfimerphotodynamic therapysalicylates: Increased risk of bleeding, possiblyhypoprothrombinemiaAdverse ReactionsCNS: Chills, dizziness, fever, headache,intracranial hemorrhageCV: Edema, hemopericardium, peripheraledema, sinus bradycardiaGI: Hematemesis, nausea, retroperitonealbleeding, vomitingGU: Hematuria, pelvic painHEME: Severe thrombocytopenia withchills, fever, and possibly fatal bleedingcomplicationsRESP: Pulmonary hemorrhageSKIN: Diaphoresis, rash, urticariaOther: Allergic reaction, anaphylaxis, infusionsite bleedingNursing ConsiderationsWARNING Dilute 50-ml vial of tirofibanbefore use; don’t dilute 500-ml containerbecause it holds premixed solution readyfor I.V. infusion. Don’t use solution unlessit’s clear and the seal is intact.• If prescribed, give tirofiban with heparinfor 48 to 108 hours. Expect to continueinfusion throughout angiography and forT

1026tizanidine hydrochloride12 to 24 hours after angioplasty oratherectomy.WARNING If patient is also receiving aheparin infusion, expect to monitor APTTbefore treatment, 6 hours after heparininfusion starts, and regularly thereafter.Expect to adjust heparin dosage to maintainAPTT at about two times the control.Notify prescriber immediately if patientdevelops an abnormally high APTT. Also,assess patient for signs and symptoms ofabnormal bleeding and report them toprescriber immediately because potentiallylife-threatening bleeding may occur.• After cardiac catheterization or percutaneoustransluminal coronary angioplasty,keep patient on bed rest with head of bedelevated. Ensure hemostasis of percutaneoussite for at least 4 hours before discharge.Minimize invasive procedures,including epidural procedures, to reducethe risk of bleeding.• Monitor patient’s platelet count, hemoglobinlevel, and hematocrit, as ordered.Expect to discontinue tirofiban if patient’splatelet count is less than 90,000/mm 3 .Expect to give a platelet transfusion, asprescribed, if platelet count falls below50,000/mm 3 .PATIENT TEACHING• Advise patient to immediately report anybleeding, bruising, headache, pain, orswelling during I.V. infusion of tirofiban.tizanidinehydrochlorideZanaflexClass and CategoryChemical class: ImidazolineTherapeutic class: AntispasmodicPregnancy category: CIndications and Dosages To manage acute and intermittentincreases of muscle tone with spasticityTABLETSAdults. 4 mg every 6 to 8 hr, p.r.n.,increased gradually by 2 to 4 mg/dose, asneeded and as prescribed. Maximum:36 mg daily or 3 doses daily.Mechanism of ActionReduces spasticity by decreasing the releaseof excitatory amino acids. This alpha 2 -adrenergic agonist’s action increases presynapticinhibition of spinal motor neurons,with the greatest effects on polysynapticpathways.Route Onset Peak DurationP.O. Unknown 1–2 hr 3–6 hrContraindicationsHypersensitivity to tizanidine or its components,use with ciprofloxacin or fluvoxamineInteractionsDRUGSacetaminophen: Delayed peak effects ofacetaminophenalpha 2 -adrenergic agonists: Possibly significanthypotensionantihypertensives: Additive hypotensiveeffectsCYP1A2 inhibitors (such as acyclovir, amiodarone,cimetidine, famotidine, mexiletine,propafenone, ticlopidine, verapamil, zileuton),fluroquinolones (includingciprofloxacin, fluvoxamine): Possiblyincreased plasma tizanidine level; increasedrisk of hypotension and sedationoral contraceptives: Decreased tizanidineclearancerofecoxib: Possibly increased adverse reactionsACTIVITIESalcohol use: Increased adverse effects oftizanidine, additive CNS depressionAdverse ReactionsCNS: Anxiety, delusions, drowsiness, dyskinesia,fatigue, fever, hallucinations, slurredspeechCV: Orthostatic hypotensionEENT: Dry mouth, pharyngitis, rhinitisGI: Abdominal pain, anorexia, constipation,diarrhea, dyspepsia, elevated liver functiontest results, hepatic failure, hepatomegaly,nausea, vomitingGU: Urinary frequency, UTIMS: Back pain, muscle weakness, myastheniaSKIN: Diaphoresis, jaundice, rash, ulceration

Nursing Considerations• Be aware that extreme caution is requiredif tizanidine is prescribed for a patientwith hepatic impairment because the drugis extensively metabolized in the liver.• Monitor hepatic and renal function forfirst 6 months and periodically thereafter.• Expect prolonged drug use to inhibit saliva.• Be aware that tizanidine should bestopped slowly to prevent withdrawal andrebound hypertension, tachycardia, andhypertonia.PATIENT TEACHING• Caution patient not to stop taking tizanidinesuddenly to prevent adverse effects.• Advise patient to change positions slowlyto minimize effects of orthostatichypotension.• Urge patient to avoid alcohol during drugtherapy because of its additive CNSeffects.• Tell patient to notify prescriber or a dentistif dry mouth lasts longer than 2 weeks.• Instruct patient to inform all prescribersand pharmacists about any drug he startsor stops taking.tobramycin sulfateTobiClass and CategoryChemical class: AminoglycosideTherapeutic class: AntibioticPregnancy category: Dtobramycin sulfate 1027Indications and Dosages To treat bacteremia; bone and joint,gynecologic, intra-abdominal, lower respiratorytract, skin and soft-tissue, andurinary tract infections; endocarditis;meningitis; neonatal sepsis; pyelonephritis;and septicemia caused by susceptiblestrains of Acinetobacter species,Aeromonas species, Citrobacter species,Enterobacter species, Escherichia coli,Haemophilus influenzae (betalactamase–negative and –positive),Klebsiella species, Morganella morganii,Proteus mirabilis, Proteus vulgaris,Providencia rettgeri, Pseudomonasaeruginosa, Salmonella species,Serratia species, Shigella species, Staphylococcusaureus, and Staphylococcusepidermidis; to treat febrile neutropeniaI.V. INFUSION, I.M. INJECTIONAdults. 3 to 6 mg/kg daily in divided dosesevery 8 to 12 hr.Children over age 5. 2 to 2.5 mg/kg every8hr.Children under age 5. 2.5 mg/kg every 8 to16 hr.Neonates over age 7 days weighing morethan 2 kg (4.4 lb). 2.5 mg/kg every 8 hr.Neonates over age 7 days weighing 1.2 to2 kg (2.6 to 4.4 lb). 2.5 mg/kg every 8 to12 hr.Neonates age 7 days and under weighing2 kg or more. 2.5 mg/kg every 12 hr.Neonates age 7 days and under weighing1.2 to 2 kg. 2.5 mg/kg every 12 to 18 hr.Preterm neonates weighing 1 to 1.2 kg(2.2 to 2.6 lb). 2.5 mg/kg every 18 to 24 hr.Preterm neonates weighing less than 1 kg.3.5 mg/kg every 24 hr. To treat pulmonary infection caused byP. aeruginosa in patients with cysticfibrosisI.V. INFUSIONAdults and children. 2.5 to 3.3 mg/kg every8 hr; dosage adjusted to achieve peak blooddrug level of 8 to 12 mcg/ml and troughblood drug level below 2 mcg/ml.INHALATIONAdults and children over age 6. 1 ampule(300 mg) b.i.d. in alternating periods of28 days on and 28 days off. To treat meningitis caused by susceptibleorganismsINTRATHECAL INJECTIONAdults. 4 to 8 mg daily with parenteraltherapy.Children. 1 to 2 mg daily with parenteraltherapy. To treat systemic infectionINTRAPERITONEAL INFUSIONAdults and children. 1.5 to 2 mg/kg. To treat dialysis-associated peritonitis inpatients with end-stage renal diseaseINTRAPERITONEAL INFUSIONAdults and children. 4 to 8 mg/L in eachdialysate exchange bag, increased, as prescribed,to 6 to 8 mg/L in documentedPseudomonas infection or to 20 mg/Ladministered in one exchange bag daily.DOSAGE ADJUSTMENT For patients withrenal impairment, dosage possibly reduced.T

1028tobramycin sulfateMechanism of ActionInhibits bacterial protein synthesis by bindingirreversibly to one of two aminoglycoside-bindingsites on the 30S ribosomalsubunit, resulting in bacteriostatic effects.Bactericidal effects may stem fromtobramycin’s ability to accumulate withincells so that the intracellular drug levelexceeds the extracellular level.IncompatibilitiesDon’t mix tobramycin in same solutionwith parenteral aminoglycosides or betalactamantibiotics because mutual inactivationmay result. Don’t dilute or mix inhalationsolution in nebulizer with dornase alfa.ContraindicationsConcurrent cidofovir therapy; hypersensitivityto tobramycin, aminoglycosides,sodium bisulfite, or their componentsInteractionsDRUGSacyclovir, aminoglycosides, amphotericin B,carboplatin, cisplatin, NSAIDs, vancomycin:Additive nephrotoxicitycarbenicillin, ticarcillin: Possibly inactivationof tobramycindimenhydrinate: Possibly masking of symptomsof ototoxicityethacrynic acid, furosemide: Additive ototoxicitygeneral anesthetics, neuromuscular blockers:Possibly increased neuromuscular blockadeAdverse ReactionsCNS: Confusion, dizziness, headache, lethargy,neurotoxicity, vertigoEENT: Hearing loss, tinnitusGI: Clostridium difficile–associated diarrhea,diarrhea, elevated liver function testresults, nausea, vomitingGU: Elevated BUN and serum creatininelevels, nephrotoxicity, oliguria, proteinuria,renal failureHEME: Anemia, leukocytosis, leukopenia,neutropenia, thrombocytopeniaSKIN: Exfoliative dermatitis, pruritus, rash,urticariaOther: Hypocalcemia, hypokalemia, hypomagnesemia,hyponatremia, injection sitepainNursing Considerations• Obtain fluid and tissue samples for cultureand sensitivity testing before and duringtobramycin therapy, as ordered. Reviewresults, if available, before therapy starts.• After reconstituting with 30 ml of sterileor bacteriostatic water for injection, dilutefurther with normal saline solution orD 5 W.• Give each I.V. dose over 20 to 60 minutes.WARNING Don’t infuse tobramycin overless than 20 minutes to avoid neuromuscularblockade and excessive peak druglevel.• Don’t expose ampules for inhalation solutionto intense light. Refrigerate them at36° to 46° F (2° to 8° C).• Because drug can cause bilateral and irreversiblehearing loss, assess for early signsof cochlear and vestibular ototoxicity,including high-frequency hearing loss andvertigo.• Monitor serum calcium, magnesium,potassium, and sodium levels to detectelectrolyte imbalances.WARNING Be alert for allergic reactions,including anaphylaxis, because someforms of drug contain sodium bisulfite.• Stop tobramycin therapy 7 days beforestarting cidofovir therapy, as prescribed.• Watch for signs of nephrotoxicity, such aselevated BUN and serum creatinine levels.• Expect dehydration to increase the risk ofnephrotoxicity.WARNING Monitor patient with myastheniagravis or parkinsonism for increased muscleweakness because of tobramycin’spotential curare-like effect.• Monitor patient closely for diarrhea,which may indicate pseudomembranouscolitis caused by C. difficile. If diarrheaoccurs, notify prescriber, expect to withholdtobramycin, and treat with fluids,electrolytes, protein, and an antibioticeffective against C. difficile.PATIENT TEACHING• For inhaled tobramycin, instruct patient toinhale over 10 to 15 minutes, using ahandheld nebulizer with a compressor.• Teach patient how to use nebulizer whilesitting or standing upright and to breathenormally through its mouthpiece. Noseclips may help patient breathe through hermouth.• Instruct patient to disinfect her nebulizerevery other treatment day by boiling the

nebulizer parts (except tubing) for a full10 minutes and then drying the parts on aclean, lint-free cloth.• Urge patient to immediately report highfrequencyhearing loss and vertigo.• Instruct female patient to notify prescriberimmediately about known or suspectedpregnancy because drug poses danger tofetus.• Urge patient to tell prescriber about diarrheathat’s severe or lasts longer than3 days. Remind patient that watery orbloody stools may occur 2 or moremonths after antibiotic therapy and maybe serious, requiring prompt treatment.tocainidehydrochlorideTonocardClass and CategoryChemical class: Lidocaine analogueTherapeutic class: Class IB antiarrhythmicPregnancy category: CIndications and Dosages To treat life-threatening, sustained ventriculartachycardiaTABLETSAdults. Initial: 400 mg every 8 hr.Maintenance: 1.2 to 1.8 g daily in divideddoses every 8 hr.DOSAGE ADJUSTMENT Dosage possiblyreduced by 25% if creatinine clearance is10 to 30 ml/min/1.73 m 2 and by 50% if creatinineclearance is less than 10 ml/min/1.73 m 2 .Route Onset Peak DurationP.O. Unknown 0.5–2 hr 8 hrMechanism of ActionCombines with fast sodium channels inmyocardial cell membranes, which inhibitssodium influx into cells and decreases ventriculardepolarization, automaticity, andexcitability during diastole.ContraindicationsHypersensitivity to tocainide or its components,second- or third-degree AV blockwithout ventricular pacemakertocainide hydrochloride 1029InteractionsDRUGSantiarrhythmics: Possibly additive cardiaceffects, additive toxicitybeta blockers: Increased cardiac index, leftventricular pressures, and pulmonary arterywedge pressurescimetidine: Possibly decreased blood tocainidelevelrifampin: Accelerated hepatic metabolism oftocainide, reduced tocainide effectivenessAdverse ReactionsCNS: Agitation, anxiety, ataxia, coma, confusion,depression, dizziness, fatigue, hallucinations,headache, mood changes, nervousness,paresthesia, psychosis, seizures,sleep disturbance, syncope, tremor, vertigoCV: AV conduction disorders, bradycardia,chest pain, heart failure, hypertension,hypotension, palpitations, prolonged QTinterval, PVCs, tachycardia, ventricular fibrillationEENT: Blurred vision, vision changesGI: Anorexia, diarrhea, nausea, vomitingHEME: Agranulocytosis, anemia, aplasticanemia, bone marrow depression, hemolysis,leukopenia, neutropenia, thrombocytopeniaRESP: Pulmonary edema, fibrosis, andhypersensitivity (pneumonitis); respiratoryarrestSKIN: Diaphoresis, exfoliative dermatitis,pruritus, rash, skin lesions, urticariaNursing Considerations• Monitor CBC with differential weekly duringfirst 3 months of tocainide treatmentand routinely thereafter to detect blooddyscrasias. Although rare, agranulocytosis,anemia, aplastic anemia, bone marrowdepression, hemolysis, leukopenia, neutropenia,or thrombocytopenia may befatal. Expect findings to normalize about1 month after therapy stops.• Maintain continuous cardiac monitoringor obtain periodic ECG tracings, asordered, to assess drug effectiveness.• Watch for tremor, a possible sign of maximumdosing.• Assess patient for additive adverse cardiaceffects, especially if tocainide is used withanother antiarrhythmic.• Be aware that tocainide is secreted inbreast milk and has the potential to causeT

1030tocilizumabserious adverse reactions in breast-feedinginfants.PATIENT TEACHING• Inform patient that electrophysiologicstudies may be performed before tocainidetherapy starts.• Tell patient to notify prescriber abouttremor because dosage may need adjustment.• Explain that chest X-rays may be needed ifadverse pulmonary reactions occur.• Inform patient that ambulatory monitoringmay be needed to verify antiarrhythmicresponse.• Stress the importance of keeping all scheduledappointments for follow-up bloodtests.tocilizumabActemraClass and CategoryChemical class: Recombinant human antihumaninterleukin 6 (IL-6) monoclonalantibodyTherapeutic class: Biologic disease-modifyingantirheumatic drug (DMARD)Pregnancy category: CIndications and Dosages To treat moderate to severe activerheumatoid arthritis in patients whohave had an inadequate response to oneor more tumor necrosis factor antagonisttherapiesI.V. INFUSIONAdults. 4 mg/kg given over 60 minutesevery 4 wk, increased, as needed, to 8 mg/kg given over 60 minutes every 4 wk.Maximum: 800 mg per infusion.DOSAGE ADJUSTMENT Dosage reduced from8 mg/kg to 4 mg/kg for management ofdose-related laboratory changes, includingelevated liver enzymes (AST or ALT 1 to3 times the upper limit of normal), neutropenia(absolute neutrophil count approaching1,000/mm 3 ), or thrombocytopenia(platelet count approaching 100,000/mm 3 ).Mechanism of ActionBinds to interleukin 6 (IL-6) receptors tointerrupt signaling through them. IL-6 is aproinflammatory cytokine produced byvarious cells, such as T- and B-cells, lymphocytes,monocytes, and fibroblasts. It alsois produced by synovial and endothelialcells, leading to local production of IL-6 injoints affected by inflammatory processessuch as rheumatoid arthritis. Binding ofIL-6 receptors prevents inflammationrelatedsignals from being relayed, whichreduces inflammatory response and relievessigns and symptoms of rheumatoid arthritis.IncompatabilitiesDon’t mix tocilizumab with other drugs.ContraindicationsHypersensitivity to tocilizumab or its components,absolute neutrophil count below2,000/mm 3 , platelet count below100,000/mm 3 , ALT or AST above 1.5 timesupper limit of normalInteractionsDRUGSanti-CD20 monoclonal antibodies, IL-1Rantagonists, selective co-stimulation modulators,TNF antagonists: Increased risk ofimmunosuppression and infectionatorvastatin; cytochrome P-450 substrateswith a narrow therapeutic index such ascyclosporine, theophylline, warfarin; CYP3A4substrates such as lovastatin, oral contraceptives,simvastain; omeprazole: Possiblydecreased plasma levels of these drugs withdecreased effectivenesslive vaccines: Increased risk of adverse vaccineeffectsAdverse ReactionsCNS: Dizziness, headacheCV: Elevated lipid levels, hypertensionEENT: Nasopharyngitis, oral ulcerationGI: Diverticulitis, elevated liver enzymes,gastritis, gastroenteritis, perforation, upperabdominal painGU: UTIHEME: Neutropenia, thrombocytopeniaMS: Bacterial arthritisRESP: Bronchitis, pneumonia, upper respiratorytract infectionSKIN: Cellulitis, pruritus, rash, urticariaOther: Anaphylaxis, anti-tocilizumab antibodies,herpes zoster, malignancies, opportunisticinfections including activation oflatent infections, sepsis, tuberculosis withpulmonary or extrapulmonary disease

Nursing Considerations• Tocilizumab may be used as monotherapyto treat rheumatoid arthritis or togetherwith methotrexate or other nonbiologicalDMARDs.• Tocilizumab isn’t recommended forpatients with active liver disease orimpairment because drug may adverselyaffect liver function.• Make sure patient has a tuberculin skintest before therapy starts. If skin test ispositive, tuberculosis treatment will needto be started before tocilizumab therapycan begin. Even patients who have testednegative for tuberculosis may developtuberculosis during therapy. Monitorpatient for persistent cough, wasting orweight loss, and low-grade fever andreport such findings to prescriber.WARNING If patient has evidence of anactive infection when drug is prescribed,therapy shouldn’t start until infection hasbeen treated. Monitor all patients forinfections, including invasive fungal infectionssuch as aspergillosis, candidiasis, orpneumocystis; or bacterial, myobacterial,protozoal, or viral opportunistic infectionsduring and after therapy, especiallypatients who are taking immunosuppressants.If a serious infection develops,expect prescriber to interrupt drug therapyuntil infection is controlled.• Obtain a baseline of patient’s absoluteneutrophil count, platelet count, and liverenzymes before starting tocilizumab therapy,as ordered. Therapy shouldn’t begin ifpatient’s absolute neutrophil count isbelow 2,000/mm 3 , platelet count below100,000/mm 3 or ALT or AST level is above1.5 times the upper limit of normal.Monitor these values, as ordered, every4 to 8 weeks and report abnormalities.Dosage adjustment may be required ordrug may need to be discontinued.• Use tocilizumab cautiously in patientswith recurrent infection or increased riskof infection, patients who live in regionswhere tuberculosis and histoplasmosis areendemic, and patients with a history ofCNS demyelinating disorders because theymay occur, although rarely, duringtocilizumab therapy.• When preparing to give tocilizumab, beginby withdrawing from a 100-ml infusionbag or bottle containing 0.9% sodiumchloride injection a volume equal to thevolume of tocilizumab solution in thepatient’s dose. Slowly add drug from eachvial into infusion bag or bottle and gentlyinvert bag to mix while avoiding foaming.Discard any unused drug left in vials.Once fully diluted, solution may be storedin the refrigerator or at room temperaturefor up to 24 hours.• Give tocilizumab with an infusion set, andnever as I.V. push or bolus. Don’t infuseconcurrently with other drugs in same I.V.line.WARNING Stop tocilizumab immediatelyand notify prescriber if patient has anallergic reaction. Provide supportive care,as needed.PATIENT TEACHING• Review the signs and symptoms of anallergic reaction (rash, swollen face, difficultybreathing), and tell patient to seekemergency care immediately if theseoccur.• Inform patient that infections, includingactivation of latent infections such astuberculosis, may occur during tocilizumabtherapy. Instruct him to report unusual,persistent, or severe signs and symptomsto prescriber.• Instruct patient to immediately contact ahealthcare provider about severe, persistantabdominal pain because it couldreflect GI perforation.• Advise patient to avoid people with infectionsand to have all prescribed laboratorytests performed.• Inform patient that risk of developing amalignancy is higher in patients takingtocilizumab but is still rare. Emphasizeimportance of follow-up visits and reportingany unusual or sudden signs or symptoms.• Caution against receiving live-virus vaccineswhile taking tocilizumab.• Advise patient to inform all health careproviders about tocilizumab use and toinform prescriber about any OTC medicationsbeing taken, including herbal remediesand vitamin and mineral supplements.• Urge woman who becomes pregnant whilereceiving tocilizumab to contact prescriberand to join the pregnancy registry by calltocilizumab1031T

1032tolazamideing 1-877-311-8972 so exposure totocilizumab can be monitored.tolazamideTolinaseClass and CategoryChemical class: First-generation sulfonylureaTherapeutic class: AntidiabeticPregnancy category: CIndications and Dosages As adjunct to treat type 2 diabetesmellitus that’s uncontrolled by diet andexerciseTABLETSAdults. Initial: 100 mg daily with breakfastif fasting blood glucose level is less than200 mg/dl; 250 mg daily if fasting bloodglucose level is more than 200 mg/dl. Doseadjusted every wk by 100 to 250 mg, ifneeded. Doses greater than 500 mg daily aredivided and given every 12 hr. Maximum:1,000 mg daily.DOSAGE ADJUSTMENT If patient takes morethan 40 units daily of insulin, initial dosageincreased to 250 mg daily and insulindosage decreased by 50%.Route Onset Peak DurationP.O. Unknown 3–4 hr 10–20 hrMechanism of ActionStimulates insulin release from beta cells inthe pancreas. Tolazamide also increasesperipheral tissue sensitivity to insulin eitherby enhancing insulin binding to cellularreceptors or by increasing the number ofinsulin receptors.ContraindicationsDiabetic coma; diabetic ketoacidosis; hypersensitivityto tolazamide, sulfonylureas, ortheir components; pregnancy; sole therapyfor type 1 diabetes mellitusInteractionsDRUGSACE inhibitors, anabolic steroids, androgens,azole antifungals, bromocriptine, chloramphenicol,clofibrate, disopyramide, guanethidine,H 2 -receptor antagonists, insulin, magnesiumsalts, MAO inhibitors, methyldopa,octreotide, oxyphenbutazone, phenylbutazone,probenecid, quinidine, salicylates, sulfonamides,tetracycline, theophylline, tricyclicantidepressants, urinary acidifiers: Increasedrisk of hypoglycemiaasparaginase, calcium channel blockers,cholestyramine, clonidine, corticosteroids,danazol, diazoxide, estrogen, glucagon,hydantoins, isoniazid, lithium, morphine,nicotinic acid, oral contraceptives, phenothiazines,rifabutin, rifampin, sympathomimetics,thiazide diuretics, thyroid drugs, urinaryalkalizers: Increased risk of hyperglycemiabeta blockers: Possibly hyperglycemia ormasking of signs and symptoms ofhypoglycemiadigoxin: Increased risk of digitalis toxicitypentamidine: Initial hypoglycemia and thenhyperglycemia if beta cell damage occursACTIVITIESalcohol use: Altered blood glucose control(usually hypoglycemia), possibly disulfiram-likereactionAdverse ReactionsCNS: Dizziness, fatigue, headache, malaise,paresthesia, vertigoENDO: HypoglycemiaGI: Anorexia, cholestasis, heartburn, nausea,vomitingHEME: Agranulocytosis, aplastic anemia,hemolysis, hemolytic anemia, leukopenia,thrombocytopeniaMS: Muscle weaknessSKIN: Erythema, photosensitivity, pruritus,rash, urticariaNursing Considerations• When switching an insulin-treated patientwith type 2 diabetes, expect to start tolazamideat 100 mg daily if patient takes lessthan 20 units daily of insulin, or 250 mgdaily if patient takes 20 to 40 units daily ofinsulin.• Anticipate that patient receiving tolazamidemay need temporary insulin treatmentduring periods of physiologic stress,such as fever, surgery, systemic infection,and trauma.• For patient over age 65, expect to starttolazamide at 100 mg daily.• Assess elderly patients for signs of hypoglycemiabecause they’re more susceptibleto drug’s hypoglycemic effect. Anticipatethat hypoglycemia may be more difficult

to detect.• Assess patient with thyroid disease foraltered blood glucose control because thyroidhormone increases GI absorption ofglucose.• Expect prescriber to stop tolazamide2 weeks before pregnant patient deliversher neonate to minimize the risk of prolongedhypoglycemia in neonate.PATIENT TEACHING• Advise patient to avoid alcohol while takingtolazamide.• Teach patient and family members how tomonitor blood glucose level and how torecognize signs of hypoglycemia andhyperglycemia.• Instruct patient to treat mild hypoglycemiawith fruit juice or other simplesugars.tolbutamideApo-Tolbutamide (CAN), Novo-Butamide (CAN), OrinaseClass and CategoryChemical class: First-generation sulfonylureaTherapeutic class: AntidiabeticPregnancy category: CIndications and Dosages As adjunct to treat type 2 diabetes mellitusthat’s uncontrolled by diet andexerciseTABLETSAdults. Initial: 1 to 2 g daily in divideddoses b.i.d. or t.i.d. Maintenance: 0.25 to 2 gdaily. Maximum: 3 g daily.Route Onset Peak DurationP.O. Unknown 3–4 hr 6–12 hrMechanism of ActionStimulates insulin release from beta cells inthe pancreas. Tolbutamide also increasesperipheral tissue sensitivity to insulin eitherby enhancing insulin binding to cellularreceptors or by increasing the number ofinsulin receptors.ContraindicationsDiabetes complicated by pregnancy; diabeticcoma; diabetic ketoacidosis; hypersensitivityto tolbutamide, sulfonylureas, or theirNursing Considerations• If patient takes 20 units or less of insulindaily, expect a possible transfer frominsulin to tolbutamide. If patient takesmore than 20 units of insulin daily, expectto reduce insulin dosage as tolbutamidetherapy starts.• Anticipate that patient receiving tolbutatolbutamide1033components; sole therapy for type 1 diabetesmellitusInteractionsDRUGSACE inhibitors, anabolic steroids, androgens,azole antifungals, bromocriptine, chloramphenicol,clofibrate, disopyramide, guanethidine,H 2 -receptor antagonists, insulin, magnesiumsalts, MAO inhibitors, methyldopa,octreotide, oxyphenbutazone, phenylbutazone,probenecid, quinidine, salicylates, sulfonamides,tetracycline, theophylline, tricyclicantidepressants, urinary acidifiers: Increasedrisk of hypoglycemiaasparaginase, calcium channel blockers,cholestyramine, clonidine, corticosteroids,danazol, diazoxide, estrogen, glucagon,hydantoins, isoniazid, lithium, morphine,nicotinic acid, oral contraceptives, phenothiazines,rifabutin, rifampin, sympathomimetics,thiazide diuretics, thyroid drugs, urinaryalkalizers: Increased risk of hyperglycemiabeta blockers: Possibly hyperglycemia ormasking of signs and symptoms of hypoglycemiadigoxin: Increased risk of digitalis toxicitypentamidine: Initial hypoglycemia and thenhyperglycemia if beta cell damage occursACTIVITIESalcohol use: Altered blood glucose control(usually hypoglycemia), possibly disulfiramlikereactionAdverse ReactionsCNS: Dizziness, fatigue, headache, malaise,paresthesia, vertigoENDO: HypoglycemiaGI: Anorexia, cholestasis, heartburn, nausea,vomitingHEME: Agranulocytosis, aplastic anemia,hemolysis, hemolytic anemia, leukopenia,thrombocytopeniaMS: Muscle weaknessSKIN: Erythema, photosensitivity, pruritus,rash, urticariaT

1034tolcaponemide may need temporary insulin treatmentduring periods of physiologic stress,such as fever, surgery, systemic infection,or trauma.• Assess elderly patients for signs of hypoglycemiabecause they’re more susceptibleto drug’s hypoglycemic effect. Anticipatethat hypoglycemia may be more difficultto detect.• Assess patient with thyroid disease foraltered blood glucose control because thyroidhormone increases GI absorption ofglucose.• Expect prescriber to stop tolbutamide2 weeks before pregnant patient deliversher neonate to minimize the risk of prolongedhypoglycemia in neonate.PATIENT TEACHING• Advise patient to avoid alcohol while takingtolbutamide.• Teach patient and family members how tomonitor blood glucose level and recognizesigns of hypoglycemia and hyperglycemia.• Instruct patient to treat mild hypoglycemiawith fruit juice or other simplesugars.tolcaponeTasmarClass and CategoryChemical class: NitrobenzophenoneTherapeutic class: AntidyskineticPregnancy category: CIndications and Dosages As adjunct (with levodopa and carbidopa)to treat Parkinson’s diseaseTABLETSAdults. Initial: 100 mg t.i.d. Maximum:200 mg t.i.d.Mechanism of ActionProlongs plasma half-life of levodopa byinhibiting catechol-O-methyltransferase(COMT), an enzyme responsible formetabolizing catecholamines—includingdopa, dopamine, epinephrine, norepinephrine,and their hydroxylated metabolites.COMT inhibition decreases the metabolizingenzyme for levodopa, which yields amore sustained plasma levodopa level,making more available for diffusion intothe CNS to be converted to dopamine.ContraindicationsConfusion, hyperpyrexia, or rhabdomyolysiswith previous use of tolcapone; hepaticdysfunction; hypersensitivity to tolcaponeor its componentsInteractionsDRUGSdesipramine: Possibly increased frequency ofadverse effectslevodopa: Increased levodopa bioavailability,with increased risk of orthostatic hypotensionand syncopeMAO inhibitors: Possibly inhibited catecholaminemetabolismAdverse ReactionsCNS: Confusion, dizziness, drowsiness, dyskinesia,fatigue, fever, hallucinations, headache,lethargy, loss of balanceCV: Chest pain, orthostatic hypotensionEENT: Dry mouthGI: Abdominal pain, acute fulminant liverfailure, anorexia, cholestasis, constipation,diarrhea, elevated liver function test results,vomitingGU: Bright yellow urine, hematuriaMS: Muscle cramps, rhabdomyolysisRESP: Dyspnea, upper respiratory tractinfectionSKIN: Diaphoresis, jaundiceOther: Intense urges to perform certainactivities (such as gambling and sex)Nursing Considerations• Ensure that patient has had the risks oftolcapone therapy explained fully to himand has signed the acknowledgement formbefore starting therapy.• Use cautiously in patient with severe dyskinesiaor dystonia because drug is knownto cause rhabdomyolysis.• Monitor liver function test results, asordered, during tolcapone therapy todetect hepatic impairment. Expect to discontinuedrug if patient’s liver enzymesexceed twice the upper limit of normal orif patient has any signs or symptoms ofliver dysfunction, such as persistent nausea,fatigue, lethargy, anorexia, jaundice,dark urine, pruritus, or right upper quadranttenderness.• Assess patient for hallucinations, especiallyin patient over age 75.

• Anticipate that drug may precipitate orexaggerate preexisting dyskinesia.• Expect tolcapone to be discontinued if noimprovement occurs after 3 weeks of drugtherapy.• Assess patient for skin changes regularlybecause risk of melanoma in higher inpatients with Parkinson’s disease. It isn’tclear whether risk results from disease ordrugs used to treat it.PATIENT TEACHING• Inform patient that urine may turn brightyellow during tolcapone therapy.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Urge patient to notify prescriber immediatelyabout darkened urine, decreasedappetite, fatigue, jaundice, lethargy, andright-sided abdominal pain.• Caution patient not to stop taking drugabruptly. Explain that prescriber willsupervise tapering of drug dosage.• Urge patient to have regular follow-upappointments and laboratory tests.• Urge patient to have regular skin examinationsby a dermatologist or other qualifiedhealth professional.• Advise patient to notify prescriber aboutintense urges (as for gambling or sex)because dosage may need to be reduced ordrug discontinued.tolmetinNovo-Tolmetin (CAN), Tolectin DS,Tolectin 200, Tolectin 400 (CAN),Tolectin 600Class and CategoryChemical class: Pyrroleacetic acid derivativeTherapeutic class: Anti-inflammatoryPregnancy category: C (first trimester), Notrated (later trimesters)Indications and Dosages To relieve moderate pain from rheumatoidarthritis and osteoarthritisCAPSULES, TABLETSAdults. Initial: 400 mg t.i.d. Maintenance:600 to 1,800 mg daily in divided doses t.i.d.or q.i.d. Maximum: 2,000 mg daily forrheumatoid arthritis, 1,600 mg daily forosteoarthritis.Adverse ReactionsCNS: Aseptic meningitis, cerebral hemorrhage,ischemic stroke, depression, dizziness,drowsiness, fatigue, headache, trantolmetin1035 To treat juvenile rheumatoid arthritisCAPSULES, TABLETSChildren over age 2. Initial: 20 mg/kg dailyin divided doses t.i.d. or q.i.d. Maintenance:15 to 30 mg/kg daily in divided doses.Maximum: 30 mg/kg daily.Route Onset Peak DurationP.O. Unknown 1–2 wk UnknownMechanism of ActionBlocks cyclooxygenase, the enzyme neededto synthesize prostaglandins, which mediatethe inflammatory response and cause localvasodilation, swelling, and pain. Prostaglandinsalso promote pain transmissionfrom the periphery to the spinal cord. Byblocking cyclooxygenase and inhibitingprostaglandins, tolmetin reduces inflammatorysymptoms and relieves pain.ContraindicationsAngioedema, asthma, bronchospasm, nasalpolyps, rhinitis, or urticaria caused byaspirin, iodides, or other NSAIDsInteractionsDRUGSACE inhibitors, beta blockers: Decreasedeffectiveness of these drugs, possiblyreduced renal functionalendronate, corticosteroids, other NSAIDs,salicylates: Possibly adverse GI effectsanticoagulants, platelet aggregation inhibitors,thrombolytics: Additive inhibition ofplatelet aggregation; prolonged bleedingtimeantineoplastics, antithymocyte globulin,strontium-89 chloride: Increased risk ofbleedingcidofovir: Possibly nephrotoxicitycyclosporine: Potentiated cyclosporine nephrotoxicitydigoxin: Increased blood digoxin levellithium: Possibly lithium toxicitymethotrexate: Increased or prolonged bloodmethotrexate levelACTIVITIESalcohol use: Increased risk of adverse GIeffectsT

1036tolmetinsient ischemic attack, weaknessCV: Chest pain, deep vein thrombosis,edema, hypertension, MI, peripheral edemaEENT: TinnitusENDO: HypoglycemiaGI: Abdominal pain; constipation; diarrhea;elevated liver function test results; flatulence;gastritis; GI bleeding, perforation, orulceration; hepatitis; indigestion; jaundice;liver failure; nausea; peptic ulcer disease;vomitingGU: Acute renal failure, dysuria, elevatedBUN level, hematuria, interstitial nephritis,nephrotic syndrome, nephrotoxicity, proteinuria,UTIHEME: Agranulocytosis, aplastic anemia,hemolytic anemia, leukopenia, pancytopenia,prolonged bleeding timeSKIN: Erythema multiforme, exfoliativedermatitis, maculopapular rash, Stevens-Johnson syndrome, toxic epidermal necrolysis,urticariaOther: Anaphylaxis, angioedema, weightgain or lossNursing Considerations• Give tolmetin with food or milk to reduceadverse GI reactions.• Assess patient for improvement within7 days and progressive improvement overseveral successive weeks.• Use tolmetin with extreme caution inpatients with a history of ulcer disease orGI bleeding because NSAIDs such as tolmetinincrease the risk of GI bleeding andulceration. Expect to use tolmetin for theshortest time possible in these patients.• Be aware that serious GI tract ulceration,bleeding, and perforation may occur withoutwarning symptoms. Elderly patientsare at greater risk. To minimize risk, givedrug with food. If GI distress occurs, withholddrug and notify prescriber at once.• Use tolmetin cautiously in patients withhypertension, and monitor blood pressureclosely throughout therapy. Drug maycause hypertension or worsen it.WARNING Monitor patient closely forthrombotic events, including MI andstroke, because NSAIDs increase the risk.WARNING If patient has bone marrow suppressionor is receiving antineoplastic drugtherapy, monitor laboratory results(including WBC count), and watch forevidence of infection because anti-inflammatoryand antipyretic actions of tolmetinmay mask signs and symptoms, such asfever and pain.• Especially if patient is elderly or takingtolmetin long-term, watch for less commonbut serious adverse GI reactions,including anorexia, constipation, diverticulitis,dysphagia, esophagitis, gastritis, gastroenteritis,gastroesophageal reflux disease,hemorrhoids, hiatal hernia, melena,stomatitis, and vomiting.• Monitor liver function test results because,rarely, elevated levels may progress tosevere hepatic reactions, including fatalhepatitis, liver necrosis, and hepatic failure.• Monitor BUN and serum creatinine levelsin patients with heart failure, impairedrenal function, or hepatic dysfunction;those taking diuretics or ACE inhibitors;and elderly patients because drug maycause renal failure.• Monitor CBC for decreased hemoglobinand hematocrit because drug may worsenanemia.• Assess patient’s skin routinely for rash orother signs of hypersensitivity reactionbecause tolmetin and other NSAIDs maycause serious skin reactions without warning,even in patients with no history ofNSAID hypersensitivity. Stop drug at firstsign of reaction, and notify prescriber.• Assess invasive sites or wounds for bleedingand bruising from drug’s effects onplatelets.PATIENT TEACHING• Tell patient to take drug with food or milk.• Urge patient to limit sodium intakebecause drug may cause fluid retention.• Tell patient to avoid alcohol during therapy.• Teach patient how to perform proper oralhygiene, and advise her to have neededdental work done before tolmetin therapystarts because of the increased risk ofbleeding.• Explain that tolmetin may increase therisk of serious adverse cardiovascular reactions;urge patient to seek immediatemedical attention if signs or symptomsarise, such as chest pain, shortness ofbreath, weakness, and slurring of speech.• Tell patient that tolmetin also may

increase the risk of serious adverse GIreactions; stress the need to seek immediatemedical attention for such signs andsymptoms as epigastric or abdominalpain, indigestion, black or tarry stools, orvomiting blood or material that looks likecoffee grounds.• Alert patient to the possibility of rare butserious skin reactions. Urge her to seekimmediate medical attention for rash, blisters,itching, fever, or other indications ofhypersensitivity.tolterodine tartrateDetrol, Detrol LAClass and CategoryChemical class: Prodrug of 5-hydroxymethyltolterodineTherapeutic class: AntispasmodicPregnancy category: CIndications and Dosages To treat overactive bladderTABLETSAdults. 2 mg b.i.d. Reduced to 1 mg b.i.d.based on patient response and tolerance.DOSAGE ADJUSTMENT Dosage reduced to1 mg b.i.d. for patients with significanthepatic or renal dysfunction and forpatients who are also receiving cytochromeP-450 3A4 inhibitors, such as clarithromycin,erythromycin, and the antifungalsitraconazole, ketoconazole, andmiconazole.E.R. TABLETSAdults. 4 mg daily. Reduced to 2 mg dailybased on individual response and tolerance.Mechanism of ActionExerts antimuscarinic (atropine-like) andpotent direct antispasmodic (papaverinelike)actions on smooth muscle in the bladder,which decreases detrusor muscle contractions.This helps reduce urinary frequencyand urgency as well as urge-relatedincontinence.ContraindicationsGastric retention, hypersensitivity totolterodine tartrate or its components,uncontrolled angle-closure glaucoma, urineretentionNursing Considerations• Use cautiously in patients with decreasedGI motility, myasthenia gravis, or narrowangleglaucoma because tolterodine couldmake these conditions worse.WARNING Monitor patients with a historyof bladder outflow obstruction fordecreased urine output or bladder distentionbecause tolterodine poses a risk ofurine retention.• Monitor patients with a history of GIobstructive disorders, such as pyloricstenosis, for abdominal distention orbloating because of increased risk of gastricretention.• Be aware that drug’s antimuscarinic effectsmay produce blurred vision, dizziness, anddrowsiness. If these occur, institute fallprecautions according to facility policy.PATIENT TEACHING• Instruct patient taking tolterodine toimmediately report to prescriber difficultyurinating or infrequent urination.• Advise patient not to drive or performactivities that require high alertness untildrug’s CNS and vision effects are known.Instruct her to notify prescriber if dizzitolterodinetartrate 1037InteractionsDRUGSclarithromycin, erythromycin, itraconazole,ketoconazole, miconazole: Possibly increasedblood tolterodine levelclass IA antiarrhythmics (such as quinidine,procainamide) or class III antiarrhythmics(such as amiodarone, sotalol): Possiblyincreased risk of prolonged QT intervalfluoxetine: Possibly decreased tolterodinemetabolismAdverse ReactionsCNS: Confusion, disorientation, dizziness,drowsiness, fatigue, hallucinations,headache, memory impairment, somnolence,worsening of dementiaCV: Chest pain, edema, hypertension, palpitations,QT interval prolongation, tachycardiaEENT: Abnormal vision, blurred vision, dryeyes, dry mouthGI: Abdominal pain, constipation, diarrhea,flatulence, indigestion, nauseaGU: Dysuria, urine retention, UTIOther: Anaphylaxis, angioedema, flulikesymptomsT

1038tolvaptanness or blurred vision persists.• Encourage patient to use sugarless candy,gum, or ice to relieve dry mouth. Adviseher to notify prescriber or dentist if drymouth persists or worsens over 2 weeks.tolvaptanSamscaClass and CategoryChemical class: Non-peptide vasopressinreceptor antagonistTherapeutic class: AntihyponatremicPregnancy category: CIndications and Dosages To treat significant hypervolemic andeuvolemic hyponatremia (serum sodiumlevel less than 125 mEq/L or symptomaticbut less-marked hyponatremiathat has resisted correction with fluidrestriction), including patients withheart failure, cirrhosis, or syndrome ofinappropriate antidiuretic hormone(SIADH)TABLETSAdults. Initial: 15 mg once daily, increasedafter at least 24 hours to 30 mg once daily.Maximum: 60 mg once daily.Mechanism of ActionRaises serum sodium levels by increasingurine output and decreasing urine osmolality.Tolvaptan does this by preventingattachment of vasopressin to vasopressinV2 receptors on cell membranes in thenephron’s collecting duct. Without vasopressinactivity, urinary water exrcetionincreases.ContraindicationsAcute need to raise serum sodium urgently;anuria; concomitant use of strong CYP3Ainhibitors such as clarithromycin, ketoconazole,indinavir, itraconazole, nefazodone,nelfinavir, ritonavir, saquinavir,telithromycin; hypovolemic hypontremia;hypersensitivity to tolvaptan or its components;inability of patient to sense orrespond appropriately to thirstInteractionsDRUGSACE inhibitors, angiotensin receptor blockers,potassium sparing diuretics, potassium supplements:Increased risk of hyperkalemiaCYP3A inducers such as barbiturates, carbamazepine,phenytoin, rifabutin, rifampin,rifapentin, St. John’s wort: Decreased serumtolvaptan level and decreased effectivenessCYP3A inhibitors such as aprepitant, clarithromycin,diltiazem, erythromycin, fluconazole,ketoconazole, indinavir, itraconazole,nefazodone, nelfinavir, ritonavir, saquinavir,telithromycin, verapamil; P-gp inhibitorssuch as cyclosporine: Increased serumtolvaptan level and risk of adverse reactionsdigoxin: Increased digoxin levelFOODSgrapefruit juice: Increased serum tolvaptanlevelAdverse ReactionsCNS: Asthenia, CVA, fever, thirstCV: Deep vein thrombosis, intracardiacthrombus, ventricular fibrillationEENT: Dry mouthENDO: Diabetic ketoacidosis, hyperglycemiaGI: Anorexia, constipation, gastrointestinalbleeding, ischemic colitis, nauseaGU: Nocturia, polyuria, urethral or vaginalhemorrhageHEME: Disseminated intravascular coagulation,prolonged prothrombin timeMS: RhabdomyolysisRESP: Pulmonary embolism, respiratoryfailureOther: Dehydration, hyperkalemia,hyponatremia, hypovolemiaNursing Considerations• Use cautiously in patients with cirrhosisbecause of increased risk of GI bleeding.WARNING Give tolvaptan, initially or if reintroduced,in a hospital setting becausetoo-rapid correction of hyponatremia(more than 12 mEq/L in 24 hour) causesosmotic demyelination (affective changes,coma, dysarthria, dysphagia, lethargy,mutism, spastic quadriparesis, seizures,death). If present, notify prescriber immediatelyand expect to stop tolvaptan andgive hypotonic fluids.• Monitor fluid and electrolyte balance regularly,especially when starting tolvaptanand adjusting dosage, as ordered.• Don’t restrict fluids during first 24 hoursof therapy because doing so may increase

the risk of overly-rapid correct of serumsodium, hypovolemia, and dehydration.• Use of hypertonic saline isn’t recommendedduring tolvaptan therapy becauseeffects are unknown.PATIENT TEACHING• Instruct patient to consume fluids accordingto thirst during first 24 hours of therapyand not to try to limit fluid intake.• When drug is discontinued, tell patientthat he’ll need to resume fluid restrictionand will need continued monitoring ofsodium level and fluid status.topiramateTopamaxClass and CategoryChemical class: Sulfamate-substitutedmonosaccharideTherapeutic class: AnticonvulsantPregnancy category: CIndications and Dosages To treat partial-onset or primarygeneralized tonic-clonic seizuresCAPSULESAdults and children age 10 and over.Initial: 25 mg b.i.d. in morning andevening. Increased by 50 mg daily every wk.Maintenance: 200 mg b.i.d. in morning andevening. As adjunct to treat partial seizures andprimary generalized tonic-clonic seizuresCAPSULES, TABLETSAdults and adolescents age 17 and over.Initial: 25 to 50 mg daily in divided dosesb.i.d. for 1 wk. Increased by 25 to 50 mgdaily every wk. Maintenance: 200 to 400 mgdaily in divided doses b.i.d. Maximum:1,600 mg daily.Children ages 2 to 16. Initial: 25 mg or lessat bedtime for 1 wk. Increased every 1 to2 wk by 1 to 3 mg/kg daily in divided dosesevery 12 hr, as prescribed. Usual: 5 to9 mg/kg daily in divided doses every 12 hr. As adjunct to treat seizures associatedwith Lennox-Gastaut syndromeCAPSULES, TABLETSChildren ages 2 to 16. 25 mg at bedtime for1 wk. Increased every 1 to 2 wk by 1 to3 mg/kg daily in divided doses every 12 hr,topiramate 1039as prescribed. Usual: 5 to 9 mg/kg daily individed doses every 12 hr. To prevent migraine headacheCAPSULES, TABLETSAdults. Initial: 25 mg daily in evening for1 wk; then 25 mg b.i.d. for 1 wk; then25 mg in morning and 50 mg in evening for1 wk. Maintenance: 50 mg b.i.d.DOSAGE ADJUSTMENT For patients withmoderate to severe renal impairment,dosage possibly reduced by 50%.Mechanism of ActionMay block the spread of seizures by reducingthe length and frequency of excitatorytransmission. Topiramate increases theavailability of the inhibitory neurotransmittergamma-aminobutyric acid by blockingvoltage-sensitive sodium channels. Thisaction promotes the movement of chlorideions into neurons.ContraindicationsHypersensitivity to topiramate or its componentsInteractionsDRUGSantihistamines, barbiturates, benzodiazepines,CNS depressants, opioid analgesics,skeletal muscle relaxants, tricyclic antidepressants:Additive CNS depressioncarbamazepine: Decreased blood topiramatelevelcarbonic anhydrase inhibitors: Increased riskof renal calculus formationdigoxin: Possibly decreased blood digoxinlevelethinyl estradiol: Increased risk of breakthroughbleedingoral contraceptives: Increased risk of breakthroughbleeding, decreased contraceptiveefficacyphenobarbital: Altered blood phenobarbitallevelphenytoin: Decreased blood level of topiramateprobenecid: Possibly blocked renal tubularreabsorption of topiramate and decreasedblood topiramate levelvalproic acid: Decreased blood levels ofboth drugs, increased risk of hyperammonemiaACTIVITIESalcohol use: Additive CNS depressionT

1040topiramateAdverse ReactionsCNS: Agitation, anxiety, asthenia, ataxia,confusion, decreased concentration, depression,dizziness, encephalopathy, fatigue,fever, hallucinations, headache, hyperthermia,hypoesthesia, insomnia, irritability,memory loss, mood changes, nervousness,paresthesia, psychomotor slowing, psychosis,slurred speech, somnolence, suicidalideation, syncope, tremorCV: Cardiac arrest, chest pain, hot flashes,hypertension, hypotension, palpitations,vasodilationEENT: Blurred vision, diplopia, dry mouth,gingivitis, hearing loss, maculopathy, nystagmus,periorbital pain, pharyngitis, rhinitis,secondary angle-closure glaucoma withacute myopia, sinusitis, taste perversion,tinnitus, tongue edema, vision changesENDO: Breast pain, hyperglycemiaGI: Abdominal pain, anorexia, constipation,diarrhea, flatulence, gastroenteritis, gastroesophagealreflux, hepatic failure, hepatitis,indigestion, nausea, pancreatitis, vomitingGU: Cystitis, decreased libido, dysmenorrhea,dysuria, frequent urination, impotence,menstrual irregularities, renal calculi,renal tubular acidosis, UTI, vaginitisHEME: Anemia, leukopeniaMS: Arthralgia, back pain, leg cramps orpain, muscle weaknessRESP: Bronchitis, cough, dyspnea, pulmonaryembolism, upper respiratory tractinfectionSKIN: Acne, alopecia, decreased sweating,erythema multiforme, pemphigus, pruritus,rash, Stevens-Johnson syndrome, toxic epidermalnecrolysisOther: Dehydration, hyperammonemia,metabolic acidosis, weight gain or lossNursing Considerations• Obtain baseline serum bicarbonate levelbefore topiramate therapy and monitorperiodically throughout therapy, asordered.• Use topiramate cautiously in patients withinborn errors of metabolism or impairedhepatic function, or who are taking valproicacid because they may be at higherrisk for hyperammonemia with or withoutencephalopathy while taking topiramate.• Give capsule with water and have patientswallow it whole. If needed, open capsulesand empty contents onto a spoonful ofsoft food. Discard unused portion.• Never store food sprinkled with drug foruse at a later time.WARNING Anticipate an increase in seizuresif therapy stops abruptly. Take seizure precautions,as appropriate. Expect drug to bewithdrawn gradually if time permits.• If patient reports ocular pain or decreasedvisual acuity, notify prescriber immediately;topiramate may cause increasedintraocular pressure and secondary angleclosureglaucoma. Expect to stop drugimmediately.• If patient has a history of renal calculi,assess for signs of recurrence.PATIENT TEACHING• Instruct patient to swallow topiramatetablets whole.• Urge patient to avoid potentially hazardousactivities until drug’s CNS effectsare known.• Advise patient to watch for decreasedsweating and significantly increased bodytemperature, especially during hot weather,and to notify prescriber immediately ifthey occur.• Tell patient to maintain adequate fluidintake to minimize the risk of developingkidney stones.• Advise female patient of possible breakthroughbleeding. If she takes an oral contraceptive,encourage her to use anotherform of contraception during therapy.• Caution patient not to stop taking topiramateabruptly because seizures may occur.Instead, patient should expect drug to bewithdrawn gradually if it needs to be discontinued.• Instruct patient to seek immediate emergencycare for blurred vision, other visualdisturbances, or periorbital pain.• Urge caregivers to watch patient closely forevidence of suicidal tendencies, especiallywhen topiramate therapy starts or dosagechanges, and to report concerns at once toprescriber.• Urge woman who becomes pregnant whiletaking topiramate to enroll in the NorthAmerican antiepileptic drug pregnancyregistry by calling 1-888-233-2334.Explain that the registry is collectinginformation about the safety of antiepilepticdrugs during pregnancy.

torsemideDemadexClass and CategoryChemical class: Anilinopyridine sulfonylureaderivativeTherapeutic class: Antihypertensive, diureticPregnancy category: BIndications and Dosages To treat edema in heart failureTABLETS, I.V. INJECTIONAdults. Initial: 10 to 20 mg daily, adjustedby doubling, as prescribed, to achievedesired effect. Maximum: 200 mg daily. To treat edema in chronic renal failureTABLETS, I.V. INJECTIONAdults. Initial: 20 mg daily, adjusted bydoubling, as prescribed, to achieve desiredeffect. Maximum: 200 mg daily. To treat ascites, alone or with amilorideor spironolactoneTABLETS, I.V. INJECTIONAdults. Initial: 5 to 10 mg daily. Maximum:40 mg daily. To manage hypertensionTABLETSAdults. Initial: 5 mg daily, increased to10 mg daily after 4 to 6 wk, as prescribed, ifresponse is inadequate. Maximum: 10 mgdaily.Route Onset Peak DurationP.O. 1 hr 1–2 hr 6–8 hrI.V. 10 min 1 hr 6–8 hrMechanism of ActionBlocks active sodium and chloride reabsorptionin the ascending loop of Henle bypromoting rapid excretion of water, sodium,and chloride. Torsemide also increasesthe production of renal prostaglandins,increasing the plasma renin level and renalvasodilation. As a result, blood pressurefalls, reducing preload and afterload.ContraindicationsHypersensitivity to torsemide, sulfonamides,or their componentsInteractionsDRUGSACE inhibitors, antihypertensives: Additivetorsemide 1041hypotensionamiloride, spironolactone, triamterene:Possibly counteracted torsemide-inducedhypokalemiaamphotericin B: Increased risk of nephrotoxicityand severe, prolonged hypokalemiaor hypomagnesemiacisplatin: Increased risk of significanthypokalemia or hypomagnesemia, possiblypermanent ototoxicitycortisone, fluorocortisone, hydrocortisone:Increased risk of sodium retention andhypokalemiadigoxin: Increased risk of arrhythmias anddigitalis toxicity due to hypokalemia orhypomagnesemiaindomethacin: Possibly decreased diureticand antihypertensive effects of torsemideand increased risk of renal failurelithium: Possibly lithium toxicitymetolazone, thiazide diuretics: Increased riskof severe fluid and electrolyte lossneuromuscular blockers: Possibly increasedneuromuscular blockade due to hypokalemiaprobenecid: Possibly decreased diureticeffect of torsemidequinidine and other ototoxic drugs: Increasedrisk of ototoxicitysalicylates: Increased risk of salicylate toxicityACTIVITIESalcohol use: Additive diuresis and, possibly,dehydrationAdverse ReactionsCNS: Dizziness, drowsiness, fatigue, headache,insomnia, lethargy, nervousness, restlessness,weaknessCV: Chest pain, ECG abnormalities, edema,hypotension, tachycardiaEENT: Dry mouth, hearing loss, ototoxicity,pharyngitis, rhinitis, tinnitusGI: Constipation, diarrhea, indigestion,nausea, thirst, vomitingGU: Azotemia (prerenal), oliguria, urinaryfrequencyMS: Muscle spasms, myalgiaRESP: CoughOther: Hypochloremia, hypokalemia, hypomagnesemia,hyponatremia, hypovolemiaNursing Considerations• Inject I.V. torsemide slowly over 2 minutes.Flush I.V. line with normal salinesolution before and afterward.T

1042tramadol hydrochloride• Don’t exceed 200 mg in a single I.V. doseof torsemide.• Monitor patient’s serum electrolyte levelsand fluid intake and output to detecthypovolemia.WARNING Expect torsemide-induced electrolyteimbalances, such as hypokalemiaand hypomagnesemia, to increase the riskof toxicity and fatal arrhythmias in apatient who takes a digitalis glycoside.Hypokalemia also potentiates the neuromuscularblockade effects of nondepolarizingneuromuscular blockers.PATIENT TEACHING• Advise patient to change position slowly tominimize the effects of orthostatichypotension.• Instruct patient to notify prescriber atonce about drowsiness, dry mouth, hearingchanges, lethargy, muscle pain, nausea,restlessness, thirst, vomiting, or weakness.• Advise diabetic patient to monitor herblood glucose level often because drugmay raise it.tramadolhydrochlorideUltram, Ultram ERClass and CategoryChemical class: CyclohexanolTherapeutic class: AnalgesicPregnancy category: CIndications and Dosages To relieve moderate to moderatelysevere painTABLETSAdults and adolescents over age 16. 50 to100 mg every 4 to 6 hr, p.r.n. Maximum:400 mg daily.DOSAGE ADJUSTMENT If patient has hepaticimpairment, dosage reduced to 50 mg every12 hr. If patient is age 75 or over, maximumdosage reduced to 300 mg daily. If creatinineclearance is 30 ml/min/1.73 m 2 or less,interval increased to every 12 hr and maximumdosage limited to 200 mg daily.E.R. TABLETSAdults. 100 mg once daily, increased in100-mg increments once daily every 5 days,as needed. Maximum: 300 mg once daily.Mechanism of ActionBinds with mu receptors and inhibits thereuptake of norepinephrine and serotonin,which may account for tramadol’s analgesiceffect.Route Onset Peak DurationP.O. 1 hr 2–3 hr 7–14 hrContraindicationsAlcohol intoxication; excessive use of central-actinganalgesics, hypnotics, opioids, orother psychotropic drugs; hypersensitivityto tramadol or its components; use within14 days of MAO inhibitor therapyInteractionsDRUGSalpha blockers, CYP2D6 and CYP3A4inhibitors (amitriptyline, erythromycin, fluoxetine,paroxetine, quinidine), linezolid,lithium, MAO inhibitors, St. John’s wort,selective serotonin and norepinephrine reuptakeinhibitors, tricyclic antidepressants, triptans:Increased risk of serotonin syndromeamiodarone, cimetidine, clomipramine,desipramine, fluphenazine, haloperidol,propa-fenone, quinidine, ritonavir, thioridazine:Decreased analgesia, increasedadverse effects of tramadolamitriptyline, amphetamines, antipsychotics,bupropion, cyclobenzaprine, dextroamphetamine,erythromycin, fluoxetine, ketoconazole,paroxetine, quinidine, MAO inhibitors,naloxone, tricyclic antidepressants: Increasedrisk of seizuresbarbiturates, benzodiazepines, opioid analgesics,sedative-hypnotics, tranquilizers:Additive CNS depressioncarbamazepine: Increased tramadol metabolismgeneral anesthetics: Increased CNS and respiratorydepressionphenothiazines, rifampin: Additive CNSdepression, increased risk of seizureswarfarin: Possibly increased INRACTIVITIESalcohol use: Additive CNS depressionAdverse ReactionsCNS: Agitation, anxiety, asthenia, depression,dizziness, emotional lability, euphoria,fatigue, fever, hallucinations, headache,hypertonia, hypoesthesia, insomnia, lethargy,nervousness, paresthesia, restlessness,

igors, seizures, serotonin syndrome, somnolence,suicidal ideation, tremor, vertigo,weaknessCV: Chest pain, orthostatic hypotension,vasodilationEENT: Blurred vision, dry mouth, nasal orsinus congestion, sore throat, vision changesENDO: Hot flashesGI: Abdominal pain, anorexia, constipation,diarrhea, indigestion, nausea, vomitingGU: Urinary frequency, urine retentionMS: Arthralgia; back, limb, or neck painRESP: Cough, dyspneaSKIN: Diaphoresis, dermatitis, flushing,pruritus, rashOther: Flulike illness, physical and psychologicaldependenceNursing Considerations• Be aware that tramadol shouldn’t be givento patients with a history of anaphylactoidreactions to codeine or other opioids.WARNING Monitor patient closely for evidenceof serotonin syndrome, such as agitation,hallucinations, coma, tachycardia,labile blood pressure, hyperthermia,hyperreflexia, incoordination, nausea,vomiting, or diarrhea. Notify prescriber atonce because serotonin syndrome may belife-threatening. Be prepared to discontinuedrug and provide supportive care.• Because tramadol may lead to physicaland psychological dependence, assesspatient for evidence of dependence orabuse. Avoid giving drug to patients with ahistory of dependence on other opioids.• Avoid giving tramadol to patients withacute abdominal conditions because itmay mask evidence and disrupt assessmentof the abdomen.• After patient receives first tramadol dose,watch for allergic reactions, includingangioedema, bronchospasm, pruritus,Stevens-Johnson syndrome, toxic epidermalnecrolysis, and urticaria. Also watchfor signs and symptoms of anaphylaxis,such as dyspnea and hypotension.• If patient has respiratory depression, assessrespiratory status often, and expect to givea nonopioid analgesic—not tramadol.• If patient develops respiratory depression,expect to give naloxone. Watch for seizuresbecause naloxone may increase this risk.Take seizure precautions.• Assess respiratory status often if patienthas increased intracranial pressure or headinjury because of possible increased carbondioxide retention and CSF pressure,either of which may cause respiratorydepression. Also, be aware that tramadolmay constrict pupils, obscuring evidenceof intracranial complications.WARNING Watch for seizures in patientswith epilepsy, a history of seizures, or anincreased risk of seizures, such as thosewith head injury, metabolic disorders,alcohol or drug withdrawal, or CNS infection.• Expect to taper tramadol rather than stoppingit abruptly to avoid such acute withdrawalsymptoms as anxiety, diarrhea,insomnia, nausea, pain, panic attacks,paresthesias, piloerection, rigors, sweating,tremor, and upper respiratory symptoms.• Monitor patient closely for evidence ofsuicidal thinking or behavior, especiallywhen therapy starts or dosage changes.PATIENT TEACHING• Urge patient to follow prescribed doselimits and dosing intervals to prevent respiratorydepression and seizures.• Instruct patient prescribed extendedreleaseform to swallow tablet whole andnot to chew, crush, or split tablet.• Caution patient not to stop tramadolabruptly.• Instruct patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to avoid alcohol while takingtramadol.• Urge patient to notify prescriber aboutknown, suspected, or intended pregnancy.• Urge caregivers to watch patient closely forevidence of suicidal tendencies, especiallywhen therapy starts or dosage changes andto report concerns at once to prescriber.• Tell patient to notify prescriber immediatelyif he develops any sudden onset,unusual, persistent, or severe adverse reactions.trandolaprilMaviktrandolapril 1043Class and CategoryChemical class: ACE inhibitor (nonsulfhydryl-containing)T

1044trandolaprilTherapeutic class: Antihypertensive,vasodilatorPregnancy category: C (first trimester), D(later trimesters)Indications and Dosages To manage hypertensionTABLETSAdults. Initial: 1 mg daily, increased everywk based on clinical response. Dosage maybe given in two daily doses if antihypertensiveeffect diminishes before 24 hr. Usual:2 to 4 mg daily. Maximum: 8 mg daily.DOSAGE ADJUSTMENT Initial dosageincreased to 2 mg daily for blacks withhypertension. Initial dosage reduced to0.5 mg for patients also receiving a diuretic,those with a creatinine clearance of lessthan or equal to 30 ml/min/1.73 m 2 , andthose with cirrhosis. To treat heart failure after MITABLETSAdults. Initial: 1 mg daily. Usual: 4 mg ormore daily. Maximum: 8 mg daily.Route Onset Peak DurationP.O. 2 hr 8 hr 24 hrMechanism of ActionReduces blood pressure by inhibiting theconversion of angiotensin I to angiotensinII. Angiotensin II is a potent vasoconstrictorthat stimulates the renal cortex tosecrete aldosterone. Decreased release ofaldosterone reduces sodium and waterretention and increases their excretion,thereby reducing blood pressure.Trandolapril may also inhibit renal and vascularproduction of angiotensin II.ContraindicationsHistory of angioedema related to previoustreatment with ACE inhibitor, hypersensitivityto trandolapril or its componentsInteractionsDRUGSallopurinol, bone marrow depressants (suchas methotrexate), corticosteroids (systemic),cytostatic drugs, procainamide: Increasedrisk of potentially fatal neutropenia oragranulocytosisantacids: Decreased blood trandolapril levelcyclosporine, potassium-containing drugs,potassium-sparing diuretics, potassium supplements:Increased risk of hyperkalemiadiuretics, other antihypertensives: Increasedhypotensive effectslithium: Increased blood lithium level andrisk of lithium toxicityNSAIDs, sympathomimetics: Possiblyreduced antihypertensive effectssodium aurothiomalate: Increased risk ofnitroid reactions such as facial flushing,nausea, vomiting, and hypotensionFOODShigh-potassium diet, low-sodium milk, potassium-containingsalt substitutes: Increasedrisk of hyperkalemiaACTIVITIESalcohol use: Possibly increased hypotensiveeffectAdverse ReactionsCNS: Dizziness, fatigue, fever, headacheCV: Hypotension, orthostatic hypotensionEENT: Loss of tasteGI: Diarrhea, nauseaGU: Decreased libido, impotenceMS: MyalgiaRESP: Cough, dyspnea, upper respiratorytract infectionSKIN: Pruritus, rashOther: AngioedemaNursing ConsiderationsWARNING Closely monitor blood pressureduring first 2 weeks of therapy and wheneverdosage is adjusted, especially inpatients with heart failure, hyponatremia,or severe volume or sodium loss. If excessivehypotension occurs, notify prescriberimmediately, place patient in supine position,and infuse I.V. normal saline solution,as prescribed.WARNING Be alert for signs and symptomsof angioedema. If swelling of tongue, glottis,or larynx causes airway obstruction,notify prescriber and be prepared to discontinuedrug and administer emergencymeasures, including subcutaneous epinephrine1:1,000 (0.3 to 0.5 ml).• Continue to monitor patient’s blood pressureto assess drug’s long-term effectiveness.PATIENT TEACHING• Instruct patient to notify prescriber immediatelyand stop taking trandolapril if sheexperiences swelling of face, eyes, lips, ortongue or has difficulty breathing.

• Explain that drug may cause dizziness andlight-headedness, especially during firstfew days of therapy. Advise patient toavoid driving and other potentially hazardousactivities until drug’s CNS effectsare known and to notify prescriber immediatelyif she faints.• Inform female patient of childbearing ageabout risks of taking trandolapril duringpregnancy, especially during second andthird trimesters. Urge her to use effectivecontraceptive method and to notify prescriberimmediately if she becomes orthinks she might be pregnant.• Advise patient planning to undergo surgeryor anesthesia to inform specialist thatshe’s taking trandolapril.• Instruct patient to consult prescriberbefore using potassium supplements orsalt substitutes containing potassium.• Inform patient about possible loss of taste,which may result in weight loss. Reassureher that loss of taste is usually reversedafter 2 to 3 months.tranexamic acidLystedaClass and CategoryChemical class: Synthetic lysine amino acidderivativeTherapeutic class: AntifibrinolyticPregnancy category: BIndications and Dosages To treat cyclic heavy menstrualbleedingTABLETSAdults. 1,300 mg three times daily for amaximum of 5 days during monthly menstruationDOSAGE ADJUSTMENT For patient with aserum creatinine level above 1.4 mg/dl butequal to or less than 2.8 mg/dl, 1,300 mgtwo times a day for a maximum of 5 daysduring menstruation; for patient with aserum creatinine level above 2.8 mg/dl butequal to or less than 5.7 mg/dl, 1,300 mgonce daily for a maximum of 5 days duringmenstruation; for patient with a serum creatininelevel above 5.7 mg/dl, 650 mg oncedaily for a maximum of 5 days during menstruation.tranexamic acid 1045Mechanism of ActionDisplaces plasminogen from surface of fibrinby binding to high-affinity lysine site ofplasminogen. This diminishes dissolutionof hemostatic fibrin, which decreases bleeding.Route Onset Peak DurationP.O. Unknown 3 hr UnknownContraindicationsActive thromboembolic disease; history orintrinsic risk of thrombosis or thromboembolism,including retinal vein or arteryocclusion; hypersensitivity to tranexamicacid or its componentsInteractionsDRUGSanti-inhibitor coagulant concentrates, factorIX complex concentrates, hormonal contraceptives:Increased thrombotic risktissue plasminogen activators: Possiblydecreased effectiveness of both tranexamicacid and the tissue plasminogen activatortretinoin (oral): Possibly exacerbation of thepro-coagulant effect of tretinoinAdverse ReactionsCNS: Cerebral thrombosis, dizziness,fatigue, headache, migraineCV: Deep vein thrombosisEENT: Central retinal artery and veinobstruction, feeling of throat tightness,impaired color vision, ligneous conjunctivitis,nasal and sinus congestion, sinusitis,visual abnormalitiesGI: Abdominal pain, diarrhea, nausea,vomitingGU: Acute renal cortical necrosisHEME: AnemiaMS: Arthralgia, back pain, muscle crampsand spasms, myalgiaRESP: Dyspnea, pulmonary embolism, respiratorycongestion,SKIN: Allergic skin reactions, facial flushingOther: Anaphylaxis, multiple allergiesincluding seasonalNursing Considerations• Tranexamic acid therapy isn’t recommendedfor women who use hormonalcontraceptives or who take factor IX complexconcentrates or anti-inhibitor coagulantconcentrates because of the increasedT

1046tranylcypromine sulfaterisk of thromboembolism.• Use tranexamic acid cautiously in patientswith acute promyelocytic leukemia takingoral tretinoin for remission inductionbecause of possible exacerbation of thepro-coagulant effect of tretinoin.• Cerebral edema and cerebral infarctionmay occur in women taking tranexamicacid if a subarachnoid hemorrhage occurs.WARNING Monitor patient closely for allergicreactions to tranexamic acid such asdyspnea, a feeling of throat tightness, andfacial flushing that may require emergencymedical treatment.PATIENT TEACHING• Instruct patient to swallow tranexamicacid tablets whole, without chewing orbreaking them. Therapy shouldn’t exceed5 days during menstruation.• Tell patient to seek emergency care immediatelyif she has any signs of allergic reaction,especially dyspnea, a feeling of throattightness, and facial flushing, and to stoptaking drug.• Advise patient to report any changes invision or ocular discomfort.tranylcyprominesulfateParnateClass and CategoryChemical class: Nonhydrazine derivativeTherapeutic class: AntidepressantPregnancy category: Not ratedIndications and Dosages To treat major depressive episodes withoutmelancholiaTABLETSAdults and adolescents over age 16. 30 mg/day in divided doses. After first 2 wk,increased by 10 mg every 1 to 2 wk, as prescribed.Maintenance: 10 to 40 mg daily.Maximum: 60 mg daily.DOSAGE ADJUSTMENT For elderly patients,initial dosage possibly reduced to 2.5 to5 mg daily and increased by 2.5 to 5 mgevery 3 to 4 days, as prescribed; maximumdosage 45 mg daily. Alternative therapiesshould be carefully considered for patientsover age 60.Mechanism of ActionReversibly binds to MAO, reducing itsactivity and resulting in increased levels ofneurotransmitters, including dopamine,epinephrine, and norepinephrine. This regulationof CNS neurotransmitters helpsease depression.Route Onset Peak DurationP.O. 7–10 days 4–8 wk 10 daysContraindicationsCardiovascular disease; cerebrovascular disease;heart failure; hepatic disease; historyof headaches; hypersensitivity totranylcypromine or its components; hypertension;pheochromocytoma; severe renalimpairment; use of anesthetics, antihypertensives,bupropion, buspirone, carbamazepine,CNS depressants, cyclobenzaprine,dextromethorphan, meperidine,other MAO inhibitors, selective serotoninreuptakeinhibitors, sympathomimetics, ortricyclic antidepressantsInteractionsDRUGSamoxapine, bupropion, maprotiline, selectivenorepinephrine reuptake inhibitors, selectiveserotonin reuptake inhibitors, trazodone, tricyclicantidepressants: Increased risk ofsevere hypertensive crisis, increasedanticholinergic effectsanticonvulsants: Additive CNS depressionantihistamines: Possibly prolonged anticholinergicand CNS depressant effectsantipsychotics: Additive anticholinergic,hypotensive, and sedative effectsbeta blockers: Possibly worsened bradycardiabromocriptine: Increased blood prolactinlevel and interference with bromocriptineeffectsbuspirone: Increased blood pressuredextroamphetamine, isometheptene, localanesthetics, naphazoline, oxymetazoline, psychostimulants,sympathomimetics, tetrahydrozoline,xylometazoline: Increased risk ofsevere hypertensive reactiondextromethorphan, tryptophan: Increasedrisk of serotonin syndromediuretics: Additive hypotensive effectsdoxapram: Increased vasopressor effectsfurazolidone, procarbazine, selegiline:Increased risk of severe hyperpyretic or

hypertensive crisis, seizures, or deathguanadrel, guanethidine: Increased risk ofmoderate to severe hypertensioninsulin, oral antidiabetic drugs: Possibly prolongedhypoglycemic responselevodopa: Increased vasopressor effects,hypertension, adverse cardiovascular effectsmeperidine: Increased risk of coma,diaphoresis, excitation, hypertension, rigidity,severe respiratory depression, shock,and, possibly, deathmethyldopa: Increased risk of hallucinationsmetrizamide, tramadol: Increased risk ofseizuressuccinylcholine: Possibly prolonged succinylcholineeffectsFOODSaged cheese; avocadoes; bananas; fava orbroad beans; cured sausage (bologna, pepperoni,salami, and summer sausage) or othermeat; overripe fruit; pickled fish, meats, orpoultry; protein extract; smoked fish, meats,or poultry; soy sauce; yeast extract; and otherfoods high in pressor amines, such as tyramine:Increased risk of sudden, severehypertensioncaffeine-containing beverages and foods:Increased risk of severe hypertensive crisisand dangerous arrhythmiasACTIVITIESalcohol-containing products that also maycontain tyramine, such as beer (includingreduced-alcohol and alcohol-free beer), wine(red and white), sherry, hard liquor, liqueurs:Increased risk of hypertensive crisisAdverse ReactionsCNS: Anxiety, chills, dizziness, drowsiness,fever, headache, insomnia, intracranialhemorrhage, paresthesia, restlessness, suicidalideation, tremor, weaknessCV: Bradycardia, chest pain, edema, hypertensivecrisis, orthostatic hypotension, palpitations,tachycardiaEENT: Blurred vision, dry mouth, mydriasis,photophobia, tinnitusGI: Abdominal pain, anorexia, constipation,diarrhea, nausea, vomitingGU: Ejaculation disorders, impotence, urineretentionHEME: Agranulocytosis, anemia, leukopenia,thrombocytopeniaMS: Muscle spasms, myoclonus, neck stiffnessSKIN: Clammy skin, diaphoresistranylcypromine sulfate 1047Nursing Considerations• Monitor patient’s blood pressure duringtranylcypromine therapy to detect hypertensivecrisis and to decrease the risk oforthostatic hypotension.WARNING Notify prescriber immediately ifpatient has evidence of hypertensive crisis,such as chest pain, headache, neck stiffness,and palpitations. Expect to stop drugright away.• Anticipate that therapeutic response maynot occur for up to 4 weeks.• Expect drug to aggravate symptoms ofParkinson’s disease, including musclespasms, myoclonic movement, and tremor.• Keep dietary restrictions in place for atleast 2 weeks after stopping tranylcyprominebecause of the slow recoveryfrom drug’s enzyme-inhibiting effects.• Expect to stop tranylcypromine 10 daysbefore elective surgery, as prescribed, toavoid hypotension.• Be aware that abrupt cessation of drug canprecipitate original symptoms.• Check diabetic patient’s blood glucoselevel often to detect loss of control.• Anticipate that coadministration with aselective serotonin reuptake inhibitor maycause confusion, seizures, severe hypertension,and other, less severe symptoms.• Monitor severely depressed patients,including children and teens, for suicidaltendencies. Take safety measures, and notifyprescriber immediately.• Assess patient for sudden insomnia. If itdevelops, notify prescriber and be preparedto administer drug early in the day.PATIENT TEACHING• Instruct patient to avoid foods that containcheese and that are high in tyramine,such as anchovies, avocadoes, bananas,beer, canned figs, caviar, Chianti wine,chocolate, dried fruit, fava beans, liqueurs,meat tenderizers, overripe fruit, pickledherring, raspberries, sauerkraut, sherry,sour cream, soy sauce, yeast extract, andyogurt while taking tranylcypromine.• Urge patient to continue dietary restrictionsfor at least 2 weeks after tranylcyprominetherapy stops.• Advise patient to notify prescriber at onceabout chest pain, dizziness, headache, nausea,neck stiffness, palpitations, rapid heartrate, sweating, and vomiting.T

1048trazodone hydrochloride• Urge patient to avoid alcohol and excessivecaffeine intake during therapy.• Urge patient to change position slowly tominimize orthostatic hypotension.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Caution patient not to take any other prescribedor OTC drugs without consultingprescriber.• Caution patient not to stop drug abruptlyto avoid recurrence of original symptoms.• Instruct female patient to use effectivecontraception during tranylcyprominetherapy to prevent fetal abnormalities.Urge her to notify prescriber immediatelyabout known or suspected pregnancy.WARNING Urge parents to watch their childor adolescent closely for abnormal thinkingor behavior or increased aggression orhostility. Stress importance of notifyingprescriber about unusual changes.trazodonehydrochlorideTrazon, TrialodineClass and CategoryChemical class: Triazolopyridine derivativeTherapeutic class: Antidepressant, anxiolyticPregnancy category: CIndications and Dosages To treat major depression, with orwithout generalized anxietyTABLETSAdults. Initial: 150 mg daily in divideddoses, increased by 50 mg daily every 3 to4 days, p.r.n., as prescribed. Maximum:400 mg daily for outpatients, 600 mg dailyfor inpatients.Children ages 6 to 18. Initial: 1.5 to 2 mg/kg daily in divided doses, increased every3 to 4 days, p.r.n., as prescribed. Maximum:6 mg/kg daily in divided doses.Mechanism of ActionBlocks serotonin reuptake along the presynapticneuronal membrane, causing anantidepressant effect. Trazodone exerts analpha-adrenergic blocking action and producesmodest histamine blockade, causing asedative effect. It also inhibits the vasopressorresponse to norepinephrine, whichreduces blood pressure.Route Onset Peak DurationP.O. 1–2 wk Unknown UnknownContraindicationsHypersensitivity to trazodone or its components,recovery from acute MIInteractionsDRUGSanticonvulsants: Decreased seizure thresholdantihypertensives: Increased risk of excessivehypotensionanxiolytics, brompheniramine, carbinoxamine,chlorpheniramine, clemastine, dimenhydrinate,diphenhydramine, doxylamine,general anesthetics, methdilazine, opioidanalgesics, phenothiazines, sedative-hypnotics,skeletal muscle relaxants: IncreasedCNS depression, increased risk of respiratorydepression and hypotensionbarbiturates: Decreased seizure thresholdand barbiturate effects, increased drowsinessbuspirone, selective serotonin-reuptakeinhibitors, tricyclic antidepressants: Possiblyexcessive serotonergic stimulationcarbamazepine: Decreased trazodone levelclonidine: Interference with clonidine’s antihypertensiveeffectdigoxin: Possibly increased blood digoxinlevel and risk of digitalis toxicityerythromycin, indinavir, itraconazole, ketoconazole,nefazodone, protease inhibitors,ritonavir: Possibly increased blood trazodonelevel with increased risk of adverseeffectsMAO inhibitors: Increased serotonin effectswarfarin: Decreased anticoagulationresponseACTIVITIESalcohol use: Increased CNS depression, riskof respiratory depression and hypotensionAdverse ReactionsCNS: Dizziness, drowsiness, fatigue, headache,light-headedness, nervousness, suicidalideation, syncope, tremorCV: Arrhythmias, hypotension, orthostatichypotension, palpitationsEENT: Blurred vision, dry mouthGI: Constipation, indigestion, nausea, vomiting

GU: Anorgasmia, ejaculation disorders,increased libido, priapismSKIN: Pruritus, rashNursing Considerations• Give trazodone shortly after the patienthas a meal or light snack to reduce nausea.• Give larger portion of daily dose at bedtimeif drowsiness occurs.• Because trazadone’s mechanism of actionis similar to that of selective serotoninreuptake inhibitors, expect high doses(6 to 8 mg/kg) to increase blood serotoninlevel and low doses (0.05 to 1 mg/kg) todecrease blood serotonin level.• Expect most patients who respond to trazodoneto do so by the end of the secondweek of therapy.• Closely monitor depressed patients,including children and teens, for suicidalthoughts and tendencies. Notify prescriberif they occur, and take suicide precautionsaccording to facility policy.• Be aware that adverse CNS reactions usuallyimprove after patient completes a fewweeks of therapy.WARNING Be aware that trazodone therapymay increase the risk of priapism.PATIENT TEACHING• Urge patient to avoid taking trazodone onan empty stomach because doing so mayincrease the risk of dizziness or lightheadedness.• Caution patient to avoid potentially hazardousactivities during therapy.• Advise patient not to fast during trazodonetherapy because of possibleadverse CNS reactions.• Instruct male patient to notify prescriberimmediately about priapism.WARNING Urge parents to watch their childor adolescent closely for abnormal thinkingor behavior or increased aggression orhostility. Stress importance of notifyingprescriber about unusual changes.treprostinil sodiumRemodulin, TyvasoClass and CategoryChemical class: Prostaglandin, tricyclic benzideneanalogTherapeutic class: VasodilatorPregnancy category: Btreprostinil sodium 1049Indications and Dosages To treat pulmonary artery hypertensionin patients who have New York HeartAssociation Class II to IV symptoms inorder to diminish exercise-inducedsymptomsI.V. INFUSION, SUBCUTANEOUS INFUSION(REMODULIN)Adults. Initial: 1.25 nanograms/kg/min.Maintenance: Infusion rate increased inincrements of no more than 1.25 nanograms/kg/mineach wk for first 4 wk, and inincrements of no more than 2.5 nanograms/kg/min each wk thereafter, as needed.Maximum: 40 nanograms/kg/min.DOSAGE ADJUSTMENT If initial dosage isn’ttolerated or if patient has mild to moderatehepatic insufficiency, decrease to0.625 nanogram/kg/min (using ideal bodyweight).ORAL INHALATION (TYVASO)Adults. Initial: 18 mcg (3 breaths) fourtimes daily, evenly spaced at 4 hr apartwhile awake. Increased in 1 to 2 wk to36 mcg (6 breaths) four times daily, evenlyspaced at 4 hr apart while awake. Thenincreased in another 1 to 2 wk to 54 mcg(9 breaths) four times daily evenly spaced4 hr apart while awake, as tolerated.Maintenance: 54 mcg (9 breaths) four timesdaily, evenly spaced at 4 hr apart whileawake. Maximum: 54 mcg (9 breaths) fourtimes daily, evenly spaced at 4 hr apartwhile awake.DOSAGE ADJUSTMENT For patient unable totolerate initial dose, dosage decreased to6 mcg (1 breath) or 12 mcg (2 breaths) fourtimes daily, evenly spaced at 4 hours apartwhile awake, and then increased to 18 mcg(3 breaths) four times daily, evenly spacedat 4 hr apart while awake when tolerated.Then increased gradually every 1 to 2 wk toachieve target range of 54 mcg or highesttolerated dose.Mechanism of ActionActs directly on pulmonary and systemicarterial vascular beds to produce vasodilation.Vasodilatory effects reduce right andleft ventricular afterload and increase cardiacoutput and stroke volume. Theseeffects improve symptoms of pulmonaryT

1050treprostinil sodiumhypertension, such as dyspnea, and enablepatients with pulmonary hypertension towalk farther with less discomfort.ContraindicationsHypersensitivity to treprostinil, its components,or structurally related compoundsInteractionsDRUGSanticoagulants: Increased risk of bleedingantihypertensives, diuretics, other vasodilators:Increased risk of hypotensioncytochrome P-450 inhibitors such as gemfibrozil:Increased plasma trepostinil leveland increased risk of adverse effectscytochrome P-450 inducers such as rifampin:Decreased plasma trepostinil level anddecreased effectivenessAdverse ReactionsCNS: Anxiety, dizziness, fatigue, headache,restlessnessCV: Chest pain, edema, hypotension, rightventricular heart failure, vasodilatationEENT: Epistaxis, jaw pain, pharyngolaryngealpain (inhalation form), throat irritation(inhalation form)GI: Diarrhea, nausea, vomitingHEME: Bleeding, thrombocytopeniaRESP: Cough (inhalation form), dyspnea,hemoptysis (inhalation form), wheezing(inhalation form)MS: Bone or jaw painSKIN: Cellulitis, pallor, pruritus, rashOther: Infusion site pain or reaction (erythema,hematoma, induration, pain, paresthesia,rash, swelling, thrombophlebitis)Nursing Considerations• Use treprostinil cautiously in patients withhepatic or renal impairment becuase ofincreased risk of adverse effects.• Assess patient’s ability to care for an I.V. orsubcutaneous catheter and to use an infusionpump. Discuss findings with prescriberbefore starting treprostinil therapy.• Be aware that drug shouldn’t be dilutedwhen given subcutaneously.• When drug will be given I.V., dilute withsterile water for injection or normal salinesolution according to instructions provided.Watch for blood-borne infections andsepsis in patients receiving drug throughan indwelling central venous catheter,which increases the risk.• Calculate infusion rate using the formulaprovided in the package insert, or refer tocharts in package insert to find infusiondelivery rate for prescribed dosage andadministration route.WARNING Don’t abruptly stop treprostinilinfusion or make sudden large reductionsin dose because symptoms of pulmonaryhypertension may worsen.• When giving drug by inhalation, use onlythe Tyvaso inhalation system.• Assess patient often for drug effectivenessand for adverse reactions. Know that thegoal of dosage adjustments is to find adose that will improve symptoms of pulmonaryhypertension, such as dyspneaand fatigue, while minimizing adverseeffects, such as headache, nausea, vomiting,restlessness, anxiety, and infusion sitepain or reaction.• Monitor patient’s platelet count and assesspatient often for bleeding because drugmay increase risk of bleeding episodes.• Be aware that patient must be dischargedwith a backup infusion pump. It should beadjustable to about 0.002 ml/hr and havealarms that indicate occlusion/no delivery,low battery, programming error, andmotor malfunction. Also, the pumpshould have a delivery accuracy of 66% orbetter, be positive-pressure driven, andhave a reservoir made of polyvinyl chloride,polypropylene, or glass. Make surepatient has additional I.V. or subcutaneousinfusion sets to prevent potential interruptionsin drug delivery. Likewise, patientprescribed drug via inhalation must bedischarged with a backup inhalation system.PATIENT TEACHING• Explain to patient that treprostinil isinfused continuously through an I.V. orsubcutaneous catheter via an infusionpump.• Teach patient to operate and maintain theI.V. or subcutaneous infusion pump andto recognize the drug’s adverse effects.• To reduce the risk of infection, cautionpatient to always use aseptic techniquewhen preparing and giving drug.• Tell patient that a vial of drug shouldn’t beused beyond 14 days after opening (forI.V. or subcutaneous use) and that oncethe drug is placed in the pump’s reservoir,

it shouldn’t be used after 72 hours.• Instruct patient to store treprostinil vialsat room temperature (about 25° C [77° F]).• Teach patient prescribed inhalation formof drug how to use the inhalation systemand how to clean it after last treatment ofthe day. Advise patient always to have abackup device in case of malfunction.Make sure patient understands that noother drug should be mixed with treprostinilin medication cup before administration.Explain that each ampule containsenough drug for all 4 treatments for a day.Tell him to twist off the top of ampulebefore first treatment of the day andsqueeze entire contents into medicationcup. Dose is controlled by how manybreaths he takes. In between treatments,inhalation device should be capped andstored in an upright position.• Caution patient to avoid skin or eye contactwith treprostinil solution. If it occurs,instruct patient to flush area immediatelywith water.• Inform patient that drug will be neededfor prolonged periods, possibly years.Stress the importance of not stoppingdrug abruptly or making sudden largereductions in dosage without consultingprescriber because symptoms could worsen.• Make sure patient understands that treprostiniluse doesn’t preclude the subsequentuse of an alternative I.V. prostacyclintherapy such as epoprostenol.• Make sure patient has emergency contactinformation for problems or questionsabout giving treprostinil at home.triamcinoloneAristocort, Aristopak, Atolone,Kenacort, Nasacort AQtriamcinoloneacetonideAllerNaze, Azmacort, Cenocort A-40,Cinonide-40, Kenaject-40, Kenalog-10,Kenalog-40, Ken-Jec-40, Nasacort,Nasacort HFA, Robalog, Tac-3,Triam-A, Triamonide, Tri-Kort, Trilogtriamcinolone 1051triamcinolonediacetateAcetocot, Amcort, Aristocort,Aristocort Forte, Articulose-LA,Cenocort Forte, Cinalone 40,Clinacort, Kenacort Diacetate, Tilone,Tramacort-D, Triam-Forte,Triamolone 40, TristojecttriamcinolonehexacetonideAristospanClass and CategoryChemical class: Synthetic glucocorticoidTherapeutic class: Anti-inflammatory,immunosuppressantPregnancy category: C (nasal and oralinhalation), Not rated (oral and parenteral)Indications and Dosages To prevent bronchospasm or providelong-term corticosteroid treatment tocontrol asthmaORAL INHALATION (TRIAMCINOLONE ACETONIDE)Adults and children age 12 and over.Initial: 2 metered sprays (200 mcg) t.i.d. orq.i.d. Maintenance: Individualized dosagegiven b.i.d. Maximum: 16 metered spraysdaily in divided doses.Children ages 6 to 11. 2 to 4 metered sprays(200 to 400 mcg) b.i.d. to q.i.d. Maximum:12 metered sprays daily. To treat acute rheumatic carditis, berylliosis,and Hodgkin’s disease; as adjunctto treat fulminating or disseminatedpulmonary tuberculosis (with appropriateantituberculosis therapy)SYRUP (TRIAMCINOLONE DIACETATE), TABLETS(TRIAMCINOLONE)Adults and children age 12 and over.Initial: 4 to 48 mg daily as a single dose orin divided doses. Some patients may requirean initial dose of 60 mg.Children under age 12. 0.42 to 1.7 mg/kgdaily as a single dose or in divided doses.I.M. INJECTION (TRIAMCINOLONE ACETONIDE)Adults and children age 12 and over. 40 to80 mg every 4 wk, as needed.Children ages 6 to 11. 40 mg every 4 wk, asneeded, or 30 to 200 mcg/kg every 1 to 7 days.T

1052triamcinoloneI.M. INJECTION (TRIAMCINOLONE DIACETATE)Adults and children age 12 and over. 40 mgevery wk, or 4 to 7 times the daily P.O. doseas a single injection every 4 days to every4wk.Children ages 6 to 11. 40 mg/wk. To relieve inflammation caused by acutegouty arthritis, acute nonspecific tenosynovitis,acute or subacute bursitis, epicondylitis,osteoarthritis, posttraumaticosteoarthritis, rheumatoid arthritis, andsynovitisSYRUP (TRIAMCINOLONE DIACETATE)Adults and children age 12 and over. 4 to48 mg daily as a single dose or in divideddoses, adjusted, as prescribed, to lowesteffective dose based on clinical response.TABLETS (TRIAMCINOLONE)Adults and children age 12 and over. 8 to16 mg daily in divided doses t.i.d. or q.i.d.,adjusted, as prescribed, to lowest effectivedose based on clinical response.SYRUP (TRIAMCINOLONE DIACETATE), TABLETS(TRIAMCINOLONE)Children ages 6 to 11. 0.42 to 1.7 mg/kgdaily as a single dose or in divided doses,adjusted based on clinical response.I.M. INJECTION (TRIAMCINOLONE ACETONIDE)Adults and children age 12 and over. 40 to80 mg every 4 wk.Children ages 6 to 11. 40 mg every 4 wk.I.M. INJECTION (TRIAMCINOLONE DIACETATE)Adults and children age 6 and over. 40 mgevery wk as single injection, repeated every4 wk if needed.INTRA-ARTICULAR OR INTRABURSAL INJECTION(TRIAMCINOLONE ACETONIDE)Adults and children age 6 and over. 2.5 to15 mg, as needed.INTRA-ARTICULAR OR INTRASYNOVIAL INJECTION(TRIAMCINOLONE DIACETATE)Adults. 5 to 40 mg, repeated as prescribedevery 1 to 8 wk, as needed.INTRA-ARTICULAR INJECTION (TRIAMCINOLONEHEXACETONIDE)Adults. 2 to 20 mg, repeated as prescribedevery 3 to 4 wk, as needed. To treat primary (Addison’s disease) orsecondary adrenocortical insufficiencySYRUP (TRIAMCINOLONE DIACETATE)Adults and children age 12 and over. 4 to12 mg daily as a single dose or in divideddoses.SYRUP (TRIAMCINOLONE DIACETATE), TABLETS(TRIAMCINOLONE)Children ages 6 to 11. 0.12 mg (base)/kgdaily as a single dose or in divided doses. To treat inflammatory dermatosesTABLETS (TRIAMCINOLONE)Adults and children age 12 and over. 8 to16 mg daily. Usual: 1 to 2 mg daily. To treat disseminated lupuserythematosusTABLETS (TRIAMCINOLONE)Adults and children age 12 and over. 20 to30 mg daily. Usual: 3 to 30 mg daily. To treat nephrotic syndromeTABLETS (TRIAMCINOLONE)Adults and children age 12 and over. 16 to20 mg daily. To relieve symptoms of perennial andseasonal allergic rhinitisTABLETS (TRIAMCINOLONE)Adults and children age 12 and over. 8 to12 mg daily. Usual: 2 to 6 mg daily.Children ages 6 to 11. 0.42 to 1.7 mg/kgdaily as a single dose or in divided doses.NASAL INHALATION (NASACORT)Adults and children age 12 and over.Initial: 220 mcg daily in 2 sprays (55 mcgeach)/nostril. Maintenance: 110 mcg dailyin 1 spray (55 mcg)/nostril. Maximum:440 mcg (8 sprays daily).NASAL INHALATION (NASACORT AQ)Adults and children age 12 and over.Initial: 110 mcg daily in 2 sprays (55 mcgeach)/nostril. Maintenance: 55 mcg daily in1 spray/ nostril. Maximum: 220 mcg or4 sprays daily.Children ages 6 to 11. 110 mcg daily in1 spray (55 mcg each)/nostril. Maximum:220 mcg or 4 sprays daily.Children ages 2 to 5. 110 mcg daily in1 spray (55 mcg)/nostril. Maximum:100 mcg or 2 sprays daily.NASAL INHALATION (NASACORT HFA)Adults and children age 12 and over.Initial: 220 mcg daily in 2 sprays (55 mcgeach)/nostril. May be increased to 440 mcgdaily in 4 sprays/nostril, as needed.Children ages 6 to 11. 220 mcg daily in2 sprays (55 mcg each)/nostril.NASAL INHALATION (ALLERNAZE)Adults and children age 12 and over.Initial: 200 mcg daily in 2 sprays (50 mcgeach)/nostril. Maximum: 400 mcg daily in4 sprays (50 mcg each)/nostril or dividedinto 2 daily doses.

To treat chronic idiopathic thrombocytopenicpurpuraTABLETS (TRIAMCINOLONE)Adults and children age 12 and over.0.8 mg/kg daily.Route Onset Peak DurationP.O. Unknown 1–2 hr 2.25 days(tablets)I.M.* 24–48 hr Unknown 1–6 wkI.M.†- Slow Unknown 4 days–4 wkInhala- 12 hr 3–4 hr UnknowntionIntra- Unknown Unknown Several wkarticular,intrabursal*Intra- Unknown Unknown 1–8 wkarticular,intrasynovial†Mechanism of ActionInhibits the release of prostaglandins andleukotrienes, thus reducing immediate andlate-phase allergic responses in chronicasthma. Triamcinolone also:• decreases peribronchial edema and mucussecretion by inhibiting the binding ofallergens to immunoglobulin E antibodieson the surface of mast cells, thereby inactivatingthe release of chemotactic substances• decreases inflammation by interferingwith leukocyte adhesion to capillary walls• inhibits the release of leukocytic acidhydrolases, preventing macrophage accumulationat the infection site• inhibits histamine and kinin release, preventingthe formation of scar tissue.IncompatibilitiesDon’t mix triamcinolone hexacetonide withparenteral local anesthetics because precipitationcan occur.ContraindicationsAcute status asthmaticus (inhalation form),hypersensitivity to triamcinolone or itscomponents, live-virus vaccine therapy, systemicfungal infection* Acetonide.† Diacetate.triamcinolone 1053InteractionsDRUGSamphotericin B, ethacrynic acid, furosemide,thiazide diuretics: Increased potassiumwastingeffect, severe hypokalemiaaspirin: Increased blood salicylate level,increased risk of salicylate toxicitybarbiturates, carbamazepine, phenytoin,rifampin: Increased triamcinolone metabolismcholinesterase inhibitors: Increased risk ofsevere muscle weakness in patients withmyasthenia gravisdigitalis glycosides: Increased risk ofarrhythmias and digitalis toxicityestrogens: Increased triamcinolone effectsinsulin, oral antidiabetic drugs: Increasedblood glucose levelisoproterenol: Increased risk of cardiotoxicitylive-virus vaccines: Decreased antibodyresponse, increased risk of neurologic complicationsneuromuscular blockers: Increased risk ofhypokalemia and enhanced neuromuscularblockadeNSAIDs: Increased risk of adverse GI effectstoxoids: Decreased resistance to toxoidsAdverse ReactionsCNS: Dizziness, emotional lability, exacerbatedpsychosis, fatigue, headache, insomnia,restlessness, seizures, vertigoCV: Edema, heart failure, hypertensionEENT: Altered sense of smell or taste,cataracts, dry mouth, epistaxis (nasal form),glaucoma, hoarseness, nasal congestion,nasal irritation (inhalation form), nasalseptal perforation (nasal form), oropharyngealcandidiasis, pharyngitis, posterior subcapsularcataracts, rhinorrhea, secondaryocular infection, sinusitis, sneezingENDO: Cushing’s syndrome, diabetes mellitus,growth retardation (children)GI: Abdominal pain, constipation, diarrhea,dyspepsia, esophageal ulceration, gastritis,nausea, vomitingGU: Cystitis, renal disease, UTI, vaginitisMS: Bone mineral density loss, bursitis,muscle wasting or weakness, myalgia, osteoporosis,tenosynovitisRESP: Asthma, bronchitis, bronchospasm(inhalation form), chest congestion, dyspnea,increased coughSKIN: Ecchymosis, petechiae (parenteralT

1054Mechanism of ActionInhibits sodium reabsorption in distal contriamtereneform), photosensitivity, pruritus, rash, striae,urticariaOther: Anaphylaxis; angioedema; facialedema; flu syndrome; herpes infection;impaired wound healing; injection site atrophy,induration, pain, soreness, and sterileabscess; weight gainNursing Considerations• Be aware that high doses of corticosteroidssuch as trimcinolone aren’t recommendedfor patients with cranial trauma who don’trequire a corticosteroid for another conditionsbecause of increased risk of death.• Triamcinolone should be administeredwith extreme caution, if at all, in patientswho have active or quiescent tuberculosisinfection of the respiratory tract, untreatedfungal or bacterial infection, systemicviral or parasitic infection, or ocular herpessimplex because this drug can makethese infections worse.• Give oral form of triamcinolone withmeals to minimize GI distress.• Use calibrated device to measure liquiddoses.• If necessary, crush tablets and mix withfood or fluids.• Shake I.M. suspension thoroughly beforedrawing it into syringe.• Be aware that specialized training may beneeded to administer parenteral triamcinolone.• Don’t administer parenteral forms of triamcinoloneI.V.• Be aware that triamcinolone may reactivatetuberculosis in patients who have ahistory of it.• Monitor patients, especially infants, closelyfor gasping syndrome because parenteraltriamcinolone contains benzyl alcohol.Exposure to high doses may result in toxicityevidenced by life-threateninghypotension and metabolic acidosis.WARNING Assess patient for signs andsymptoms of adrenal insufficiency(fatigue, hypotension, lassitude, nausea,vomiting, and weakness) during times ofstress, such as infection, surgery, or trauma.Notify prescriber immediately ifyou detect these signs and symptomsbecause adrenal insufficiency may be lifethreatening.• Be aware that, although rare, bone mineraldensity loss and osteoporosis may occur,which may increase risk of fractures, especiallyin patients on prolonged triamcinolonetherapy.PATIENT TEACHING• Caution patient not to adjust triamcinolonedosage without consulting prescriber.• Teach patient how to administer nasalaerosols properly, using manufacturer’sinstructions, to avoid nasal irritation.• Instruct patient to dispose of aerosol canisterafter 240 uses (100 uses for NasacortHFA) because dosage may not be correctafter that time.• Teach patient how to use nasal spray,including how to prime spray pump bottlebefore use. Caution patient to not to getnasal spray in eyes. If this occurs, patientshould rinse his eyes well with water.• Inform patient that maximum benefit oftriamcinolone therapy may not occur forup to 2 weeks.• Advise patient to notify prescriber immediatelyif asthma fails to respond toinhaled drug because additional systemictherapy may be needed.• Caution patient to avoid exposure to peoplewho have chickenpox or measlesthroughout triamcinolone therapy and for12 months afterward.• Advise patient to have periodic eye examinationsduring long-term therapy becausetriamcinolone can cause glaucoma or ocularnerve damage.triamtereneDyreniumClass and CategoryChemical class: Pterdine derivativeTherapeutic class: DiureticPregnancy category: BIndications and Dosages To treat edema in cirrhosis, heart failure,and nephrotic syndromeCAPSULESAdults. Initial: 25 to 100 mg daily.Maximum: 300 mg daily.

voluted tubules and cortical collectingducts, causing sodium and water loss andenhancing potassium retention.Route Onset Peak DurationP.O. 2–4 hr 1 to several 7–9 hrdaysContraindicationsAnuria, diabetic nephropathy or renal diseaselinked to renal insufficiency, hyperkalemia(potassium level of 5.5 mEq/L ormore), hypersensitivity to triamterene or itscomponents, severe hepatic dysfunctionInteractionsDRUGSACE inhibitors, amiloride, angiotensin-IIreceptor antagonists, cyclosporine, heparin,potassium-containing drugs, potassium salts,potassium supplements, spironolactone:Increased risk of hyperkalemiaamantadine: Decreased amantadine clearance,possibly amantadine toxicityantihypertensives: Increased antihypertensiveeffectdiuretics: Increased diuretic effectfolic acid: Possibly antagonized action offolic acidindomethacin: Increased risk of renalimpairmentlithium: Increased risk of lithium toxicityNSAIDs: Decreased diuretic effect of triamterene,increased risk of hyperkalemiaoral antidiabetic drugs: Altered blood glucosecontrolAdverse ReactionsCNS: Dizziness, fatigue, headache, weaknessEENT: Dry mouthENDO: Hyperglycemia, hypoglycemiaGI: Diarrhea, nausea, vomitingGU: Azotemia, elevated BUN and serumcreatinine levels, renal calculiSKIN: Jaundice, photosensitivity, rashNursing Considerations• Be aware that triamterene shouldn’t begiven to patient with creatinine clearancebelow 10 ml/min/1.73 m 2 because thiscondition increases the risk of druginducedhyperkalemia.• Monitor serum potassium level duringtherapy, especially in patient with renalimpairment or diabetes mellitus. Alsomonitor patient’s BUN and serum creatininelevels to assess renal function andprevent hyperkalemia.• Monitor patient for irregular heartbeat,which is usually the first sign of hyperkalemia.• If you suspect hyperkalemia, obtain anECG tracing, as ordered. A widened QRScomplex or an arrhythmia requiresprompt additional therapy.• Monitor laboratory test results and watchfor signs of metabolic or respiratory acidosis,which may occur suddenly inpatient with cardiac disease or uncontrolleddiabetes mellitus.• Monitor patient’s serum uric acid andsodium levels, as ordered, because triamterenemay reduce uric acid clearanceand increase the risk of gout and hyperuricemia.This drug also may worsen preexistinghyponatremia.• Monitor CBC with differential becausedrug may increase the risk of megaloblasticanemia in patient with folic acid deficiency.PATIENT TEACHING• Advise patient to take triamterene withfood or milk.• Instruct patient to avoid exposure toexcessive heat or sunlight to prevent dehydrationand, possibly, photosensitivity.• Explain to patient with a history of goutthat drug may increase the risk of attack.• Advise patient to notify prescriber aboutineffective diuresis and unexplainedweight gain during therapy.triazolamtriazolam 1055Alti-Triazolam (CAN), Apo-Triazo (CAN),Gen Triazolam (CAN), Halcion, Novo-Triolam (CAN)Class, Category, and ScheduleChemical class: BenzodiazepineTherapeutic class: Sedative-hypnoticPregnancy category: XControlled substance schedule: IVIndications and Dosages To provide short-term management ofinsomniaTABLETSAdults. 0.125 to 0.25 mg at bedtime.T

1056triazolamMaximum: 0.5 mg daily (for patients withinadequate response to usual dose).DOSAGE ADJUSTMENT For elderly or debilitatedpatients, initial dosage reduced to0.125 mg at bedtime and maximum dosagelimited to 0.25 mg daily.Route Onset Peak DurationP.O. 15–30 min Unknown UnknownMechanism of ActionPotentiates effects of the inhibitory neurotransmittergamma-aminobutyric acid,which increases inhibition of the ascendingreticular activating system and producesvarying levels of CNS depression, includingsedation, hypnosis, skeletal muscle relaxation,anticonvulsant activity, and coma.ContraindicationsHypersensitivity to triazolam or its components;itraconazole, ketoconazole, or nefazodonetherapy; pregnancyInteractionsDRUGSanxiolytics, barbiturates, brompheniramine,carbinoxamine, cetirizine, chlorpheniramine,clemastine, cyproheptadine, dimenhydrinate,diphenhydramine, doxylamine, general anesthetics,methdilazine, opioid analgesics, sedative-hypnotics,phenothiazines, promethazine,tramadol, tricyclic antidepressants, trimeprazine:Increased sedation, respiratorydepressioncimetidine, diltiazem, disulfiram, erythromycin,probenecid, verapamil: Increased sedationfluconazole: Increased blood triazolam leveland effectsflumazenil: Increased risk of withdrawalsymptomsitraconazole, ketoconazole, nefazodone:Delayed triazolam eliminationoral contraceptives: Increased blood triazolamlevelFOODSgrapefruit juice: Increased blood triazolamlevel and sedationACTIVITIESalcohol use: Increased sedation, respiratorydepressionAdverse ReactionsCNS: Anxiety, ataxia, complex behaviors(such as sleep driving), confusion, depression,dizziness, drowsiness, fatigue,headache, insomnia, nightmares, syncope,talkativeness, tremor, vertigoEENT: Throat tightnessGI: Nausea, vomitingRESP: DyspneaOther: Anaphylaxis, angioedema, physicaland psychological dependenceNursing Considerations• Be aware that triazolam shouldn’t be discontinuedabruptly, even after only 1 to2 weeks of therapy. Doing so can causewithdrawal symptoms, including abdominalcramps, confusion, depression,diaphoresis, hyperacusis, insomnia, irritability,nausea, nervousness, paresthesia,perceptual disturbances, photophobia,tachycardia, tremor, and vomiting.WARNING Assess patient for signs of physicaland psychological dependence, andnotify prescriber if they occur.• Monitor patient’s respiratory rate anddepth and ABG results, as appropriate,because drug may worsen ventilatory failurein patient with pulmonary disease,such as severe COPD, respiratory depression,or sleep apnea. Use drug cautiouslyin patients with acute intermittent porphyria,myasthenia gravis, and severe renalimpairment because it may aggravatethese conditions.• Take safety precautions for elderly patientsbecause triazolam may impair cognitiveand motor function and increase the riskfor falls.• Use drug cautiously in patients withadvanced Parkinson’s disease because itmay worsen cognition, coordination, andpsychosis.WARNING Monitor patient closely forhypersensitivity reactions such as dyspnea,throat tightness, nausea, vomiting, andswelling. If present, stop triazolam immediately,notify prescriber, and provide supportivecare.PATIENT TEACHING• Instruct patient to take triazolam exactlyas prescribed and not to stop taking itabruptly because of the risk of havingwithdrawal symptoms.• Instruct patient to stop taking triazolamand seek emergency care if she has trouble

eathing, throat tightness, nausea, vomiting,or abnormal swelling.• Advise patient that drug may cause abnormalbehaviors during sleep, such as drivinga car, eating, talking on the phone, orhaving sex without any recall of the event.If family notices any such behavior orpatient sees evidence of such behaviorupon awakening, the prescriber should benotified.• Caution patient about possible drowsinessduring therapy.• Urge patient to avoid alcohol consumptionbecause it increases drug’s sedativeeffects and risk of abnormal behaviors,such as sleep driving.• Advise patient to notify prescriber aboutexcessive drowsiness, known or suspectedpregnancy, and nausea.trifluoperazinehydrochlorideApo-Trifluoperazine (CAN),PMS-Trifluoperazine (CAN)Class and CategoryChemical class: Piperazine phenothiazineTherapeutic class: Antianxiety, antipsychoticPregnancy category: Not ratedIndications and Dosages To treat psychotic disordersSYRUP, TABLETSAdults and adolescents. Initial: 2 to 5 mgb.i.d., increased gradually, as needed.Maintenance: 15 to 20 mg daily. Maximum:40 mg daily.Children age 6 and over. Initial: 1 mg dailyor in divided doses b.i.d., increased gradually,as needed.I.M. INJECTIONAdults and adolescents. 1 to 2 mg every4 to 6 hr, as needed. Maximum: 10 mgdaily.Children age 6 and over. 1 mg daily or individed doses b.i.d., as needed. To relieve anxietySYRUP, TABLETS, I.M. INJECTIONAdults and adolescents. Initial: 1 to 2 mgdaily, increased gradually, as needed.Maximum: 6 mg daily for 12 wk.InteractionsDRUGSadsorbent antidiarrheals, aluminum- andmagnesium-containing antacids: Possiblyinhibited absorption of oral trifluoperazineamantadine, anticholinergics, antidyskinetics,antihistamines: Possibly intensified adverseanticholinergic effects, increased risk of trifluoperazine-inducedhyperpyrexiaamphetamines: Decreased stimulant effectof amphetamines, decreased antipsychoticeffect of trifluoperazineanticonvulsants: Lowered seizure thresholdantithyroid drugs: Increased risk of agranulocytosisapomorphine: Possibly decreased emeticresponse to apomorphine, additive CNSdepressionappetite suppressants: Decreased effects ofappetite suppressantsastemizole, cisapride, disopyramide, erythromycin,pimozide, probucol, procainamide,quinidine: Prolonged QT interval, increasedrisk of ventricular tachycardiabeta blockers: Increased blood levels of bothdrugs, possibly leading to additive hypotensiveeffect, arrhythmias, irreversibleretinopathy, and tardive dyskinesiabromocriptine: Impaired therapeutic effectsof bromocriptineCNS depressants: Additive CNS depressionephedrine, metaraminol: Decreased vasotrifluoperazinehydrochloride 1057Mechanism of ActionBlocks postsynaptic dopamine receptors,increasing dopamine turnover and decreasingdopamine neurotransmission. Thisaction may depress the areas of the brainthat control activity and aggression, includingthe cerebral cortex, hypothalamus, andlimbic system. Trifluoperazine may relieveanxiety by indirectly reducing arousal andincreasing the filtering of internal stimuli tothe reticular activating system.ContraindicationsBlood dyscrasias; bone marrow depression;cerebral arteriosclerosis; coma; coronaryartery disease; hepatic dysfunction;hypersensitivity to trifluoperazine, otherphenothiazines, or their components;myeloproliferative disorders; severe hypertensionor hypotension; significant CNSdepression; subcortical brain damage; useof high doses of CNS depressantsT

1058trifluoperazine hydrochloridepressor response to ephedrineepinephrine: Blocked alpha-adrenergiceffects of epinephrineextrapyramidal reaction–causing drugs (droperidol,haloperidol, metoclopramide, metyrosine,risperidone): Increased severity andfrequency of extrapyramidal reactionshepatotoxic drugs: Increased risk of hepatotoxicityhypotension-producing drugs: Possibly severehypotension with syncopelevodopa: Decreased antidyskinetic effect oflevodopalithium: Reduced absorption of oral trifluoperazine,possibly encephalopathy andadditive extrapyramidal effectsMAO inhibitors, maprotiline, tricyclic antidepressants:Possibly prolonged and intensifiedsedative and anticholinergic effects,increased blood level of antidepressants,impaired trifluoperazine metabolism,increased risk of neuroleptic malignant syndromemephentermine: Decreased antipsychoticeffect of trifluoperazine and vasopressoreffect of mephenterminemethoxamine, phenylephrine: Decreasedvasopressor effect and shortened durationof action of these drugsmetrizamide: Increased risk of seizuresopioid analgesics: Increased risk of CNS andrespiratory depression, orthostatic hypotension,severe constipation, and urine retentionototoxic drugs: Possibly masking of somesymptoms of ototoxicity, such as dizziness,tinnitus, and vertigophenytoin: Lowered seizure threshold;inhibited phenytoin metabolism, possiblyleading to phenytoin toxicityphotosensitizing drugs: Possibly additivephotosensitivity and intraocular photochemicaldamage to choroid, lens, or retinathiazide diuretics: Possibly hyponatremiaand water intoxicationACTIVITIESalcohol use: Increased CNS and respiratorydepression, increased hypotensive effectAdverse ReactionsCNS: Akathisia, altered temperature regulation,dizziness, drowsiness, extrapyramidalreactions (dystonia, pseudoparkinsonism,tardive dyskinesia)CV: Hypotension, orthostatic hypotension,tachycardiaEENT: Blurred vision, dry mouth, nasalcongestion, ocular changes (deposits of fineparticles in cornea and lens), pigmentaryretinopathyENDO: Galactorrhea, gynecomastiaGI: Constipation, epigastric pain, nausea,vomitingGU: Ejaculation disorders, menstrual irregularities,urine retentionSKIN: Contact dermatitis, decreased sweating,photosensitivity, pruritus, rashOther: Injection site irritation and sterileabscess, weight gainNursing ConsiderationsWARNING Trifluoperazine shouldn’t beused to treat elderly patients with dementia-relatedpsychosis because drug increasesthe risk of death in these patients• Use trifluoperazine cautiously in patientswith glaucoma because of drug’s anticholinergiceffect.• Before administration, observe parenteralsolution, which may turn slightly yellowwithout altering its potency. Don’t usesolution if discoloration is pronounced orprecipitate is present.• For I.M. administration, inject drug slowlyand deep into upper outer quadrant of thebuttocks. Keep patient in a supine positionfor 30 minutes after injection to minimizehypotensive effect.• Rotate I.M. injection sites to avoid irritationand sterile abscesses.WARNING Watch closely for tardive dyskinesia,which may continue after treatmentstops. Signs include uncontrolledmovements of arms, body, cheeks, jaw,legs, mouth, or tongue. Notify prescriber ifsuch signs occur.• Closely monitor elderly patients andseverely ill or dehydrated children. They’reat increased risk for certain adverse CNSreactions.• To prevent contact dermatitis, avoid skincontact with oral or injection solution.PATIENT TEACHING• Instruct patient to take trifluoperazineexactly as prescribed and not to stop takingdrug abruptly or without consultingprescriber.• Advise patient to take drug with food or a

full glass of milk or water to minimizeadverse GI reactions.• Urge patient to consult prescriber beforeusing other drugs because of possibleinteractions.• Instruct patient to notify prescriber immediatelyif she experiences difficulty swallowingor speaking and her tongue protrudesfrom her mouth.• Caution patient to avoid alcohol duringtherapy.• Advise patient to avoid potentially hazardousactivities until drug’s CNS effectsare known.• Instruct patient to change position slowlyto minimize effects of orthostatichypotension.• Urge patient to avoid exposure to the sunand extreme heat because drug may causephotosensitivity and interfere withthermoregulation. Encourage her to wearsunscreen when outdoors.triflupromazineVesprinClass and CategoryChemical class: PhenothiazineTherapeutic class: Antiemetic, antipsychoticPregnancy category: Not ratedIndications and Dosages To treat psychotic disordersI.M. INJECTIONAdults and adolescents. 60 mg, as needed.Maximum: 150 mg daily.Children age 30 months and over. 0.2 to0.25 mg/kg, as needed. Maximum: 10 mgdaily. To treat nausea and vomitingI.V. INJECTIONAdults. 1 mg, p.r.n. Maximum: 3 mg daily.I.M. INJECTIONAdults and adolescents. 5 to 15 mg every4hr.Maximum: 60 mg daily.Children age 30 months and over. 0.2 to0.25 mg/kg, p.r.n. Maximum: 10 mg daily.Mechanism of ActionBlocks postsynaptic dopamine receptors,increasing dopamine turnover and decreasingdopamine neurotransmission. Thisaction may depress the areas of the braintriflupromazine 1059that control activity and aggression, includingthe cerebral cortex, hypothalamus, andlimbic system. Triflupromazine also preventsnausea and vomiting by inhibiting orblocking dopamine receptors in themedullary chemoreceptor trigger zone and,peripherally, by blocking the vagus nerve inthe GI tract.ContraindicationsBlood dyscrasias, bone marrow depression,cerebral arteriosclerosis, coma or severeCNS depression, concurrent use of largeamount of CNS depressants, coronaryartery disease, hepatic dysfunction, hypersensitivityto phenothiazines, severe hypertensionor hypotension, subcortical braindamageInteractionsDRUGSamantadine, anticholinergics, antidyskinetics,antihistamines: Possibly intensified adverseanticholinergic effects and increased risk oftriflupromazine-induced hyperpyrexiaamphetamines: Decreased stimulant effectof amphetamines, decreased antipsychoticeffect of triflupromazineanticonvulsants: Lowered seizure thresholdantithyroid drugs: Increased risk of agranulocytosisapomorphine: Possibly decreased emeticresponse to apomorphine, additive CNSdepressionappetite suppressants: Decreased anorecticeffect of appetite suppressantsastemizole, cisapride, disopyramide, erythromycin,pimozide, probucol, procainamide,quinidine: Prolonged QT interval, increasedrisk of ventricular tachycardiabeta blockers: Increased blood levels of bothdrugs, possibly leading to additive hypotensiveeffect, arrhythmias, irreversibleretinopathy, and tardive dyskinesiabromocriptine: Impaired therapeutic effectsof bromocriptineCNS depressants: Additive CNS depressanteffectsephedrine: Decreased vasopressor responseto ephedrineepinephrine: Blocked alpha-adrenergiceffects of epinephrineextrapyramidal reaction–causing drugs (droperidol,haloperidol, metoclopramide, metyrosine,risperidone): Increased severity andT

1060triflupromazinefrequency of extrapyramidal reactionshepatotoxic drugs: Increased risk of hepatotoxicityhypotension-producing drugs: Possibly severehypotension with syncopelevodopa: Decreased antidyskinetic effect oflevodopalithium: Possibly encephalopathy and additiveextrapyramidal effectsMAO inhibitors, maprotiline, tricyclic antidepressants:Increased CNS depression,impaired triflupromazine metabolism,increased risk of neuroleptic malignant syndromemephentermine: Possibly antagonized antipsychoticeffect of triflupromazine andvasopressor effect of mephenterminemetaraminol: Decreased vasopressor effectof metaraminolmethoxamine, phenylephrine: Decreasedvasopressor effect and shortened durationof action of these drugsmetrizamide: Increased risk of seizuresopioid analgesics: Increased risk of CNSand respiratory depression, orthostatichypotension, severe constipation, and urineretentionototoxic drugs: Possibly masking of symptomsof ototoxicity, such as dizziness, tinnitus,and vertigophenytoin: Lowered seizure threshold;inhibited phenytoin metabolism, possiblyleading to phenytoin toxicityphotosensitizing drugs: Possibly additivephotosensitivity and intraocular photochemicaldamage to choroid, lens, or retinathiazide diuretics: Possibly hyponatremiaand water intoxicationACTIVITIESalcohol use: Increased CNS and respiratorydepression, increased hypotensive effectAdverse ReactionsCNS: Akathisia, altered temperature regulation,dizziness, drowsiness, extrapyramidalreactions (dystonia, pseudoparkinsonism,tardive dyskinesia)CV: Hypotension, orthostatic hypotension,tachycardiaEENT: Blurred vision, dry mouth, nasalcongestion, ocular changes (deposits of fineparticles in cornea and lens), pigmentaryretinopathyENDO: Galactorrhea, gynecomastiaGI: Constipation, epigastric pain, nausea,vomitingGU: Ejaculation disorders, menstrual irregularities,urine retentionSKIN: Decreased sweating, photosensitivity,pruritus, rashOther: Injection site irritation and sterileabscess, weight gainNursing Considerations• Use triflupromazine cautiously in patientswith glaucoma because of drug’s anticholinergiceffects.• Before administration, observe parenteralsolution, which may turn slightly yellowwithout altering potency. Don’t use solutionif discoloration is pronounced or precipitateis present.• Don’t let solution come in contact withyour skin because contact dermatitis mayoccur.• For I.M. administration, slowly inject triflupromazinedeep into upper outer quadrantof buttocks. Keep patient supine for30 minutes afterward to minimizehypotensive effect.• Rotate I.M. injection sites to avoid irritationand sterile abscesses.WARNING Watch closely for tardive dyskinesia,which may continue after treatmentstops. Signs include uncontrolledmovements of arms, body, cheeks, jaw,legs, mouth, or tongue. Notify prescriber ifsuch signs occur.• Closely monitor elderly patients andseverely ill or dehydrated children. They’reat increased risk for certain adverse CNSreactions.PATIENT TEACHING• Instruct patient to change position slowlyto minimize effects of orthostatichypotension.• Urge patient to avoid potentially hazardousactivities until triflupromazine’sCNS effects are known.• Instruct patient to notify prescriber immediatelyif she experiences difficulty swallowingor speaking and her tongue protrudesfrom her mouth.• Caution patient to avoid alcohol duringtherapy.• Urge patient to avoid exposure to the sunand extreme heat because drug may causephotosensitivity and interfere with

thermoregulation. Encourage her to wearsunscreen when outdoors.trihexyphenidylhydrochlorideApo-Trihex (CAN), Artane, PMSTrihexyphenidyl (CAN), Trihexane,TrihexyClass and CategoryChemical class: Tertiary amineTherapeutic class: AntidyskineticPregnancy category: CIndications and Dosages To treat parkinsonismELIXIR, TABLETSAdults. Initial: 1 to 2 mg on day 1, dividedinto 3 equal doses and given with meals.Total daily dose increased by 2 mg every3 to 5 days until desired response or maximumdose is reached. Maximum: 15 mgdaily.E.R. CAPSULESAdults. 5 mg after breakfast; additional5 mg 12 hr later, if needed. Maximum:15 mg daily. To treat drug-induced extrapyramidalsymptomsTABLETSAdults. 1 mg daily, increased to 5 to 15 mg/day, as prescribed, to control symptoms.Route Onset Peak DurationP.O. 1 hr Unknown 6–12 hrMechanism of ActionBlocks acetylcholine’s action at cholinergicreceptor sites, which restores normaldopamine and acetylcholine balance in thebrain, relaxing muscle movement anddecreasing drooling, rigidity, and tremor.Drug also may inhibit reuptake and storageof dopamine, prolonging its action.ContraindicationsAchalasia, bladder neck or prostatic obstruction,narrow-angle glaucoma, hypersensitivityto trihexyphenidyl or its components,megacolon, myasthenia gravis,pyloric or duodenal obstruction, stenosingpeptic ulcertrihexyphenidyl hydrochloride 1061InteractionsDRUGSamantadine, anticholinergics, MAO inhibitors,tricyclic antidepressants: Increased anticholinergiceffectsantidiarrheals (adsorbent): Possiblydecreased therapeutic effects of trihexyphenidylchlorpromazine: Decreased blood chlorpromazinelevelCNS depressants: Increased sedative effectlevodopa: Increased efficacy of levodopaACTIVITIESalcohol use: Increased sedationAdverse ReactionsCNS: Confusion, dizziness, drowsiness,nervousnessEENT: Blurred vision; dry eyes, mouth,nose, or throat; mydriasisGI: Constipation, nausea, vomitingGU: Dysuria, urine retentionSKIN: Decreased sweatingNursing Considerations• Use trihexyphenidyl cautiously in patientswith cardiovascular, hepatic, or renal disorders.Patients with cardiovascular disorders,such as atherosclerosis, hypertension,and ischemic heart disease, are at risk fortachycardia and coronary ischemia fromdrug’s positive chronotropic effects.Hepatic and renal dysfunction increase therisk of adverse reactions.• Before therapy begins, assess patient’smuscle rigidity and tremor to establish abaseline. During therapy, reassess patientto detect improvement in these signs andevaluate drug effectiveness.• Obtain patient’s intraocular pressurebefore and periodically during trihexyphenidyltherapy, as ordered, becausedrug can precipitate incipient glaucoma.PATIENT TEACHING• Instruct patient to take trihexyphenidylafter meals.• Teach patient not to break or chew E.R.capsules.• Instruct patient to use calibrated device tomeasure elixir.• Advise patient to avoid potentially hazardousactivities until drug’s CNS effects areknown.• Advise patient with dry eyes or increasedcontact lens awareness to use lubricatingT

1062trimethobenzamide hydrochloride; trimethoprimdrops or stop wearing contact lenses duringdrug therapy.• Caution patient being treated for parkinsonismnot to stop taking trihexyphenidylsuddenly because doing so may worsensymptoms.• Advise patient to maintain adequatehydration and avoid exercising during hotweather because trihexyphenidyl increasesthe risk of heatstroke.trimethobenzamidehydrochlorideBenzacot, Tebamide, Tigan,Tribenzagan, TrimazideClass and CategoryChemical class: Ethanolamine derivativeTherapeutic class: AntiemeticPregnancy category: Not ratedIndications and Dosages To treat nausea and vomitingCAPSULESAdults and adolescents. 250 mg every 6 to8 hr, p.r.n.Children weighing 15 to 45 kg (33 to99 lb). 100 to 200 mg every 6 to 8 hr, p.r.n.I.M. INJECTIONAdults and adolescents. 200 mg every 6 to8 hr, p.r.n.DOSAGE ADJUSTMENT For patient with renalimpairment, dosage decreased or doseinterval lengthened.Mechanism of ActionPrevents or stops nausea and vomiting byblocking dopamine receptors and emeticimpulses at the chemoreceptor trigger zonein the brain.ContraindicationsChildren (I.M.); hypersensitivity totrimetho-benzamide, benzocaine, or any oftheir componentsInteractionsDRUGSapomorphine: Decreased emetic response toapomorphine, increased CNS effectsbarbiturates, belladonna alkaloids, phenothiazines:Increased risk of coma, extrapyramidalreactions, opisthotonos, and seizuresCNS depressants: Possibly enhanced effectsof both drugsototoxic drugs: Possibly masked signs of ototoxicityAdverse ReactionsCNS: Dizziness, drowsiness, headacheEENT: Blurred visionGI: DiarrheaMS: Muscle crampsOther: Injection site burning, irritation,pain, redness, or swellingNursing Considerations• Use trimethobenzamide cautiously indehydrated patients and those with anelectrolyte imbalance, encephalitis, encephalopathy,gastroenteritis, or high fever.• Be aware that trimethobenzamide shouldn’tbe used in children who have viral illnessesbecause they’re at increased risk forReye’s syndrome, characterized by abruptonset of irrational behavior; lethargy; persistent,severe vomiting; progressiveencephalopathy leading to coma, seizures,and possibly death.• To minimize injection site irritation, injecttrimethobenzamide deep into a large musclemass using the Z-track technique,which blocks solution from escaping alongthe injection route.PATIENT TEACHING• Inform patient that drug may causeblurred vision, dizziness, and drowsiness.Advise her to avoid hazardous activitiesuntil drug’s CNS effects are known.• Inform patient’s parents or caregivers thattrimethobenzamide may cause Reye’s syndrome,and urge them to notify prescriberimmediately if they notice decreased levelof consciousness, irrational behavior,lethargy, or severe vomiting.trimethoprimProloprim, TrimpexClass and CategoryChemical class: Dihydrofolic acid analogueTherapeutic class: AntibioticPregnancy category: CIndications and Dosages To treat UTI caused by Enterobacter

species, Escherichia coli, Klebsiellapneumoniae, Proteus mirabilis, orcoagulase-negative staphylococci, includingStaphylococcus saprophyticusTABLETSAdults and children age 12 and over.100 mg every 12 hr or 200 mg daily for10 days.DOSAGE ADJUSTMENT For patients withcreatinine clearance of 15 to 30 ml/min/1.73 m 2 , dosage usually reduced by 50%.Mechanism of ActionInhibits formation of tetrahydrofolic acid,the metabolically active form of folic acid,in susceptible bacteria. This depletes folate,an essential component of bacterial development,thereby disrupting production ofbacterial nucleic acid and protein.ContraindicationsHypersensitivity to trimethoprim or itscomponents, megaloblastic anemia fromfolate deficiency, severe renal impairment(creatinine clearance less than 15 ml/min/1.73 m 2 )InteractionsDRUGSbone marrow depressants: Increased risk ofleukopenia, thrombocytopeniacyclosporine: Increased risk of nephrotoxicitydapsone: Increased blood levels and risk ofadverse effects (especially methemoglobinemia)of both drugsfolate antagonists: Increased risk of megaloblasticanemiaphenytoin: Decreased phenytoin metabolism,increased risk of phenytoin toxicityprocainamide: Increased blood levels of procainamideand its metabolite, N-acetylprocainamiderifampin: Increased elimination anddecreased effectiveness of trimethoprimwarfarin: Increased anticoagulant activity ofwarfarinAdverse ReactionsCNS: Fever, headacheEENT: GlossitisGI: Abdominal pain, anorexia, diarrhea,elevated liver function test results, epigastricpain, nausea, vomitingGU: Elevated BUN and serum creatininelevelsHEME: Leukopenia, megaloblastic anemia,trimipramine maleate 1063methemoglobinemia, neutropenia, thrombocytopeniaSKIN: Exfoliative dermatitis, pruritus, rashNursing Considerations• Obtain urine specimen, as ordered, beforetrimethoprim therapy starts.• Give drug on an empty stomach toenhance absorption.• Evaluate patient’s test values for folic aciddeficiency and signs of bone marrowdepression.• Monitor serum potassium level and renalfunction studies, as ordered, in patientswith decreased renal function becausethese patients are at increased risk forhyperkalemia and toxic reactions whenreceiving trimethoprim.PATIENT TEACHING• Instruct patient to complete entire courseof trimethoprim therapy, as prescribed,even if she feels better beforehand.• Advise patient to take drug with food ormilk if GI distress occurs.• Instruct patient to notify prescriber if sheexperiences rash, severe fatigue, sorethroat, or unusual bleeding or bruising.trimipraminemaleateApo-Trimip (CAN), Novo-Tripramine(CAN), Rhotrimine (CAN), SurmontilClass and CategoryChemical class: Dibenzazepine derivativeTherapeutic class: AntidepressantPregnancy category: CIndications and Dosages To treat depressionCAPSULESAdults in inpatient settings. Initial: 100 mgdaily in divided doses, increased graduallyin a few days to 200 mg daily. Maximum:300 mg daily in 2 to 3 wk.Adolescents in inpatient settings. Initial:50 mg daily in divided doses, increased asneeded. Maximum: 100 mg daily.Adults in outpatient settings. Initial:75 mg/day in divided doses, increased graduallyup to 150 mg daily, as needed.Maintenance: 50 to 150 mg daily.T

1064trimipramine maleateMaximum: 200 mg daily.Adolescents in outpatient settings. Initial:50 mg daily in divided doses, increased asneeded. Maximum: 100 mg daily.DOSAGE ADJUSTMENT For elderly patients,initial dosage reduced to 50 mg daily individed doses, and maximum dosage limitedto 100 mg daily.Route Onset Peak DurationP.O. 2–3 wk Unknown UnknownMechanism of ActionInhibits the reuptake of norepinephrine atpresynaptic neurons, thus increasing itsconcentration in synapses. This action mayelevate mood and relieve depression.ContraindicationsHypersensitivity to trimipramine, other dibenzazepinetricyclic antidepressants, ortheir components; recovery period after anMI; use within 14 days of an MAOinhibitor or other tricyclic antidepressantInteractionsDRUGSamantadine, anticholinergics, antidyskinetics,antihistamines: Increased anticholinergiceffects (confusion, hallucinations, nightmares)anticonvulsants: Increased CNS depression,lowered seizure threshold (high trimipraminedoses), decreased anticonvulsanteffectantithyroid drugs: Risk of agranulocytosisbarbiturates, carbamazepine: Decreasedblood level and effects of trimipraminebupropion, clozapine, cyclobenzaprine, haloperidol,loxapine, maprotiline, molindone,phenothiazines, thioxanthenes: Increasedand prolonged sedative and anticholinergiceffects of both drugs, increased risk of seizurescimetidine: Decreased trimipramine metabolism,possibly leading to trimipraminetoxicityclonidine: Decreased hypotensive effect andincreased CNS depressant effect of clonidineCNS depressants: Increased hypotensionand CNS and respiratory depressiondisulfiram, ethchlorvynol: Transient delirium,risk of CNS depression (ethchlorvynol)fluoxetine: Increased trimipramine levelguanadrel, guanethidine: Decreasedhypotensive effectMAO inhibitors: Increased risk of death,hyperpyrexia, hypertensive crisis, severeseizuresmethylphenidate: Decreased methylphenidateeffects, increased blood trimipraminelevelmetrizamide: Increased risk of seizuresnaphazoline (ophthalmic), oxymetazoline(nasal or ophthalmic), phenylephrine (nasalor ophthalmic), xylometazoline (nasal):Increased vasopressor effect of these drugsoral anticoagulants: Increased anticoagulationphenothiazines: Increased blood trimipraminelevel, decreased phenothiazine metabolismpimozide, probucol: Increased risk ofarrhythmias, possibly prolonged QT intervalsympathomimetics: Increased risk ofarrhythmias, hyperpyrexia, severe hypertensionthyroid hormones: Increased therapeutic andtoxic effects of both drugsACTIVITIESalcohol use: Increased hypotension and CNSand respiratory depressionAdverse ReactionsCNS: Anxiety, ataxia, confusion, delirium,dizziness, drowsiness, excitement, extrapyramidalreactions, hallucinations, headache,insomnia, nervousness, nightmares,parkinsonism, seizures, stroke, suicidalideation, tremorCV: Arrhythmias, orthostatic hypotensionEENT: Blurred vision, dry mouth, increasedintraocular pressure, taste perversion, tinnitus,tongue swellingENDO: Gynecomastia, syndrome of inappropriateADH secretionGI: Constipation, diarrhea, heartburn, ileus,increased appetite, nausea, vomitingGU: Sexual dysfunction, testicular swelling,urine retentionHEME: Agranulocytosis, bone marrowdepressionRESP: WheezingSKIN: Alopecia, diaphoresis, jaundice, photosensitivity,pruritus, rash, urticariaOther: Facial edema, weight gain

Nursing Considerations• Watch patient closely for suicidal tendencies,especially when therapy starts ordosage changes and particularly if patientis a child, teenager, or young adult.• Expect to gradually reduce trimipraminedosage, as prescribed, before electroconvulsivetherapy.PATIENT TEACHING• Instruct patient to take the last dose earlyin the evening to avoid insomnia.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Urge patient to change position slowly tominimize orthostatic hypotension.• Urge patient to avoid alcohol during therapy.• Advise patient to avoid exposure to excessivesunlight and to wear sunscreen whenshe’s outdoors.• Instruct patient to notify prescriber aboutthe development of unusual bruising andsigns of infection.• Suggest that patient use sugarless gum orhard candy to relieve dry mouth.WARNING Urge parents to watch their childor adolescent closely for abnormal behavior,increased aggression or hostility, orsuicidal tendencies, especially when therapystarts or dosage is adjusted. Stress needto notify prescriber about changes.tromethamineThamClass and CategoryChemical class: Organic amineTherapeutic class: AlkalinizerPregnancy category: CIndications and Dosages To treat metabolic acidosis associatedwith cardiac arrestI.V. INFUSIONAdults and children. 3.6 to 10.8 g (111 to333 ml) of 0.3 M solution.I.V. INJECTIONAdults and children. If chest is opened,2 to 6 g injected directly into open ventricularcavity. To treat metabolic acidosis during cardiacbypass surgerytromethamine 1065I.V. INFUSIONAdults and children. 9 ml (2.7 mEq or0.32 g) of 0.3 M solution/kg as a singledose. Usual: 500 ml (150 mEq or 18 g)infused over 1 hr. Maximum: 500 mg/kgover 1 hr.Mechanism of ActionCombines with hydrogen ions and theirassociated acid anions, including lactic,pyruvic, and carbonic acid, to form saltsthat are excreted in urine. Tromethamineexerts additional alkalinizing effects by actingas an osmotic diuretic, promoting theexcretion of alkaline urine that containsincreased amounts of carbon dioxide andelectrolytes.ContraindicationsAnuria, chronic respiratory acidosis, hypersensitivityto tromethamine or its components,uremiaInteractionsDRUGSamphetamines, quinidine, other pHdependentdrugs: Altered excretion of thesedrugsAdverse ReactionsCNS: FeverCV: VasospasmENDO: HypoglycemiaGI: Hepatic necrosis (hemorrhagic)RESP: Respiratory depressionOther: Hypervolemia; infusion site infection,phlebitis, or venous thrombosis; metabolicalkalosisNursing Considerations• Evaluate blood pH, blood glucose, and serumbicarbonate and electrolyte levels,and partial pressure of arterial carbondioxide before, during, and aftertromethamine therapy, as ordered.• Be aware that, except in life-threateningsituations, tromethamine therapy is limitedto no more than 1 day because of therisk of alkalosis.WARNING Be aware that exceeding the recommendeddosage can cause alkalosis, respiratorydepression, and reduced carbondioxide level.• Expect I.V. tromethamine administrationto increase the risk of hypervolemia andpulmonary edema.T

1066trospium chloride• Assess the infusion site often for infiltration,which may cause inflammation,necrosis, thrombosis, tissue sloughing, andvasospasm.• Be aware that patients with renal failurehave an increased risk of developinghyperkalemia. For such patients, be preparedto monitor ECG continuously andassess serum potassium level frequently.• Monitor patient’s blood glucose level oftenduring and after therapy because rapiddelivery can cause hypoglycemia for severalhours.PATIENT TEACHING• Inform family members that patient’s vitalsigns and laboratory test results will bemeasured frequently to monitor herprogress.trospium chlorideSanctura, Sanctura XRClass and CategoryChemical class: Quaternary ammoniumcompoundTherapeutic class: Bladder antispasmodicPregnancy category: CIndications and Dosages To treat overactive bladder with symptomsof urge urinary incontinence,urgency, and urinary frequencyTABLETSAdults. 20 mg b.i.d. 1 hour before meals oron empty stomach.DOSAGE ADJUSTMENT For patients withsevere renal insufficiency (creatinine clearanceless than 30 ml/min/1.73 m 2 ) andpatients age 75 or over, dosage reduced to20 mg daily at bedtime.E.R. TABLETSAdults. 60 mg daily in the morning, 1 hourbefore a meal or on empty stomach.Route Onset Peak DurationP.O. Unknown 5–6 hr UnknownMechanism of ActionAntagonizes the effect of acetylcholine onmuscarinic receptors in the bladder.Trospium’s parasympatholytic actionreduces the tonus of smooth muscle in thebladder. These actions increase maximumcystometric bladder capacity and volumewith the first detrusor contraction, whichrelieves the sensation of urgency and frequencyand enhances bladder control.ContraindicationsGastric retention, hypersensitivity to trospiumor its components, uncontrolled angleclosureglaucoma, urine retentionInteractionsDRUGSanticholinergics: Increased frequency orseverity of adverse effects; possibly reducedabsorption of trospiumdigoxin, metformin, morphine, pancuronium,procainamide: Possibly increased plasmaconcentration of trospium, digoxin, metformin,morphine, pancuronium, procainamideACTIVITIESalcohol use: Possibly increased drowsinessAdverse ReactionsCNS: Dizziness, drowsiness, fatigue,headache, light-headednessCV: Palpitations, tachycardiaEENT: Blurred vision; dry eyes, mouth, orthroatGI: Abdominal distention or pain, constipation,flatulence, indigestion, vomitingGU: Urine retentionSKIN: Decreased sweating, dry skin, flushing,rashOther: AngioedemaNursing Considerations• Use trospium cautiously in patients withulcerative colitis, intestinal atony, or myastheniagravis because drug may decreaseGI motility; patients with significant bladderoutflow obstruction because drug maycause urine retention; patients with hepaticimpairment because drug’s effects onthe liver are unknown; and patients withrenal impairment because drug excretionmay be impaired.• Monitor elderly patients carefully, especiallythose age 75 or over, for adversereactions because elderly patients have anincreased risk of trospium-inducedadverse reactions.PATIENT TEACHING• Instruct patient to take trospium on an

tubocurarine chloride 1067empty stomach or at least 1 hour beforeeating because food delays its absorption.• Caution patient to avoid performing activitiesin a warm or hot environmentbecause sweating may be delayed, whichcould cause a sudden increase in bodytemperature and heatstroke.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Inform patient that alcohol may increasethe risk of drowsiness; urge patient tolimit or abstain from alcoholic beverageswhile taking trospium.tubocurarinechlorideClass and CategoryChemical class: Isoquinoline derivativeTherapeutic class: AnticonvulsantPregnancy category: CIndications and Dosages To manage muscle contractions ofseizures associated with electroshocktherapyI.V. INJECTIONAdults. 157 mcg/kg (0.157 mg/kg) over30 to 90 sec, given just before electroshocktherapy. Expect initial dose to be 3 mg lessthan calculated total dose. To produce skeletal muscle paralysisduring anesthesiaI.V. OR I.M. INJECTIONAdults. Initial: 6 to 9 mg. Maintenance: 3 to4.5 mg in 3 to 5 min. if needed. For prolongedprocedures, 3-mg supplementaldoses given.Infants and children. 500 mcg/kg I.V.Neonates. Initial: 250 to 500 mcg/kg I.V.Maintenance: One-fifth to one-sixth of initialdose if needed. To facilitate endotracheal intubationand aid controlled respiration duringmechanical ventilationI.V. INJECTIONMechanism of ActionTubocurarine reduces the intensity ofskeletal muscle contractions caused byelectrically induced seizures. Normally,when a nerve impulse arrives at a somaticmotor nerve terminal, it triggers acetylcholine(ACh) stored in synaptic vesiclesto be released into the neuromuscularjunction. The released ACh binds withnicotinic receptors embedded in theskeletal muscle motor endplate, as shownbelow left, triggering muscle cell depolarizationand contraction.Tubocurarine is a nondepolarizing neuromuscularblocker that acts as a competitiveantagonist of ACh. By binding to thenicotinic receptors, as shown below right, itprevents transmission of the action potentialat the neuromuscular junction, therebysustaining skeletal muscle relaxation andeliminating the peripheral muscular manifestationsof seizures. The drug has noeffect on the CNS processes involved withseizures because it doesn’t cross the bloodbrainbarrier.Nerve impulseACh AChSomatic motornerve terminalACh ACh binding to tonicotinic receptorTubocurarinebinding to tonicotinic receptorTMotorendplateMuscle contractionMuscle relaxation

1068tubocurarine chlorideAdults. Initial: 16.5 mcg/kg. Maintenance:Dosage individualized based on patientresponse. To aid in the diagnosis of myastheniagravisI.V. INJECTIONAdults. 4 to 33 mcg/kg. After 2 to 3 min,1.5 mg of neostigmine is given I.V. to terminatethe test.• Keep emergency equipment and drugsreadily available in case respiratory depressionoccurs.PATIENT TEACHING• Explain the need for frequent hemodynamicmonitoring.Route Onset Peak DurationI.V. 1 min 2–5 min 20–40 minIncompatibilitiesDon’t mix tubocurarine with barbiturates,such as methohexital or thiopental, becausea precipitate may form.ContraindicationsHypersensitivity to tubocurarine or itscomponents, patients in whom histaminerelease may be dangerousInteractionsDRUGSalfentanil, fentanyl, sufentanil: Prevented orreversed muscle rigidity from these drugsaminoglycosides, anesthetics, capreomycin,citrate-anticoagulated blood, clindamycin,lidocaine (I.V.), lincomycin, polymyxins, procaine(I.V.), trimethaphan: Additive neuromuscularblocking effectsbeta blockers, calcium salts: Prolonged andenhanced effects of tubocurarinemagnesium salts, procainamide, quinidine:Enhanced blockade effectsopioid analgesics: Additive histamine releaseeffects, additive respiratory depressanteffects, worsened bradycardia and hypotensionAdverse ReactionsCV: Arrhythmias, bradycardia, edema,hypotension, shock, tachycardiaRESP: BronchospasmSKIN: Erythema, flushing, itching, rashOther: AnaphylaxisNursing Considerations• If patient has a history of CV disease or ishypotensive, monitor her for furtherdecrease in blood pressure.• Monitor patient for bronchospasm andhypotension because tubocurarine maycause increased histamine release.

U V Wurea(carbamide)UreaphilClass and CategoryChemical class: Carbonic acid diamide saltTherapeutic class: Antiglaucoma, diureticPregnancy category: CIndications and Dosages To reduce cerebral edema andintracranial pressureI.V. INFUSIONAdults and children age 2 and over. 500 mgto 1.5 g/kg as 30% solution in D 5 W, D 10 W,or 10% invert sugar solution infused over30 min to 2 hr at 4 or 6 ml/min, accordingto manufacturer’s instructions. Maximum:2 g/kg daily.Children under age 2. 100 mg to 1.5 g/kg as30% solution in D 5 W, D 10 W, or 10% invertsugar solution infused over 30 min to 2 hrat 4 or 6 ml/min, according to manufacturer’sinstructions. To treat malignant or secondaryglaucomaI.V. INFUSIONAdults. 500 mg to 1.5 g/kg as 30% solutionin D 5 W, D 10 W, or 10% invert sugar solutioninfused over 30 min to 2 hr at 4 or6 ml/min, according to manufacturer’sinstructions. Maximum: 2 g/kg daily.DOSAGE ADJUSTMENT Dosage reduced ordrug withheld for patients with renalimpairment if BUN level rises to 75 mg/dlor more or if diuresis fails to occur within2 hr after administration.urea 1069Mechanism of ActionElevates blood plasma osmolality, creatingan osmotic effect that increases movementof water from the brain, CSF, and anteriorportion of the eyes into interstitial fluid andplasma. This action reduces cerebral edema,intracranial pressure, CSF volume, andintraocular pressure. Large doses inhibitreabsorption of water and solutes in therenal tubules and induce diuresis by affectingthe osmotic pressure gradient of theglomerular filtrate.Route Onset Peak DurationI.V. 10 min 1–2 hr 3–10 hr*ContraindicationsActive intracranial bleeding, hepatic failure,hypersensitivity to urea or its components,renal impairment, severe dehydrationInteractionsDRUGScarbonic anhydrase inhibitors, other diuretics:Additive diuretic and intraocular pressure–reducing effectslithium: Increased renal excretion of lithiumAdverse ReactionsCNS: Agitation, confusion, fever, headache,hyperthermia, nervousness, subarachnoidhemorrhage, subdural hematoma, syncopeCV: TachycardiaEENT: Dry mouth, intraocular hemorrhageGI: Nausea, thirst, vomitingGU: Elevated BUN levelHEME: HemolysisSKIN: Blemishes, extravasation with tissuenecrosis and sloughingOther: Dehydration, hypokalemia, hyponatremia,infusion site phlebitis or thrombosisNursing Considerations• For maximum reduction of intracranial orintraocular pressure, expect to give urea60 minutes before ocular or intracranialsurgery.• Don’t mix urea with invert sugar solutionif patient has fructose intolerance fromaldolase deficiency.• Avoid infusing drug into leg veins toreduce risk of phlebitis and thrombosis.• Discard unused portion of drug after24 hours.• Be aware that rapid administration maycause hemolysis, increased capillary bleeding,and, in patients with glaucoma, intraocularhemorrhage.• Maintain adequate hydration to minimizeadverse reactions. Assess for signs of dehydration,including dry mucous mem-* For diuresis; 5 to 6 hr for reduced intraocularpressure.UVW

1070urokinasebranes and tenting.• Monitor BUN and serum electrolyte levelsas well as fluid intake and output duringurea therapy because prolonged use cancause diuresis.PATIENT TEACHING• Instruct patient to notify prescriber immediatelyabout difficulty breathing or shortnessof breath because drug can causetransient increases in circulatory volume,leading to circulatory overload, worseningof heart failure, or pulmonary edema.• Tell patient to expect increased urine output.• Encourage patient to remain on bed restduring therapy.urokinaseAbbokinase, Abbokinase Open-CathClass and CategoryChemical class: Renal enzymatic proteinTherapeutic class: ThrombolyticPregnancy category: BIndications and Dosages To treat acute coronary artery thrombosisINTRACORONARY INFUSIONAdults. 6,000 international units/min untilartery is maximally opened (up to 2 hr maybe required). Usual: 500,000 internationalunits. To treat acute pulmonary thromboembolismincluding massive eventsI.V. INFUSIONAdults. Initial: 4,400 international units/kgover 10 min, followed by 4,400 internationalunits/kg/hr for 12 hr. To clear I.V. catheter occlusionINSTILLATIONAdults and children. 5,000 internationalunits/ml instilled into occluded line.Route Onset Peak DurationI.V. Unknown 20 min– 4 hr2 hrIntra- Unknown Unknown 4 hrcoronaryMechanism of ActionIndirectly promotes conversion of plasminogento plasmin, an enzyme that breaksdown fibrin clots, fibrinogen, and otherplasma proteins, including procoagulantfactors V and VIII.IncompatibilitiesDon’t administer I.V. urokinase throughsame I.V. line as other drugs or add otherdrugs to urokinase solution.ContraindicationsArteriovenous malformation, bleeding disorder,hypersensitivity to urokinase or itscomponents, internal bleeding, intracranialaneurysm, intracranial or intraspinal surgeryduring previous 2 months, intracranialtumor, recent cardiopulmonary resuscitation,recent trauma, severe uncontrolledhypertension (systolic blood pressure200 mm Hg or higher, or diastolic bloodpressure 110 mm Hg or higher), stroke duringprevious 2 monthsInteractionsDRUGSantifibrinolytics (aminocaproic acid, aprotinin):Mutual antagonismantihypertensives: Increased risk of severehypotensioncefamandole, cefoperazone, cefotetan, plicamycin,valproic acid: Increased risk ofhypoprothrombinemia and severe hemorrhagecorticosteroids, ethacrynic acid, salicylates(nonacetylated): Increased risk of GI ulcerationand bleedingenoxaparin, heparin, NSAIDs, oral anticoagulants,platelet-aggregation inhibitors:Increased risk of hemorrhagethiotepa: Increased therapeutic effects ofthiotepaAdverse ReactionsCNS: Chills, CVA, fever, headacheCV: Arrhythmias, including tachycardia;chest pain; cholesterol embolization; hypertension;hypotensionEENT: Orolingual edemaGI: Nausea, vomitingHEME: Unusual bleedingMS: Back pain, myalgiaRESP: Bronchospasm, dyspnea, hypoxemia,wheezingSKIN: Cyanosis, ecchymosis, flushing, pruritus,rash, urticariaOther: Anaphylaxis, infusion site reactions,metabolic acidosis

Nursing Considerations• To prevent foaming, don’t shake urokinasewhen reconstituting. Consult pharmacistabout giving drug through 0.45-micron orsmaller cellulose membrane filter.• Assess baseline hematocrit, platelet count,thrombin time, APTT, PT, and INR asordered.• Monitor heart rate and rhythm by continuousECG during therapy, especially duringrapid lysis of coronary thrombi.Arrhythmias can occur with reperfusion.• Monitor blood pressure for hypotension.If it occurs, notify prescriber and expect toreduce infusion rate.• Check for bleeding at puncture sites andin urine and stool. Check for intracranialbleeding by performing frequent neurologicassessments.• After arterial puncture, apply pressure forat least 30 minutes and then apply pressuredressing. Check often for bleedingduring therapy.• To prevent bleeding and associated complications,avoid venipunctures; use anexternal blood pressure cuff to measureblood pressure; give acetaminophen (notaspirin), as prescribed, for fever; and handlepatient as little as possible.WARNING If serious bleeding begins andcan’t be controlled with local pressure,stop infusion immediately and notify prescriber.PATIENT TEACHING• Instruct patient to remain on bed rest duringurokinase therapy.• Inform patient that minor bleeding mayoccur at wounds or puncture sites.ursodiol(ursodeoxycholic acid)Actigall, Urso Forte, URSO 250,Ursofalk (CAN)Class and CategoryChemical class: Naturally occurring bile acidTherapeutic class: Bile salt replenisher,cholelitholyticPregnancy category: BIndications and Dosages To prevent gallstone formation in obeseursodiol 1071patients during rapid weight lossCAPSULESAdults and adolescents. 300 mg b.i.d. Or,8 to 10 mg/kg daily in divided doses b.i.d ort.i.d. To dissolve gallstonesCAPSULESAdults and adolescents. 8 to 10 mg/kg dailyin divided doses b.i.d. or t.i.d. To treat primary biliary cirrhosisTABLETSAdults. 13 to 15 mg/kg daily in two to fourdivided doses.Mechanism of ActionSuppresses hepatic synthesis, biliary secretion,and intestinal reabsorption of cholesterol.Prolonged use promotes dissolutionof gallstones.ContraindicationsAcute cholangiitis; gallstone complications(such as biliary GI fistula; biliary obstruction;calcified, radiopaque, or radiotranslucentbile-pigment gallstones; cholecystitis;pancreatitis); hypersensitivity to ursodiol,other bile acids, or their componentsInteractionsDRUGSaluminum-containing antacids, cholestyramine,colestipol: Decreased absorption andtherapeutic effects of ursodiolclofibrate, estrogens, neomycin, oral contraceptives,progestins: Interference with ursodiol’stherapeutic effects; increased risk ofgallstone formationFOODSany foods: Increased dissolution of drugAdverse ReactionsCNS: Anxiety, asthenia, depression, fatigue,headache, sleep disturbanceCV: Chest pain, hypertension, peripheraledemaENDO: HyperglycemiaEENT: Metallic taste, rhinitis, stomatitisGI: Abdominal pain, cholecystitis, constipation,diarrhea, esophagitis, flatulence, indigestion,nausea, peptic ulcer, vomitingGU: Elevated creatinine levelHEME: Leukopenia, thrombocytopeniaMS: Arthralgia, back pain, myalgiaRESP: CoughSKIN: Alopecia, diaphoresis, dry skin, pruritus,rash, urticariaUVW

1072ustekinumabNursing Considerations• Administer ursodiol with food to increasedrug dissolution.• Give aluminum-containing antacids,cholestyramine, and colestipol at least1 hour before or 4 hours after ursodiolbecause they may decrease drug’s effects.• Expect drug to be discontinued if gallstoneshaven’t partially dissolved after12 months of therapy.• If patient inadvertently takes too muchursodiol, diarrhea will most likely resultand may warrant systemic treatment.PATIENT TEACHING• Tell patient to take ursodiol with meals.• Urge patient to take aluminum-containingantacids at least 1 hour before or 4 hoursafter ursodiol to support absorption.• Urge patient to notify prescriber immediatelyif evidence of acute cholecystitisdevelops, such as acute right-upper-quadrantabdominal pain.• Inform patient that he may need to takeursodiol for a prolonged period beforegallstones dissolve.• Advise diabetic patient to monitor bloodglucose levels during therapy becauseursodiol may alter blood glucose control.ustekinumabStelaraClass and CategoryChemical class: Human IgG1k monoclonalantibodyTherapeutic class: AntipsoriasiticPregnancy category: BIndications and Dosages To treat moderate to severe plaque psoriasisin patients who are candidates forphototherapy or systemic therapySUBCUTANEOUS INJECTIONAdults weighing 100 kg (220 lb) or less:Initial: 45 mg followed by 45 mg 4 wk laterand then 45 mg every 12 wk.Adults weighing more than 100 kg(220 lb): Initial: 90 mg followed by 90 mg4 wk later and then 90 mg ever 12 wk.Mechanism of ActionBinds to p40 protein subunit used by interleukin(IL)-12 and IL-23 cytokines. Thesespecific cytokines are involved in inflammatoryand immune responses, such as naturalkiller cell activation and CD4+ T-cell differentiationand activation. By disrupting signalingmediated by IL-12 and IL-23, signsand symptoms caused by inflammatory andimmune responses in plaque psoriasis arediminished or relieved.Route Onset Peak DurationSubQ Unknown 7–13.5 days UnknownContraindicationsHypersensitivity to ustekinumab or itscomponentsInteractionsDRUGScytochrome P-450 substrates such as cyclosporine,theophylline, warfarin: Possiblyaltered effects or blood levels of these drugswhen ustekinumab is started or stoppedlive-virus vaccines: Increased risk of adversevaccine effectsAdverse ReactionsCNS: Depression, dizziness, fatigue,headache, reversible leukoencephalopathysyndromeENDO: Nasopharyngitis, pharyngolaryngealpainGI: Diarrhea, diverticulitis, gastroenteritisGU: UTIMS: Back pain, myalgia, osteomyelitisRESP: Pneumonia, upper respiratory tractinfectionSKIN: Cellulitis, pruritusOther: Anti-ustekinumab antibodies, injectionsite reactions (bruising, erythema,hemorrhage, induration, irritation, pain,pruritus, swelling), malignancies (breast;colon; head and neck; kidney; nonmelanomaof skin, kidney, prostate, thyroid),serious infection including bacterial,fungal and viral infections and reactivationof latent infectionsNursing Considerations• Make sure patient has a tuberculin skintest before therapy starts. If skin test ispositive, treatment of latent tuberculosisshould start before ustekinumab therapystarts. Also expect antituberculosis therapyto start if patient has a history of latent oractive tuberculosis but adequate therapy

can’t be confirmed or if patient has a negativetest for latent tuberculosis but hasrisk factors for tuberculosis.• Make sure patient is current with allimmunizations before starting ustekinumabtherapy because patient shouldn’treceive live vaccines during treatment.BCG vaccines shouldn’t be given for 1 yearbefore or after ustekinumab therapy.WARNING If patient has evidence of anactive infection when drug is prescribed,therapy shouldn’t start until infection hasbeen treated. Monitor all patients forinfection during therapy, especially thosereceiving immunosuppressants. If a seriousinfection, an opportunistic infection,or sepsis develops, expect prescriber tostop ustekinumab and start appropriateantimicrobial therapy.• Patients with a history of cancer or whohave genetic deficiencies in IL-12 or IL-23should be thoroughly evaluated beforeustekinumab therapy starts because variouscancers have occurred in patientsbeing treated with ustekinumab. Monitorpatients throughout therapy for unusual,persistent, or severe signs and symptoms.• Use ustekinumab cautiously in patientswith recurrent infection or increased riskof infection and in patients who live inregions where tuberculosis and histoplasmosisare endemic.• Give ustekinumab using a 27G, half-inchneedle into upper arms, gluteal region,thighs, or any quadrant of abdomen.Rotate sites, and avoid areas that are tender,bruised, erythematous, or indurated.• Note that needle cover on prefilled syringecontains a latex derivative and shouldn’tbe handled by persons with a latex allergy.• Monitor patient for headache, seizures,vision disturbances, and confusion, whichmay signal reversible posterior leukoencephalopathysyndrome, a rare neurologicdisorder that may occur with ustekinumabtherapy. If present, notify prescriber, discontinueustekinumab therapy, and provideappropriate treatment, as ordered.PATIENT TEACHING• Inform patient that treatment must besupervised by a health care professional.• Inform patient that tuberculosis mayoccur during ustekinumab therapy.Instruct him to report persistent cough,valproic acid 1073wasting or weight loss, and low-gradefever to prescriber.• Teach patient to recognize and report evidenceof infection; drug may need to bestopped. Advise patient to avoid peoplewith infections and to have all prescribedlaboratory tests performed.• Inform patient that the risk of developingcertain kinds of cancer is higher inpatients taking ustekinumab. Emphasizeimportance of follow-up visits and reportingany unusual, persistent, or suddenonsetsigns or symptoms.• Caution against receiving live-virus vaccineswhile taking ustekinumab; doing somay adversely affect the immune system.• Urge patient to inform all health careproviders about ustekinumab use and toinform prescriber about all OTC medicationsbeing taken, including herbal remediesand vitamin and mineral supplements.valproic acidAlti-Valproic (CAN), Depakene,Depakote ER, Deproic (CAN), Dom-Proic (CAN), Med-Valproic (CAN), Novo-Valproic (CAN), Nu-Valproic (CAN),PMS-Valproic Acid (CAN), Stavzorvalproate sodiumDepacondivalproex sodiumDepakote, Depakote Sprinkle,Epival (CAN)Class and CategoryChemical class: Carboxylic acid derivativeTherapeutic class: AnticonvulsantPregnancy category: DIndications and Dosages To treat simple or complex absenceseizures, complex partial seizures, myoclonicseizures, and generalized tonicclonicseizures as monotherapyCAPSULES, DELAYED-RELEASE SPRINKLE CAPSULES,DELAYED-RELEASE TABLETS, SYRUP, I.V. INFUSION(VALPROIC ACID, VALPROATE SODIUM, DIVALPROEXSODIUM)Adults and adolescents. Initial: 10 to15 mg/kg/day in divided doses b.i.d. orUVW

1074vaproic acidt.i.d., increased by 5 to 10 mg/kg daily everywk, as needed and as prescribed. Maximum:60 mg/kg daily.Children. Initial: 15 to 45 mg/kg daily individed doses b.i.d. or t.i.d., increased by5 to 10 mg/kg/day every wk, as needed andas prescribed. As adjunct to treat simple or complexabsence seizures, complex partialseizures, myoclonic seizures, and generalizedtonic-clonic seizuresCAPSULES, DELAYED-RELEASE SPRINKLE CAPSULES,DELAYED-RELEASE TABLETS, SYRUP, I.V. INFUSION(VALPROIC ACID, VALPROATE SODIUM, DIVALPROEXSODIUM)Adults and adolescents. 10 to 30 mg/kg/dayin divided doses, increased by 5 to 10 mg/kg/day every wk, as needed and as prescribed.Children. 30 to 100 mg/kg daily in divideddoses, as prescribed.DOSAGE ADJUSTMENT For adults being convertedfrom immediate-release divalproextablets to delayed-release tablets, dosageincreased to 8% to 20% more than totaldaily dose of immediate-release tablets andgiven once daily. To treat acute manic phase of bipolardisorderDELAYED-RELEASE TABLETS (DIVALPROEX SODIUM),DELAYED-RELEASE CAPSULES (STAVZOR)Adults. Initial: 750 mg daily in divideddoses. Maximum: 60 mg/kg daily. To prevent migraine headacheTABLETS, TABLETS (DIVALPROEX SODIUM),DELAYED-RELEASE CAPSULES (STAVZOR)Adults. 250 mg every 12 hr, increased p.r.n.Maximum: 1 g daily.DELAYED-RELEASE TABLETS (DIVALPROEX SODIUM)Adults. 500 mg daily, increased, as neededand prescribed, up to 1 g daily. Maximum:1 g daily.Mechanism of ActionMay decrease seizure activity by blockingreuptake of gamma-aminobutyric acid(GABA), the most common inhibitory neurotransmitterin the brain. GABA suppressesthe rapid firing of neurons by inhibitingvoltage-sensitive sodium channels.ContraindicationsHepatic dysfunction; hypersensitivity tovalproic acid, valproate sodium, divalproexsodium, or their components; urea cycledisordersInteractionsDRUGSaspirin, heparin, NSAIDs, oral anticoagulants,thrombolytics: Increased inhibition ofplatelet aggregation and risk of bleedingbarbiturates, primidone: Increased bloodlevels of both drugs, additive CNS effectscarbamazepine: Possibly decreased valproicacid effectivenesscarbapenem antibiotics (ertapenem, imipenem,meropenem): Reduced serum valproicacid level, causing loss of seizure controlcholestyramine: Decreased bioavailability ofvalproic acidclonazepam: Increased risk of absenceseizuresCNS depressants: Increased CNS depressiondiazepam: Inhibited diazepam metabolismethosuximide: Unpredictable blood ethosuximidelevelfelbamate: Impaired valproic acid metabolismand increased blood drug levelhaloperidol, loxapine, MAO inhibitors,maprotiline, phenothiazines, thioxanthenes,tricyclic antidepressants: Increased CNSdepression, lowered seizure thresholdlamotrigine: Decreased lamotrigine clearancemefloquine: Decreased blood levels of valproicacid, divalproex, and valproate sodium;increased risk of seizuresphenytoin: Increased risk of phenytoin toxicity,loss of seizure controlACTIVITIESalcohol use: Additive CNS depressionAdverse ReactionsCNS: Agitation, ataxia, confusion, depression,dizziness, drowsiness, euphoria, hallucinations,headache, hyperesthesia,hypothermia, lack of coordination, lethargy,loss of seizure control, paresthesia, psychosis,sedation, suicidal ideation, tremor,vertigo, weaknessEENT: Diplopia, nystagmus, pharyngitis,spots before eyesENDO: Galactorrhea, hyperglycemiaGI: Abdominal pain, anorexia, constipation,diarrhea, elevated liver function test results,hepatotoxicity, increased appetite, indigestion,nausea, pancreatitis, vomitingGU: Menstrual irregularitiesHEME: Eosinophilia, hematoma, leukopenia,prolonged bleeding time, thrombocytopeniaMS: Dysarthria

SKIN: Alopecia, diaphoresis, erythemamultiforme, jaundice, petechiae, photosensitivity,pruritus, rash, Stevens-Johnson syndromeOther: Facial edema, hyperammonemia,injection site pain, weight gain or lossNursing Considerations• Give oral valproic acid or divalproex withfood to minimize GI irritation, if needed.• Administer drug at least 2 hours before or6 hours after cholestyramine.• Don’t mix syrup with carbonated beverages;result ay be an unpleasant-tastingmixture and irritate mouth and throat.• Don’t break or let patient chew delayedreleasetablets.• As needed, sprinkle contents of delayedreleasesprinkle capsules on small amountof semisolid food just before administration.Instruct patient not to chew contentsof delayed-release sprinkle capsules.• For I.V. administration, dilute prescribeddose with at least 50 ml compatible diluentand infuse over 60 minutes.• Patient should be switched from I.V. to P.O.form of valproic acid as soon as possible.• Patient with hypoalbuminemia or anotherprotein-binding deficiency is at increasedrisk for valproic acid toxicity.• Watch for evidence of decreased hepaticfunction, including anorexia, facial edema,jaundice, lethargy, loss of seizure control,malaise, vomiting, and weakness.• Monitor liver function test results, asordered. Assess for signs and symptoms ofhepatotoxicity during first 6 months oftreatment, especially in children under age2. Notify prescriber immediately if yoususpect hepatotoxicity.• Monitor platelet count, as ordered, forsigns of thrombocytopenia, and notifyprescriber if they appear.WARNING Hyperammonemia may occureven if liver function test results are normal.Monitor ammonia levels, as ordered.If patient develops unexplained lethargy,vomiting, or changes in mental status withan increase in ammonia level; if asymptomaticammonia elevations are detectedand persist; or if patient developshypothermia even without hyperammonemia,expect to discontinue valproic acid.• Watch patient closely for suicidal tendencies,particularly when therapy starts anddosage changes, because depression mayworsen temporarily during these times,possibly leading to suicidal ideation.• Monitor patient’s drug level, as ordered,especially early in therapy and if patienttakes other drugs because interactions canalter the blood level.• Drug may alter urine ketone test and thyroidfunction tests.PATIENT TEACHING• Instruct patient to swallow capsules wholeto prevent irritation to mouth and throat.However, delayed-release sprinkle capsulesmay be opened and contents mixed withfood for easier swallowing. Instruct patientnot to chew contents of delayed-releasesprinkle capsules.• Advise patient to avoid hazardous activitiesduring therapy because drug mayaffect mental and motor performance.• Urge patient to avoid alcohol during therapy.• Urge woman to notify prescriber at onceabout suspected or known pregnancy.• Advise patient to notify prescriber iftremor develops during therapy; it may bedose-related.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes.• Encourage woman who becomes pregnantwhile taking valproic acid to enroll in theNorth American antiepileptic drug pregnancyregistry by calling 1-888-233-2334.Explain that the registry is collectinginformation about the safety of antiepilepticdrugs during pregnancy.valsartanDiovanvalsartan 1075Class and CategoryChemical class: Nonpeptide tetrazole derivativeTherapeutic class: AntihypertensivePregnancy category: C (first trimester), D(later trimesters)Indications and Dosages To manage hypertension, alone or withother antihypertensivesCAPSULESAdults. Initial: 80 or 160 mg daily,increased as needed and prescribed.UVW

1076vancomycin hydrochlorideMaximum: 320 mg/day.Children ages 6 to 16. 1.3 mg/kg (up to40 mg total) once daily, increased as neededand prescribed. Maximum: 2.7 mg/kg (upto 160 mg) daily. To treat New York Heart Association(NYHA) class II to IV heart failureCAPSULESAdults. Initial: 40 mg b.i.d., increased to80 mg b.i.d. and then 160 mg b.i.d., as neededand prescribed. Maximum: 320 mg daily. To reduce cardiovascular mortality instable patients with left ventricular failureor dysfunction following an MICAPSULESAdults. Initial: 20 mg b.i.d. starting as earlyas 12 hr after MI, increased to 40 mg b.i.d.within 7 days, followed by subsequentadjustments to 160 mg b.i.d., as tolerated.Maintenance: 160 mg b.i.d.DOSAGE ADJUSTMENT If patient developssymptomatic hypotension or renal dysfunction,dosage decreased.Route Onset Peak DurationP.O. 2 hr 6 hr 24 hrMechanism of ActionBlocks the hormone angiotensin II frombinding to receptor sites in vascular smoothmuscle, adrenal glands, and other tissues.This action inhibits vasoconstrictive andaldosterone-secreting effects of angiotensinII, thereby reducing blood pressure.ContraindicationsHypersensitivity to valsartan or its componentsInteractionsDRUGSantihypertensives, diuretics: Additive hypotensiveeffectpotassium salts, potassium-sparing diuretics:Possibly hyperkalemiaFOODSpotassium-containing salt substitutes:Possibly hyperkalemiaAdverse ReactionsCNS: Dizziness, fatigue, headache, insomniaCV: Edema, hypotension, vasculitisEENT: Pharyngitis, rhinitis, sinusitisGI: Abdominal pain, diarrhea, elevatedliver enzymes, hepatitis, indigestion, nausea,vomitingGU: Increased blood creatinine levelHEME: ThrombocytopeniaMS: Arthralgia, back pain, rhabdomyolysisRESP: Cough, upper respiratory tract infectionSKIN: Alopecia, rashOther: Angioedema, hyperkalemia, viralinfectionNursing Considerations• Valsartan shouldn’t be given to patientswho have hypovolemia or are taking adiuretic because of increased risk of severehypotension from volume depletion.• Check patient’s blood pressure often duringtherapy.• Be aware that maximal blood pressurereduction typically occurs after 4 weeks.• Monitor serum potassium level becausedrug may elevate potassium level byblocking aldosterone secretion.PATIENT TEACHING• Instruct patient to take valsartan exactly asprescribed at the same time each day tomaintain therapeutic effect.• Advise patient to avoid hazardous activitiesuntil drug’s CNS effects are known.• Advise patient to avoid using potassiumcontainingsalt substitutes without consultingprescriber.• Instruct female patient of childbearing ageto use reliable birth control during therapyand to notify prescriber at once aboutknown or suspected pregnancy becausevalsartan will need to be discontinued.• Urge patient to keep follow-up appointmentsto monitor progress.vancomycinhydrochlorideVancocinClass and CategoryChemical class: Tricyclic glycopeptide derivativeTherapeutic class: AntibioticPregnancy category: B (oral), C (parenteral)Indications and Dosages To treat pseudomembranous colitis

caused by Clostridium difficile and enterocolitiscaused by staphylococciCAPSULES, ORAL SOLUTIONAdults and adolescents. 125 to 500 mgevery 6 hr for 7 to 10 days. Maximum: 2 gdaily.Children. 10 mg/kg (up to 125 mg) every6 hr for 7 to 10 days. Maximum: 2 g daily. To treat bacterial endocarditis caused bymethicillin-resistant StaphylococcusaureusI.V. INFUSIONAdults. 30 mg/kg daily in equally divideddoses b.i.d. for 4 to 6 wk. Maximum: 2 gdaily. As adjunct to treat bacterial endocarditiscaused by methicillin-resistant S. aureusin patients with prosthetic heart valveI.V. INFUSIONAdults. 30 mg/kg daily in equally divideddoses b.i.d. to q.i.d. for 6 wk or longer inconjunction with rifampin and gentamicin.Maximum: 2 g daily. To treat bacterial endocarditis caused byStreptococcus bovis or StreptococcusviridansI.V. INFUSIONAdults. 30 mg/kg daily in equally divideddoses b.i.d. for 4 wk. Maximum: 2 g daily. As adjunct to treat bacterial endocarditiscaused by enterococciI.V. INFUSIONAdults. 30 mg/kg daily in equally divideddoses b.i.d. for 4 to 6 wk in conjunctionwith gentamicin. Maximum: 2 g daily. To treat bacterial septicemia, bone andjoint infections, pneumonia, and skinand soft-tissue infections caused bystaphylococcus, including methicillinresistantstrains, and life-threateninginfectionsI.V. INFUSIONAdults and children age 12 and over.500 mg every 6 hr or 1 g every 12 hr infusedover at least 60 min. Maximum: 4 g daily.Children ages 1 month to 12 years. 10 mg/kg every 6 hr or 20 mg/kg every 12 hrinfused over at least 60 min.Neonates ages 1 week to 1 month. Initial:15 mg/kg followed by 10 mg/kg every 8 hrinfused over at least 60 min.Neonates under age 1 week. Initial: 15 mg/kg followed by 10 mg/kg every 12 hrinfused over at least 60 min.vancomycin hydrochloride 1077Mechanism of ActionInhibits bacterial RNA and cell wall synthesis;alters permeability of bacterial membranes,causing cell wall lysis and cell death.IncompatibilitiesDon’t give I.V. vancomycin through sameI.V. line as other drugs. Don’t add to albumin-containingsolutions, alkaline solutions,aminophylline, amobarbital sodium,aztreonam, cefepime, ceftazidime, chloramphenicolsodium succinate, chlorothiazidesodium, dexamethasone sodium phosphate,foscarnet sodium, heparin sodium, methicillinsodium, penicillin G, pentobarbitalsodium, phenobarbital sodium, piperacillinsodium and tazobactam sodium, secobarbitalsodium, and sodium bicarbonate.Vancomycin may precipitate with heavymetals.ContraindicationsHypersensitivity to vancomycin or its components,hypersensitivity to corn or cornproducts when vancomycin is given withdextrose solutionsInteractionsDRUGSaminoglycosides (amikacin, gentamicin,tobramycin), amphotericin B, bacitracin(parenteral), bumetanide, capreomycin, carmustine,cidofovir, cisplatin, cyclosporine,ethacrynic acid, furosemide, paromomycin,pentamidine (parenteral), polymyxins, salicylates(parenteral), streptozocin: Additivenephrotoxicity or ototoxicityantihistamines, buclizine, cyclizine, meclizine,phenothiazines, thioxanthenes, trimethobenzamide:Masked symptoms of ototoxicitycholestyramine, colestipol: Decreased antibacterialactivity of oral vancomycindexamethasone: Decreased penetration ofvancomycin into CSFnephrotoxic drugs: Increased risk of nephrotoxicityAdverse ReactionsCNS: Chills, dizziness, vertigoCV: HypotensionEENT: OtotoxicityGI: Nausea, pseudomembranous colitisGU: NephrotoxicityHEME: Eosinophilia, neutropeniaRESP: Dyspnea, wheezingSKIN: Exfoliative dermatitis; drug rash withUVW

1078Mechanism of ActionEnhances effect of nitric oxide (released inthe penis by sexual stimulation) andinhibits phosphodiesterase type 5, whichincreases cGMP level, relaxes smooth muscle,and increases blood flow into the corvardenafilhydrochlorideeosinophilia and systemic symptoms(DRESS); extravasation with pain, tenderness,thrombophlebitis, and tissue necrosis;pruritus; rash; toxic epidermal necrolysis;urticariaOther: Anaphylaxis, drug-induced fever,injection site inflammation, superinfectionNursing Considerations• To reconstitute 500-mg vial of vancomycinfor I.V. use, add 10 ml of sterile water forinjection; further dilute with at least 100ml of compatible I.V. solution. For 1-g vialof dry, sterile powder, add 20 ml of sterilewater for injection; further dilute with atleast 200 ml of compatible I.V. solution.WARNING Infuse over at least 1 hour. Rapiddelivery may cause hypotension or transient“red man syndrome,” characterizedby chills; fainting; fever; flushing of face,neck, upper arms, and torso; hypotension;nausea; tachycardia; and vomiting.• Monitor blood vancomycin levels, asordered; therapeutic levels are 10 to 15 mcg/ml trough and 30 to 40 mcg/ml peak.• Monitor serum vancomycin concentrationin patients with renal impairment or colitisbecause significant increases in blooddrug level have occurred in such patientstaking multiple oral doses of vancomycin.• If patient has an inflammatory intestinaldisorder, assess him often for adverse reactionsbecause vancomycin absorption maybe increased in these conditions.• Check CBC results and serum creatinineand BUN levels during therapy, especiallyif patient has renal impairment or takes anaminoglycoside.• Observe I.V. infusion site for evidence ofextravasation, including necrosis, pain,tenderness, and thrombophlebitis. Ifextravasation occurs, discontinue infusionimmediately and notify prescriber.• Assess hearing during therapy. Transientor permanent ototoxicity may occur ifpatient receives an excessive amount ofdrug, has an underlying hearing loss, orreceives concurrent aminoglycosides.• Monitor patient closely for diarrheabecause it may indicate pseudomembranouscolitis aused by Clostridium difficile,a risk with many antibiotics. If diarrheaoccurs during therapy, notify prescriberand expect to withhold drug. If confirmed,treat with fluids, electrolytes, protein,and an antibiotic effective against C.difficile.PATIENT TEACHING• Instruct patient to use a calibrated measuringdevice to accurately measure dosesof oral solution.• Advise patient to notify prescriber if noimprovement occurs after a few days.• Instruct patient to complete full course ofvancomycin, as prescribed.• Instruct patient to notify prescriber if shedevelops severe or persistent diarrhea.• Instruct patient to keep follow-upappointments during and after treatment.vardenafilhydrochlorideLevitraClass and CategoryChemical class: Phosphodiesterase type 5inhibitorTherapeutic class: Anti-impotence agentPregnancy category: BIndications and Dosages To treat erectile dysfunctionTABLETSAdults. 10 mg taken 1 hr before sexualactivity; increased to 20 mg or decreased to5 mg, as needed. Maximum: 20 mg andonce-daily limit regardless of dosage.DOSAGE ADJUSTMENT If patient takes ritonavir,vardenfil dosage shouldn’t exceed2.5 mg in 72 hr. If patient takes indinavir,saquinavir, atazanavir, clarithromycin, ketoconazole400 mg daily, itraconazole 400 mgdaily, or another potent CYP3A4 inhibitor,vardenafil dosage shouldn’t exceed 2.5 mg in24 hr. If patient takes ketoconazole 200 mgand itraconazole 200 mg daily, vardenafildosage shouldn’t exceed 5 mg in 24 hr.Route Onset Peak DurationP.O. 30 min 30 min–2 hr 4–5 hr

pus cavernosum, producing an erection.ContraindicationsConcurrent administration of alpha blockers,concurrent continuous or intermittentnitrate therapy, hypersensitivity to vardenafilor its componentsInteractionsDRUGSalpha blockers, nitrates: Profound hypotensionatazanavir, clarithromycin, erythromycin,indinavir, itraconazole, ketoconazole, ritonavir,saquinavir: Increased vardenafil effectsclass IA (procainamide, quinidine) and classIII (amiodarone, sotalol) antiarrhythmics:Possibly increased QT-interval prolongationindinavir, ritonavir: Reduced blood levels ofindinavir and ritonavirFOODSgrapefruit juice: Possibly increased vardenafileffectAdverse ReactionsCNS: Dizziness, headache, seizures, transientglobal amnesiaCV: HypotensionEENT: Decreased vision, hearing loss,nonarteritic anterior ischemic optic neuropathy,rhinitis, sinusitis, tinnitusGI: Indigestion, nauseaMS: Back painSKIN: FlushingOther: Flulike symptoms, increased creatinekinase levelNursing Considerations• Vardenafil shouldn’t be used by men takingclass IA (procainamide, quinidine) orclass III (amiodarone, sotalol) antiarrhythmicsor by men who have congenital prolongedQT interval. Drug may potentiateprolonged QT interval.• Use vardenafil cautiously in men withrenal or hepatic dysfunction, in elderlymen, and in men with penile abnormalitiesthat may predispose them to priapism.• Also use cautiously in patients with leftventricular outflow obstruction, such asaortic stenosis, and those with severelyimpaired autonomic control of bloodpressure. These conditions increase sensitivityto vasodilators, such as vardenafil.• Monitor blood pressure and heart ratebefore and after giving drug, especially ifpatient takes an alpha blocker, because ofincreased risk of symptomatic hypotension.• Monitor patient’s vision, especially if he’sover age 50; has diabetes, hypertension,coronary artery disease, or hyperlipidemia;or smokes, because vardenafil rarely leadsto nonarteritic ischemic optic neuropathyand decreased vision, possibly permanent.• Monitor patient’s hearing. Suddendecrease or loss, possibly with tinnitus anddizziness, may occur with vardenafil use.Report such changes immediately, andexpect drug to be discontinued.PATIENT TEACHING• For best results, tell patient to take drug1 hour before anticipated sexual activity.WARNING Tell patient not to take vardenafilif he takes an organic nitrate, continuouslyor intermittently, or within 4 hoursof taking an alpha blocker because profoundhypotension and death could result.• Caution patient not to take vardenafilmore than once daily or to exceed 20 mgdaily.• Tell patient to stop taking vardenafil andnotify prescriber if he has a sudden loss ofvision in one or both eyes, sudden hearingloss, seizures, or trouble remembering.• Advise patient to seek sexual counseling toenhance drug’s effects.• To avoid possible penile damage and permanentloss of erectile function, urgepatient to notify prescriber at once if erectionis painful or lasts longer than 4 hours.vareniclineChantixvarenicline 1079Class and CategoryChemical class: Tartrate saltTherapeutic class: Nicotinic blockerPregnancy classification: CIndications and Dosages As adjunct to smoking cessation treatmentTABLETSAdults. Initial: 0.5 mg daily for 3 days; thenincreased to 0.5 mg b.i.d. for 4 days, andthen increased to 1 mg b.i.d. for a total of12 wk of therapy. If effective, an additional12 wk of therapy may be given.DOSAGE ADJUSTMENT If patient has severerenal impairment, maximum dosage isUVW

1080varenicline0.5 mg b.i.d. If patient is having hemodialysisfor end-stage renal disease, maximumdosage is 0.5 mg daily.Mechanism of ActionBlocks nicotine from activating alpha 4 beta 2receptors by binding to them. This inhibitsnicotine stimulation of the central nervousmesolimbic dopamine system, which probablyis the area that produces pleasure inand reinforcement of smoking.ContraindicationsHypersensitivity to varenicline or its componentsInteractionsDRUGSnicotine (transdermal): Increased adversereactionsAdverse ReactionsCNS: Abnormal dreams, agitation, anxiety,asthenia, attention difficulties, behaviorchanges, delusions, depression, dizziness,dysgeusia, fatigue, hallucinations, headache,homicidal ideation, hostility, insomnia, irritability,lethargy, loss of consciousness,malaise, mania, mental impairment, panic,paranoia, psychosis, restlessness, sensorydisturbances, seizures, somnolence, stroke,suicidal ideation, thirstCV: Angina, chest pain, edema, hypertension,MI, peripheral ischemia, thrombosis,ventricular extrasystolesEENT: Dry mouth, epistaxis, gingivitis,rhinorrheaENDO: Hot flashesGI: Abdominal pain, acute pancreatitis,anorexia, constipation, diarrhea, dyspepsia,flatuence, gastroesophageal reflux disease,GI hemorrhage, increased appetite, liverenzyme abnormalities, nausea, vomitingGU: Acute renal failure, polyuria, urineretentionHEME: Leukocytosis, lymphadenopathy,splenomegaly, thrombocytopeniaRESP: Asthma, dyspnea, pulmonaryembolismMS: Arthralgia, back pain, muscle cramp,musculoskeletal pain, myalgiaSKIN: Diaphoresis, erythema multiforme,pruritus, rash, Stevens-Johnson syndrome,urticariaOther: Angioedema, flulike syndrome, hyperkalemia,hypersensitivity, hypokalemiaNursing Considerations• Use cautiously in patients with renal diseasebecause varenicline is substantiallyexcreted by the kidneys.• Review patient’s medication history beforestarting varenicline because dosage adjustmentsmay be needed for such drugs astheophylline, warfarin, and insulin.WARNING Monitor patient for angioedema,difficult breathing, rash with mucosallesions, or other signs of hypersenstivity.Report immediately, stop varenicline therapy,and provide supportive emergencycare, as prescribed.• If patient has nausea, the most commonadverse reaction to varenicline, notify prescriber.Dosage reduction may help.• Even with varenicline therapy, nicotinewithdrawal symptoms and worsening ofunderlying psychiatric illness may occurwith smoking cessation. Monitor patientfor neurospychiatric symptoms, includingchanges in behavior, hostility, agitation,depressed mood, suicidal ideation, andworsening of pre-existing psychiatric illness.If present, notify prescriber immediately,institute safety measures, and expectdrug to be discontinued.• Watch patient closely for suicidal tendencies,particularly when therapy starts anddosage changes, because depression mayworsen temporarily during these times,possibly leading to suicidal ideation.PATIENT TEACHING• Explain that using nicotine patches whiletaking varenicline won’t increase its effectivenessand may increase adverse reactionssuch as dizziness, nausea, and vomiting.• Instruct patient to set a date to quit smokingand then start taking varenicline1 week before the quit date.• Explain how to adjust dose when drug isused for smoking cessation. Tell patient totake drug after eating and with a full glassof water.• Encourage patient to continue trying tostop smoking even if an early relapseoccurs during varenicline therapy.WARNING Tell patient to seek medical attentionimmediately if he develops swelling ofhis face, mouth, limbs, or neck; difficultybreathing; mucosal lesions; or any othersigns of hypersensitivity during therapy.• Inform patient that the most common

vasopressin 1081adverse reactions to varenicline therapyare nausea and insomnia, usually transient.If they persist, patient should notifyprescriber; dosage reduction may help.• Caution patient to avoid hazardous activitiesuntil CNS effects of drug are known.Explain that near miss traffic accidentsand other accidential injuries haveoccurred in patients taking varenicline.•Explain that vivid, unusual, or strangedreams may occur during therapy.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes.• Tell patient that nicotine withdrawal canoccur even with varenicline use and thatpre-existing mental illness may worsenduring smoking cessation. Advise patientor family to notify prescriber about abnormalthinking or behavior and to stop takingdrug immediately.vasopressin(antidiuretic hormone[ADH])Pitressin, Pressyn (CAN)Class and CategoryChemical class: Polypeptide hormoneTherapeutic class: AntidiureticPregnancy category: CIndications and Dosages To prevent or control symptoms ofcentral diabetes insipidus caused byinsufficient ADHI.M. OR SUBCUTANEOUS INJECTIONAdults. 5 to 10 units b.i.d. or t.i.d., as needed.Children. 2.5 to 10 units t.i.d. or q.i.d., asneeded. To prevent or treat abdominal distentionI.M. INJECTIONAdults. 5 units, increased to 10 units every3 to 4 hr, as needed.Route Onset Peak DurationI.M., SubQ Unknown Unknown 2–8 hrContraindicationsChronic nephritis with nitrogen retention,hypersensitivity to vasopressin or its componentsInteractionsDRUGScarbamazepine, chlorpropamide, clofibrate,fludrocortisone, tricyclic antidepressants:Increased antidiuretic effectdemeclocycline, lithium, norepinephrine:Decreased antidiuretic effectAdverse ReactionsCNS: Dizziness, headache, light-headedness,tremorCV: Angina, MIEENT: Circumoral pallorENDO: Water intoxicationGI: Abdominal cramps, diarrhea, eructation,flatulence, intestinal hypermotility,nausea, vomitingSKIN: Diaphoresis, pallorOther: Allergic reactionMechanism of ActionVasopressin, a synthetic form of antidiuretichormone, treats diabetes insipidusby decreasing urine output andraising urine osmolality. When vasopressinattaches to vasopressin2 (V2)receptors on cell membranes in thenephron’s collecting duct, it activatesthe enzyme adenyl cyclase to convertadenosine triphosphate (ATP) to cyclicadenosine monophosphate (cAMP).This action increases the collectingduct’s permeability and enhanceswater reabsorption into the blood.VasopressinV 2 receptorH 2 OATPAdenylcyclaseH 2 OcAMPH 2 OH 2 OBlood vesselCollectingductUVW

1082venlafaxine hydrochlorideNursing Considerations• Use vasopressin with extreme caution inpatients with coronary artery diseasebecause it may cause angina or MI; inthose with hypertension because it mayincrease blood pressure; and in those withasthma, epilepsy, heart failure, or migraineheadache because extracellular fluid mayincrease rapidly.• Monitor fluid and electrolyte balance duringtherapy. Check intake and output atleast every 8 hours, and watch for evidenceof water intoxication and hyponatremia,including anuria, confusion, drowsiness,headache, listlessness, and weight gain.PATIENT TEACHING• Teach patient how to administer vasopressin;stress the need to rotate injection sites.• Urge patient to notify prescriber immediatelyif he has evidence of possible waterintoxication, including anuria, confusion,drowsiness, headache, listlessness, andunexplained weight gain.• Inform patient that abdominal cramps,nausea, and skin blanching will subsideafter a few minutes and can be minimizedby drinking one or two glasses of water.venlafaxinehydrochlorideEffexor, Effexor XRdesvenlafaxinesuccinatePristiqClass and CategoryChemical class: Phenylethylamine derivativeTherapeutic class: AntidepressantPregnancy category: CIndications and Dosages To treat and prevent relapse of majordepressionE.R. CAPSULES (EFFEXOR XR)Adults. 75 mg daily with a meal at sametime each day, morning or evening (forsome patients, 37.5 mg daily for 4 to 7 daysbefore increasing to 75 mg daily); thenincreased by 75 mg daily every 4 days, asprescribed. Maximum: 225 mg daily.DOSAGE ADJUSTMENT Initial daily dosedecreased by 25% to 50% for patients withmild to moderate renal impairment and by50% for patients with hepatic impairment.E.R. TABLETS (PRISTIQ)Adults. 50 mg daily, with a meal, at thesame time each day morning or eveningDOSAGE ADJUSTMENT For patients withsevere renal impairment and for elderlypatients having difficulty tolerating drug,50 mg every other day.TABLETS (EFFEXOR)Adults. 75 mg daily in divided doses b.i.d.or t.i.d., increased by 75 mg daily every4 days, as prescribed. Maximum: 375 mgdaily (225 mg/day for outpatients). To treat generalized anxiety disorder orsocial anxiety disorderE.R. CAPSULES (EFFEXOR XR)Adults. 75 mg daily with a meal at sametime each day, morning or evening (forsome patients, 37.5 mg daily for 4 to 7 daysbefore increasing to 75 mg daily); thenincreased by 75 mg daily every 4 days, asprescribed. Maximum: 225 mg daily.DOSAGE ADJUSTMENT Initial daily dosedecreased by 25% to 50% for patients withmild to moderate renal impairment and by50% for patients with hepatic impairment.Route Onset Peak DurationP.O. 2 wk Unknown UnknownMechanism of ActionInhibits neuronal reuptake of serotonin andnorepinephrine, along with its activemetabolite, O-desmethylvenlafaxine. Theseactions raise serotonin and norepinephrinelevels at nerve synapses, elevating moodand reducing depression.ContraindicationsHypersensitivity to desvenlafaxine, venlafaxine,or their components; use of anMAO inhibitor within 14 daysInteractionsDRUGSamitriptyline, clomipramine, desipramine,doxepin, haloperidol, imipramine, linezolid,lithium, nortriptyline, protriptyline, St. John’swort, tramadol, trazodone, triptans: Possiblyserotonin syndromeaspirin, NSAIDs, warfarin: Increased risk ofbleeding

cimetidine: Decreased clearance andincreased levels of desvenlafaxine and venlafaxineclozapine: Possibly increased blood clozapinelevel and serious adverse reactions,including seizuresCYP3A4 inhibitors, ketoconazole: Increasedplasma venlafaxine level and risk of adversereactionsMAO inhibitors: Increased risk of hypertension;hyperthermia; mental status changes,including coma and delirium; muscle rigidity;and severe myoclonusmetoprolol: Increased plasma metoprolollevel but decreased effectiveness in loweringblood pressurewarfarin: Possibly increased PT, partialthromboplastin time, and INRAdverse ReactionsCNS: Abnormal dreams, agitation, amnesia,anxiety, asthenia, cerebral ischemia, chills,confusion, delusions, depersonalization,depression, dizziness, dream disturbances,drowsiness, dyskinesia, fever, headache,hyp-esthesia, hypomania, impaired balanceand coordination, insomnia, mania,migraine, mood changes, nervousness, neurolepticmalignant syndrome, paresthesia,seizures, serotonin syndrome, somnolence,suicidal ideation, syncope, tremor, vertigoCV: Arrhythmias, AV block, chest pain,congestive heart failure, elevated cholesteroland triglyceride levels, edema, extrasystoles,hypertension, hypotension, MI, palpitations,sinus tachycardia, thrombophlebitis,vasodilation, worsening of peripheral vasculardiseaseEENT: Abnormal vision, accommodationabnormality, angle-closure glaucoma,blurred vision, dry mouth, mydriasis,pharyngitis, rhinitis, taste alteration, tinnitusENDO: Hyperglycemia, syndrome of inappropriateADH secretionGI: Abdominal pain, anorexia, colitis, constipation,diarrhea, elevated liver enzymes,flatulence, GI hemorrhage, indigestion,nausea, vomitingGU: Anorgasmia (women), decreased libido,ejaculation disorder, impotence, urinaryincontinence or urgency, urine retentionHEME: Anemia, leukocytosis, leukopenia,lymphadenopathy, thrombocytopeniaMS: Neck pain, rhabdomyolysisNursing Considerations• Use cautiously in patients with a history ofmania because desvenlafaxine and venlafaxinetherapy may worsen condition.Also use cautiously in patients with a historyof seizures, and expect to discontinuedrug, as ordered, if seizures occur.• Use cautiously in patients who have medicalconditions that might be made worseby an increased heart rate, as in hyperthyroidism,heart failure, or recent MI.WARNING Be aware that serotonin syndromein its most severe form may resembleneuroleptic malignant syndrome,which includes hyperthermia, musclerigidity, autonomic instability with possiblyrapid changes in vital signs, and mentalstatus changes. Stop drug immediatelyand provide supportive care.• Monitor blood pressure often during therapybecause it may cause dose-related sustainedincrease in supine diastolic pressure.Expect to reduce or stop drug, asprescribed, if increase develops.• Assess patient’s electrolyte balance, asordered, because drug can cause hyponatremia,especially in elderly patients and inpatients who take diuretics or are volumedepleted.If patient has evidence ofhyponatremia (headache, trouble concentrating,confusion, weakness, unsteadiness),notify prescriber. If imbalance isconfirmed, expect to stop drug and giveappropriate care.• Watch patient for suicidal tendencies,especially when therapy starts and dosagechanges.WARNING Drug shouldn’t be stoppedabruptly because doing so may cause multipleadverse effects, including asthenia,dizziness, headache, insomnia, nervousness,and flulike symptoms.PATIENT TEACHING• Instruct patient not to crush or chew E.R.capsules or tablets. If she has trouble swallowingcapsules, tell her to open capsule,sprinkle contents on a spoonful of applevenlafaxinehydrochloride 1083RESP: Cough, eosinophilic pneumonia,increased dyspnea, interstitial lung diseaseSKIN: Diaphoresis, ecchymosis, pruritus,Stevens-Johnson syndrome, toxic epidermalnecrolysisOther: Angioedema, hyponatremia, weightlossUVW

1084verapamilsauce, and swallow immediately withoutchewing, followed by a glass of water.• Advise patient to avoid alcohol duringvenlafaxine therapy.• Advise patient not to stop taking desvenlafaxineor venlafaxine abruptly.• Caution patient to notify prescriber if shebecomes pregnant during therapy becauseshe’ll need a different antidepressant.Taking desvenlafaxine or venlafaxine duringthird trimester of pregnancy increasesrisk of complications in the newborn.• Advise patient to tell prescriber about allother prescribed drugs or OTC productsshe takes because of risk of interactions.• Urge caregivers to monitor patient closelyfor suicidal tendencies, especially whentherapy starts or dosage changes.• Caution patient to avoid aspirin andNSAIDs, if possible, while taking desvenlafaxineor venlafaxine.WARNING Tell patient to immediatelyreport sudden onset, severe, or persistentsymptoms.verapamilApo-Verap (CAN), Calan, Isoptin,Novo-Veramil (CAN), Nu-Verap (CAN)verapamilhydrochlorideCalan SR, Isoptin SR, VerelanClass and CategoryChemical class: Phenylalkylamine derivativeTherapeutic class: Antianginal, antiarrhythmic,antihypertensivePregnancy category: CIndications and Dosages To treat chronic angina pectorisTABLETS (VERAPAMIL)Adults and adolescents age 15 and over.Initial: 80 to 120 mg t.i.d., increased everyday or wk, as needed and prescribed.Maximum: 480 mg daily in divided doses.Infants and children up to age 15. 4 to8 mg/kg daily in divided doses. To manage hypertensionE.R. CAPSULES (VERAPAMIL HYDROCHLORIDE)Adults and adolescents. Initial: 240 mgdaily, increased every day or wk, as neededand prescribed. Maximum: 480 mg daily.E.R. TABLETS (VERAPAMIL HYDROCHLORIDE)Adults and adolescents. Initial: 180 mgdaily, increased every day or wk, as neededand prescribed, according to followingschedule: 240 mg daily in the morning;180 mg every 12 hr or 240 mg in the morningand 120 mg in the evening; then 240 mgevery 12 hr. Maximum: 480 mg daily individed doses.TABLETS (VERAPAMIL)Adults and adolescents age 15 and over.Initial: 80 to 120 mg t.i.d., increased everyday or wk, as needed and prescribed.Maximum: 480 mg daily in divided doses.Infants and children up to age 15. 4 to8 mg/kg daily in divided doses. To prevent or treat supraventriculartachycardiaTABLETS (VERAPAMIL)Adults and adolescents age 15 and over.Initial: 80 to 120 mg t.i.d., increased everyday or wk, as needed and prescribed.Maximum: 480 mg daily in divided doses.DOSAGE ADJUSTMENT Initial P.O. dosagepossibly reduced to 40 mg t.i.d. (120 mgdaily for E.R. tablets or capsules) for elderlypatients and those with impaired hepatic orleft ventricular function.I.V. INJECTION (VERAPAMIL HYDROCHLORIDE)Adults and adolescents age 15 and over.Initial: 5 to 10 mg slowly over 2 min; then10 mg, as prescribed, if response isn’t adequateafter 30 min.Children ages 1 to 15. Initial: 100 to300 mcg/kg slowly over 2 min, up to maximumof 5 mg; then 10 mg, as prescribed, ifresponse isn’t adequate after 30 min.Infants up to age 1. Initial: 100 to 200 mcg/kg slowly over 2 min.DOSAGE ADJUSTMENT I.V. drug administeredover 3 minutes in elderly patients.Mechanism of ActionInhibits calcium movement into coronaryand vascular smooth-muscle cells by blockingslow calcium channels in cell membranes.The resulting decrease in intracellularcalcium level has the following effects:• inhibits smooth-muscle cell contractions• decreases myocardial oxygen demand byrelaxing coronary and vascular smoothmuscle, reducing peripheral vascularresistance, and decreasing systolic anddiastolic pressures

• slows AV conduction time and prolongsAV nodal refractoriness• interrupts reentry circuit in AV nodalreentrant tachycardias.Route Onset Peak DurationP.O. 1–2 hr 30–90 min 6–8 hrP.O. (E.R.) 1–2 hr 30–90 min UnknownI.V. 1–5 min 3–5 min 10 min–6 hrIncompatibilitiesDon’t mix I.V. verapamil with albumin,amphotericin B injection, hydralazinehydrochloride injection, nafcillin, or sulfamethoxazoleand trimethoprim injection.Solutions with pH above 6.0 cause precipitation.ContraindicationsCardiogenic shock, concomitant use of betablockers (with I.V. verapamil), hypersensitivityto verapamil or its components,hypotension, severe heart failure unless secondaryto supraventricular tachycardia thatresponds to verapamil, severe left ventriculardysfunction, sick sinus syndrome orsecond- or third-degree heart block unlessartificial pacemaker is in place, ventriculartachycardia (with I.V. verapamil)InteractionsDRUGSalpha blockers, antihypertensives, generalanesthetics (hydrocarbon), prazosin: Hypotensiveeffectsaspirin: Increased bleeding timebeta blockers: Increased risk of heart failure,hypotension, and severe bradycardiacalcium supplements: Decreased response toverapamilcarbamazepine, cyclosporine, theophylline,valproate: Increased risk of toxicity fromthese drugscimetidine: Decreased metabolism andincreased blood level of verapamilclonidine: Increased risk of severe sinusbradycardiacyclophosphamide, oncovin, procarbazine,prednissone (COPP) regimen; vindesine,adriamycin, cisplatin (VAC) regimen:Decreased verapamil absorptiondantrolene: Increased risk of hyperkalemiaand myocardial depressiondigoxin: Increased blood digoxin level andrisk of digitalis toxicityverapamil 1085disopyramide, flecainide: Additive negativeinotropic effectsdoxorubicin: Increase plasma doxorubicinlevelerythromycin, ritonavir: Increased blood verapamillevellithium: Increased risk of neurotoxicityneuromuscular blockers: Prolonged recoveryfrom neuromuscular blockadeNSAIDs, sympathomimetics: Decreased antihypertensiveeffect of verapamilpaclitaxel: Decreased paclitaxel clearancephenobarbital: Increased verapamil clearanceprocainamide: Increased QT interval, additivenegative inotropic effectsprotein-bound drugs (hydantoins, salicylates,sulfonamides, sulfonylureas, and warfarinand other oral anticoagulants): Alteredblood levels of these drugsquinidine: Increased risk of quinidine toxicity,increased QT interval, additive negativeinotropic effectsrifampin: Decreased bioavailability of oralverapamiltelithromycin: Increased risk of bradyarrhythmias,hypotension, and lactic acidosisFOODSgrapefruit juice: Increased verapamil levelACTIVITIESalcohol use: Increased blood alcohol leveland prolonged CNS effectsAdverse ReactionsCNS: Asthenia, confusion, disequilibrium,dizziness, equilibrium disorders, extrapyramidalreactions, fatigue, headache, insomnia,paresthesia, psychosis, shakiness, somnolence,stroke, syncopeCV: Abnormal ECG, angina, AV conductiondisorders, bradycardia, claudication, heartfailure, hypertension, hypotension, MI, palpitations,peripheral edema, tachycardia,vasculitisEENT: Blurred vision, dry mouth, tinnitusENDO: Gynecomastia, hyperprolactinemiaGI: Constipation, diarrhea, elevated liverfunction test results, GI distress, nauseaGU: Galactorrhea, impotence, increasedurination, menstrual irregularitiesMS: Arthralgia, muscle spasmsRESP: Dyspnea, pulmonary edema,SKIN: Alopecia, diaphroesis, ecchymosis,erythema multiforme, exanthema, flushing,hyperkeratosis, rash, Stevens-Johnson syndrome,urticariaUVW

1086vigabatrinOther: Allergy aggravatedNursing Considerations• Administer I.V. verapamil with compatiblesolutions, including Ringer’s injection,D 5 W, or normal saline solution.• Maintain continuous ECG monitoringand keep emergency resuscitative equipmentand drugs readily available duringI.V. therapy.• Assess patient with hypertrophic cardiomyopathyor idiopathic hypertrophic subaorticstenosis for early development ofhypotension and pulmonary edemabecause second-degree AV block and sinusarrest can result.• Assess for bradycardia and hypotension,and notify prescriber if heart rate or bloodpressure declines significantly.• Disopyramide or flecainide shouldn’t begiven within 48 hours before or 24 hoursafter verapamil because additive negativeinotropic effects can result.• Institute measures to prevent constipation,including a high-fiber diet and a stool softener,as prescribed.PATIENT TEACHING• Instruct patient not to crush or chewverapamil E.R. tablets or capsules. Informher that she may break E.R. tablets in halfif necessary to aid swallowing.• Direct patient to check her pulse beforetaking verapamil and to notify prescriberif it’s below 50 beats/minute or as instructedby prescriber.• Caution patient about possible dizzinessand the need to avoid potentially hazardousactivities until drug’s CNS effectsare known.• Inform patient that adverse skin reactionsmay subside with continued verapamiluse. Advise her to notify prescriber if rashpersists.• Encourage patient to increase dietary fiberintake to help prevent constipation. Adviseher to notify prescriber if problembecomes persistent or severe.vigabatrinSabrilClass and CategoryChemical class: Amino-hexenoic acidTherapeutic: class AnticonvulsantPregnancy category: CIndications and Dosages As adjunct therapy for refractorycomplex partial seizures in patientswith inadequate response to severalalternative treatments and for whompotential benefits outweigh the risk ofvision lossTABLETSAdults. Initial: 500 mg twice daily,increased weekly in 500 mg increments, asneeded. Maximum: 1.5 g twice daily.DOSAGE ADJUSTMENT For patient with mildrenal impairment (creatinine clearance51 to 80 ml/min/1.73 m 2 ), reduce dose by25%. For patients with moderate renalimpairment (creatinine clearance 31 to50 ml/min/1.73 m 2 ), reduce dose by 50%.For patients with severe renal impairment(creatinine clearance 11 to 30 ml/min/1.73 m 2 ), reduce dose by 75%. As monotherapy for pediatric patientswith infantile spasms for whom potentialbenefits outweight risk of vision lossORAL SOLUTIONChildren age 1 month to 2 years. Initial:50 mg/kg/day in 2 divided doses, increasedevery 3 days by 25 to 50 mg/kg/day, asneeded. Maximum: 150 mg/kg/day.DOSAGE ADJUSTMENT For patient with mildrenal impairment (creatinine clearance51 to 80 ml/min), reduce dose by 25%. Forpatients with moderate renal impairment(creatinine clearance 31 to 50 ml/min/1.73 m 2 ), reduce dose by 50%. For patientswith severe renal impairment (creatinineclearance 11 to 30 ml/min/1.73 m 2 ), reducedose by 75%.Route Onset Peak DurationP.O. Unknown 1 hr UnknownMechanism of ActionInhibits the action of gamma aminobutyricacid transaminase (GABA-T), the enzymeresponsible for metabolism of the inhibitoryneurotransmitter GABA. This increasesGABA level in the CNS, which may play arole in suppression of seizure activity.ContraindicationsHypersensitivity to vigabatrin and its components

InteractionsDRUGSphenytoin: Decreased serum phenytoin levelAdverse ReactionsCNS: Abnormal magnetic resonance imaging(MRI), abnormal behavior or dreams,acute psychosis, anxiety, apathy, asthenia,attention disturbance, confusion, coordinationabnormality, delirium, depression,dizziness, encephalopathy, expressive languagedisorder, fatigue, fever, gait disturbance,headache, hyperreflexia, hypertonia,hypoaesthesia, hyporeflexia, hypomania,hypotonia, insomnia, irritability, lethargy,malaise, malignant hyperthermia, memoryloss, myoclonus, nervousness, paraesthesia,peripheral neuropathy, postictal state,seizures, sensory disturbance, somnolence,status epilepticus, suicidal ideation, thirst,tremor, vertigoCV: Chest pain, edema, peripheral edemaEENT: Asthenopia, blurred vision, deafness,diplopia, eye pain, laryngeal edema, nasopharyngitis,nsytagmus, optic neuritis,pharyngolaryngeal pain, tinnitus, toothache,vision loss (severe), visual field defectGI: Abdominal or stomach pain, cholestasis,constipation, decreased liver enzymes,diarrhea, distention, dyspepsia, esophagitis,GI hemorrhage, nausea, vomitingGU: Dysmenorrhea, erectile dysfunction,UTIHEME: AnemiaMS: Arthralgia; back or limb pain; dysarthria;muscle spasticity, spasms or twitchingRESP: Bronchitis, cough, pulmonaryedema, respiratory failure, stridor, upperrespiratory infectionSKIN: Facial edema, maculopapular rash,pruritus,Other: Angioedema, birth defects, developmentaldelay, influenza, multi-organ failure,weight gainNursing Considerations• Vigabatrin therapy is only available undera restricted distribution program calledthe SHARE program (1-888-45-SHARE).WARNING Monitor patient’s vision, andmake sure patient has been examined byan ophthalmic professional in which visualfields and retinal examination has beenperformed no later than 4 weeks aftervigabatrin therapy has begun and thenvigabatrin 1087periodically thereafter because drug cancause progressive and permanent bilateralconcentric visual field constriction andreduce visual acuity. Be aware that whilerisk increases with total dose and durationof therapy, all patients are at risk for visualabnormalities even after drug has beenstopped. Because of the risk of permanentand possibly severe vision loss, drug canbe prescribed and obtained only throughthe SHARE distribution program. Reportany visual abnormalities immediately, andexpect drug to be discontinued.• Abnormal MRI results have been noted insome infants receiving vigabatrin.• Monitor patient for suicidal ideationthroughout therapy but especially whentherapy starts or dosage changes.• When discontinuing vigabatrin therapy,expect to do so gradually by decreasingdaily dose by 1 gram each week until drugis discontinued, as ordered.• When discontinuing vigabatrin therapy inchildren, expect to do so gradually bydecreasing dose by 25 to 50 mg/kg/dayevery 3 to 4 days.• Monitor patient for evidence of peripheralneuropathy, such as numbness or tinglingin toes or feet, reduced distal lower limbvibration or position sense, or progressiveloss of reflexes, starting at the ankles. Alertprescriber if abnormalities are present.• Assess patient routinely for edema, includingperipheral edema.PATIENT TEACHING• Explain the risk of possibly permanentvision loss before patient starts vigabatrin.• Warn patient not to stop taking vigabatrinabruptly; it will need to be weaned offgradually over several weeks.• Advise female patient of childbearing ageto use effective contraception if sexuallyactive and to report suspected or confirmedpregnancy immediately.• Advise patient or caregiver to notify prescriberif patient has unusual feelings orbehaviors, especially if related to suicidalideation and particularly at the beginningof therapy and during dosage adjustments.• Caution patient not to perform hazardousactivities such as operating equipmentuntil CNS effects of the drug are known.• Alert patient to monitor his weightbecause drug may cause weight gain.UVW

1088InteractionsDRUGSalfentanil: Increased plasma alfentanil leveland increased risk of adverse reactionsbenzodiazepines: Possibly prolonged sedavoriconazolevoriconazoleVfendClass and CategoryChemical class: TriazoleTherapeutic class: AntifungalPregnancy category: DIndications and Dosages To treat invasive aspergillosis; to treatserious fungal infections caused byScedosporium apiospermum andFusarium species, including Fusariumsolani, in patients intolerant of orrefractory to other therapyI.V. INFUSIONAdults and children age 12 and over.Initial: 6 mg/kg over 1 to 2 hr at no morethan 3 mg/kg/hr every 12 hr for 2 doses.Maintenance: 4 mg/kg over 1 to 2 hr at nomore than 3 mg/kg/hr every 12 hr.TABLETSAdults and children age 12 and overweighing 40 kg (88 lb) or more.Maintenance: 200 mg every 12 hr, increasedto 300 mg every 12 hr, as needed, and takenat least 1 hr before or after a meal.Adults and children age 12 and overweighing less than 40 kg. Maintenance:100 mg every 12 hr, increased to 150 mgevery 12 hr, as needed, and taken at least1 hr before or after a meal. To treat candidemia in nonneutropenicpatients and other deep-tissue disseminatinatedCandida infections involvingthe abdomen, kidney, bladder wall, skin,or a woundI.V. INFUSIONAdults. Initial: 6 mg/kg over 1 to 2 hr at nomore than 3 mg/kg/hr every 12 hr for2 doses. Maintenance: 3 to 4 mg/kg over1 to 2 hr at no more than 3 mg/kg/hr every12 hr for at least 14 days after symptomsresolve or last positive culture, whichevertakes longer.TABLETSAdults. Maintenance: 200 mg every 12 hrtaken at least 1 hr before or after a meal. To treat esophageal candidiasisTABLETSAdults. 200 mg every 12 hr taken at least1 hr before or after a meal for at least14 days and at least 7 days after signs andsymptoms resolve.DOSAGE ADJUSTMENT If patient can’t toleratedrug, I.V. maintenance dose may bereduced to 3 mg/kg every 12 hr and oralmaintenance dose by 50-mg decrements toat least 200 mg every 12 hr (100 mg every12 hr for patients weighing less than 40 kg).For use with phenytoin, maintenance dosemay be increased to 5 mg/kg I.V. every12 hr or from 200 mg to 400 mg P.O. every12 hr (100 mg to 200 mg every 12 hr forpatients weighing less than 40 kg). Forpatients with mild to moderate hepatic cirrhosis,standard loading dose should beused but maintenance dose halved for I.V.or P.O. use. For patients with moderate tosevere renal insufficiency (creatinine clearancegreater than 50 ml/min/1.73 m 2 ), onlythe oral form should be given, if possible.Mechanism of ActionPrevents fungal ergosterol biosynthesis byinhibiting fungal cytochrome P-450–mediated14 alpha-lanosterol demethylation.The loss of ergosterol in the fungal cell wallrenders the fungal cell inactive.IncompatibilitiesDon’t infuse into the same line or cannulawith other drugs, including parenteralnutrition, to prevent an increase in subvisibleparticulate matter. Avoid infusion withblood products and any electrolyte supplements.Don’t dilute with 4.2% sodiumbicarbonate infusion because the mildlyalkaline nature of the diluent causes slightdegradation of voriconazole after 24 hoursof storage at room temperature.ContraindicationsCoadministration with long-acting barbiturates,carbamazepine, CYP3A4 substrates(astemizole, cisapride, pimozide, quinidine,or terfenadine), efavirenz, ergot alkaloids,rifabutin, rifampin, ritonavir, sirolimus, orSt. John’s wort; hypersensitivity tovoriconazole or its components; galactoseintolerance, glucose-galactose malabsorption,or Lapp lactase deficiency (oral formonly contains lactose)

tive effect of benzodiazepinescalcium channel blockers; HMG-CoA reductaseinhibitors, such as lovastatin; omeprazole;sirolimus: Possibly increased plasmalevels of these drugs, leading to increasedrisk of adverse reactions and toxicitycarbamazepine, long-acting barbiturates,phenytoin, rifampin: Decreased plasmavoriconazole concentrationcoumarin, warfarin: Possibly increased PTTcyclosporine, sirolimus, tacrolimus: Increasedserum concentrations of these drugs andrisk of toxicity, especially nephrotoxicityCYP3A4 substrates (astemizole, cisapride,pimozide, quinidine, terfenadine): Increasedplasma levels of these drugs, which maylead to prolonged QT interval and, rarely,torsades de pointesergot alkaloids (ergotamine, dihydroergotamine):May increase plasma level of ergotalkaloids, leading to ergotismHIV protease inhibitors (amprenavir, nelfinavir,ritonavir, saquinavir), non-nucleosidereverse transcriptase inhibitors (delavirdine,efavirenz): Possibly inhibited metabolism ofthese drugs and voriconazolemethadone: Increased plasma level ofmethadone, possibly leading to toxicity,including QT-interval prolongationoral contraceptives: Increased plasmavoriconazole level and risk of toxicityrifabutin: Increased rifabutin plasma level;decreased voriconazole plasma levelSt. John’s wort: Decreased plasma voriconazolelevelsulfonylureas: Possibly increased plasmalevel of sulfonylureas and increased risk ofhypoglycemiavinca alkaloids: Possibly increased risk ofneurotoxicityAdverse ReactionsCNS: Chills, dizziness, fever, hallucinations,headacheCV: Chest pain, hypertension, hypotension,peripheral edema, tachycardia, vasodilationEENT: Abnormal or blurred vision, alteredor enhanced visual perception, change incolor perception, chromatopsia, dry mouth,eye hemorrhage, photophobia, visual disturbancesGI: Abdominal pain, diarrhea, elevated liverfunction test results, nausea, pancreatitis,vomitingGU: Abnormal kidney function, acute renalvoriconazole 1089failure, elevated serum creatinine levelHEME: Anemia, leukopenia, pancytopenia,thrombocytopeniaRESP: Respiratory disordersSKIN: Cholestatic jaundice, erythema multiforme,jaundice, maculopapular rash,photosensitivity, pruritus, rash, Stevens-Johnson syndrome, toxic epidermal necrolysisOther: Anaphylaxis (I.V. form), elevatedalkaline phosphatase, hypokalemia, hypomagnesemia,sepsisNursing Considerations• Use voriconazole cautiously in patientshypersensitive to other azoles and inpatients at risk for proarrhythmic events(such as those receiving cardiotoxicchemotherapy or those who have cardiomyopathyor hypokalemia) becausesome azoles may prolong the QT interval.• Determine if patient has any problemswith galactose intolerance, Lapp lactasedeficiency, or glucose-galactose malabsorptionbefore starting therapy becausevoriconazole tablets contain lactose andshouldn’t be given to patients with theseconditions.• Obtain specimens for fungal culture andother relevant laboratory studies (includinghistopathology), as ordered, beforegiving first dose. Expect to begin drugbefore test results are known.• Assess patient’s liver function, includingbilirubin, as ordered, at the start ofvoriconazole therapy and periodicallythereafter. Be aware that drug may be discontinuedif liver abnormalities occur.• Check patient’s electrolyte levels and correctany imbalances, as ordered, beforegiving voriconazole because electrolyteimbalances increase the risk of adversereactions.• For I.V. infusion, reconstitute powder with19 ml water for injection to obtain 20 mlof concentrate containing 10 mg/mlvoriconazole. To make sure exact amountof water is injected into vial, use a standard10-ml non-automated syringe. Shakevial until all powder is dissolved. Furtherdilute so final concentration is no less than0.5 mg/ml and no more than 5 mg/ml.This requires withdrawing and discardingat least an equal volume of diluent frominfusion bag or bottle before instillationUVW

1090Mechanism of ActionInterferes with the liver’s ability to synthesizevitamin K–dependent clotting factors,depleting clotting factors II (prothrombin),VII, IX, and X. This action, in turn, interwarfarinsodiumof concentrate.• Discard partially used vials after mixing. Ifinfusion isn’t administered immediately,store at 2° to 8° C (37° to 46° F) for nolonger than 24 hours.• Administer I.V. infusion over 1 to 2 hoursat no more than 3 mg/kg/hr.• Monitor renal function, especially serumcreatinine level, when giving I.V. form ofvoriconazole because drug may accumulatein body when creatinine clearance isless than 50 ml/min/1.73 m 2 , increasingthe risk of adverse reactions.WARNING Observe patient receiving I.V.voriconazole closely for anaphylactoidtypereactions—such as flushing, fever,sweating, tachycardia, chest tightness, dyspnea,faintness, nausea, pruritus, andrash—which may occur immediately afterstarting infusion. Stop infusion if thesereactions occur, and notify prescriberimmediately.• Monitor patient closely throughout therapyfor rash, which may indicate a seriouscutaneous reaction, such as Stevens-Johnson syndrome. If rash occurs, notifyprescriber, and expect that voriconazolemay be discontinued.• Monitor cyclosporine, tacrolimus, andwarfarin closely for elevated levels whenvoriconazole is given with any of thesedrugs.• Monitor diabetic patients also taking sulfonylureasclosely for hypoglycemia, andcheck blood glucose levels regularly.• Voriconazole dosage will need to beadjusted when given with phenytoin.Expect to monitor plasma phenytoin leveland observe patient closely for phenytoinrelatedadverse reactions.• Assess patient’s visual function, includingvisual acuity, visual field, and color perception,if voriconazole therapy continueslonger than 28 days.• Monitor patient closely for pancreatitis,especially if patient is a child or has riskfactors for acute pancreatitis, such asrecent chemotherapy or hematopoieticstem cell transplantation.PATIENT TEACHING• Instruct patient taking oral voriconazoleto take the tablets at least 1 hour before or1 hour after a meal.• Inform female patient of possible fetalrisk, and stress need to avoid pregnancy.Tell her to use effective contraception duringtherapy and to notify prescriberimmediately if pregnancy is suspected.• Caution patient not to drive at night andto avoid hazardous activities because drugmay cause visual disturbances, includingblurring or photophobia.• Advise patient to avoid exposure to directsunlight or UV light and to wear sunscreenwhen outdoors.warfarin sodiumCoumadinClass and CategoryChemical class: Coumarin derivativeTherapeutic class: AnticoagulantPregnancy category: XIndications and Dosages To prevent or treat pulmonary embolism;recurrent MI; thromboemboliccomplications from atrial fibrillation,heart valve replacement, or MI; andvenous thrombosis (and its extension)TABLETSAdults. Initial: 2 to 5 mg daily for 2 to4 days. Usual: 2 to 10 mg daily based ontarget PT and INR results. Maximum:Determined by target PT and INR results,as prescribed.I.V. INJECTIONAdults. Initial: 2 to 5 mg daily infused over1 to 2 min. Usual: 2 to 10 mg daily infusedover 1 to 2 min. Maximum: Determined bytarget PT and INR results, as prescribed.DOSAGE ADJUSTMENT For patients withhepatic dysfunction, dosage reduced to0.1 mg/kg, as prescribed. For elderlypatients, dosage possibly reduced based onPT and INR results.Route Onset Peak DurationP.O 24 hr 3–4 days 2–5 daysI.V. Unknown 3–4 days 2–5 days

feres with the clotting cascade. By depletingvitamin K–dependent clotting factors andinterfering with the clotting cascade, warfarinprevents coagulation.IncompatibilitiesDon’t mix warfarin in solution with amikacinsulfate, epinephrine hydrochloride,metaraminol tartrate, oxytocin, promazinehydrochloride, tetracycline hydrochloride,or vancomycin hydrochloride.ContraindicationsBleeding or bleeding tendencies; blood dyscrasias;cerebral or dissecting aneurysm;cerebrovascular hemorrhage; diverticulitis;eclampsia or preeclampsia; history ofwarfarin-induced necrosis; hypersensitivityto warfarin or its components; malignantor severe uncontrolled hypertension; malnutritionand emaciation; mental state orcondition that leads to lack of patient cooperation;pericardial effusion; pericarditis;polyarthritis; pregnancy; prostatectomy;recent or planned neurosurgery, ophthalmicsurgery, or spinal puncture; severe hepaticor renal diseaseInteractionsDRUGSacetaminophen, agrimony, aminoglycosides,amiodarone, androgens, argatroban, betablockers, bivalirudin, capecitabine,cephalosporins, chloral hydrate, chloramphenicol,chlorpropamide, cimetidine, clofibrate,corticosteroids, cyclophosphamide, dextrothyroxine,diflunisal, disulfiram, erythromycin,ezetimibe, fluconazole, gemfibrozil,glucagon, hydantoins, ifosfamide, influenzavirus vaccine, isoniazid, ketoconazole, lepirudin,loop diuretics, lovastatin, metronidazole,miconazole, mineral oil, moricizine,nalidixic acid, NSAIDs, omeprazole, penicillins,phenylbutazones, propafenone,propoxyphene, quinidine, quinine,quinolones, salicylates, streptokinase, sulfamethoxazole-trimethoprim,sulfinpyrazone,sulfonamides, tamoxifen, tetracyclines, thyroidhormones, urokinase, valdecoxib, vitaminE: Increased anticoagulant effect ofwarfarin, increased risk of bleedingaminoglutethimide, barbiturates, carbamazepine,cholestyramine, dicloxacillin, estrogens,ethchlorvynol, etretinate, glutethimide, griseofulvin,nafcillin, oral contraceptives,Nursing Considerations• Reconstitute parenteral warfarin just beforeadministration with 2.7 ml sterile water forinjection to yield 2 mg/ml. Then give slowlyover 1 to 2 minutes through peripheral I.V.• Expect to give another parenteral anticoagulant,such as heparin or enoxaparin,with oral warfarin for at least 3 days, oruntil desired response occurs, before givingwarfarin only.• Avoid I.M. injections during warfarintherapy, if possible, because they can resultin bleeding, bruising, and hematoma.• Monitor INR (daily in acute care setting)and assess for therapeutic effects, as prewarfarinsodium 1091rifampin, spironolactone, sucralfate, thiazidediuretics, trazodone, vitamin C, vitamin K:Decreased anticoagulant effect of warfarinatorvastatin, pravastatin: Increased ordecreased anticoagulant effect of warfarinherbal remedies (including bromelains, danshen,dong quai, garlic, ginkgo biloba, andginseng): Increased anticoagulant effect ofwarfarin, increased risk of bleedingI.V. lipid emulsion, other medical productsthat contain soybean oil: Possibly decreasedvitamin K absorption and increased anticoagulanteffect of warfarinnicotine patch: Altered response to warfarinFOODScertain multivitamins, enteral feedings, vitaminK–rich foods: Decreased warfarineffectsACTIVITIESalcohol use: Increased risk of hypoprothrombinemiasmoking, smoking cessation: Altered responseto warfarinAdverse ReactionsCNS: Coma, intracranial hemorrhage, lossof consciousness, syncope, weaknessCV: Angina, chest pain, hypotensionEENT: Epistaxis, intraocular hemorrhageGI: Abdominal cramps and pain, diarrhea,hepatitis, nausea, vomitingGU: Hematuria, vaginal bleeding (abnormal)HEME: Anemia, potentially fatal hemorrhage(from any tissue or organ)SKIN: Alopecia, ecchymosis, jaundice,petechiae, pruritus, purple-toe syndrome,tissue necrosisOther: AnaphylaxisUVW

1092warfarin sodiumscribed. Therapeutic INR levels are 2.0 to3.0 for bioprosthetic heart valve, nonvalvularatrial fibrillation, and venous thromboembolism,and 2.5 to 3.5 after MI andfor mechanical heart valve.• Expect treatment to last up to 12 weeks forbioprosthetic heart valve, 1 to 3 monthsfor nonvalvular atrial fibrillation orvenous thromboembolism, and for rest oflife after MI and for mechanical heartvalve replacement.WARNING Be aware of the increased risk forintracranial hemorrhage if patient hascerebral ischemia (such as recent transientischemic attack or minor ischemic stroke)and INR of 3 to 4.5. As prescribed, withholdnext warfarin dose and give vitaminK if INR exceeds 4 because of the risk ofbleeding.• Assess for occult bleeding if patientreceives I.V. lipid emulsion or other medicalproduct that contains soybean oil.Such products can decrease vitamin Kabsorption and increase warfarin’s anticoagulanteffect.PATIENT TEACHING• Explain that warfarin therapy aims to preventthrombosis by decreasing clottingability while avoiding the risk of spontaneousbleeding.• Instruct patient to take drug exactly asprescribed at the same time each evening.• Urge patient to keep weekly follow-upappointments for blood tests after dischargeuntil PT and INR levels are stabilized.• Advise patient to avoid alcohol duringwarfarin therapy.• Urge patient to take precautions againstbleeding, such as using an electric shaverand a soft-bristled toothbrush. Advise himto continue these precautions for 2 to5 days after therapy stops, as directed,because anticoagulant effect may persistduring this time.• Caution patient to avoid activities thatcould cause traumatic injury and bleeding.• Advise patient to eat consistent amountsof vitamin K–rich foods, such as darkgreen, leafy vegetables.• Urge patient to notify prescriber immediatelyabout unusual bleeding and anyunexplained symptoms, such as abnormalvaginal bleeding; dizziness; easy bruising;gum bleeding; headache; nosebleeds; prolongedbleeding from cuts; red, black, ortarry stool; red or dark brown urine;swelling; and weakness.• Advise patient to consult prescriber beforetaking other drugs—including OTC drugsand herbal remedies—during therapy.• Instruct female patient of childbearing ageto stop taking warfarin and notifyprescriber immediately if she is or couldbe pregnant.• Explain that drug may cause reversiblepurple-toe syndrome and that this syndromeisn’t harmful.• Urge patient to carry medical identificationthat reveals he’s taking warfarin.

X Y ZzafirlukastAccolateClass and CategoryChemical class: Peptide leukotriene receptorantagonistTherapeutic class: AntiasthmaticPregnancy category: BIndications and Dosages To treat chronic asthmaTABLETSAdults and children over age 11. 20 mg b.i.d.Children ages 5 to 11. 10 mg b.i.d.Route Onset Peak DurationP.O. 1 wk Unknown UnknownMechanism of ActionInhibits the selective binding of cysteinylleukotrienes (arachidonic acid derivativesthat usually mediate inflammation in asthmaand other inflammatory disorders) bycompetitively blocking receptor sites. Thisaction causes bronchial relaxation anddecreases vascular leakage and edema, mucussecretion, eosinophil movement, andbronchial hyperresponsiveness.ContraindicationsHypersensitivity to zafirlukast or its componentsInteractionsDRUGSalprazolam, amitriptyline, calcium channelblockers, carbamazepine, citalopram, corticosteroids,cyclosporine, diazepam, diclofenac,ibuprofen, imipramine, irbesartan, lidocaine,lovastatin, midazolam, phenytoin, quinidine,simvastatin, tolbutamide, tolterodine, triazolam:Inhibited metabolism and, possibly,additive adverse effects of these drugsaspirin: Increased blood zafirlukast levelerythromycin, terfenadine: Decreasedresponse to zafirlukastsildenafil: Increased adverse sildenafil effectstheophylline: Decreased zafirlukast levelwarfarin: Prolonged PTzafirlukast; zaleplon 1093FOODSany food: Possibly decreased bioavailabilityof zafirlukastAdverse ReactionsCNS: Asthenia, dizziness, fever, headache,insomnia, malaiseGI: Abdominal pain, diarrhea, elevated liverfunction test results, hepatic failure, indigestion,nausea, vomitingMS: Back pain, myalgiaSKIN: PruritusOther: Generalized painNursing Considerations• Zafirlukast shouldn’t be used to treatbronchospasm during an acute asthmaattack or status asthmaticus; it can’t relievesymptoms quickly enough.• Assess respiratory rate, depth, and qualityas well as breath sounds before and duringtreatment to evaluate response to therapy.• If patient is being weaned from corticosteroidswhile taking zafirlukast, monitorher for Churg-Strauss syndrome, a rareallergic reaction characterized byeosinophilia, fever, myalgia, weight loss, ascardiac complications, neuropathy, andworsening pulmonary symptoms.PATIENT TEACHING• Instruct patient to take drug exactly asprescribed, in evenly spaced doses, everyday, even during symptom-free periodsand acute exacerbations.• Instruct patient to take drug on an emptystomach at least 1 hour before or 2 hoursafter meals.• Urge patient to continue using prescribedrescue inhalants for acute asthma attacks.• Teach patient how to use peak-flow meterto monitor pulmonary function.• Tell patient to immediately report evidenceof liver dysfunction, such as rightupper-quadrant abdominal pain, nausea,fatigue, lethargy, pruritus, jaundice, flulikesymptoms, and anorexia.zaleplonSonataClass, Category, and ScheduleChemical class: Imidazopyridine derivativeTherapeutic class: Sedative-hypnoticXYZ

1094Nursing Considerations• Give zaleplon just before bedtime becauseits onset of action is rapid.• Avoid giving drug with or after a heavy,high-fat meal because decreased absorptionmay reduce drug’s effects.• Watch patient closely for suicidal tendencies,particularly when therapy starts anddosage changes, because depression mayworsen temporarily during these times,possibly leading to suicidal ideation.• Monitor patient for signs of drug abusebecause zaleplon has an abuse potentialsimilar to that of benzodiazepines andbenzodiazepine-like hypnotics.WARNING Monitor patient closely forhypersensitivity reactions, such as dyspnea,throat tightness, nausea, vomiting,and swelling. If present, discontinue zaleplonimmediately, notify prescriber, andprovide supportive care.PATIENT TEACHING• Explain that zaleplon is intended forshort-term use. Advise against using it forany condition other than insomnia.• Caution patient against exceeding prescribeddosage.• Instruct patient to take zaleplon immediatelybefore bedtime or right after havingtrouble falling asleep because of drug’srapid onset of action.• Teach patient alternative measures forrelaxation and sleep induction.• Advise patient to consult prescriber beforetaking other CNS depressants.• Urge patient to avoid alcohol during zalezaleplonPregnancy category: CControlled substance schedule: IVIndications and Dosages Short-term treatment of insomniaCAPSULESAdults up to age 65. 10 mg daily at bedtime,as prescribed, for up to 35 days.Usual: 10 mg daily at bedtime for 7 to10 days. Maximum: 20 mg daily.DOSAGE ADJUSTMENT For patients who areelderly, have hepatic impairment, or takecimetidine, dosage possibly reduced to5 mg daily.Route Onset Peak DurationP.O. 30 min Unknown 4 hrMechanism of ActionSelectively binds with type 1 benzodiazepine(BZ1 or omega 1 ) receptors on thegamma-aminobutyric acid-A receptor complex.This binding produces muscle relaxationand sedation as well as antianxietyand anticonvulsant effects.ContraindicationsHypersensitivity to zaleplon or its componentsInteractionsDRUGSamitriptyline; amoxapine; azatadine; benzodiazepines;brompheniramine; chlorpheniramine;clemastine; clomipramine; clozapine;cyproheptadine; dexchlorpheniramine; diphenhydramine;doxepin; entacapone; haloperidol;hydroxyzine; imipramine; maprotiline;mirtazapine; molindone; nefazodone;nortriptyline; olanzapine; opioid analgesics;other anxiolytics, sedatives, and hypnotics;phenindamine; phenothiazines; pimozide;pramipexole; promethazine; quetiapine; risperidone;ropinirole; thioridazine; trazodone;trimipramine; tripelennamine: Possiblyadditive CNS depressioncarbamazepine, phenobarbital, phenytoin,rifampin: Reduced zaleplon effectscimetidine: Increased blood zaleplon levelflumazenil: Reversal of zaleplon’s sedationFOODShigh-fat foods: Prolonged absorption timeand reduced effectiveness of zaleplonACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Amnesia, anxiety, complex behaviors(such as sleep driving), depression, dizziness,drowsiness, fever, hallucinations,hypertonia, insomnia, paresthesia, seizures,suicidal ideation, tremor, vertigoEENT: Dry mouth, gingivitis, glossitis,mouth ulcers, stomatitis, throat tightnessGI: Anorexia, colitis, constipation, eructation,esophagitis, flatulence, gastritis, gastroenteritis,increased appetite, indigestion,melena, nausea, rectal bleeding, vomitingMS: Back painRESP: DyspneaSKIN: Photosensitivity, pruritus, rashOther: Anaphylaxis, angioedema, physicaland psychological dependence

plon therapy because it increases risk ofabnormal behaviors, such as sleep driving.• Warn patient that zaleplon contains FD &C Yellow No. 5 (tartrazine), which cancause an allergic reaction, especially inthose with an aspirin sensitivity. Instructpatient to report allergic reactions, such asrash or difficulty breathing, to prescriber.• Instruct patient to notify prescriber ifinability to sleep continues. Dosage mayneed to be adjusted.• Instruct patient to stop taking zaleplonand seek emergency care if she has troublebreathing, throat tightness, nausea, vomiting,or abnormal swelling.• Explain that drug may cause abnormalbehaviors during sleep, such as driving acar, eating, talking on the phone, or havingsex without any recall of the event. If familynotices any such behavior or patientsees evidence of such behavior uponawakening, prescriber should be notified.• Urge family or caregiver to watch patientclosely for suicidal tendencies, especiallywhen therapy starts or dosage changes.ziconotidePrialtClass and CategoryChemical class: 25 amino acid polybasicpeptideTherapeutic class: AnalgesicPregnancy category: CIndications and Dosages To manage severe chronic pain inpatients intolerant of or refractory toother pain management measuresINTRATHECALAdults. Initial: 2.4 mcg daily (0.1 mcg/hr),increased as needed by 2.4 mcg daily but nomore than 3 times/wk. Maximum: 19.2 mcg/day (0.8 mcg/hr) by day 21.ContraindicationsHistory of psychosis; hypersensitivity toziconotide or its components; conditions ortreatment that make intrathecal use hazardous(infection at microinfusion site,uncontrolled bleeding diathesis, spinalcanal obstruction that impairs CSF circulation).ziconotide 1095InteractionsDRUGSCNS depressants: Increased risk of adverseCNS reactionsAdverse ReactionsCNS: Abnormal gait, agitation, anxiety,aphasia, asthenia, ataxia, chills, confusion,CSF abnormality, decreased reflexes,depression, difficulty concentrating, dizziness,dysesthesia, emotional lability, fever,hallucinations, headache, hostility, hyperesthesia,hypertonia, incoordination, insomnia,malaise, memory loss, meningitis, nervousness,neuralgia, paranoia, paresthesia,psychosis, seizures, somnolence, speech disorder,stroke, stupor, suicidal ideation, syncope,tremor, twitching, unusual dreams,vertigoCV: Atrial fibrillation, bradycardia, chestpain, edema, hypertension, hypotension,orthostatic hypotension, peripheral edema,tachycardia, T-wave changes on ECG, vasodilationEENT: Abnormal vision, diplopia, drymouth, nystagmus, pharyngitis, photophobia,rhinitis, sinusitis, taste perversion,tinnitusGI: Abdominal pain, anorexia, constipation,diarrhea, indigestion, nausea, vomitingGU: Acute renal failure, dysuria, urinaryhesitancy or incontinence, urine retention,UTIHEME: AnemiaMS: Arthralgia, arthritis, back pain, legcramps, muscle spasms or weakness, myalgia,myasthenia, neck pain or rigidity, rhabdomyolysisRESP: Aspiration pneumonia, bronchitis,cough, dyspnea, lung disorder, pneumonia,respiratory distressSKIN: Cellulitis, diaphoresis, dry skin,ecchymosis, pruritus, rashOther: Catheter site infection or pain, dehydration,elevated CK level, flulike symptoms,generalized pain, hypokalemia, sepsis,viral infection, weight lossNursing Considerations• Determine if patient will receive ziconotidetherapy by implanted variable-ratemicroinfusion device or by externalmicroinfusion device and catheter. Then,follow manufacturer guidelines for programmingthe microinfusion devise andXYZ

1096ziconotideMechanism of ActionPain sensations are transmitted by sensory neurons that travel through N-type calciumchannels in the dorsal horn of the spinal cord and ascend to the brain, as shown below.Pain stimulationDorsalhornPathway to the brainDendritesSensoryneuronN-type calciumchannelSensory neuronZiconotide binds to N-type calcium channels on primary nociceptive afferent nerves insuperficial layers of the dorsal horn, as shown below. By blocking these channels thedrug prevents excitatory neurotransmitter release in primary afferent nerve terminalsand relieves pain.BlockedN-type calciumchannelSensory neuronsZiconotide moleculesdoing an initial pump fill, including primingusing only undiluted 25-mcg/ml solutionand rinsing the internal pump surfaceswith 2 ml of drug three times.• Use strict aseptic technique when preparingziconotide solution and filling, refilling,or handling the microinfusion device.• Be aware that initial ziconotide dosageshouldn’t exceed 2.4 mcg daily.• Know that refills can use diluted or undilutedziconotide solutions. If dilutingziconotide, use only normal saline solutionwithout preservatives, following manufacturerguidelines. Refrigerate solutionup to 24 hours if it isn’t used immediately.Expect device to need refilling about every40 days if ziconotide is given diluted orabout 60 days if given undiluted.• Assess patient’s response to ziconotide regularly.Notify prescriber if pain relief isn’tadequate, and expect to increase dosage.• Check infusion site regularly, and be awarethat meningitis can occur within 24 hoursafter contamination of delivery system; adisconnected catheter is the most commonproblem with external devices.• Monitor patient closely for evidence ofmeningitis, such as headache, stiff neck,

altered mental status, nausea, vomiting,and occasionally seizures caused by inadvertentcontamination of microinfusiondevice or catheter tract used to deliverziconotide. Notify prescriber immediatelyif you suspect meningitis.• Monitor patient closely for cognitiveimpairment, hallucinations, or changes inmood or consciousness because ziconotidemay cause severe psychiatric symptomsand neurologic impairment. If present,notify prescriber and expect to decreasedosage or stop ziconotide. Provide supportivecare, as prescribed, for adverseeffects. Tell prescriber again if adverseeffects are still present after 2 weeks.• Expect to stop ziconotide temporarily ifpatient becomes unresponsive or stuporousduring therapy; drug may be continuedwhen patient reverts to previousmental status.• Ziconotide can be stopped abruptly withoutcausing withdrawal symptoms.• Monitor patient’s serum CK level everyother week for first month of therapy andmonthly thereafter, as ordered. If levelsbecome elevated, notify prescriber andexpect to decrease ziconotide dosage orstop drug until levels return to normal.PATIENT TEACHING• Teach caregiver how to care for externaldevice, if present. Stress the need for strictaseptic technique with the microinfusiondevice and connections and the need tocheck the site often for problems, such as adisconnected catheter, which increase therisk of meningitis.• Review evidence of meningitis with caregiver,and tell her to contact prescriberimmediately if she suspects meningitis.• Advise patient to notify prescriber if painrelief isn’t adequate.• Tell patient and caregiver to notify prescriberimmediately about muscle pain,soreness, and weakness with or withoutdark urine or a change in mental status ormood, including depression or suicidalideation.• Advise patient to avoid hazardous activitiesthat require mental alertness or motorcoordination while receiving ziconotide.• Caution patient to avoid taking OTCpreparations that contain CNS depressantsbecause of the risk of adverse CNS effects.zileutonZyflo CRzileuton 1097Class and CategoryChemical class: Leukotriene inhibitorTherapeutic class: AntiasthmaticPregnancy category: CIndications and Dosages To prevent or treat chronic asthmaE.R. TABLETSAdults and adolescents. 600 mg b.i.d.Maximum: 2,400 mg daily.Route Onset Peak DurationP.O. 2 hr Unknown UnknownMechanism of ActionInhibits formation of leukotrienes foundmainly in neutrophils, eosinophils, monocytes,macrophages, and mast cells.Normally, leukotrienes augment neutrophiland eosinophil migration, neutrophil andmonocyte aggregation, leukocyte adhesion,capillary permeability, and smooth-musclecontraction. By inhibiting leukotriene formation,zileuton causes bronchial relaxationand decreases vascular leakage andedema, mucus secretion, eosinophil movement,and bronchial hyperresponsiveness.ContraindicationsHepatic impairment, hypersensitivity to zileutonor its componentsInteractionsDRUGSpropranolol, terfenadine: Increased effects ofthese drugstheophylline: Doubled theophylline levelwarfarin: Prolonged PT and INRAdverse ReactionsCNS: Asthenia, dizziness, fever, headache,hypertonia, insomnia, malaise, nervousness,neuropsychiatric events, sleep disorders,somnolenceCV: Chest painEENT: ConjunctivitisGI: Abdominal pain, constipation, flatulence,indigestion, nausea, vomitingGU: UTI, vaginitisMS: Arthralgia, myalgia, neck pain or rigiditySKIN: Pruritus, rash, urticariaXYZ

1098zincOther: LymphadenopathyNursing Considerations• Zileuton shouldn’t be used to treat bronchospasmduring an acute asthma attackor status asthmaticus; it can’t relievesymptoms quickly enough.• Monitor serum ALT level, as ordered, usuallybefore treatment starts, once a monthfor 3 months, every 2 to 3 months forremainder of first year, and periodicallythereafter during therapy.• Monitor results of liver and pulmonaryfunction tests and CBC during therapy.• Monitor patient taking zileuton for neurospychiatricsymptoms including worseningof pre-existing psychiatric illness. Ifpresent, notify prescriber immediately,institute safety measures and expect drugto be discontinued.PATIENT TEACHING• Advise patient to take drug exactly as prescribed,in evenly spaced doses, every day.Stress need to take drug even during symptom-freeperiods and acute exacerbations.• Urge patient not to chew, cut, or crushcapsule but to swallow it whole.• Instruct patient to continue using rescueinhalants, as prescribed, for acute attacks.• Teach patient how to use peak-flow meterto assess and monitor pulmonary function.• Instruct patient to report any abnormalthoughts or behavior.zinc acetate(contains 25 or 50 mg of elemental zincper capsule)Galzinzinc chloride(contains 1 mg of elemental zinc per mlfor I.V. infusion)zinc gluconate(contains 1.4 mg of elemental zinc perlozenge; 1.4, 2, 4, 7, 8, 10, 11, 13, 31, 50,or 52 mg of elemental zinc per tablet)Orazinczinc sulfate(contains 25 or 50 mg of elemental zincper capsule; 15, 25, 45, or 50 mg of elementalzinc per tablet; 50 mg of elementalzinc per E.R. tablet; and 1 or 5 mg of elementalzinc per ml for I.V. infusion)Orazinc, Verazinc, Zinc 15, Zinc-220,Zinca-Pak, ZincateClass and CategoryChemical class: Trace element, mineralTherapeutic class: Copper absorptioninhibitor, nutritional supplementPregnancy category: A (oral), C (I.V.)Indications and Dosages To prevent zinc deficiency based on U.S.and Canadian recommended dailyallowancesCAPSULES, E.R. TABLETS, LOZENGES, TABLETSMen and boys age 11 and over. 15 mg (9 to12 mg Canadian) elemental zinc daily.Women and girls age 11 and over. 12 mg(9 mg Canadian) elemental zinc daily.Pregnant women. 15 mg (15 mg Canadian)elemental zinc daily.Breast-feeding women. 16 to 19 mg (15 mgCanadian) elemental zinc daily.Children ages 7 to 10. 10 mg (7 to 9 mgCanadian) elemental zinc daily.Children ages 4 to 6. 10 mg (5 mgCanadian) elemental zinc daily.Children from birth to age 3. 5 to 10 mg(2 to 4 mg Canadian) elemental zinc daily.I.V. INFUSIONAdults and children. 2.5 to 4 mg dailyadded to total parenteral nutrition (TPN)solution. Maximum: 12 mg daily.Children from birth to age 5. 100 mcg/kgdaily added to TPN solution.Premature infants weighing up to 3 kg.300 mcg/kg daily added to TPN solution. To treat zinc deficiencyCAPSULES, E.R. TABLETS, LOZENGES, TABLETSAdults and children. Dosage individualizedbased on severity of deficiency.I.V. INFUSIONAdults and adolescents. 2.5 to 4 mg dailyadded to TPN solution. Maximum: 12 mgdaily.Children from birth to age 5. 100 mcg/kgdaily added to TPN solution.Premature infants weighing up to 3 kg.300 mcg/kg daily added to TPN solution. As adjunct maintenance therapy for

patients previously treated for Wilson’sdiseaseCAPSULESAdults. 50 mg t.i.d.Pregnant women. 25 mg t.i.d., increased to50 mg t.i.d. if drug effectiveness decreases.Children age 10 and over. 25 mg t.i.d.,increased to 50 mg t.i.d. if drug effectivenessdecreases.Mechanism of ActionNeeded for proper function of more than200 metalloenzymes (those with tightlybound zinc atoms as an integral part oftheir structure), including carbonic anhydrase,carboxypeptidase A, alcohol dehydrogenase,alkaline phosphatase, and RNApolymerase. Zinc also helps maintain nucleicacid, protein, and cell membrane structureand is essential for certain physiologicfunctions, including cell growth and division,sexual maturation and reproduction,dark adaptation and night vision, woundhealing, host immunity, and taste acuity.This mineral also provides cellular antioxidantprotection by scavenging free radicals.In addition, zinc acetate interferes withintestinal absorption of copper and producesa protein that binds with copper, preventingits transfer to blood. Bound copperis then excreted in stools, thus decreasingcopper toxicity in Wilson’s disease.ContraindicationsHypersensitivity to zinc or its componentsInteractionsDRUGScopper supplements: Impaired copperabsorption (with large doses of zinc)oral iron supplements, oral phosphate salts,penicillamine, phosphorus-containing drugs:Decreased zinc absorptionquinolones, tetracyclines: Decreased absorptionand possibly decreased effectiveness ofthese antibioticsthiazide diuretics: Increased urinary excretionof zinczinc-containing preparations: Increasedblood zinc levelFOODSfiber- or phylate-containing foods (such asbran, whole-grain breads, cereal), phosphorus-containingfoods (including milk, poultry):Decreased zinc absorptionzinc 1099Nursing ConsiderationsWARNING Don’t give I.V. zinc preparationsthat contain benzyl alcohol to neonates orpremature infants because this preservativemay cause a fatal toxic syndromecharacterized by metabolic acidosis andCNS, respiratory, circulatory, and renalfunction impairment.• Give oral zinc supplements 1 hour beforeor 2 to 3 hours after meals; at least 2 hoursafter giving oral iron supplements (to preventdecreased zinc absorption) or coppersupplements (to prevent decreased copperabsorption); and at least 6 hours before or2 hours after administering quinolone ortetracycline antibiotics (to preventdecreased absorption of these drugs).• Monitor patient receiving long-term zinctherapy for sideroblastic anemia, whichmay result from zinc-induced copperdeficiency and is characterized by anemia,leukopenia, neutropenia, granulocytopenia,and bone marrow problems. Be awarethat these effects are reversible after zincis discontinued.• Monitor patient with preexisting copperdeficiency for exacerbation of this condition;zinc can decrease serum copper level.• Assess for signs and symptoms of zincdeficiency, such as growth retardation,hypogonadism, delayed sexual maturation,alopecia, impaired wound healing,skin lesions, immune deficiencies, behavioraldisturbances, night blindness, andimpaired sense of taste.• Monitor blood alkaline phosphatase (ALP)level monthly, as ordered; it may increase.• Be aware that zinc chloride contains aluminum,which may accumulate to thepoint of toxicity if patient’s kidney functionis impaired. Assess kidney functionregularly.PATIENT TEACHING• Explain the need for a zinc supplement.• Instruct patient to take zinc on an emptystomach, at least 1 hour before or 2 hoursafter meals. Caution her not to take zincwithin 2 hours of iron or copper supplementsor phosphorus-containing drugs.• Instruct patient to let zinc lozenge dissolvein mouth slowly and completely and notto swallow it whole or chew it. Advise hernot to take zinc lozenges more often thandirected.XYZ

1100Adverse ReactionsCNS: Agitation, akathisia, amnesia, anxiety,asthenia, CVA, depression, dizziness, dystonia,extrapyramidal reactions, headache,hypertonia, hypomania, insomnia, mania,neuroleptic malignant syndrome, paresthesia,personality or speech disorder, serotoninsyndrome, somnolence, syncope, suicidalideation, tardive dyskinesia, tremorCV: Bradycardia, chest pain, hypercholesterolemia,hypertension, orthostatichypotension, prolonged QT or QTc interval,tachycardia, thrombophlebitis, vasodilationEENT: Abnormal vision, dry mouth,increased salivation, rhinitis, tongueswellingENDO: Dysmenorrhea, hyperglycemiaGI: Abdominal pain, anorexia, constipation,diarrhea, dysphagia, indigestion, nausea,rectal bleeding, vomitingGU: Priapism, urinary incontinenceHEME: Agranulocytosis, leukopenia, neutropeniaMS: Arthralgia, back pain, dysarthria, myalgiaRESP: Cough, pulmonary embolism, upperrespiratory tract infectionSKIN: Allergic dermatitis, diaphoresis,furunculosis, rash, urticariaOther: Accidental injury, angioedema, fluziprasidoneziprasidonehydrochlorideGeodonziprasidonemesylateGeodon for InjectionClass and CategoryChemical class: Benzisoxazole derivativeTherapeutic class: AntipsychoticPregnancy category: CIndications and Dosages To treat schizophreniaCAPSULESAdults. Initial: 20 mg b.i.d. Dosage increasedas indicated every 2 or more days. Usual:20 to 80 mg b.i.d. Maximum: 100 mg b.i.d.I.M. INJECTIONAdults. Initial: 10 to 20 mg. 10 mg dosemay be given every 2 hr up to maximumdose; 20 mg dose may be given every 4 hrup to maximum dose. Maximum: 40 mgdaily. To treat acute manic or mixed episodesof bipolar disorderCAPSULESAdults. Initial: 40 mg b.i.d. with food onday 1; then increased to 60 or 80 mg on day2 with further adjustments as needed. As adjunct to lithium or valproate formaintenance treatment of bipolar I disorderCAPSULESAdults. Same dose patient was initially stabilizedon that falls within 40 mg to 80 mgtwice daily.Mechanism of ActionSelectively blocks serotonin and dopaminereceptors in the mesocortical tract of theCNS, thereby suppressing psychotic symptoms.IncompatibilitiesDon’t mix injection form with drugs or solventsother than sterile water for injection.ContraindicationsConcurrent use of other drugs that prolongQT interval, history of arrhythmia, hypersensitivityto ziprasidone or its components,history of prolonged QT interval,recent acute MI, uncompensated heart failureInteractionsDRUGSantihypertensives: Additive antihypertensiveeffectscarbamazepine: Possibly decreased bloodziprasidone levelCNS depressants: Increased CNS depressiondopamine agonists, levodopa: Decreasedtherapeutic effects of these drugsdrugs that prolong QT interval (includingquinidine, dofetilide, pimozide, sotalol, thioridazine,and sparfloxacin): Increased risk ofprolonged QT or QTc interval, torsades depointes, and sudden deathketoconazole: Possibly increased bloodziprasidone levelFOODSall foods: Increased ziprasidone absorption

like symptoms, injection site pain, weightgainNursing ConsiderationsWARNING Ziprasidone shouldn’t be used totreat elderly patients with dementia-relatedpsychosis because drug increases therisk of death in these patients.• Protect ziprasidone vials from light.Reconstitute by adding 1.2 ml sterile waterfor injection to vial and shaking vigorouslyuntil drug is dissolved. Each ml ofreconstituted solution contains 20 mgziprasidone. Discard any unused portion.• Give only by I.M. route.• Reconstituted drug may be stored 24 hoursprotected from light or up to 7 days ifrefrigerated and protected from light.• Administer I.M. form cautiously topatients with impaired renal function.WARNING Assess cardiac rhythm in patientswith hypokalemia or hypomagnesemia.Dizziness, palpitations, and syncope mayindicate life-threatening torsades depointes. Be prepared to stop ziprasidone ifQTc interval is greater than 500 msec.• Monitor patient, especially elderly woman,for involuntary movements, which maybecome irreversible tardive dyskinesia. Ifsymptoms develop, notify prescriberimmediately and be prepared to stop drug.• Immediately report evidence of neurolepticmalignant syndrome, a rare but potentiallyfatal adverse reaction includinghyperpyrexia, muscle rigidity, altered mentalstatus, irregular pulse, blood pressurechanges, tachycardia, diaphoresis, arrhythmia,myoglobinuria (rhabdomyolysis), andacute renal failure.• Monitor patient’s blood glucose and lipidlevels routinely, as ordered, because drugincreases risk of hyperglycemia and hypercholesterolemia.• Monitor patient’s CBC, as ordered,because serious adverse hematologic reactionsmay occur, such as agranulocytosis,leukopenia, and neutropenia. Monitormore frequently during first few monthsof therapy if patient has a history of druginducedleukopenia, neutropenia, or significantlylow WBC count. If abnormalitiesoccur during ziprasidone therapy,watch for fever and other evidence ofinfection, notify prescriber, and expect todiscontinue drug if severe.• Monitor patient closely for evidence ofsuicidal thinking or behavior, especiallywhen therapy starts or dosage changes.PATIENT TEACHING• Instruct patient to take ziprasidone withfood to increase absorption.• Advise patient to avoid hazardous activitiesuntil CNS effects are known.• Tell family to monitor patient closely forsuicidal tendencies; patients with psychoticillness or bipolar disorder are at greaterrisk.• Urge patient to rise slowly from seated orlying position to minimize orthostatichypotension.• Urge patient to notify prescriber immediatelyif he develops any sudden onset,unusual, persistent, or servere adversereactions.zoledronic acidReclast, Zometazoledronic acid 1101Class and CategoryChemical class: BisphosphonateTherapeutic class: Antihypercalcemic, boneresorption inhibitorPregnancy category: DIndications and Dosages To treat hypercalcemia caused by cancerI.V. INFUSION (ZOMETA)Adults. 4 mg infused over at least 15 min.After 7 days, retreatment with 4 mg ifserum calcium level doesn't remain at orreturn to normal. Maximum: 4 mg/dose. As adjunct treatment for patients withmultiple myeloma or bony metastasiswho are receiving standard antineoplastictherapy and have a creatinine clearanceabove 60 ml/min/1.73 m 2I.V. INFUSION (ZOMETA)Adults. 4 mg infused over at least 15 minevery 3 to 4 wk.DOSAGE ADJUSTMENT If patient’s creatinineclearance is 50 to 60 ml/min/1.73 m 2 ,dosage decreased to 3.5 mg; if it’s 40 to49 ml/min/1.73 m 2 , dosage decreased to3.3 mg; and if it’s 30 to 39 ml/min/1.73 m 2 ,dosage decreased to 3 mg. To treat postmenopausal osteoporosis inXYZ

1102zoledronic acidwomen; to treat osteoporosis in men; totreat and prevent glucocorticoid-inducedosteoporosis in patients receiving dailyprednisone doses of 7.5 mg or greater forat least 12 monthsI.V. INFUSION (RECLAST)Adults. 5 mg infused over at least 15 minonce yearly. To treat Paget’s disease of the boneI.V. INFUSION (RECLAST)Adults. 5 mg infused over at least 15 minafter 2 wk of receiving 1,500 mg elementalcalcium daily in divided doses and 800 internationalunits vitamin D daily. To prevent osteoporosis in postmenopausalwomenI.V. INFUSION (RECLAST)Adults. 5 mg infused over at least 15 minevery 2 years.Mechanism of ActionInhibits resorption of mineralized bone andcartilage by osteoclasts and induces osteoclastbreakdown. In cancer-related hypercalcemia,hyperactive osteoclasts cause boneresorption and release of calcium intoblood, which causes polyuria, GI disruption,progressive dehydration, and decreasingGFR. This, in turn, increases renal calciumresorption and worsens hypercalcemia.Zoledronic acid interrupts this process.IncompatibilitiesDon’t mix zoledronic acid with calciumcontainingI.V. solutions, such as lactatedRinger’s solution.ContraindicationsHypersensitivity to zoledronic acid, otherbisphosphonates, or their componentsInteractionsDRUGSaminoglycosides: Possibly additive serumcalcium–lowering effectloop diuretics, such as furosemide: Possiblyincreased risk of hypocalcemiaNSAIDs: Increased risk of nephrotoxicityAdverse ReactionsCNS: Anxiety, asthenia, chills, confusion,depression, dizziness, fatigue, fever,headache, hyperesthesia, hypoesthesia,insomnia, malaise, paresthesia, tremor, vertigo,weaknessCV: Atrial fibrillation, bradycardia, chestpain, hypertension, hypotension, peripheraledemaEENT: Blurred vision, conjunctivitis, episcleritis,iritis, orbital edema or inflammation,scleritis, sore throat, stomatitis, tastedisturbance, uveitisGI: Abdominal pain, anorexia, constipation,diarrhea, dyspepsia, nausea, vomitingGU: Elevated serum creatinine level, hematuria,proteinuria, renal insufficiency orfailure, UTIHEME: Anemia, neutropenia, thrombocytopeniaMS: Arthralgia; incapacitating bone, joint,or muscle pain; muscle spasms; myalgia;osteo-necrosis of the jawRESP: Bronchospasm, cough, dyspnea,upper respiratory tract infectionSKIN: Alopecia, dermatitis, flushing,urticariaOther: Aggravated malignant neoplasm,anaphylaxis, angioedema, flulike illness,hypersensitivity reaction, hyperkalemia,hypernatremia, hypocalcemia, hypomagnesemia,hypophosphatemia, infusion siteredness and swelling, weight gainNursing Considerations• Be aware that zoledronic acid isn’t indicatedfor hypercalcemia from hyperparathyroidismor other non-tumor conditions.• Use cautiously in patients with aspirinsensitivity because biphosphonates such aszoledronic acid have caused bronchoconstrictionin these patients.• Make sure patient has had a dental checkupbefore zoledronic acid starts, especiallyif patient has cancer; is receivingchemotherapy, head or neck radiation, ora corticosteroid; or has poor oral hygienebecause risk of osteonecrosis is increasedin these patients, and invasive dental proceduresduring zoledronic acid therapymay worsen osteonecrosis.• Expect to aggressively hydrate hypercalcemicpatient with I.V. normal saline solutionbefore and during zoledronic acidtherapy, as prescribed, to achieve andmaintain urine output of about 2 L daily.WARNING During hydration, monitor fluidintake and output often and assess patient,especially one with heart failure, for evidenceof life-threatening overhydration.• Hypocalcemia and mineral metabolism

disorders must be treated before zoledronicacid therapy begins.• Be aware that Reclast doesn’t need reconstitution.• Reconstitute Zometa by adding 5 ml ofsterile water for injection to drug vial toyield solution that contains 4 mg of zoledronicacid. Make sure drug is completelydissolved before withdrawing prescribeddose. Further dilute in 100 ml normalsaline solution or 5% dextrose injection,and infuse over no less than 15 minutes.• Before giving zoledronic acid, inspectreconstituted and diluted solution and discardit if particles or discoloration arepresent.• Expect to give acetaminophen, if not contraindicated,before zoledronic acid toreduce adverse reactions, such as fever,headache, myalgia, and flulike symptoms.These reactions usually occur within first3 days after zoledronic acid administrationand resolve within 3 days (although resolutionmay take up to 14 days for somepatients).• Refrigerate reconstituted drug at 2° to 8° C(36° to 46° F) and discard after 24 hours.• Give drug as a single I.V. solution in a separateI.V. line.WARNING Be aware that a single dose ofZometa shouldn’t exceed 4 mg and thatneither Zometa nor Reclast should beinfused over less than 15 minutes becauseexceeding these limits may lead to significantrenal function deterioration, whichmay progress to renal failure.WARNING Assess patient’s renal function, asordered, before and during zoledronic acidtherapy to detect renal deterioration. Forpatient with a normal serum creatininelevel who develops an increase of 0.5 mg/dl within 2 weeks of receiving zoledronicacid, expect to withhold next dose untilserum creatinine level is within 10% ofpatient’s baseline value. For patient withan abnormal serum creatinine level whodevelops an increase of 1.0 mg/dl within2 weeks of receiving drug, expect to withholdnext dose until serum creatinine levelis within 10% of baseline value.• Monitor patient’s serum calcium, magnesium,and phosphate levels, as ordered,during zoledronic acid therapy. If hypocalcemia,hypomagnesemia, or hypophosphatemiaoccurs, expect to give short-termsupplemental therapy.• Assess aspirin-sensitive asthma patientsfor worsening of respiratory symptomsduring zoledronic acid therapy becauseother bisphosphonates have caused bronchoconstrictionin these patients.• Store drug at 25° C (77° F).PATIENT TEACHING• Teach patient the importance of consuminga nutritious diet, including adequateamounts of calcium and vitamin D.• Advise patient to alert prescriber aboutmuscle or bone pain.• Instruct patient on proper oral hygieneand on need to notify prescriber beforeundergoing invasive dental procedures.• Advise women of childbearing age to notifyprescriber immediately if they are orcould be pregnant because drug will needto be stopped.zolmitriptanZomig, Zomig ZMTzolmitriptan 1103Class and CategoryChemical class: Selective 5-hydroxytryptamineagonistTherapeutic class: AntimigrainePregnancy category: CIndications and Dosages To treat acute migraine headache withor without auraDISINTEGRATING TABLETSAdults. 2.5 mg, repeated every 2 hr p.r.n.Maximum: 10 mg in 24 hr or three headaches/mo.TABLETSAdults. 2.5 mg or less, repeated every 2 hrp.r.n. Maximum: 10 mg in 24 hr or threeheadaches/mo.NASAL SPRAYAdults. 5 mg, repeated in 2 hr if needed.Maximum: 10 mg/24 hr.DOSAGE ADJUSTMENT Dosage reduced toless than 2.5 mg for patients with hepaticimpairment.Mechanism of ActionConstricts inflamed and dilated cranialblood vessels in the carotid circulation andinhibits production of proinflammatoryXYZ

1104zolpidem tartrateneuropeptides by binding to receptors onintracranial blood vessels and sensorynerves in the trigeminal-vascular system tostimulate negative feedback, which halts therelease of serotonin.ContraindicationsBasilar or hemiplegic migraine, cardiovasculardisease, concurrent use of ergotamine-containingdrugs, hypersensitivity tozolmitriptan or its components, ischemicheart disease, peripheral vascular disease,Prinzmetal’s angina, symptomatic Wolff-Parkinson-White syndrome or other accessorypathway conduction disorder, use ofanother 5-hydroxytryptamine agonist withinpast 24 hours, use of an MAO inhibitorwithin 14 daysInteractionsDRUGSacetaminophen: Delayed peak effect of acetaminophen(by 1 hour)cimetidine: Prolonged zolmitriptan half-lifeergot alkaloids: Prolonged vasoconstrictioneffectsfluoxetine, fluvoxamine, paroxetine, sertraline:Hyperreflexia, lack of coordination,and weaknessMAO inhibitors: Increased zolmitriptaneffectsnaratriptan, rizatriptan, sumatriptan:Prolonged zolmitriptan effectsoral contraceptives, propranolol: Increasedblood zolmitriptan levelserotonin and norepinephrine reuptakeinhibitors: Increased risk of developingserotonin syndromeAdverse ReactionsCNS: Asthenia, dizziness, hyperesthesia,paresthesia, somnolence, vertigoCV: Angina, coronary artery vasospasm,hypertension, MI, palpitations, transientmyocardial ischemia, ventricular fibrillationor tachycardiaEENT: Dry mouth, vision disturbanceGI: Abdominal pain, bloody diarrhea, dysphagia,GI or splenic infarction, indigestion,ischemic colitis, nausea, vomitingMS: Myalgia; myasthenia; pain, pressure, ortightness in jaw, neck, or throatSKIN: Diaphoresis, flushingOther: Anaphylaxis, anaphylactoid reaction,angioedemaNursing ConsiderationsWARNING Monitor patient for signs andsymptoms of vasoconstriction, which maylead to vascular and colonic ischemia withabdominal pain and bloody diarrhea,especially if patient has peripheral vasculardisease (including Raynaud’s phenomenon)or ischemic bowel disease.• Monitor elderly patients and those withhepatic impairment for increased bloodpressure, and notify prescriber immediatelyif it occurs.• Monitor patient closely for signs andsymptoms of angina. If patient developschest pain, notify prescriber.WARNING Monitor patient closely for signsand symptoms of serotonin syndrome,which may include agitation, hallucinations,coma, tachycardia, labile blood pressure,hyperthermia, hyperreflexia, incoordination,nausea, vomiting, and diarrhea.Notify prescriber immediately becauseserotonin syndrome may be life-threatening.Be prepared to provide supportivecare and discontinue zolmitriptan.PATIENT TEACHING• Urge patient to consult prescriber beforetreating more than three headaches in30 days.• Advise patient not to remove disintegratingtablet from blister pack until justbefore taking the tablet. Instruct her topeel open pack, let tablet dissolve on hertongue, and then swallow.• Urge patient to notify prescriber aboutunusual or severe adverse reactions.• Caution patient using nasal spray to avoidspraying drug into her eyes.• Instruct patient not to take zolmitriptanwithin 24 hours of other drugs in thesame class.zolpidem tartrateAmbien, Ambien CR, TovaltClass, Category, and ScheduleChemical class: Imidazopyridine derivativeTherapeutic class: Antianxiety, sedativehypnoticPregnancy category: BControlled substance schedule: IV

Indications and Dosages To provide short-term treatment ofinsomniaTABLETS, ORALLY DISINTEGRATING TABLETSAdults. 10 mg at bedtime for 7 to 10 days.Maximum: 10 mg daily.DOSAGE ADJUSTMENT For elderly or debilitatedpatients and those with hepaticimpairment, dosage possibly reduced to5 mg at bedtime, with a maximum of 5 mgdaily for nursing facility residentsE.R. TABLETSAdults. 12.5 mg immediately before at bedtime.DOSAGE ADJUSTMENT For elderly or debilitatedpatients and those with hepaticimpairment, dosage reduced to 6.25 mgimmediately before at bedtime.Mechanism of ActionMay potentiate the effects of gammaaminobutyricacid (GABA) and otherinhibitory neurotransmitters. By binding tospecific benzodiazepine receptors in thelimbic and cortical areas of the CNS, zolpidemincreases GABA’s inhibitory effects,blocks cortical and limbic arousal, and preservesdeep sleep (stages 3 and 4).ContraindicationsHypersensitivity to zolpidem or its components,ritonavir therapyInteractionsDRUGSazole antifungals: Increased CNS activityand additive adverse effects of zolpidembarbiturates, chlorpromazine, generalanesthetics, opioid agonists, other CNSdepressants, phenothiazines, tramadol, tricyclicantidepressants: Possibly increasedCNS depression and reduced psychomotorfunctionbupropion: Increased blood zolpidem level,possibly visual hallucinations, loss of alertnessdesipramine, imipramine: Increased risk ofvisual hallucinations and reduced alertnessflumazenil: Antagonized sedative effecthaloperidol: Increased CNS depressionnevirapine: Decreased blood zolpidem levelrifabutin, rifampin: Increased zolpidemclearanceselective serotonin-reuptake inhibitors:Increased risk of delusions, disorientation,Nursing Considerations• Use zolpidem cautiously in patients withadditional disorders because it isn’t knownif zolpidem therapy might aggravate theseconditions.• Administer zolpidem just before patient’sbedtime because drug has a rapid onset ofaction.• Expect patient to receive no more than a1-month supply of zolpidem for outpatienttherapy.WARNING If zolpidem is withdrawnabruptly (especially after prolonged therapy),monitor patient for withdrawal symptoms,such as abdominal cramps or discomfort,fatigue, flushing, inconsolablecrying, light-headedness, nausea, nervousness,panic attack, rebound insomnia, andvomiting.• Expect that zolpidem will produce anticonvulsantand muscle relaxant effects athigh doses.• If patient takes other CNS depressants,expect to reduce zolpidem dosage, as prescribed.WARNING Monitor patient closely forhypersensitivity reactions such as dyspnea,throat tightness, nausea, vomiting, andswelling. If present, discontinue zolpidemimmediately, notify prescriber, and prozolpidemtartrate 1105and hallucinationsFOODSall foods: Increased time to peak blood zolpidemlevel, decreased effects of zolpidemACTIVITIESalcohol use: Increased CNS depressionAdverse ReactionsCNS: Amnesia, asthenia, ataxia, complexbehaviors (such as sleep driving), confusion,dizziness, drowsiness, euphoria, hallucinations,headache, insomnia, lethargy,paradoxical CNS stimulation (includingagitation, euphoria, hallucinations, hyperactivity,and nightmares), vertigoEENT: Diplopia, throat tightness, visualabnormalityGI: Constipation, diarrhea, hiccups, indigestion,nausea, vomitingGU: UTIMS: Arthralgia, myalgiaRESP: Dyspnea, upper respiratory infectionOther: Anaphylaxis, angioedema, withdrawalsymptomsXYZ

1106zonisamidevide supportive care.PATIENT TEACHING• Caution patient to take drug exactly asprescribed and not to increase dosageunless directed by prescriber.• Advise patient taking extended-releaseform to swallow tablet whole and not tobreak, crush, or chew it.• Advise patient taking orally disintegratingform to place tablet on tongue, let it dissolve,and then swallow with saliva or, ifpatient prefers, with water.• Instruct patient to take zolpidem immediatelybefore going to bed, on an emptystomach.• Advise patient to notify prescriber immediatelyabout abdominal cramps or discomfort,fatigue, flushing, inconsolablecrying, light-headedness, nausea, nervousness,panic attack, and vomiting.• Instruct patient to stop taking zolpidemand seek emergency care if she has troublebreathing, throat tightness, nausea, vomiting,or abnormally swelling.• Advise patient that zolpidem may produceabnormal behaviors during sleep, such asdriving a car, eating, talking on the phone,or having sex without any recall of theevent. If patient’s family notices any suchbehavior or if patient sees evidence ofsuch behavior upon awakening, prescribershould be notified.zonisamideZonegranClass and CategoryChemical class: Benzisoxazole derivative,sulfonamideTherapeutic class: AnticonvulsantPregnancy category: CIndications and Dosages As adjunct to treat partial seizuresCAPSULESAdults. Initial: 100 mg daily. Dosageincreased by 100 mg daily every 2 wk, asneeded. Usual: 200 to 400 mg daily.Maximum: 600 mg daily.Mechanism of ActionMay stop seizures and suppress their foci byblocking sodium channels and reducingvoltage-dependent, inward currents fromcalcium channels. This action stabilizesneuronal membranes and suppresses synchronizedneuronal hyperactivity.ContraindicationsHypersensitivity to sulfonamides, zonisamide,or their componentsInteractionsDRUGScarbamazepine, phenobarbital, phenytoin,valproate: Possibly decreased blood zonisamidelevelCNS depressants: Additive CNS depressanteffectsFOODSgrapefruit juice: Possibly decreased metabolismof zonisamideAdverse ReactionsCNS: Agitation, ataxia, dizziness, irritability,somnolence, suicidal ideationGI: AnorexiaOther: Metabolic acidosisNursing Considerations• Obtain a serum bicarbonate level beforestartsing zonisamide and then periodicallyduring therapy, as prescribed because drugmay cause metabolic acidosis, especially inpatients with predisposing conditions ortherapies or who are younger in age.WARNING Monitor results of patient’s CBCand other laboratory tests for signs ofblood dyscrasias because zonisamide is asulfonamide and can be absorbed systemically.Systemic absorption may result inlife-threatening reactions, including toxicepidermal necrolysis, Stevens-Johnsonsyndrome, fulminant hepatic necrosis,agranulocytosis, aplastic anemia, andother blood dyscrasias.• Be aware that patients receiving doses of300 mg daily or more are at increased riskfor adverse CNS reactions, includingdecreased concentration, fatigue, drowsiness,and impaired speech.• Monitor serum creatinine and BUN levelsfor signs of abnormally decreasedglomerular filtration rate (GFR). Expectsome decrease in GFR during first 4 weeksof treatment and return to baseline within2 to 3 weeks after drug is discontinued.

zonisamide 1107• Monitor patient for signs and symptomsof renal calculi.• Be aware that zonisamide shouldn’t be discontinuedabruptly because doing so mayincrease frequency of seizures.• Monitor patient closely for evidence ofsuicidal thinking or behavior, especiallywhen therapy starts or dosage changes.PATIENT TEACHING• Inform patient that zonisamide is usuallyprescribed with other anticonvulsants andthat she should continue to take all drugsas prescribed.• Instruct patient to swallow zonisamidecapsules whole and not to chew them orbreak them open.• Inform patient that prescriber may have toadjust zonisamide dosage over severalweeks or months before stable dose isachieved.• Advise patient to use caution when drivingor performing other activities that arehazardous or require mental alertnessbecause zonisamide commonly causessomnolence, dizziness, and decreased concentration,particularly during first monthof therapy.• Advise patient to wear a medical identificationbracelet or necklace or carry medicalidentification with information abouther seizure disorder.• Unless contraindicated, encourage patientto drink 6 to 8 glasses of water each day toprevent kidney stones.• Advise patient to rise slowly from a lyingor seated position to reduce the risk ofdizziness.• Urge caregivers to watch closely for evidenceof suicidal tendencies, especiallywhen therapy starts or dosage changes,and to report concerns immediately toprescriber.• Encourage woman who becomes pregnantwhile taking zonisamide to enroll in theNorth American antiepileptic drug pregnancyregistry by calling 1-888-233-2334.Explain that the registry is collectinginformation about the safety of antiepilepticdrugs during pregnancy.XYZ

AppendicesInsulin Preparations 1111Selected Ophthalmic Drugs 1114Antihistamines 1124Selected Topical Drugs 1126Selected Antivirals 1142Selected Antineoplastic Drugs 1149Selected Antihypertensive Combinations 1166Vitamins 1174Interferons 1186Compatible Drugs in a Syringe 1192Drug Formulas and Calculations 1194Weights and Equivalents 1199Equianalgesic Doses for Opioid Agonists 1201Abbreviations 1202

Insulin Preparations 1111Insulin PreparationsFor each category of insulin, the following table lists the species; common trade names; onset, peak,and duration; and key nursing considerations.CATEGORY, SPECIES,AND TRADE NAMESRapid-acting insulinKEY NURSING CONSIDERATIONSOnset: 15 min Peak: 30–90 min Duration: In 6 hrHuman•Apidra (insulin glulisine)•Humalog (insulin lispro)•NovoLog (insulin aspart)•Mix Humalog or NovoLog with other insulin types, butmix Apidra only with NPH insulin, if needed. Administerimmediately after mixing.•When mixing rapid-acting insulin with a longer-actinginsulin, always draw the rapid-acting insulin into thesyringe first to avoid dosage errors.•Give Humalog only SubQ, up to 15 minutes before a meal.Give NovoLog only SubQ 5 to 10 minutes before a meal orvia external insulin pump. Give Apidra SubQ up to 15 to20 minutes before a meal or via insulin pump. If using apump, NovoLog and Apidra shouldn’t be diluted or mixedwith any other insulin.•Be aware that 1 unit of rapid-acting insulin has the sameglucose-lowering ability as 1 unit of short-acting insulin.•Rapid-acting insulin is available as a cartridge. Make sureto use the correct device for the brand of insulin prescribed,and don’t add any other insulin to the cartridge.•Absorption rate of rapid-acting insulin may slow whenthis type of insulin is mixed in a syringe with human isophaneinsulin (NPH). Monitor blood glucose level often.Short-acting insulinOnset: 30 min Peak: 2–5 hr Duration: 6–8 hrHuman•Humulin-R•Novolin ge Toronto (CAN)•Novolin R•Novolin R Prefilled•Velosulin BR•Velosulin Human (CAN)Pork•Regular (concentrated),Iletin II, U-500•Don’t use short-acting insulin if it’s cloudy, discolored, orunusually viscous.•Use the U-500 strength to treat insulin resistance, as prescribed.•Mix short-acting insulin with other insulin types, if needed.However, don’t mix phosphate-buffered insulin with azinc-containing insulin because the short-acting insulin’seffectiveness may be reduced.•Administer SubQ, I.M., or I.V., as prescribed. Use a continuousSubQ infusion pump, if ordered. For an insulin pump,phosphate-buffered insulin is preferred over nonphosphate-bufferedinsulin. The catheter tubing and reservoirinsulin should be changed every 48 hours or as specifiedby the pump manufacturer.•When giving SubQ or I.M. injections, give the short-actinginsulin 15 to 30 minutes before a meal or bedtime snack.•Consider religious restrictions when choosing insulintype.(continued)

1112Insulin PreparationsInsulin Preparations (continued)CATEGORY, SPECIES,AND TRADE NAMESIntermediate-acting insulinKEY NURSING CONSIDERATIONSOnset: 1–3 hr Peak: 4–15 hr Duration: 18–24 hrHuman•Humulin N•Novolin ge Lente (CAN)•Novolin ge NPH (CAN)•Novolin N•Novolin N Prefilled•Don’t use intermediate-acting insulin if it contains precipitatethat is clumped or granular or that clings to the sidesof the vial.•Roll the vial gently between your palms to mix; don’t shakeit. Also gently turn the prefilled syringe up and down severaltimes before using to achieve a uniform mixture.•Administer by SubQ injection only, 30 minutes before ameal or bedtime snack.•Be aware that intermediate-acting insulin rarely producesa blood glucose level that’s as close to normal as possible.So expect to mix it with a short-acting insulin, as prescribed,for optimum blood glucose control.•Consider religious restrictions when choosing insulin.Long-acting insulinOnset: 4–6 hr Peak: 8–20 hr Duration: 24–28 hrHuman•Humulin-U (CAN)•Lantus (insulin glargine)•Levemir (insulin detemir)•Novolin ge Ultralente (CAN)•Don’t use long-acting insulin if it contains precipitate that isclumped or granular or that clings to the sides of the vial.•Mix Humulin-U or Novolin ge Ultralente with other insulintypes—usually a short-acting insulin—if needed. Do not mixLantus or Levemir with another insulin or solution.•Roll the vial gently between your palms to obtain a uniformmixture; don’t shake it.•Administer by the SubQ route only. Inject Humulin-U orNovolin ge Ultralente 30 to 60 minutes before a meal orbedtime snack. Inject Lantus once daily at any time, keepingthe daily injection time consistent. Inject Levemir prescribedonce daily with the evening meal or at bedtime;inject Levemir prescribed twice daily with the morningmeal and with the evening meal, at bedtime, or 12 hoursafter the morning dose.•Give Lentus at bedtime, if possible, so that additionalinsulin can be given while patient is awake if Lentus effectsdecline before 24 hours pass. If Lentus is given in themorning and its effects don’t last 24 hours, hyperglycemiamay occur while patient sleeps.

Insulin Preparations (continued)CATEGORY, SPECIES,AND TRADE NAMESCombination insulinsKEY NURSING CONSIDERATIONSOnset: 30 min Peak: 2–12 hr Duration: 18–24 hrHuman•Humalog Mix 75/25•Humalog Mix 50/50•Humulin 10/90 (CAN)•Humulin 20/80 (CAN)•Humulin 30/70 (CAN)•Humulin 40/60 (CAN)•Humulin 70/30•Novolin 70/30•Novolin ge 10/90 (CAN)•Novolin ge 20/80 (CAN)•Novolin ge 30/70 (CAN)•Novolin ge 40/60 (CAN)•Novolin ge 50/50 (CAN)•NovoLog Mix 70/30•NovoLog Mix 50/50Insulin Preparations 1113•Don’t use combination insulin if it contains precipitate thatis clumped or granular.•Roll the vial gently between your palms to mix; don’t shakeit. Also gently turn the prefilled syringe up and down severaltimes before using to achieve a uniform mixture.•Administer combination insulin by the SubQ route only, 30minutes before a meal.•Be aware that Canadian and American products containthe same insulin ratio but express it differently. For example,the Canadian Humulin 30/70 and the AmericanHumulin 70/30 both contain 30 units of a short-actinginsulin and 70 units of an intermediate-acting insulin.Canadian products list the short-acting insulin first;American products list it second.

1114Selected Ophthalmic DrugsSelected Ophthalmic DrugsAlthough less commonly prescribed than oraldrugs, drugs instilled into the eyes are frequentlybrought into the clinical setting bypatients with chronic conditions. In most cases,the patient or a family member has administeredthese preparations at home. Your patientteaching should include a review of properadministration and storage of these drugs.Have the patient or a family member demonstrateproper use of the drug to make sure itwill be administered correctly at home. Use thistime to reassess the patient’s ability to continueself-medication. Also, instruct him to report anychanges in the condition being treated, eithernegative or positive. A properly educatedpatient not only ensures safe drug administration,but also is more likely to detect adversereactions that require a dosage reduction ordrug discontinuation, thus preventing thedevelopment of more serious health problems.The following chart lists the generic andtrade names, FDA-approved indications, andusual adult dosages for those ophthalmicpreparations you’re most likely to see in yourpractice setting. The drugs are divided accordingto therapeutic use.GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESOphthalmic antibioticsbacitracinAK-TracinchloramphenicolDiochloram, Dioptic (CAN),Pentamycetin (CAN),Sopamycetin (CAN)ciprofloxacinhydrochloride 0.3%CiloxanerythromycinIlotycinganciclovir 0.15%ZirganTo treat surface bacterialinfections affecting theconjunctiva and corneaTo treat surface bacterialinfections affecting theconjunctiva and corneaTo treat corneal ulcers dueto Pseudomonas aeruginosa,Staphylococcusaureus, Staphylococcusepidermidis, Streptococcuspneumoniae, and possiblySerratia marcescens andStreptococcus viridansTo treat bacterial conjunctivitisdue to Haemophilusinfluenzae, S. aureus,S.epidermidis, and possiblyS. pneumoniaeTo treat acute or chronicconjunctivitis and othereye infectionsTo treat chlamydial ophthalmicinfections (trachoma)To treat acute herpeskeratitis (dendritic ulcers)Small amount of ointment appliedto conjunctival sac p.r.n.Apply small amount of ointmentto lower conjunctival sac every3 to 6 hr and p.r.n. for at least 48 hrafter eye resumes normal appearance2 gtt in affected eye every 15 minfor first 6 hr, then 2 gtt every30 min for rest of first day; on day2, 2 gtt in affected eye every hr; ondays 3 to 14, 2 gtt in affected eyeevery 4 hr1 or 2 gtt in conjunctival sac ofaffected eye every 2 hr whileawake for first 2 days and then 1 or2 gtt every 4 hr while awake fornext 5 days; or 1⁄2-inch strip ofointment in affected eye t.i.d. for2 days, then b.i.d. for next 5 days1 cm (0.39 in) of ointment appliedin infected eye up to 6 times/day,depending on severity of infectionSmall amount applied in each eyeb.i.d. for 2 mo; or b.i.d. on first 5days of each month for 6 mo1 gtt 5 times daily (about every 3hr while awake) until corneal ulcerheals; then 1 gtt t.i.d. for 7 days

Selected Ophthalmic Drugs 1115Selected Ophthalmic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESOphthalmic antibiotics (continued)gatifloxacin 0.3%Zymargentamicin sulfateGaramycin, Genoptic,Gentacidin, Gentaklevofloxacin 0.5%Quixinmoxifloxacin 0.5%Vigamoxofloxacin 0.3%OcufloxTo treat bacterial conjunctivitisdue to Corynebacteriumpropinquum, Staphylococcusaureus, Staphylococcusepidermidis,Streptococcus mitis, Streptococcuspneumoniae, andHaemophilus influenzaeTo treat blepharitis, blepharoconjunctivitis,conjunctivitis,corneal ulcers,dacryocystitis, keratoconjunctivitis,or meibomianitisdue to susceptibleorganismsTo treat bacterial conjunctivitisTo treat bacterial conjunctivitisdue to Staphylococcusaureus, Staphylococcusepidermidis, Staphylococcushaemolyticus,Staphylococcus hominis,Streptococcus pneumoniae,Streptococcus viridansgroup, Haemophilusinfluenzae, Chlamydia trachomatisTo treat conjunctivitis dueto Staphylococcus aureus,Staphylococcus epidermidis,Streptococcus pneumoniae,Enterobacter cloacae,Haemophilus influenzae,Proteus mirabilis, Pseudomonasaeruginosa, andPropionibacterium acnesTo treat bacterial cornealulcers due to S. aureus, S.epidermidis, S. pneumoniae,E. cloacae, H. influenzae, P.mirabilis, P. aeruginosa,Serratia marcescens, andP. acnes1 gtt every 2 hr while awake, up to8 times daily on days 1 and 2; then1 gtt up to q.i.d. while awake ondays 3 to 71 or 2 gtt every 4 hr or, for severeinfection, up to 2 gtt/hr; alternatively,1 cm (.39 in) of ointmentapplied to lower conjunctival sacb.i.d. or t.i.d.On days 1 and 2: 1 or 2 gtt every2 hr while awake, up to 8 times/day; on days 3 to 7: 1 or 2 gtt every4 hr while awake, up to 4 times/day1 gtt t.i.d. for 7 days1 or 2 gtt in conjunctival sac every2 to 4 hr while awake for first2 days; then 1 gtt q.i.d. for up to5 more days1 or 2 gtt every 30 min whileawake and 1 or 2 gtt every 4 to6 hr after retiring for 2 days; then1 or 2 gtt/hr while awake for up to7 more days; then 1 gtt q.i.d. untilend of treatment(continued)

1116Selected Ophthalmic DrugsSelected Ophthalmic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESOphthalmic antibiotics (continued)polymyxin B sulfatesulfacetamidesodium 10%AK-Sulf, Bleph-10,Ocusulf-10, SodiumSulamyd 10% (CAN),Sulf-10sulfacetamidesodium 15%Isopto Cetamidesulfacetamidesodium 30%tobramycinAKTob, Tobrextobramycin 0.3% (3 mg)and dexamethasone0.1% (1 mg)TobraDexTo treat superficial eyeinfections involving theconjunctiva or corneacaused by Pseudomonas orother gram-negativeorganismsTo treat inclusion conjunctivitis,corneal ulcers, andchlamydial infectionsTo treat trachomaTo treat superficial ocularinfections involving theconjunctiva or corneaTo treat steroid-responsiveinflammatory ocular conditionsfor which a corticosteroidis indicated andwhere superficial bacterialocular infection or a risk ofbacterial ocular infectionexists1 to 3 gtt of 0.1% to 0.25% (10,000to 25,000 units/ml) every hr; or upto 10,000 units in lower conjunctivalsac daily.1 or 2 gtt solution (10%) in lowerconjunctival sac every 2 to 3 hrduring day, less often at night; or1 or 2 gtt (15%) in conjunctival sacevery 1 to 2 hr; or 1 gtt (30%) inconjunctival sac every 2 hr; or1.25 to 2.5 cm ointment (10%) inconjunctival sac q.i.d. and bedtime.2 gtt (30%) in lower conjunctivalsac every 2 hr in combination withsystemic sulfonamide or tetracycline1 to 2 gtt every 1 to 4 hr, dependingon severity of infection; or1 cm (.39 in) of ointment appliedto lower conjunctival sac every8 to 12 hr for mild to moderateinfections or every 3 to 4 hr forsevere infections1 to 2 gtt every 4 to 6 hr; duringfirst 24 to 48 hrs, dosage may beincreased to 1 to 2 gtt every 2 hr;or apply 1 cm (.39 inch) of ointmentinto the conjunctival sac upto q.i.d.Ophthalmic anti-inflammatory drugsbromfenac 0.09%XibromTo treat postoperativeinflammation and reduceocular pain after cataractextraction1 gtt in operative eye b.i.d., starting24 hr after cataract surgeryand continuing through first 2 wkof postoperative period

Selected Ophthalmic Drugs 1117Selected Ophthalmic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESOphthalmic anti-inflammatory drugs (continued)dexamethasoneMaxidexdexamethasonesodium phosphateAK-Dex, Boldex,R.O. Dexasone (CAN)diclofenac sodium 0.1%Voltaren, VoltarenOphtha (CAN)difluprednateDurezolfluorometholoneFluor-Op, FML Forte,FML Liquifilm, FMLS.O.P.fluorometholone acetateEflone, Flarexflurbiprofen sodiumOcufenketorolac tromethamineAcularAcuvailTo treat allergic conjunctivitis;corneal injury fromchemical or thermal burnsor from penetration of foreignbodies; inflammatoryconditions of the anteriorsegment of globe, conjunctiva,cornea, or eyelids;iridocyclitis; suppression ofgraft rejection after keratoplasty;and uveitisTo treat postoperativeinflammation afterremoval of cataractTo treat photophobia inincisional refractive surgeryTo treat inflammation andpain associated with ocularsurgeryTo treat inflammatory andallergic conditions of theanterior uvea, conjunctiva,cornea, or scleraTo inhibit intraoperativemiosisTo relieve ocular itchingdue to seasonal allergicconjunctivitisTo treat postoperativeinflammation in patientswho have undergonecataract extractionTo treat postoperativeinflammation in patientswho have undergonecataract extraction1 or 2 gtt of suspension or solutionor 1.25 to 2.5 cm of ointment inconjunctival sac from every hr (insevere disease) to 6 times/day; orointment may be applied t.i.d. orq.i.d., then tapered to b.i.d., andthen daily.1 gtt in conjunctival sac q.i.d.,starting 24 hr after surgerythrough first 2 postoperative wk1 or 2 gtt in operative eye 1 hrbefore surgery. Then 1 or 2 gtt15 min after surgery. Then 1 gttq.i.d. starting 4 to 6 hr after surgeryfor up to 3 days, p.r.n.1 gtt in conjunctival sac of affectedeye(s) q.i.d. for 2 wk starting 24 hrafter surgery. Then 1 gtt b.i.d. for1 wk.1 or 2 gtt suspension in conjunctivalsac b.i.d. to q.i.d. or, in severeconditions, up to every 2 hr duringfirst 1 to 2 days p.r.n.; or 1 cm(0.39 in) ointment in conjunctivalsac once daily to t.i.d.1 gtt in affected eye every 30 min,beginning 2 hr before surgery, upto total of 4 gtt1 gtt in conjunctival sac of eacheye q.i.d.1 gtt in operative eye q.i.d., starting24 hr after surgery throughfirst 2 postoperative wk1 gtt in affected eye b.i.d., starting1 day before surgery, continuingthrough day of surgery and first2 wk of postoperative period(continued)

1118Selected Ophthalmic DrugsSelected Ophthalmic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESOphthalmic anti-inflammatory drugs (continued)loteprednol etabonateAlrex, LotemaxmedrysoneHMS Liquifilmolopatadinehydrochloride 0.1%PatanolTo relieve seasonal allergicconjunctivitis and to treatsteroid-responsive inflammatoryconditions of thepalpebral and bulbar conjunctiva,cornea, and anteriorsegment of the globeTo treat postoperativeinflammation followingocular surgeryTo treat allergic conjunctivitis,episcleritis,ephinephrine sensitivity,and vernal conjunctivitisTo treat signs and symptomsof allergic conjunctivitis1 gtt of 0.2% suspension in affectedeyes q.i.d.; or 1 or 2 gtt of 0.5%suspension in conjunctival sac ofaffected eye q.i.d. up to 1 gtt/hr1 or 2 gtt in conjunctival sac ofoperated eye q.i.d., beginning24 hr after surgery and continuingthrough first 2 wk of postoperativeperiod1 gtt into conjunctival sac up toevery 4 hr1 gtt b.i.d. at 6- to 8-hr intervalsprednisolone acetatesuspensionEconopred Plus, PredForte, Pred Mildprednisolone sodiumphosphate solutionAK-Pred, InflamaseForte, Inflamase MildTo treat inflammation ofthe anterior segment ofglobe, cornea, andpalpebral and bulbar conjunctiva1 or 2 gtt in conjunctival sac b.i.d.to q.i.d. (suspension) or up to6 times/day (solution)rimexoloneVexolTo treat anterior uveitisTo treat postoperativeinflammation after ocularsurgery1 or 2 gtt in conjunctival sac everyhr while awake in first week; 1 gttevery 2 hr while awake in secondweek; then tapered until uveitisresolves1 or 2 gtt in conjunctival sac ofaffected eye q.i.d., starting 24 hrafter surgery and continuingthrough first 2 postoperative wkOphthalmic cycloplegic mydriaticsatropine sulfateAtropisol, IsoptoAtropine, MinimsAtropine (CAN)To treat acute iritis oruveitisTo produce dilation forcycloplegic refraction1 gtt up to q.i.d.; or small strip ofointment applied to conjunctivalsac up to b.i.d.1 or 2 gtt of 1% solution 1 hrbefore refraction

Selected Ophthalmic Drugs 1119Selected Ophthalmic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESOphthalmic cycloplegic mydriatics (continued)cyclopentolatehydrochlorideAK-Pentolate, Cyclogyl,Minims Cyclopentolate(CAN), PentolairhomatropinehydrobromideIsopto Homatropine,Minims Homatropine (CAN)scopolaminehydrobromideIsopto HyoscinetropicamideMydriacyl, Opticyl,TropicacylOphthalmic mioticsacetylcholine chlorideMiochol-Ecarbachol 0.01%Carbastat, Miostatcarbachol 0.75%, 1.5%,2.25%, 3%Carboptic, IsoptoCarbacholpilocarpineOcusert Pilo-20,Ocusert Pilo-40pilocarpinehydrochlorideAdsorbocarpine, Akarpine,Isopto Carpine, Miocarpine(CAN), Pilocar, Pilopine HS,Pilostatpilocarpine nitratePilagan, P.V. CarpineLiquifilm (CAN), MinimsPilocarpine (CAN)To produce mydriasis andcycloplegia required inspecific diagnostic proceduresTo dilate pupils for cycloplegicrefractionTo treat uveitisTo dilate pupils for cycloplegicrefractionTo treat iritis or uveitisTo dilate pupils for cycloplegicrefractionTo produce papillarymiosis in anterior segmentsurgeryTo produce papillarymiosis in ocular surgeryTo treat open-angleglaucomaTo treat primary openangleglaucomaTo treat acute angleclosureglaucoma as emergencytherapyTo treat mydriasis due tomydriatic or cycloplegicdrug therapy1 gtt of 0.5%, 1%, or 2% solution ineach eye; then 1 or 2 gtt in 5 to 10min p.r.n.1 or 2 gtt in each eye, repeated in5 to 10 min for 2 or 3 doses p.r.n.1 or 2 gtt in each eye every 3 to 4 hr1 or 2 gtt of 0.25% solution 1 hrbefore refraction1 or 2 gtt of 0.25% solution oncedaily to q.i.d.1 gtt of 1% solution, repeated in5 min; additional 1 gtt in 20 to30 min p.r.n.0.5 to 2 ml gently into anteriorchamber before or after suturessecured0.5 ml (solution) into anteriorchamber before or after suturessecured1 or 2 gtt up to t.i.d.1 or 2 gtt up to q.i.d.; or 1-cm(0.39 cm) ribbon of 4% gel at bedtime;or 1 Ocusert Pilo (20 or40 mcg/hr) every 7 days1 gtt of 2% solution every 5 to10 min for 3 to 6 doses; then 1 gttevery 1 to 3 hr until pressure iscontrolled1 gtt of 1% solution(continued)

1120Selected Ophthalmic DrugsSelected Ophthalmic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESOphthalmic vasoconstrictorsnaphazolinehydrochlorideAk-Con, Albalon Liquifilm,Allerest, Clear Eyes,Comfort Eye Drops,Degest 2, Vasocon RegularoxymetazolinehydrochlorideOcuClear, Visine L.R.phenylephrinehydrochlorideAk-Dilate, Ak-Nefrin,Isopto Frin, Mydfrin,Phenoptic, Relief EyeDrops for Red EyesproparacainehydrochlorideAlcaine, Ophthaine,OphthetictetracainePontocainetetrahydrozolinehydrochlorideCollyrium Fresh EyeDrops, Eyesine, MurinePlus, Optigene 3,Tetrasine, VisineMoisturizing, Visine ExtraTo treat ocular congestion,irritation, or itchingTo provide relief from eyeredness due to minor eyeirritationsTo produce mydriasiswithout cycloplegiaTo produce mydriasis andvasoconstrictionTo treat chronic mydriasisTo treat posterior adhesionof irisTo provide deep anesthesiaduring cataractextractionTo provide anesthesia duringremoval of eye suturesTo provide anesthesiaduring removal of foreignbodiesTo provide anesthesiaduring tonometryTo provide eye anesthesia(short term)To treat conjunctival congestion,irritation, andallergic conditions1 gtt of 0.1% solution every 3 to4 hr; or 1 gtt of 0.012% to 0.03%solution up to q.i.d. for no morethan 72 hr1 or 2 gtt in conjunctival sac b.i.d.to q.i.d. (at least 6 hr apart)1 gtt of 2.5% or 10% solutionbefore eye exam, then repeated in1 hr p.r.n.1 gtt of 2.5% or 10% solution assingle dose1 gtt of 2.5% or 10% solution b.i.d.or t.i.d.1 gtt of 2.5% or 10% solution assingle dose1 gtt every 5 to 10 min for 5 to7 doses1 or 2 gtt 2 to 3 min beforeprocedure1 or 2 gtt in affected eye beforesurgery1 or 2 gtt immediately beforemeasurement1 or 2 gtt p.r.n.1 or 2 gtt of 0.05% solution up toq.i.d. or as directedMiscellaneous ophthalmic drugsapraclonidinehydrochlorideIopidineTo prevent or controlelevated intraocular pressure(IOP) before and afterocular laser surgery1 gtt of 1% solution 1 hr beforelaser surgery on anterior segment;then 1 drop immediately aftersurgery

Selected Ophthalmic Drugs 1121Selected Ophthalmic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESMiscellaneous ophthalmic drugs (continued)azelastinehydrochloride 0.05%Optivarbepotastine besilate1.5%Beprevebetaxolol hydrochlorideBetoptic, Betoptic Sbimatoprost 0.03%Lumiganbrimonidine tartrateAlphagan, Alphagan Pbrinzolamide 1%Azoptcarteolol hydrochlorideOcupresscyclosporine emulsion0.05%Restasisdipivefrin hydrochlorideOphto-Dipivefrin (CAN),PropinedorzolamidehydrochlorideTrusoptemedastine difumarateEmadineTo treat itching of the eyeassociated with allergicconjunctivitisTo treat itching of the eyeassociated with allergicconjunctivitisTo treat chronic openangleglaucoma or ocularhypertensionTo reduce elevated IOP inpatients with open-angleglaucoma or ocular hypertensionwho can’t tolerateor have insufficientlyresponded to other IOPloweringmedicationsTo reduce IOP in openangleglaucoma or ocularhypertensionTo reduce IOP in ocularhypertension or openangleglaucomaTo treat chronic openangleglaucoma orintraocular hypertensionTo increase tear productionin keratoconjunctivitissiccaTo reduce IOP in chronicopen-angle glaucomaTo treat increased IOP inocular hypertension oropen-angle glaucomaTo treat allergic conjunctivitis1 gtt in affected eye b.i.d.1 gtt in affected eye b.i.d.1 or 2 gtt of 0.5% solution or0.25% suspension b.i.d.1 gtt in affected eye daily inevening1 gtt in affected eye t.i.d., about8 hr apart1 gtt t.i.d.1 gtt in conjunctival sac of affectedeye b.i.d.1 gtt every 12 hr1 gtt of 0.1% solution every 12 hr1 gtt in conjunctival sac of affectedeye t.i.d.1 gtt in affected eye up to q.i.d.(continued)

1122Selected Ophthalmic DrugsSelected Ophthalmic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESMiscellaneous ophthalmic drugs (continued)fluorescein sodiumAK-Fluor, Fluorescite,Fluor-I-Strip,Fluor-I-Strip-A.T., Ful-Glo,Funduscein-10,Funduscein-25, Ophthifluorketotifen fumarateZaditorlatanoprostXalatanlevobunololhydrochlorideAKBeta, Betagan, Novo-Levobunolol (CAN)levocabastinehydrochloride 0.05%LivostinmetipranololhydrochlorideOptiPranololTo diagnose cornealabrasions and foreignbodies, fit hard contactlenses, determine lacrimalpatency, and assist infundus photography andapplanation tonometryTo treat allergicconjunctivitisTo reduce IOP in ocularhypertension or openangleglaucomaTo treat chronic openangleglaucoma or ocularhypertensionTo treat signs andsymptoms of seasonalallergic conjunctivitisTo reduce IOP in ocularhypertension or chronicopen-angle glaucoma1 or 2 gtt of 2% solution followedby irrigation; or moisten strip withsterile water, then touch conjunctivaor fornix with moistened tip,and flush with irrigating solution;have patient blink several timesafter application1 gtt in affected eye b.i.d. every8 to 12 hr1 gtt in conjunctival sac of affectedeye daily in evening1 or 2 gtt of 0.5% solution oncedaily or 0.25% solution b.i.d.1 gtt q.i.d.1 gtt in affected eye b.i.d.nedocromil sodium 2%Alocrilsodium chloride,hypertonicAdsorbonac, AK-NaCl,Muro-128, Muroptic-5To treat itching associatedwith both seasonal andperennial allergicconjunctivitisTo provide temporaryrelief from corneal edema1 or 2 gtt b.i.d.1 or 2 gtt every 3 to 4 hr; or 6 mm(1/4 in) of ointment applied every3 to 4 hrtimolol hemihydrateBetimoltimolol maleateApo-Timop (CAN), Timoptictimolol maleateextended-releasesolutionTimoptic-XETo reduce IOP in ocularhypertension or openangleglaucoma1 gtt of 0.25% or 0.5% solution inaffected eye b.i.d., then 1 gtt daily;or 1 gtt extended-release solutionin affected eye daily

Selected Ophthalmic Drugs 1123Selected Ophthalmic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESMiscellaneous ophthalmic drugs (continued)travoprost 0.004%Travatanunoprostoneisopropyl 0.15%ResculaTo reduce elevated IOP inpatients with open-angleglaucoma or ocular hypertensionwho can’t tolerateor have insufficientlyresponded to other IOPloweringmedicationsTo reduce elevated IOP inpatients with open-angleglaucoma or ocular hypertensionwho can’t tolerateor have insufficientlyresponded to other IOPloweringmedications1 gtt in affected eye daily inevening1 gtt in affected eye b.i.d.

1124AntihistaminesAntihistaminesAntihistamines are usually used to relieveimmediate hypersensitivity reactions. They’realso used as sedatives, antiemetics (especiallyin motion sickness), antitussives, antidyskinetics,and adjuncts to preoperative or postoperativeanalgesia.Antihistamines are contraindicated inpatients taking drugs that prolong the QT interval(including some macrolide antibiotics,quinidine, itraconazole, ketoconazole,mibefradil, and zileuton). They’re also contraindicatedin patients hypersensitive to antihistaminesor their components.The table below includes trade names; usualdosages; and onset, peak, and duration for antihistaminesyour patient is most likely to usedaily or intermittently to control symptoms ofallergic rhinitis. When caring for a patient whotakes an antihistamine, individualize your planof care but be sure to include these generalinterventions:•Use antihistamines cautiously in patients witha history of glaucoma, peptic ulcer, or urineretention because anticholinergic effects mayworsen these conditions.•Before antihistamine therapy, assess thepatient for hypokalemia and correct the imbalance,as prescribed, to reduce the risk ofarrhythmias.•Before antihistamine therapy, obtain a detailedmedication history to help prevent drug interactions.•Give antihistamines with food if GI distressoccurs.•Urge patient to avoid alcohol and other CNSdepressants during antihistamine use becausethe combination can cause additive CNSdepression.•Monitor blood pressure because these drugs’anticholinergic effects may cause hypertension.•Be aware that short- and long-acting antihistaminesmay be combined and H 2 blockersadded to increase antihistamine effects.•Be aware that products containing pseudoephedrineshould be used for less than 7 days.GENERIC AND USUAL ADULT ONSET, PEAK,TRADE NAMES DOSAGE AND DURATIONacrivastineSemprex-D (also includespseudoephedrine)azatadineOptimineTrinalin Repetabs (alsoincludes pseudoephedrine)azelastineAstelinAstepro 0.1%Astepro 0.15%cetirizineZyrtecZyrtec D (also includespseudoephedrine)8 mg P.O. every 4 to 6 hr1 to 2 mg P.O. every 8 to 12 hr1 tablet P.O. every 12 hr2 sprays (137 mcg/spray) ineach nostril b.i.d.1 to 2 sprays (137 mcg/spray) ineach nostril b.i.d.1 to 2 sprays (205.5 mcg/spray)in each nostril b.i.d.5 to 10 mg P.O. daily5 mg/120 mg b.i.d.Onset: 30 minPeak: UnknownDuration: 6 to 8 hrOnset: 15 to 60 minPeak: 4 hrDuration: 12 hrOnset: In 3 hrPeak: UnknownDuration: 12 hrOnset: 30 to 60 minPeak: 1 hrDuration: Up to 24 hr

Antihistamines 1125Antihistamines (continued)GENERIC AND USUAL ADULT ONSET, PEAK,TRADE NAMES DOSAGE AND DURATIONdesloratadineClarinexClarinex Reditabs5 mg P.O. daily5 mg P.O. dailyOnset: UnknownPeak: Unknown (Clarinex);3 hr (Clarinex Reditabs)Duration: UnknownfexofenadineAllegraAllegra-D (also includespseudoephedrine)60 mg P.O. b.i.d. or 180 mg P.O.daily1 tablet P.O. every 12 hrOnset: 1 hrPeak: 2 to 3 hrDuration: 12 hrlevocetirizineXyzal2.5 to 5 mg P.O. daily in eveningOnset: Less than 1 hrPeak: 0.9 hrDuration: 24 hrloratadineClaritinClaritin-D12 (also includespseudoephedrine)Claritin-D24 (also includespseudoephedrine)10 mg P.O. daily1 tablet P.O. every 12 hr1 tablet P.O. every 24 hrOnset: 1 to 3 hrPeak: 8 to 12 hrDuration: At least 24 hrolopatadinePatanase2 sprays (665 mcg/spray) ineach nostril b.i.d.Onset: UnknownPeak: 15 to 120 minutesDuration: Unknown

1126Selected Topical DrugsSelected Topical DrugsTopical drugs consist of an active drug preparedin a specified medium that promotesabsorption through the skin. Media commonlyare chosen based on drug solubility; rate ofdrug release; ability to hydrate the outer skinlayer; ability to enhance penetration; drug stability;and interactions between the chosenmedium, skin, and active ingredient.Topical media include aerosols, creams, gels,lotions, ointments, powders, tinctures, and wetdressings. Aerosols, gels, lotions, and tincturesare convenient for application to the scalp andother hairy areas. Acutely inflamed areas arebest treated with drying preparations, such aslotions, tinctures, and wet dressings. Chronicinflammation does well with applications oflubricating preparations, including creams andointments.Because of its physical properties, the skincan act as a holding area for many drugs, allowingslow penetration and prolonged durationof action. (This characteristic makes it importantto understand the patient’s allergies.)However, when administering topical or transdermaldrugs that aren’t prescribed for a specificlocation, keep in mind that penetration propertiesmay vary in different areas of the body.For example, the scrotum, face, axillae, andscalp are more permeable than the limbs, andventral surfaces typically are more permeablethan dorsal surfaces.Topical Drug TypesTopical drugs are classified as antibacterials,antifungals (the largest group), antivirals,corticosteroids, retinoids, and other miscellaneouspreparations.• Antibacterials may be useful in the early treatmentof minor skin infections and wounds.Minor skin infections may respond well to topicaldrugs applied at the infection site. Minorwounds should be treated at the site and inthe immediately surrounding area to preventother pathogens from colonizing the area.• Antifungals usually are used to treat mucocutaneousinfections, such as tineas, primarilyringworm and athlete’s foot. Systemic use ofantifungals is limited by their potentially toxicadverse effects, most commonly renal orhepatic damage. All fungi are completelyresistant to conventional antibacterial drugs.• Antivirals are used to inhibit viral replication.They work by targeting any one of the stepsinvolved in viral replication: penetration intosusceptible host cells; uncoating of the viralnucleic acid; synthesis of regulatory proteins,RNA and DNA, and structural proteins; assemblyof viral particles; and release of the virusfrom the cell. Topical antivirals such as penciclovircan shorten the duration of herpeticlesions, lessen lesion pain, and minimize viralshedding.• Corticosteroids reduce the signs and symptomsof inflammation. Topical corticosteroids causevasoconstriction, probably by suppressing celldegranulation. They also cause decreased cellpermeability by reducing histamine releasefrom basal and mast cells.• Retinoids, typically derivatives of vitamin A, arevery effective in treating acne vulgaris,although the acne may appear to worsenbefore it improves. Retinoids are also useful forreducing wrinkles. When applied to the skin,retinoids remain primarily in the dermis; lessthan 10% of the drug is absorbed into the circulation.Prolonged use of retinoids promotesnew dermal growth, new blood vessel formation,and thickening of the epidermis. Becausethese drugs are absorbed systemically andmay have teratogenic effects, they shoudln’tbe used by pregnant women.• Miscellaneous topical drugs are used to treat avariety of topical skin conditions, including dryskin, ichthyosis, parasitic infestations, psoriasis,and unwanted hair growth.Administration TipsBefore you apply a topical drug, clean the siteand let it dry. Use gloves or a finger cot duringapplication to prevent the drug from beingabsorbed through your own skin. Inform yourpatient of any expected discomfort, such astemporary stinging or burning. After application,cover the site only if required; some topicaldrugs shouldn’t be covered with an occlusivedressing.Be sure to teach the patient and a familymember correct administration technique. Also,review possible adverse reactions, highlightingthose that should be reported to the prescriber.Stress the importance of complying with thedrug regimen because some topical drugsrequire weeks or months of therapy to eradicatethe underlying condition.The following table includes the genericand trade names of many commonly prescribedtopical drugs as well as their FDAapprovedindications and usual adult dosages.

Selected Topical Drugs 1127Selected Topical Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntibacterialsazelaic acid creamAzelex, Finacea, Finevinbacitracinbenzoyl peroxideBenzac AC Wash, ClearasilMaximum Strength,Desquam-E 2.5 Gel,Fostex 10 BPO Gel, TriazTo treat mild to moderateinflammatory acne vulgarisTo treat topical infections,abrasions, cuts, and minorburns or woundsTo treat mild to moderateinflammatory acne vulgarisGently massage thin film intoaffected area b.i.d., morningand evening.Apply thin film to affected areaonce daily to t.i.d. up to 3 wk.Apply to affected area oncedaily, gradually increasing tob.i.d. or t.i.d.clindamycin phosphateCleocin, Cleocin T Gel,Cleocin T Lotion, Clinda-Derm, Dalacin, Dalacin TTopical Solution (CAN)To treat inflammatory acnevulgarisTo treat bacterial vaginosisApply to affected area b.i.d.,morning and evening.1 applicatorful (100 mg) intravaginallyat bedtime for 7 days.clindamycin 1% andbenzoyl peroxide 5%Benzaclin gel DUACerythromycinAkne-Mycin, A/T/S, Erycette,EryDerm, Erygel, Erymax,Ery-Sol (CAN), Erythrogel,ETS (CAN), Sans-Acne (CAN),Staticin, T-Stat (CAN)erythromycin 3% andbenzoyl peroxide 5%BenzamycinTo treat acne vulgarisTo treat inflammatory acnevulgarisTo treat moderateinflammatory acneApply once or twice daily(morning and/or evening) toaffected areasApply to affected areas b.i.d.,morning and evening.Apply to affected areas b.i.d.,morning and evening.gentamicin sulfateGaramycin, G-myticinTo prevent or treat superficialskin infections due tosusceptible bacteria; to treatsuperficial burnsRub small amount gently intoskin t.i.d. or q.i.d.mafenide gel 1%SulfamylonAs adjunct to treat secondandthird-degree burnsApply 1⁄16-inch layeraseptically to affected areasonce or twice daily(continued)

1128Selected Topical DrugsSelected Topical Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntibacterials (continued)metronidazoleMetroCream, MetroGel,MetroGel-Vaginalmupirocin 2%Bactroban, BactrobanCream, Bactroban Nasalneomycin sulfateMyciguentnitrofurazoneFuracinpovidone-iodineBetadine, BetadineCream, Betadine SprayTo treat inflammatory papulesand pustules of acne rosaceaTo treat bacterial vaginosisTo treat impetigoTo treat secondary infectionsof traumatic skin lesions dueto Staphylococcus aureus andStreptococcus pyogenesTo eradicate nasal colonizationof methicillin-resistantS. aureusTo prevent or treat superficialbacterial infectionsAs adjunct to treat thirddegreeburns and to treatinfection in skin graftsTo disinfect wounds and burnsApply thin film to affected areab.i.d., morning and evening.1 applicatorful (37.5 mg) intravaginallyat bedtime or b.i.d. for5 days.Apply to affected areas t.i.d. for1 to 2 wk.Apply thin film and cover withan occlusive dressing t.i.d. for10 days.Apply half of the contents of aunit-dose tube to each nostrilb.i.d. for 5 days.Rub fingertip-size dose intoaffected area once daily to t.i.d.Apply aseptically, directly tolesions or on gauze; repeatp.r.n.Apply or spray to affected areap.r.n.silver sulfadiazineFlamazine (CAN),Silvadene, Thermazinesulfacetamidesodium 10%KlaronTo prevent and treat bacterialand fungal infection insecond- and third-degreeburnsTo treat acne vulgarisApply 1⁄16-inch layer asepticallyonce to twice daily to cleandebrided burns; reapplypromptly if removed.Apply thin film b.i.d.sulfacetamide sodium10% and sulfur 5%Sulfacet-RTo treat acne rosacea, acnevulgaris, and seborrheic dermatitisApply thin film, and massageinto affected area once daily tot.i.d.tetracyclinehydrochlorideAchromycin, TopicyclineTo treat acne vulgarisTo prevent or treat superficialskin infections due to susceptiblebacteriaRub solution into affected areab.i.d.Apply to affected area b.i.d.(morning and evening) or t.i.d.

Selected Topical Drugs 1129Selected Topical Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntifungalsbutenafine hydrochloride1%Lotrimin Ultra, MentaxTo treat tinea corporis, tineacruris, or tinea versicolorTo treat interdigital tinea pedisdue to Epidermophytonfloccosum, Trychophytonmentagrophytes, or T. rubrumApply to affected surroundingarea once daily for 2 wk.Apply to affected and immediatelysurrounding area oncedaily for 4 wk or b.i.d. for 1 wk.butoconazole nitrateFemstat, Femstat One,Mycelex 3Gynazole-1To treat vulvovaginal mycoticinfections caused by CandidaspeciesTo treat vulvovaginal infectionscaused by Candidaalbicans1 applicatorful (100 mg) intravaginallyat bedtime for 3 days;may repeat course for total of6days.1 applicatorful (100 mg) intravaginallyonce anytime day ornight.ciclopirox olamine 1%Loprox 0.77%ciclopirox olamine 8%PenlacclotrimazoleCanesten (CAN),Gyne-Lotrimin,Gyne-Lotrimin 3,Lotrimin,Lotrimin Antifungal,Mycelex, Mycelex-7,Mycelex-G, Mycelex OTC,Trivagizole 3To treat candidiasis due toCandida albicans; tineacorporis, tinea cruris, and tineapedis due to E. floccosum,T. mentagrophytes, T. rubrum, orMicrosporum canis; tinea versicolordue to Malassezia furfur;onychomycosis due toT. rubrum; and seborrheicdermatitisTo treat onychomycosis of thefingernails and toenailsTo treat superficial fungalinfections (tinea corporis, tineacruris, tinea pedis, tinea versicolor,candidiasis)To treat vulvovaginalcandidiasisTo treat oropharyngeal candidiasisTo prevent oropharyngealcandidiasisMassage gently into affectedand surrounding area b.i.d.,morning and evening.Apply evenly to entire nail surfaceand surrounding 5 mm ofskin at bedtime for up to 48wk.Apply thin film and massageinto affected and surroundingarea b.i.d., morning andevening, for 2 to 4 wk.Insert 100-mg vaginal tablet atbedtime for 7 days; or 500-mgvaginal tablet at bedtime for1 day; or 1 applicatorful intravaginallyat bedtime for 7 days(or 3 days if using Trivagizole3).Dissolve oral troche over 15 to30 min 5 times/day for 14 days.Dissolve oral troche over 15 to30 min t.i.d. for duration ofchemotherapy or until corticosteroiddosage is reduced tomaintenance levels.(continued)

1130Selected Topical DrugsSelected Topical Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntifungals (continued)econazole nitrateEcostatin (CAN),SpectazoleTo treat tinea corporis, tineacruris, tinea pedis, tinea versicolor,cutaneous candidiasisTo treat cutaneous candidiasisRub into affected area once ortwice daily for at least 2 wk.Rub into affected area b.i.d. for2 wk.gentian violetGenapaxhaloproginHalotexketoconazole 2%NizoralTo treat candidiasisTo treat tinea corporis, tineacruris, tinea manuum, andtinea pedis due to E. floccosum,M. canis, T. mentagrophytes,T. rubrum, or T. tonsurans; totreat tinea versicolor due toM. furfurTo treat tinea corporis, tineacruris, and tinea versicolor dueto susceptible organisms; totreat cutaneous candidiasisTo treat tinea pedisTo treat seborrheic dermatitisInsert 1 intravaginal tampont.i.d. to q.i.d. for 12 days; orapply 1% or 2% solution toaffected area once or twicedaily for 3 days.Apply liberally to affected areab.i.d. for 2 to 3 wk or, for intertriginouslesions, up to 4 wk.Apply thin film to affected andimmediately surrounding areaand cover with occlusive dressingdaily for at least 2 wk.Apply to affected and immediatelysurrounding area daily for6 wk; or apply shampoo to wethair, lather, massage for 1 min,leave drug on scalp for 3 min,then rinse and repeat 2 times/wk for 4 weeks (with at least3 days between shampoos),then intermittently p.r.n.Apply to affected and immediatelysurrounding area b.i.d. for4 wk.

Selected Topical Drugs (continued)Selected Topical Drugs 1131GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntifungals (continued)miconazole nitrateFemizol-M, Fungoid,M-Zole 3, Micatin,Monistat-Derm,Monistat 3, Monistat 7,Ony-Clear NailTo treat tinea corporis, tineacruris, tinea pedis; cutaneouscandidiasis; and common dermatophyteinfectionsTo treat tinea versicolorTo treat vulvovaginalcandidiasisApply cream sparingly (orpowder or spray liberally) overaffected area. b.i.d. for 2 to 4 wk.Apply sparingly to affectedarea daily for 2 wk.1 applicatorful (100 mg) orvaginal suppository (100 mg)at bedtime for 7 days, repeatedp.r.n.; or insert vaginal suppository(200 mg) at bedtime for3 days.naftifine hydrochlorideNaftinnystatinMycostatin, Nadostine(CAN), Nilstatoxiconazole nitrateOxistat, Oxizold (CAN)To treat onychomycosisTo treat tinea corporis, tineacruris, and tinea pedisTo treat cutaneous and mucocutaneousinfections due toC. albicansTo treat vulvovaginalcandidiasisTo treat tinea corporis, tineacruris, and tinea pedis causedby E. floccosum, T. mentagrophytes,or T. rubrumTo treat tinea versicolorcaused by M. furfurBrush tincture on affectedareas of nail surface, beds, andedges and under nail surfaceb.i.d. for up to several mo; orspray on clean, dry, affectednails, holding actuator downfor 1 or 2 sec.Apply cream to affected areadaily; or apply gel to affectedarea b.i.d., morning andevening.Apply cream to affected areab.i.d. or as indicated; or applypowder b.i.d. or t.i.d.; or insert1 or 2 lozenges (200,000 to400,000 units) 4 to 5 times/dayfor up to 48 hr after symptomshave subsided or 14 days; orinsert 4 to 6 ml (400,000 to600,000 units) of oral suspensionin mouth q.i.d. (one-half ofdose in each side of mouth)and retain as long as possiblebefore swallowing.Insert 1 intravaginal tablet(100,000 units) or 1 applicatorful(100,000 to 500,000 units)once or twice daily for 14 days.Apply to affected and surroundingarea once or twicedaily for 2 wk (tinea corporisand tinea cruris) or for 4 wk(tinea pedis).Apply cream to affected andsurrounding area daily for 2 wk.(continued)

1132Selected Topical DrugsSelected Topical Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntifungals (continued)selenium sulfideSelsunTo treat tinea versicolorTo treat dandruff and seborrheicscalp dermatitisApply to scalp, lather with smallamount of water, wait 10 min,then rinse, every 7 days.Massage into wet scalp, wait2 to 3 min, rinse, and repeat2 times/wk for 2 wk, then p.r.n.sulconazole nitrateExeldermterbinafinehydrochlorideLamisil DermGel,Lamisil SolutionLamisil AT CreamLamisil AT SolutionterconazoleTerazol 3, Terazol 7tioconazoleGyneCure Ovules (CAN),Vagistat-1To treat tinea corporis, tineacruris, and tinea pedis (creamonly) caused by E. floccosum,M. canis, T. mentagrophytes,or T. rubrum; to treat tineaversicolorTo treat tinea versicolorTo treat tinea corporis, tineacruris, and tinea pedisTo treat interdigital tineapedis, tinea corporis, and tineacrurisTo treat vulvovaginalcandidiasisTo treat vulvovaginalcandidiasisMassage small amount gentlyinto affected and surroundingareas once or twice daily (tineapedis) for up to 6 wk.Apply to affected area b.i.d. for1 wk.Apply thin film to affected areab.i.d. for 1 wk or 2 wk (plantartinea pedis).Apply between the toes b.i.d.for 1 wk (interdigital tineapedis) or to affected area dailyfor 1 wk (tinea corporis andtinea cruris).1 applicatorful (20 mg) intravaginallyat bedtime for 3 days(0.4%) or 1 applicatorful (40mg) for 7 days (0.8%); or insert80-mg vaginal suppository atbedtime for 3 consecutivedays.Insert 1 applicatorful (300 mg)or 1 suppository (300 mg)intravaginally at bedtime as asingle dose.

Selected Topical Drugs 1133Selected Topical Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntifungals (continued)tolnaftateAbsorbine Footcare,Aftate for Athlete’s Foot,Aftate for Jock Itch,Dr. Scholl’s Athlete’s Foot,Genaspore, NP-27, Pitrex,Quinsana Plus, Tinactin,Ting, Zeasorb-AFAntiviralsacyclovirZoviraxdocosanolAbrevaTo treat tinea capitis, corporis,cruris, manuum, pedis, andversicolorTo treat mucocutaneousherpes simplex in immunocompromisedpatientsTo treat recurrent oral-facialherpes simplexApply 1% aerosol, cream, gel,powder, or solution to affectedand surrounding areas b.i.d.;continue for 2 wk after symptomssubside or up to 6 wk.Apply cream to affected area4 to 6 times daily for 10 days.Apply ointment every 3 hr(6 times/day) for 7 days. Usefinger cot, rubber glove, orapplicator stick for both formsto prevent herpetic whitlow.Apply cream gently and completelyto affected area 5 timesdaily, starting with first visiblesign of lesion and continuinguntil lesion is healed.penciclovirDenavirCorticosteroidsalclometasonedipropionateAclovateTo treat recurrent herpeslabialis of lips and faceTo treat corticosteroidresponsivedermatosesApply every 2 hr while awakefor 4 days.Apply thin film to affected areaand massage b.i.d. to t.i.d.amcinonideCyclocortTo treat corticosteroidresponsivedermatosesApply thin film to affected areaand massage b.i.d. (ointment,lotion) or b.i.d. to t.i.d. (cream).betamethasonebenzoateBeben (CAN), UticortbetamethasonedipropionateDiprolene, Diprolene AF,Diprosone, Topilene (CAN)To treat corticosteroidresponsivedermatosesTo treat corticosteroidresponsivedermatosesApply thin film or a few dropsto affected area once or twicedaily up to 45 g/wk (ointment,cream), 50 g/wk (gel), or 50 ml(lotion).Apply thin film or a few dropsto affected area once or twicedaily up to 45 g/wk (ointment,cream), 50 g/wk (gel), or 50 ml(lotion).(continued)

1134Selected Topical DrugsSelected Topical Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESCorticosteroids (continued)betamethasomevalerateLuxiq, Valisoneclobetasol propionateDermovate (CAN), Embeline,TemovateOluxdesonideDesowen, Tridesilondiflorasone diacetateFlorone, Maxiflor,Psorconfluocinolone acetonideBio-Syn, Derma Smooth FS,Fluocet, Fluoderm (CAN),Fluolar (CAN), Fluonid (CAN),Fluonide (CAN), Flurosyn,Synalar, Synalar-HP,Synamol (CAN), SynemolfluocinonideLidemol (CAN), LidexflurandrenolideCordran, Cordran Tape,Drenison (CAN)fluticasone propionateCutivatehalcinonideHalogTo treat corticosteroidresponsivedermatosesTo treat corticosteroidresponsivedermatosesTo treat corticosteroidresponsivedermatoses ofscalpTo treat corticosteroidresponsivedermatosesTo treat corticosteroidresponsivedermatosesTo treat corticosteroidresponsivedermatosesTo treat corticosteroidresponsivedermatosesTo treat corticosteroidresponsivedermatosesTo treat atopic dermatitis andcorticosteroid-responsive.dermatosesTo treat corticosteroidresponsivedermatosesApply foam to scalp, and massageuntil foam disappears,b.i.d. Apply thin film of ointmentb.i.d.Apply thin film to affected areaand rub in gently b.i.d. to t.i.d.,up to 50 g/wk, for 2 wk.Apply to affected area of scalpb.i.d., once in morning andonce at night, for 2 wk.Apply thin film to affected areab.i.d. to q.i.d.Apply thin film to affected areaonce daily to q.i.d.Apply thin film to affected areab.i.d. to q.i.d.Apply thin film to affected areab.i.d. to q.i.d.Apply thin film to affected areaand massage b.i.d. to t.i.d.; orapply tape every 12 to 24 hr.Apply thin film daily (atopicdermatitis) or b.i.d. (dermatoses).Apply sparingly and massageonce daily to t.i.d.halobetasol propionateUltravateTo treat corticosteroidresponsivedermatosesApply thin film to affected areaand rub in gently once or twicedaily, up to 50 g/wk, for 2 wk.

Selected Topical Drugs 1135Selected Topical Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESCorticosteroids (continued)hydrocortisone 0.25%Cetacort, Cort-Domehydrocortisone 0.5%Bactine, Cetacort,Cortate (CAN), Cort-Dome,Cortifair, Delacort,DermiCort, Dermtex HC,Emo-Cort (CAN), Hydro-Tex, Hytone, MyCort,Sential (CAN), S-T Corthydrocortisone 1%Ala-Cort, Allercort,Alphaderm, Acticort 100,Barriere-HC (CAN),Beta-HC, Cetacort,Cort-Dome, Cortifair,Cortril, Dermacort,Emo-Cort (CAN), Gly-Cort,Hi-Cor 1.0, Hydro-Tex,Hytone, LactiCare-HC,Lemoderm, Nutracort,Penecort, Prevex-HC (CAN),Rederm, Sarna HC (CAN),Synacort, Unicort (CAN)hydrocortisone 2%Ala-Scalp HPhydrocortisone 2.5%Allercort, Anusol-HC,Emo-Cort (CAN), Hi-Cor 2.5,Hytone, LactiCare-HC,Lemoderm, Nutracort,Penecort, Synacorthydrocortisoneacetate 0.1%Corticreme (CAN)hydrocortisoneacetate 0.5%9-1-1, Corticaine,Cortacet (CAN), Cortaid,Cortoderm (CAN),FoilleCort, Gynecort,Hyderm (CAN), Lanacort,Novohydrocort (CAN),Pharma-CortTo treat corticosteroidresponsivedermatosesApply thin film (aerosol foam,cream, lotion, ointment, solution)to affected area oncedaily to q.i.d.(continued)

1136Selected Topical DrugsSelected Topical Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESCorticosteroids (continued)hydrocortisoneacetate 1%, 2%, 2.5%Cortaid, Cortef FeminineItch, Corticreme (CAN),Cortoderm (CAN),Hyderm (CAN), MaximumStrength Cortaid,Micort HC-Lipocream,Novohydrocort (CAN)hydrocortisone acetatetopical aerosol foamEpifoamhydrocortisone acetatedental pasteOrabase-HCAhydrocortisone butyrateLocoidhydrocortisone valerateWestcorthydrocortisone acetate,polymyxin B sulfate,and neomycin sulfateCortisporinhydrocortisone andiodoquinolVytonemometasone furoateElocom (CAN), EloconTo treat corticosteroidresponsivedermatosesTo treat inflamed oral mucosaTo treat corticosteroid-responsivedermatosesTo treat corticosteroidresponsivedermatoses (shortterm) with mild bacterialinfectionTo treat corticosteroidresponsivedermatoses withmild bacterial or fungalinfection (short term)To treat corticosteroidresponsivedermatosesApply thin film (aerosol foam,cream, lotion, ointment,solution) to affected area oncedaily to q.i.d.Apply to oral mucosa b.i.d. tot.i.d. after meals and at bedtime.Apply to affected area b.i.d. tot.i.d.Apply sparingly and massageb.i.d. to q.i.d.Apply to affected area oncedaily to t.i.d.Apply thin film or a few dropsto affected area daily.prednicarbateDermatopTo treat corticosteroidresponsivedermatosesApply thin film to affected areab.i.d.triamcinoloneacetonide 0.025%, 0.5%Aristocort, Aristocort A,Aristocort D (CAN), Flutex,Kenac, Kenalog, Kenonel,Triacet, Triaderm (CAN),Trianide Mild (CAN)To treat corticosteroidresponsivedermatosesApply thin film (cream) toaffected area b.i.d. to q.i.d.;0.025% lotion or ointmentonce or twice daily; 0.1% lotionor ointment once daily; or 0.5%ointment once daily.

Selected Topical Drugs 1137Selected Topical Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESCorticosteroids (continued)triamcinoloneacetonide 0.1%Aristocort, Aristocort A,Aristocort R (CAN), Delta-Tritex, Flutex, Kenac,Kenalog, Kenalog-H,Kenonel, Triacet,Triaderm (CAN), TrianideRegular (CAN)triamcinoloneacetonide 0.5%Aristocort, Aristocort A,Aristocort C (CAN), Flutex,Kenalog, Kenonel, Triacettriamcinoloneacetonide dental pasteKenalog in Orabase,Oracort, Oralonetriamcinolone acetonidetopical aerosolKenalogRetinoidsadapaleneDifferinTo treat corticosteroidresponsivedermatosesTo treat inflammatory orulcerative oral lesionsTo treat corticosteroidresponsivedermatosesTo treat acne vulgarisApply thin film (cream) toaffected area b.i.d. to q.i.d.;0.025% lotion or ointmentonce or twice daily; 0.1% lotionor ointment once daily; or 0.5%ointment once daily.Apply to oral mucosa b.i.d. tot.i.d. after meals and at bedtime.Spray affected area t.i.d. to q.i.d.Apply to affected area at bedtime.tazarotene 0.05%, 0.1%Avage, Tazoractazarotene 0.1%Avage, TazoracTo treat plaque psoriasisTo treat facial acne vulgaris orplaque psoriasisApply thin film to affected areaat bedtime.Apply thin film to affected areaat bedtime.tretinoinAvita, Renova, Retin-A,Retin-A Micro,Stieva-A (CAN)To treat acne vulgarisApply sparingly to clean, dryaffected area at bedtime.(continued)

1138Selected Topical DrugsSelected Topical Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESMiscellaneous topical drugsammonium lactate, 12%Lac-HydrinTo treat dry skin andichthyosisApply to affected area, and rubin b.i.d.anthralinAnthranol 1 (CAN),Drithocreme, Dritho-ScalpbecaplerminRegranexcalcipotrieneDovonexTo treat chronic psoriasisTo treat chronic scalp psoriasisTo treat lower-extremitydiabetic neuropathic ulcersthat extend into the subcutaneoustissue or beyond andthat have an adequate bloodsupplyTo treat plaque psoriasisApply sparingly and massageinto affected lesions daily,Apply to lesions daily for 1 wk.Apply to ulcers daily.Apply cream or scalp lotion in athin layer b.i.d. up to 8 wk.Apply thin layer of ointmentonce or twice daily up to 8 wk.calcipotriene hydrate0.005% and betamethasonedipropionate 0.064%Taclonex, Taclonex ScalpTo treat psoriasis vulgarisTo treat moderate to severepsoriasis vulgaris of the scalpApply ointment to affectedskin; rub in gently and completelyonce daily for up to 4wk.Apply suspension to affectedscalp areas and rub in gentlyonce daily for 2 to 8 wk or untilskin clears.capsaicinZostrixCapsinCapzacin-PchlorhexidineHibiclenschloroxineCapitrolclotrimazole andbetamethasonedipropionate 0.05%, 1%LotrisoneTo provide temporary painrelief from rheumatoid arthritisand osteoarthritis; torelieve neuralgias from painfollowing shingles (herpeszoster) infectionTo clean skin woundsTo treat dandruff and seborrheicdermatitisTo treat symptomatic inflammatorytinea corporis, tineacruris, and tinea pedisApply to affected area no morethan q.i.d.Rinse area, apply minimalamount to cover, then washand rinse thoroughly.Massage into wet scalp, wait3 min, rinse, and repeat2 times/wk.Massage cream gently intoaffected and surrounding skinareas b.i.d. for 2 wk (tinea corporis,tinea cruris) or for 4 wk(tinea pedis).

Selected Topical Drugs 1139Selected Topical Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESMiscellaneous topical drugs (continued)coal tarZetar, Zetar Shampoocrotamiton 10%EuraxdesoximetasoneTopicortdiclofenac sodium 3%Solarazedoxepin hydrochlorideZonalonTo treat psoriasisTo treat dandruff or scalpseborrheaTo treat scabiesTo relieve inflammatory andpruritic manifestations ofcorticosteroid-responsive dermatoses,including psoriasis,atopic dermatitis, and eczemaTo treat actinic keratosesTo treat pruritus associatedwith dermatitis and chroniclichen simplexAdd 15 to 20 ml to lukewarmbath, immerse affected areafor 15 to 20 min, and rinsethoroughly 3 to 7 times/wk.Massage into wet scalp, rinse,repeat application and wait5 min, then rinse again.Massage into cleansed bodyfrom chin to soles of feet, andreapply after 24 hr; change bedlinens next day, and bathe48 hr after second dose; repeatin 7 to 10 days if new lesionsappear.Apply thin film b.i.d. to affectedareas; occlusive dressings maybe added for severe dermatoses.Massage gel gently onto affectedlesion areas b.i.d. for 60 to90 days.Apply thin film to affected areaq.i.d. (every 3 to 4 hr) for up to8days.eflornithineVaniqafluocinolone acetonide0.01%, hydroquinone 4%,tretinoin 0.05%TRI-LUMA CreamTo retard unwanted hairgrowthTo treat severe facial melasmaApply thin film to affected areaof face and chin b.i.d. (at least8 hr apart); don’t wash treatedarea for at least 4 hr.Apply a thin film lightly anduniformly to hyperpigmentedareas of melasma includingabout 1⁄2 in of skin surroundingeach lesion daily at least30 min before bedtime.fluorouracil creamCarac, Efudex,FluoroplexTo treat actinic and solar keratosesApply to lesions b.i.d. for 2 to6 weeks.(continued)

1140Selected Topical DrugsSelected Topical Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESMiscellaneous topical drugs (continued)hexachlorophenepHisoHexTo treat skin preoperativelyRinse area, apply minimalamount to cover; then washand rinse thoroughly.hydrocortisone acetate,polymyxin B sulfate, andneomycin sulfateCortisporinhydroquinoneAlustra, Claripel,Eldopaque, Eldoquin,Glyquin, Melaneximiquimod 5%Aldaralidocaine and prilocaineEMLATo treat dermatoses associatedwith secondary bacterialinfectionTo treat hyperpigmentationand melaninTo treat external genital andperianal wartsFor local anesthesiaApply small amount to affectedareas b.i.d. to q.i.d.Apply b.i.d. to the affectedareas for no longer than2 months.Apply thin layer to affectedarea and rub in 3 times/wk aybedtime for up to 16 wk;remove with soap and waterafter 6 to 10 hr.Apply 1 disk or thick layer of2.5-g cream occlusively for atleast 1 hr.malathion lotion 0.5%Ovidemequinol 2%, retinol0.01%SolageTo treat pediculus humanuscapitisTo treat solar lentiginesApply to dry hair in amountjust sufficient to thoroughlywet the hair and scalp; then lethair dry naturally. After 8 to12 hr, shampoo and rinse hairto remove dead lice and eggs.If lice are still present after 7 to9 days, repeat application.Apply solution b.i.d. morningand evening at least 8 hoursapart. Avoid application to surroundingskin, and do notbathe for 6 hr after application.minoxidilRogaine 2% and 5%To treat alopecia andandrogeneticaApply 1 ml to affected areasb.i.d.monobenzone 20%BenoquinTo treat final depigmentationin extensive vitiligoApply b.i.d. to t.i.d. for 1 to4 months, then b.i.d. weekly formaintenance.

Selected Topical Drugs 1141Selected Topical Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESMiscellaneous topical drugs (continued)permethrin 1%Nixpermethrin 5%Acticin, ElimiteTo prevent or treat head liceTo treat scabiesWash and dry hair, saturatescalp with 1% cream, leave onhair for 10 min, then rinse;remove nits with providedcomb; repeat in 7 days if livingmites are still present.Massage 5% cream into skinfrom head to soles of feet, andremove after 8 to 10 hr; repeatin 14 days if living mites are stillpresent.pimecrolimus 1%ElidelTo treat mild-to-moderateatopic dermatitisApply to affected areas b.i.d.podofiloxCondyloxpyrethrum extract andpiperonyl butoxideRID, End Lice, Tegrin-LTtacrolimusProtopicTo treat anogenital warts (gel);to treat external genital warts(gel or solution)To treat head, pubic, and bodyliceTo treat moderate to severeatopic dermatitis in patientsunresponsive to othertherapiesApply 0.5% gel to anogenitalwarts for 3 days, then withholdfor 4 days; repeat cycle up to4 times.Apply 0.5% solution or gel toexternal genital warts every12 hr in the morning andevening for 3 days, then withholdfor 4 days; repeat cycle upto 4 timesApply to dry hair or affectedbody area. Massage through allhairy areas until hair is wet.Leave on hair for 10 min; thenwash with warm water andsoap or shampoo. Repeat in7 to 10 days.Apply thin layer to affectedareas b.i.d., rubbing in gentlyand completely. Continue for1 wk after signs and symptomshave disappeared.

1142Selected AntiviralsSelected AntiviralsAntivirals are used to treat viral infections, suchas influenza, human immunodeficiency virus(HIV), herpes simplex virus (HSV) I and II, herpeszoster, and cytomegalovirus (CMV) infections.The following table lists the generic andtrade names, indications, and usual adultdosages for some commonly used antivirals.Although you must individualize your care for apatient who receives an antiviral, be sure toinclude these general interventions in yourplan of care:•Avoid administering HIV drugs all at once.•If patient takes an antacid, administer it 1 hourbefore or 2 hours after an antiviral becauseantacids may reduce antiviral absorption.•Monitor hepatic enzyme levels to detect elevationsand help prevent hepatotoxicity.•Monitor BUN and serum creatinine levels todetect signs of impaired renal function.•Monitor I.V. injection site for pain or phlebitis,which may result from the high pH of reconstitutedsolutions.•Assess the immunosuppressed patient foropportunistic infections during antiviral therapy.•Inform female patient that oral contraceptivesmay be ineffective when taken with HIV drugs.Suggest alternate contraceptive methods.GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntivirals used for HIV infectionabacavir sulfateZiagenTo treat HIV infection300 mg P.O. b.i.d. or600 mg P.O. once dailyabacavir sulfateand lamivudineEpzicomabacavir sulfate,lamivudine, andzidovudineTriziviratazanavir sulfateReyatazdarunavirPrezistadelavirdineRescriptorTo treat HIV-1 infectionTo treat HIV infectionTo treat HIV infection in patientsnot previously treatedTo treat HIV infection in patientspreviously treatedTo treat HIV-1 infection along withritonavir in patients not previouslytreatedTo treat HIV-1 infection along withritonavir in patients previouslytreatedTo treat HIV infection600 mg abacavir and 300 mglamivudine (1 tablet) P.O. daily300 mg abacavir, 150 mglamivudine, and 300 mgzidovudine (1 tablet) P.O. b.i.d.400 mg P.O. daily300 mg P.O. daily with ritonavir100 mg P.O. daily800 mg P.O. b.i.d.600 mg P.O. b.i.d.400 mg P.O. t.i.d.efavirenzSustivaTo treat HIV infection600 mg P.O. dailyemtricitabineEmtrivaenfuvirtideFuzeonTo treat HIV infectionTo treat HIV infection200 mg P.O. daily (capsules) or240 mg P.O. daily (oral solution)90 mg b.i.d. SubQ

Selected Antivirals 1143Selected Antivirals (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntivirals used for HIV infection (continued)etravirineIntelencefosamprenavircalciumLexivaindinavirCrixivanlamivudine(3TC, lamivudinetriphosphate)Epivirlamivudine andzidovudine(3TC/AZT, 3TC/ZDV)Combivirlopinavir and ritonavirKaletramaravirocSelzentrynelfinavirViraceptTo treat HIV-1 infectionTo treat HIV infection in patientswho don’t take ritonavirTo treat HIV infection in patientswho take ritonavir but don’t take aprotease inhibitorTo treat HIV infection in patientswho take ritonavir and a proteaseinhibitorTo treat HIV infectionTo treat HIV infection in patientswho weigh 50 kg (110 lb) or moreTo treat HIV infection in patientswho weigh less than 50 kgTo treat HIV infection in patientswho weigh 50 kg or moreTo treat HIV infection in patientswho weigh more than 40 kg(88 lb) and don’t take nevirapineor efavirenzAs adjunct to treat HIV infection inpatients who weigh more than 50kg and take nevirapine orefavirenzTo treat HIV infection in patientswith no previous treatmentTo treat HIV infectionTo treat HIV infection200 mg P.O. b.i.d.1,400 mg P.O. b.i.d.1,400 mg P.O. once daily or700 mg P.O. b.i.d.700 mg P.O. b.i.d.800 mg P.O. every 8 hr.150 mg P.O. b.i.d. or 300 mg P.O.once daily2 mg/kg P.O. b.i.d.150 mg of lamivudine and300 mg of zidovudine P.O. b.i.d.400 mg lopinavir and 100 mgritonavir P.O. b.i.d.533 mg lopinavir and 133 mgritonavir P.O. b.i.d.800 mg lopinavir and 200 mgritonavir P.O. daily150 mg P.O. b.i.d. with CYP3Ainhibitor; 600 mg P.O. b.i.d. withCYP3A inducers; 300 mg P.O.b.i.d. with all other drugs750 mg P.O. t.i.d.nelfinavir mesylateViraceptTo treat HIV infection1,250 mg P.O. b.i.d. or750 mg P.O. t.i.d.(continued)

1144Selected AntiviralsSelected Antivirals (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntivirals used for HIV infection (continued)nevirapineViramuneraltegravirIsentressritonavirNorvirsaquinavirFortovase, InvirasestavudineZerit, Zerit XRtenofovirVireadtenofovir andemtricitabineTruvadatipranavirAptivusTo treat HIV infectionTo treat HIV-1 infectionTo treat HIV infectionTo treat HIV infectionTo treat HIV infection in patientswho weigh 60 kg or moreTo treat HIV infection in patientswho weigh less than 60 kgTo treat HIV infectionTo treat HIV-1 infectionTo treat HIV infection200 mg P.O. daily400 mg P.O. b.i.d. or800 mg P.O. b.i.d. if givenconcurrently with rifampin600 mg P.O. b.i.d.1,200 mg P.O. t.i.d. (Fortovase)or 1,000 mg (Invirase orFortovase) and 100 mg ritonavirP.O. b.i.d.40 mg P.O. every 12 hr (Zerit) or100 mg P.O. daily (Zerit XR).30 mg P.O. every 12 hr (Zerit) or75 mg P.O. daily (Zerit XR).300 mg P.O. daily300 mg tenofovir and 200 mgemtricitabine (1 tablet) P.O.daily500 mg tipranavir and 200 mgritonavir P.O. b.i.d.zidovudine(AZT, ZDV)Apo-Zidovudine (CAN),Novo-AZT (CAN), RetrovirTo treat HIV infectionTo prevent maternal-fetal HIVtransmission100 mg P.O. every 4 hr whileawake, up to 600 mg/day;or 1 to 2 mg/kg I.V. over 1 hrevery 4 hr, up to 6 times/dayor 6 mg/kg/day.100 mg P.O. 5 times daily after14 wk of pregnancy and continueduntil labor. During laborand delivery, 2 mg/kg I.V. over1 hr followed by continuousinfusion of 1 mg/kg/hr untilumbilical cord clamped.Starting within 12 hr afterbirth, neonate given 2 mg/kg P.O. every 6 hr for 6 wk.

Selected Antivirals 1145Selected Antivirals (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntivirals used for CCR5-tropic HIV-1 infectionmaravirocSelzentryAntivirals used for herpes virus infectionacyclovirZoviraxTo treat CCR5-tropic HIV-1 infectionTo treat CCR5-tropic HIV-1 infectionconcurrently with potentCYP3A inhibitors (excepttipranavir/ritonavir)To treat CCR5-tropic HIV-1 infectionconcurrently with potentCYP3A inducersTo treat HSV encephalitisTo treat HSV genitalisTo treat herpes zoster infection300 mg P.O. b.i.d.150 mg P.O. b.i.d.600 mg P.O. b.i.d.10 mg/kg I.V. over 1 hr every8 hr for 21 days.200 mg P.O. every 4 hr whileawake, up to 5 times/day, for10 days.800 mg P.O. every 4 hr whileawake, up to 5 times/day, for7 to 10 days; or 10 mg/kg I.V.over 1 hr every 8 hr for 7 daysfamciclovirFamvirTo treat HSV genitalisTo treat herpes zoster infection125 mg P.O. b.i.d. for 5 days.500 mg P.O. every 8 hr for7days.foscarnetFoscavirTo treat acyclovir-resistant HSV Iand II infections40 mg/kg I.V. every hr every8 to 12 hr for 2 to 3 wk or untilhealed.idoxuridineHerplex Liquifilm,StoxilpenciclovirDenavirTo treat HSV keratitisTo treat HSV labialis1 cm applied to conjunctivaevery 4 hr while awake, up to5 times/day; or 1 gtt of 0.1%solution every hr during daytimeand every 2 hr duringnighttime for 7 to 10 days.1% cream applied to lipsevery 2 hr while awake for4 days.(continued)

1146Selected AntiviralsSelected Antivirals (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntivirals used for herpes virus infection (continued)valacyclovirValtrexvidarabineVira-ATo treat HSV genitalisTo suppress recurrent HSVgenitalisTo reduce transmission of genitalherpesTo treat herpes zoster infectionTo treat herpes labialis (cold sores)To treat acute viral conjunctivitisand recurrent epithelial keratitiscaused by HSV infection1 g P.O. b.i.d. for 10 days forinitial episode; 500 mg P.O. b.i.d.for 3 days for recurrentepisodes1 g P.O. daily; or, 500 mg P.O.daily for patients with a historyof nine or fewer recurrences/year or who have HIV500 mg P.O. daily for sourcepartner with a history of nineor fewer recurrences/year1 g P.O. t.i.d. for 7 days2 g P.O. b.i.d. for 1 day taken12 hr apart1.25 cm applied to conjunctivaevery 3 hr until re-epithelialized;then 1.25 cm b.i.d. for7daysAntivirals used for CMV infectioncidofovirVistidefoscarnetFoscavirganciclovirCytoveneTo treat CMV retinitisTo treat CMV infectionTo treat CMV infection5 mg/kg I.V. over 1 hr every wkfor 2 wkInduction: 90 mg/kg I.V.over1.5 to 2 hr every 12 hr;or, 60 mg/kg I.V. over 1 hr every8 hr for 2 to 3 wk.Maintenance: 90 to 120 mg/kgI.V. over 2 hr every 24 hr5 mg/kg I.V. over 1 hr every12 hr for 14 to 21 days.Maintenance: 1,000 mg P.O. t.i.d.valganciclovirhydrochlorideValcyteTo treat CMV retinitisTo prevent CMV infection in highriskkidney, heart, and kidneypancreastransplant patients900 mg P.O. b.i.d. for 21 days.Then 900 mg P.O. daily900 mg P.O. daily, starting within10 days of transplantationand continuing until 100 daysafter transplantation

Selected Antivirals 1147Selected Antivirals (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntivirals used for influenza infectionoseltamivirphosphateTamifluzanamivirRelenzaTo treat uncomplicated, acuteinfections caused by influenzavirus A or B in adults who havehad symptoms for no more than2daysTo prevent influenza followingclose contact withan infectedpersonTo prevent influenza during acommunity outbreakTo treat infections caused byinfluenza virus A or B75 mg P.O. b.i.d. for 5 days, startingwithin 2 days after symptomsbegin. Maximum: 75 mgb.i.d. for 5 days75 mg P.O. daily for 7 days;start within 2 days of exposure75 mg P.O. daily during periodof potential exposure2 inhalations (10 mg) every12 hr for 5 daysAntivirals used for hepatitis B infectionadefovir dipivoxilHepseraTo treat chronic hepatitis B10 mg P.O. dailyFor patients with creatinineclearance of 20 to 49 ml/min/1.73 m 2 , dosage intervalchanged to every 48 hrFor creatinine clearance of10 to 19 ml/min/1.73 m 2 ,dosage interval changed toevery 72 hrFor patients receivinghemodialysis, drug given every7 days following dialysislamivudineEpivir HBVTo treat chronic hepatitis B100 mg P.O. dailytelbivudineTyzekaTo treat chronic hepatitis B600 mg P.O. daily(continued)

1148Selected AntiviralsSelected Antivirals (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntivirals used for hepatitis C infectionribavirinCopegus, Rebetol,RibasphereTo treat chronic hepatitis C incombination with interferon alfa-2b in patients who weigh morethan 75 kg (165 lb)To treat chronic hepatitis C incombination with interferon alfa-2b in patients who weigh 75 kg(165 lb) or lessTo treat chronic hepatitis C incombination with peginterferonalfa-2bTo treat chronic hepatitis C incombination with interferon alfa-2a in patients with compensatedliver disease who have neverreceived interferon alfa400 mg in the morning and600 mg in the evening daily600 mg b.i.d.400 mg b.i.d.400 to 600 mg b.i.d.

Selected Antineoplastic Drugs 1149Selected Antineoplastic DrugsAntineoplastic drugs are the standard of treatmentfor most types of cancer today. Most ofthese drugs work by inhibiting cell proliferation,which leads to cell death. They’re mosteffective at killing actively dividing cells.Cell-specific antineoplastics exert theiractions during one or more phases of the cellcycle. S-phase antineoplastics interfere withdeoxyribonucleic acid (DNA) synthesis; M-phase drugs interfere with the formation ofmicrotubules and disrupt mitosis.Most antineoplastics impair DNA in one ofthe following four ways:•preventing separation of DNA strands•inhibiting DNA repair•mimicking DNA bases•disrupting the triplicate codons or producingoxygen free radicals that damage the DNA.Antineoplastic drugs are cytotoxic, whichmeans that they affect both neoplastic cellsand normal cells. As a result, they may causeserious and sometimes life-threatening adversereactions.Antineoplastics are most harmful to normalcells that exhibit rapid activity and growth,such as bone marrow tissue, the epithelium ofthe GI mucosa, and hair follicles. When thesedrugs suppress bone marrow activity, thepatient may develop leukopenia, thrombocytopenia,or anemia. When they affect the GImucosa, the patient may experience nausea,vomiting, anorexia, bowel dysfunction, andmucosal ulcerations. When antineoplastic drugsaffect the hair follicles, the result is hair loss(alopecia), one of the most common adversereactions. Although not life-threatening, hairloss can be emotionally traumatic for patients,especially women.Antieoplastic ClassificationAntineoplastic drugs are classified according totheir mechanism of action.ALKYLATING DRUGSThe first drugs developed to fight cancer, alkylatingdrugs are most effective against slowgrowingtumors. These agents can damage tissueat the injection site and produce systemictoxicity. They can damage cells during all stagesof growth, causing mitotic arrest. Because theiractions are not limited to neoplastic cells, theyalso cause myelosuppression, a predictableadverse reaction. They can also result in secondarytumor development, even years afterthe initial therapy.ANTIBIOTICSAntibiotic antineoplastics originated from agenus of fungus-like bacteria calledStreptomyces. Their classification is based ontheir origin, not on mechanism of action, toxicity,pharmacokinetics, or varying clinical indications.Many of these drugs bind to specificbases and block DNA synthesis to interfere withcell replication.ANTIMETABOLITESThese are cell-cycle-specific drugs that act bypreventing synthesis of nucleotides or inhibitingenzymes by mimicking nucleotides. Thesedrugs are often more effective when used incombination.ANTIMITOTICSAntimitotic antineoplastics disrupt the formationof microtubule structures in the cell duringmitosis. This breakdown of microtubule productionstops the formation of the mitotic spindle,inhibiting cellular reproduction.BIOLOGICAL RESPONSE MODIFIERSThese drugs alter tumor-host metabolic andimmunologic relationships.ANTINEOPLASTIC ENZYMESAntineoplastic enzymes interfere with thebreakdown of extracellular asparagine, anendogenous enzyme that leukemic cellsdepend on for their survival.The rapid depletionof asparagine eventually kills leukemiccells by fragmenting them into membraneboundparticles that are eliminated by phagocytosis.HORMONAL DRUGSThese drugs act as agonists to inhibit tumorcell growth or as antagonists to compete withendogenous growth-promoting hormones.Steroid hormones form specific receptor complexesthat bind to certain nuclear proteinsnecessary for DNA transcription.MISCELLANEOUS ANTINEOPLASTICSThese drugs act in a variety of ways, such as bydestroying microtubules that are essential fortumor cell structure before mitosis and byinhibiting topoisomerase, the enzyme thataffects the degree of supercoiling in DNA bycutting one or both strands. This inhibitioncauses DNA strands to break and synthesizestoxic compounds that inhibit DNA strandrepair.The following chart lists the generic andcommon trade names of common antineoplasticdrugs, which are grouped according tomechanism of action. It also includes FDAapprovedindications and the usual adultdosage for each drug.(continued)

1150Selected Antineoplastic DrugsSelected Antineoplastic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAlkylating drugsbendamustineTreandaTo treat chronic lymphocyticleukemia (CLL)To treat indolent B-cell non-Hodgkin’s lymphoma (NHL)that has progressed within6 months of treatment withrituximab or a rituximabcontainingregimen100 mg/m 2 I.V. infused over30 minutes on days 1 and 2 of a28-day cycle for up to 6 cycles120 mg/m 2 I.V. infused over60 minutes on days 1 and 2 of a21-day cycle for up to 8 cyclesbusulfanBusulfex, MyleranTo provide palliative treatmentof chronic myelocyticleukemia (CML)To prepare for hematopoieticprogenitor cell transplantationfor CMLInitial: 0.06 mg/kg P.O. daily untilWBC count is below 15,000/mm 3 .Usual: 4 to 8 mg P.O. daily (but mayrange from 1 to 12 mg P.O. daily)Maintenance: 1 to 3 mg daily.During remission, treatmentresumed when WBC count reaches50,000/mm 30.8 mg/kg I.V. over 2 hr every 6 hrfor 4 days for a total of 16 doses asan adjunct with cyclophosphamidecarmustine (BCNU)BiCNU, Gliadel WaferchlorambucilLeukeranTo treat primary brain tumorsand glioblastoma multiformeTo treat primary brain tumors,Hodgkin’s disease, non-Hodgkin’s lymphoma, andmultiple myelomaTo provide palliative treatmentof chronic lymphocyticleukemia, Hodgkin’s disease,malignant lymphomas(including lymphosarcomaand giant follicular lymphoma),and non-Hodgkin’s lymphomaUp to 8 implants per surgicalprocedure150 to 200 mg/m 2 by slow I.V. infusionas a single dose every 6 to8 wk; or 75 to 100 mg/m 2 by slowI.V. infusion daily for 2 days every6 wk0.1 to 0.2 mg/kg/day as a singledose or in divided doses for 3 to6 wk. Usual: 4 to 10 mg/day as asingle dose or in divided doses for3 to 6 wkcyclophosphamideCytoxan, Neosar,Procytox (CAN)To treat acute lymphocyticleukemia, acute nonlymphocyticleukemia, chronic lymphocyticleukemia, chronicmyelocytic leukemia, breastcancer, epithelial ovarian cancer,Hodgkin’s disease, multiplemyeloma, neuroblastoma,non-Hodgkin’s lymphoma, andretinoblastoma1 to 5 mg/kg P.O. daily; or 40 to50 mg/kg I.V. in divided doses over2 to 5 days; or 10 to 15 mg/kg I.V.every 7 to 10 days; or 3 to 5 mg/kgI.V. 2 times/wk; or 1.5 to 3 mg/kgI.V. daily

Selected Antineoplastic Drugs (continued)Selected Antineoplastic Drugs 1151GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAlkylating drugs (continued)ifosfamideIFEXlomustine (CCNU)CeeNUTo treat germ cell testiculartumorsTo treat primary brain tumorsand Hodgkin’s disease1.2 g/m 2 /day by I.V. infusion for5 days every 3 wk100 to 130 mg/m2 P.O. as a singledose every 6 wkmechlorethaminehydrochloride(nitrogen mustard)MustargenTo treat bronchiogenic carcinoma,CML, Hodgkin’s disease,lymphosarcoma, and mycosisfungoidesTo treat malignant pericardial,peritoneal, or pleural effusions0.4 mg/kg I.V. as a single dose or individed doses over 2 to 4 days0.4 mg/kg (peritoneal or pleuraleffusion); 0.2 mg/kg into affectedcavity (pericardial effusion)melphalan(L-phenylalaninemustard)AlkeranmelphalanhydrochlorideAlkeranTo treat multiple myelomaTo treat epithelial ovariancancer0.15 mg/kg P.O. daily for 7 days;then 0.05 mg/kg daily after 3 wk ofno drug. Or, 0.1 to 0.15 mg/kg dailyfor 2 to 3 wk or 0.25 mg/kg for4 days; then 2 to 4 mg daily after2 to 4 wk of no drug16 mg/m 2 /I.V. over 15 min every2 wk for 4 doses, then at 4 wk0.2 mg/kg P.O. daily for 5 days,repeated every 4 to 5 wkoxaliplatinEloxatinTo provide adjuvant treatmentof stage III colon cancerTo treat advanced colorectalcancer85 mg/m 2 I.V. over 2 hr every 2 wkfor 12 cycles with 5-fluorouracil85 mg/m 2 I.V. over 2 hr every 2 wkwith fluorouracil until disease progressionor unacceptable toxicitystreptozocinZanosartemozolomideTemodarTo treat islet cell or pancreaticcarcinomaTo treat astrocytomaTo treat glioblastoma multiformeTo treat refractory anaplasticastrocytoma500 mg/m 2 I.V. for 5 days every6 wk, or 1,000 mg/m 2 I.V. every wkfor 2 wk150 mg/m 2 P.O. daily for first 5 daysof 28-day cycle, followed by200 mg/m 2 P.O. daily, if tolerated,for first 5 days of subsequent28-day cycles75 mg/m 2 P.O. or I.V. over 90 minfor 42 consecutive days, followedby maintenance dose of 150 mg/m 2 P.O. or I.V. over 90 min daily forfirst 5 days of every 28 days for6 cycles as adjunct to radiotherapy150 mg/m 2 P.O. or I.V. over 90 mindaily for first 5 days of every28 days(continued)

1152Selected Antineoplastic DrugsSelected Antineoplastic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAlkylating drugs (continued)thiotepa (TESPA,triethylenethiophosphoramide,TSPA)ThioplexAntibiotic antineoplasticsTo treat malignant pericardialor pleural effusionsTo treat breast cancer, epithelialovarian cancer, andHodgkin’s diseaseTo treat bladder tumors0.6 to 0.8 mg/kg into affectedcavity0.3 to 0.4 mg/kg I.V. every 1 to4 wk, or 0.2 mg/kg for 4 to 5 daysevery 2 to 3 wk30 to 60 mg mixed in 30 to 60 mlof normal saline, instilled into bladderevery wk for 4 wkbleomycin sulfateBlenoxanecisplatinPlatinol, Platinol-AQTo treat non-Hodgkin’s lymphoma,squamous cell carcinoma,and testicular cancerTo treat Hodgkin’s diseaseTo treat malignant pleuraleffusionsTo treat squamous cell carcinomaof the cervix, head andneck, penis, or vulvaTo treat bladder cancerTo treat advanced ovariancancerTo treat testicular cancer0.25 to 0.5 unit/kg or 10 to20 units/m 2 1 to 2 times/wk I.V.,I.M., or SubQ; or 0.25 unit/kg or15 units/m 2 daily by I.V. infusionover 24 hr0.25 to 0.5 unit/kg I.V., I.M., or SubQ,or 10 to 20 units/m 2 1 to 2 times/wk60 units intrapleural single bolusdissolved in 50–100 ml of normalsaline solution30 to 60 units by arterial infusionover 1 to 24 hr50 to 70 mg/m 2 by I.V. infusion as asingle dose every 3 to 4 wk withother agents75 to 100 mg/m 2 by I.V. infusion asa single dose every 21 days withpaclitaxel20 mg/m 2 by I.V. infusion daily for5 days with bleomycin and etoposide;repeated every 3 wk for twoor more cyclesdactinomycin(actinomycin-D)CosmegenTo treat Ewing’s sarcoma, gestationaltrophoblastic orWilms’ tumors, rhabdomyosarcoma,sarcoma botryoides,and testicular cancer ortumorsTo treat Ewing’s sarcoma andsarcoma botryoides0.15 to 500 mcg/kg/day I.V. dailyfor 5 days; may repeat after 3 wk0.05 mg/kg for lower extremity orpelvis; 0.035 mg/kg for upperextremity as an isolation-perfusion

Selected Antineoplastic Drugs (continued)Selected Antineoplastic Drugs 1153GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntibiotic antineoplastics (continued)daunorubicinhydrochlorideCerubidineTo treat acute lymphocyticleukemiaTo treat acute nonlymphocyticleukemia45 mg/m 2 daily for first 3 days of a32-day course of vincristine, prednisone,and asparaginase combinationtherapy45 mg/m 2 daily for first 3 days offirst course of cytarabine combinationtherapy and first 2 days of secondcourse of cytarabine combinationtherapydaunorubicin,liposomalDaunoXomeTo treat AIDS-related Kaposi’ssarcoma40 mg/m 2 I.V. over 60 min every 2wkdoxorubicinhydrochlorideAdriamycin PFS,Adriamycin RDF, RubexTo treat acute lymphocyticleukemia, acute nonlymphocyticleukemia; bladder, breast,gastric, epithelial ovarian, orthyroid cancer; Hodgkin’s disease;neuroblastoma or Wilms’tumor; non-Hodgkin’s lymphoma;small-cell lung carcinoma;and soft-tissue sarcomaor osteosarcoma60 to 75 mg/m 2 I.V. as single doseevery 21 days; or 25 to 30 mg/m 2I.V. daily for 2 to 3 days every 3 to4 wk; or 20 mg/m 2 every wk; or40 to 60 mg/m 2 every 21 to28 days in combination with otherchemotherapeutic drugsdoxorubicin, liposomalCaelyx (CAN), DoxilepirubicinhydrochlorideEllenceeverolimusAfinitorTo treat AIDS-relatedKaposi’s sarcomaTo treat breast cancerTo treat advanced renal cancerafter failure with sunitinib orsorafenib20 mg/m 2 I.V. over 30 min every3 wk as tolerated100 to 120 mg/m 2 by I.V. infusionover 3 to 5 min via a free-flowingI.V. solution as a single dose on day1 or in divided doses on days 1 and8, repeated every 3 to 4 wk for6 cycles in combination with otherchemotherapy agents10 mg P.O. dailyidarubicinhydrochlorideIdamycinTo treat acute nonlymphocyticleukemia12 mg/m 2 /day I.V. over 10 to15 min for 3 days in combinationwith cytarabine therapymitomycin(mitomycin-C)MutamycinTo treat gastric or pancreaticcancer20 mg/m 2 as a single dose every6 to 8 wk(continued)

1154Selected Antineoplastic DrugsSelected Antineoplastic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntibiotic antineoplastics (continued)pentostatin(2-deoxycoformycin)Nipentplicamycin(mithramycin)MithracinromidepsinIstodaxvalrubicinValstarAntimetabolitescapecitabineXelodacladribine (2-CdA,2-chlorodeoxyadenosine)LeustatinTo treat hairy cell leukemiaTo treat testicular cancerTo treat hypercalcemia andhypercalciuriaTo treat cutaneous T-cell lymphomain patients who havereceived one previous systemictherapyTo treat bladder cancerTo treat locally advanced ormetastatic breast cancer ormetastatic colorectal cancerTo treat hairy cell leukemia4 mg/m 2 by rapid I.V. injection ordiluted for infusion over 20 to30 min as a single dose every otherwk0.025 to 0.03 mg/kg I.V. daily over4 to 6 hr for 8 to 10 days0.015 to 0.025 mg/kg I.V. daily over4 to 6 hr for 3 to 4 days; may repeatdose every wk as needed14 mg/m 2 I.V. over 4 hr on days 1, 8,and 15 of a 28-day cycle, repeatedevery 28 days800 mg every wk for 6 wk intoaffected cavity1,250 mg/m 2 P.O. after a meal b.i.d.(morning and evening) for 2 wk,followed by 1-wk rest period; doserepeated in 3-wk cycles0.1 mg/kg/day by continuous I.V.infusion for 7 dayscytarabine (ARA-C,cytosine arabinoside)Cytosar, Cytosar-UTo treat acute nonlymphocyticleukemiaTo treat meningeal leukemiaTo prevent or treat acute lymphocyticleukemia and chronicmyelocytic leukemiaInitially, 100 mg/m 2 /day by continuousI.V. infusion for 7 days, aloneor with other agents; or 100 mg/m 2I.V. every 12 hr on days 1 to 7, thenconsult manufacturer’s literaturefor specific dosing; or high-dosetherapy of 2 to 3 g/m 2 I.V over 1 to3 hr for 2 to 6 days, then consultmanufacturer’s literature for specificdosing30 mg/m 2 intrathecally as a singledose every 4 daysConsult manufacturer’s literaturefor specific dosage.

Selected Antineoplastic Drugs (continued)Selected Antineoplastic Drugs 1155GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntimetabolites (continued)cytarabine, liposomalDepoCyt, Depro Techfloxuridine(fluorodeoxyuridine)FUDRfludarabinephosphateFludaraTo treat lymphomatousmeningitisTo treat colorectal or hepaticcancerTo treat chronic lymphocyticleukemiaInitially, 50 mg intrathecally (intraventricularor lumbar puncture)over 1 to 5 min every 14 days fortwo doses (wk 1 and 3); then 50 mgintrathecally every 14 days forthree doses (wk 5, 7, and 9), followedby 1 50-mg dose at wk 13;then 50 mg intrathecally every28 days for four doses (wk 17, 21,25, and 29) in combination withdexamethasone 4 mg P.O. or I.V.b.i.d. for 5 days0.1 to 0.6 mg/kg/day by continuousintra-arterial infusion for 14 to21 days, followed by 2 wk of nodrug; dose repeated in 5-wk cycles25 mg/m 2 I.V. infused over 30 minfor 5 days; cycle repeated every 28daysfluorouracil(5-fluorouracil, 5-FU)Adrucil, Carac, Efudex,FluoroplexTo treat colorectal, breast,gastric, or pancreaticcancerTo treat multiple actinic (solar)keratosesTo treat superficial basal cellcarcinoma7 to 12 mg/kg/day I.V. for 4 days,followed by no drug for 3 days,then 7 to 10 mg/kg every 3 to4 days for total of 2 wk; or12 mg/kg/day for 4 days, followedby 1 day of no drug, then 6 mg/kgevery other day for 4 or 5 days, fortotal of 12 days; thereafter,7 to12 mg/kg/day I.V. every 7 to10 days0.5% cream (face, anterior scalp),1% cream (head, neck, chest), or 2%to 5% cream (hands) applied toskin once or twice daily to coverlesions5% cream applied to skin b.i.d. forup to 12 wk to cover lesionshydroxyureaDroxia, HydreaTo treat epithelial ovariancancerTo treat resistant chronicmyelocytic leukemia60 to 80 mg/kg P.O. as a single doseevery 3 days alone or with radiationtherapy; or 20 to 30 mg/kg P.O.daily20 to 30 mg/kg P.O. once daily or individed doses b.i.d.(continued)

1156Selected Antineoplastic DrugsSelected Antineoplastic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntimetabolites (continued)mercaptopurine(6-mercaptopurine,6-MP)Purinetholmethotrexate(amethopterin)methotrexate sodiumpemetrexed disodiumAlimtaTo treat acute lymphocyticleukemia or acute nonlymphocyticleukemiaTo treat chorioadenomadestruens, choriocarcinoma,or hydatidiform moleTo treat acute lymphocyticleukemia or meningealleukemiaTo treat Burkitt’s lymphoma(stage I or II)To treat Burkitt’s lymphoma(stage III)To treat lymphosarcoma(stage III)To treat mycosis fungoidesTo treat osteosarcomaTo treat breast or head andneck cancer and non–smallcellor small-cell lungcarcinomaTo treat nonsquamousnon–small-cell lung cancer ormalignant pleural mesotheliomaTo treat nonsquamousnon–small-cell lung cancer2.5 mg/kg/day or 80 to 100 mg/m 2 /day (rounded to nearest 25 mg)P.O. as a single dose or in divideddoses, followed by 1.5 to 2.5 mg/kg/day P.O. or 50 to 100 mg/m 2 /day15 to 30 mg/day P.O. or I.M. for5 days; repeat three to five timeswith 2 to 3 wk between coursesInitially, 3.3 mg/m 2 /day P.O., I.M., orI.V. in combination with prednisoneor other drug; as maintenancedose, 30 mg/m 2 /wk P.O. or I.M. intwo divided doses or 2.5 mg/kg I.V.every 14 days10 to 25 mg/day P.O. for 4 to8 days, followed by no drug for 7 to10 days; course repeated as neededSame as for stage I or II in combinationwith other drug0.625 to 2.5 mg/kg/day P.O.2.5 to 10 mg/day P.O. for weeks ormonths; or 50 mg I.M. every wk or25 mg I.M. 2 times/wk12 g/m 2 by I.V. infusion over 12 hr,followed by leucovorin rescue onweeks 4, 5, 6, 7, 11, 12, 15, 16, 29, 30,44, and 45 after surgery in combinationwith bleomycin, cisplatin,cyclophosphamide, dactinomycin,and doxorubicinConsult manufacturer’s literaturefor specific dosing.500 mg/m 2 I.V. over 10 min on day1 of each 21-day cycle as adjunctto cisplatin500 mg/m 2 I.V. over 10 min on day1 of each 21-day cycle

Selected Antineoplastic Drugs (continued)Selected Antineoplastic Drugs 1157GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntimetabolites (continued)pralatrexateFolotynTo treat peripheral T-celllymphoma30 mg/m 2 I.V. over 3 to 5 min onceweekly for 6 wk in 7-wk cyclesthioguanine (6-TG,6-thioguanine)Lanvis (CAN), TabloidTo treat acute nonlymphocyticleukemia2 mg/kg/day P.O. as a single dose; ifno improvement after 4 wk,increase to 3 mg/kg/dayAntimitotic antineoplasticsdocetaxelTaxotereixabepiloneIxemprapaclitaxelTaxolvinblastine sulfate(VLB)Velban, Velbe (CAN)vincristine sulfate(VCR)Oncovin, Vincasar PFSTo treat breast cancerTo treat non–small-cell lungcarcinomaTo treat advanced breastcancerTo treat ovarian cancerTo treat breast cancerTo treat AIDS-relatedKaposi’s sarcomaTo treat non–small-cell lungcarcinomaTo treat breast cancer,Hodgkin’s disease, lymphomas,Kaposi’s sarcoma,Letterer-Siwe disease, mycosisfungoides, non-Hodgkin’slymphoma, testicular cancer,and trophoblastic gestationaltumorsTo treat acute lymphocyticleukemia, Hodgkin’s disease,lymphomas, non-Hodgkin’slymphoma, rhabdomyosarcoma,and Wilms’ tumor60 to 100 mg/m 2 by I.V. infusionover 1 hr every 3 wk75 mg/m 2 by I.V. infusion over 1 hrevery 3 wk40 mg/m 2 I.V. over 3 hr every 3 wk,as adjunct to capecitabine, asneeded135 or 175 mg/m 2 by I.V. infusionover 3 or 24 hr every 21 days175 mg/m 2 by I.V. infusion over3 or 24 hr every 21 days135 mg/m 2 by I.V. infusion over3 or 24 hr every 21 days; or100 mg/m 2 by I.V. infusion over3 or 24 hr every 14 days135 mg/m 2 by I.V. infusion over3 or 24 hr, followed by cisplatin75 mg/m 2 I.V. every 21 days0.15 to 0.2 mg/kg I.V. every wk0.01 to 0.03 mg/kg I.V.; or 0.4 to1.4 mg/m 2 I.V. every wk as a singledose (maximum of 2 mg)(continued)

1158Selected Antineoplastic DrugsSelected Antineoplastic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESAntimitotic antineoplastics (continued)vinorelbine tartrateNavelbineTo treat non–small-cell lungcarcinoma30 mg/m 2 I.V. over 6 to 10 minevery wk alone, or 25 mg/m 2 I.V.over 6 to 10 min every wk with cisplatin100 mg/m 2 every 4 wkAntineoplastic enzymesasparaginaseColaspase, Elspar,Kidrolase (CAN)pegaspargase(PEG-L-asparaginase)OncasparTo treat acute lymphocyticleukemiaTo treat acute lymphoblasticleukemia in adults up to age21200 international units/kg I.V. dailyfor 28 days2,500 international units/m 2 I.M. orI.V. every 14 daysBiological response modifiersaldesleukin (IL-2,interleukin-2)ProleukinTo treat renal cancer andmetastatic melanoma600,000 international units/kg byI.V. infusion over 15 min every 8 hrfor 14 doses; then 9 days of nodrug; then repeat course of14 doses for total of 28 dosesalemtuzumabCampathTo treat B-cell chronic lymphocyticleukemiaInitial: 3 mg I.V. over 2 hr daily, thenincreased to 10 mg I.V. over 2 hrdaily. Maintenance: 30 mg I.V. over2 hr 3 times/wk on alternate daysfor up to 12 wkbacillus Calmette-Guérin (BCG) live,Connaught strainImmuCyst (CAN),TheraCysbacillus Calmette-Guérin, Tice strainTICE BCGTo treat bladder cancer81 mg (reconstitute and dilute with50 ml preservative-free normalsaline solution to 53 ml or less)instilled into bladder for 1 to 2 hrevery wk for 6 wk, then as a singledosetreatment at 3, 6, 12, 18, and24 mo50 mg (reconstitute and dilute with50 ml preservative-free normalsaline to 50 ml or less) for 1 to 2 hrevery 6 wk; may repeat once, followedby single-dose treatmentevery mo for 6 to 12 mo

Selected Antineoplastic Drugs (continued)Selected Antineoplastic Drugs 1159GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESBiological response modifiers (continued)denileukin diftitoxOntakTo treat cutaneous or T-celllymphomas, including mycosisfungoides9 or 18 mcg/kg/day by I.V. infusionover at least 15 min for 5 days;repeated every 21 daysinterferon alfa-2a,recombinantRoferon-Ainterferon alfa-2b,recombinantIntron ATo treat hairy cell leukemiaTo treat AIDS-related Kaposi’ssarcomaTo treat hairy cell leukemiaTo treat AIDS-related Kaposi’ssarcomaTo treat malignant melanoma3 million units/day I.M. or SubQ for16 to 24 wk, followed by 3 millionunits 3 times/wk36 million units/day I.M. or SubQfor 10 to 12 wk; or 3 millionunits/day I.M. or SubQ on days 1 to3, 9 million units/day on days 4 to6, 18 million units/day on days 7 to9, and 36 million units/day fromday 10 until completion of 10- to12-wk course; maintenance dose,36 million units 3 times/wk2 million units/m 2 I.M. or SubQ3 times/wk30 million units/m 2 I.M. or SubQ3 times/wk20 million units/m 2 by I.V. infusionon days 1 to 5 every wk for 4 wk,followed by 10 million units/m 2 I.V.3 times/wk for 48 wklevamisolehydrochlorideErgamisolHormonal antineoplasticsTo treat colorectal cancerBeginning 7 to 30 days after surgery,50 mg P.O. every 8 hr for3 days, repeated every 2 wk for 1 yr,with fluorouracil 450 mg/m 2 byrapid I.V. infusion daily for 5 days,starting with first or second courseof levamisoleanastrozoleArimidexTo treat breast cancer1 mg P.O. dailybicalutamideCasodexTo treat prostate cancer50 mg P.O. daily in combinationwith luteinizing hormone-releasinghormone (LHRH) analog or aftersurgical castration(continued)

1160Selected Antineoplastic DrugsSelected Antineoplastic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESHormonal antineoplastics (continued)degarelixFirmagonestramustinephosphate sodiumEmcytTo treat advanced prostatecancerTo treat prostate cancerTo treat postmenopausalbreast cancerInitial: 240 mg SubQ divided into2 injections; then 80 mg SubQevery 28 days14 mg/kg/day P.O. in three or fourdivided doses 1 hr before or 2 hrafter mealsexemestaneAromasinTo treat prostate cancerAs adjunct for postmenopausalwomen withestrogen receptor–positiveearly breast cancer who havereceived 2 to 3 yr of tamoxifentherapyTo treat advanced breast cancerin postmenopausalwomen whose disease hasprogressed after tamoxifentherapy25 mg P.O. daily after a meal25 mg P.O. daily until completion of5 years with combined therapy25 mg P.O. dailyflutamideEuflex (CAN), Eulexingoserelin acetateZoladex, Zoladex LA,Zoladex 3-MonthletrozoleFemaraleuprolide acetateLupron, Lupron Depot,Lupron Depot-3 Month,Lupron Depot-4 Month,ViadurmedroxyprogesteroneacetateDepo-ProveraTo treat breast cancerTo treat prostate cancerTo treat breast cancerTo treat prostate cancerTo treat endometrial or renalcancer250 mg P.O. every 8 hr3.6 mg SubQ into upper abdominalwall every 28 days3.6 mg SubQ into upper abdominalwall every 28 days; or 10.8 mgSubQ every 12 wk2.5 mg P.O. dailyRegular: 1 mg SubQ daily; Depot:7.5 mg every mo; or 22.5 mg every3 mo; or 30 mg every 4 mo;Implant: 1 every 12 mo400 to 1,000 mg every wk until stable,then 400 mg or more every mo

Selected Antineoplastic Drugs (continued)Selected Antineoplastic Drugs 1161GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESHormonal antineoplastics (continued)megestrol acetateMegacenilutamideAnandron (CAN),NilandronTo treat breast cancerTo treat endometrial cancerTo treat prostate cancer160 mg/day P.O. daily or in divideddoses40 to 320 mg P.O. daily or in divideddoses300 mg P.O. daily up to 30 days,then 150 mg P.O. dailytamoxifen citrateApo-Tamox (CAN),Gen-Tamoxifen (CAN),Nolva-dex,Nolvadex-D (CAN),NovoTamoxifen (CAN),Tamofen (CAN),Tamone (CAN)To prevent breast cancer orreduce the risk of invasivebreast cancer in women withductal carcinoma in situTo treat breast cancer (nodenegativeor node-positive)20 mg P.O. daily for 5 yr10 mg P.O. b.i.d. or, in metastaticdisease, 10 to 20 mg P.O. b.i.d.testolactoneTeslacTo treat breast cancer250 mg P.O. q.i.d.toremifene citrateFarestonTo treat breast cancer60 mg P.O. dailytriptorelin pamoateTrelstar LATo provide palliative treatmentof advanced prostatecancer11.25 mg I.M. every 84 daysMiscellaneous antineoplasticsarsenic trioxideTrisenoxTo treat acute promyelocyticleukemiaInduction: 0.15 mg/kg I.V. daily untilbone marrow remission occurs.Maximum: 60 doses. Consolidation:Begun 3 to 6 wk after completionof induction, 0.15 mg/kg I.V. dailyfor 25 doses over up to 5 wk(continued)

1162Selected Antineoplastic DrugsSelected Antineoplastic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESMiscellaneous antineoplastics (continued)bexaroteneTargretinTargretin GelbevacizumabAvastindacarbazineDTIC (CAN),DTIC-Domeetoposide (VP-16)Toposar, VePesidTo treat cutaneous manifestationsof cutaneous T-celllymphomaTo treat cutaneous lesions ofcutaneous T-cell lymphoma(stages IA and IB)To treat metastatic colorectalcancerTo treat non-squamous, nonsmall-celllung cancerTo treat metastatic breastcancerTo treat glioblastomaTo treat metastatic renal cellcancerTo treat Hodgkin’s diseaseTo treat malignant melanomaTo treat germ-cell testiculartumorsTo treat small-cell lung carcinoma300 mg/m2 P.O. daily with food;after 8 wk, may increase to 400 mg/m 2 P.O. daily with food, as neededand tolerated.Apply generously to cover onlylesions every other day on 1st wk;then increased as tolerated to oncedaily on 2nd wk, b.i.d. on 3rd wk,t.i.d on 4th wk and, finally, q.i.d. on5th wk5 or 10 mg/kg I.V. over 90 minevery 2 wk as adjunct to I.V.fluorouacil-based chemotherapy15 mg/kg I.V. over 90 min every3 wk as adjunct to carboplatin andpaclitaxel10 mg/kg I.V. over 90 min every2 wk as adjunct to paclitaxel10 mg/kg I.V. over 90 min every2wk10 mg/kg I.V. over 90 min every2 wk as adjunct to interferon alfa150 mg/m 2 I.V. daily for 5 days incombination with other drugs; mayrepeat every 28 days; or 375 mg/m 2 every 15 days in combinationwith other drugs2 to 4.5 mg/kg I.V. daily for 10 daysand every 28 days thereafter; or250 mg/m 2 I.V. daily for 5 days andevery 21 days thereafter50 to 100 mg/m 2 /day I.V. on days 1through 5 up to 100 mg/m 2 I.V. ondays 1, 3, and 5; course repeatedevery 3 to 4 wk35 mg/m 2 /day I.V. for 4 days up to50 mg/m 2 /day I.V. for 5 days,repeated every 3 to 4 wk; or70 mg/m 2 /day P.O. for 4 days to100 mg/m 2 /day P.O. for 5 days,repeated every 3 to 4 wk

Selected Antineoplastic Drugs (continued)Selected Antineoplastic Drugs 1163GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESMiscellaneous antineoplastics (continued)etoposide phosphateEtopophosgemcitabinehydrochlorideGemzargemtuzumabozogamicinMylotargTo treat germ-cell testiculartumorsTo treat small-cell lung carcinomaTo treat non–small-cell lungcarcinomaTo treat pancreatic cancerTo treat first relapse inpatients with CD33-positiveacute myeloid leukemia whoare age 60 or over and whoare not candidates for cytotoxictherapy50 to 100 mg/m 2 /day by I.V. infusionon days 1 through 5 to 100mg/m 2 /day by I.V. infusion on days1, 3, and 5; course repeated every3 to 4 wk35 mg/m 2 /day by I.V. infusion for4 days to 50 mg/m 2 /day by I.V. infusionfor 5 days, repeated every 3 to4 wk1,000 mg/m 2 by I.V. infusion over30 min daily on days 1, 8, and15 every 28 days with cisplatin100 mg/m 2 on day 28; or 1,250 mg/m 2 I.V. daily on days 1 and 8 every21 days in combination with cisplatin100 mg/m 2 I.V. on day 211,000 mg/m 2 by I.V. infusion over30 min every wk for 7 wk, followedby 1 wk of no drug; then every wkfor 3 wk, followed by 1 wk of nodrug; then repeat 4-wk cycle9 mg/m 2 by I.V. infusion over 2 hr;repeated in 14 daysimatinib mesylateGleevecTo treat chronic myeloidleukemia in accelerated phaseor blast crisis, or in chronicphase after failure of interferon-alphatherapyTo treat GI stromal tumor400 mg P.O. daily with food (chronicphase) or 600 mg P.O. daily withfood (accelerated phase or blastcrisis); after 3 mo, dosage may beincreased to 600 mg P.O. daily(chronic phase) or 800 mg P.O.given in 2 divided doses of 400 mg(accelerated phase or blast crisis),as needed.400 mg/day P.O. or 600 mg/day P.O.irinotecanhydrochlorideCamptosarTo treat colorectal cancer125 mg/m 2 I.V. over 90 min everywk for 4 wk, followed by 2 wk of nodrug, then repeat 6-wk cycle; or350 mg/m 2 I.V. over 90 min every3 wk(continued)

1164Selected Antineoplastic DrugsSelected Antineoplastic Drugs (continued)GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESMiscellaneous antineoplastics (continued)iressaGefitinibTo treat refractory metastaticnon–small-cell lung cancer250 mg P.O. dailyixabepiloneIxempraTo treat metastatic or locallyadvanced breast cancer incombination with capecitabineafter failure with ananthracycline and a taxane; totreat metastatic or locallyadvanced breast cancer afterfailure with an anthracycline, ataxane, and capecitabine40 mg/m 2 I.V. infused over 3 hrevery 3 wkmitotane (o,p-DDD)LysodrenTo treat adrenocorticalcarcinoma2 to 6 g P.O. daily in divided dosest.i.d. or q.i.d.mitoxantronehydrochlorideNovantroneTo treat hormone-refractoryprostate cancerTo treat acute nonlymphocyticleukemia12 to 14 mg/m 2 I.V. every 21 days12 mg/m 2 by I.V. infusion in freeflowingnormal saline solution orD 5 W over 3 min daily on days 1 to3, with cytarabine 100 mg/m 2 /dayby continuous I.V. infusion on days1 to 7; if response is inadequate,second course at same dosage maybe givennilotinibTasignaTo treat Philadelphia chromosomepositive chronic myelogenousleukemia400 mg P.O. every 12 hrporfimer sodiumPhotofrinTo treat esophageal cancerand non–small-cell lung carcinoma2 mg/kg I.V. over 3 to 5 min, followedby laser light illuminationand debridement of tumor; mayrepeat course every 30 days threetimesprocarbazinehydrochlorideMatulane, Natulan (CAN)To treat Hodgkin’s disease2 to 4 mg/kg/day (rounded tonearest 50 mg) P.O. as a single doseor in divided doses for 1 wk, followedby 4 to 6 mg/kg/day untilleukopenia, thrombocytopenia, ormaximal responserituximabRituxanTo treat non-Hodgkin’s lymphomas375 mg/m 2 /day by I.V. infusionevery wk for 4 or 8 doses

Selected Antineoplastic Drugs (continued)Selected Antineoplastic Drugs 1165GENERIC ANDTRADE NAMES INDICATIONS USUAL ADULT DOSAGESMiscellaneous antineoplastics (continued)sorafenibNexavarTo treat unresectable hepatocellularcarcinoma; to treatadvanced renal cell carcinoma400 mg P.O. b.i.d.sunitinib malateSutenttopotecanhydrochlorideHycamtinTo treat GI stromal tumor progressionTo treat advanced renal cellcancerTo treat ovarian cancer andsmall-cell lung carcinoma50 mg P.O. daily for 4 wk, followedby 2 wk off; then cycle repeated asneeded1.5 mg/m 2 I.V. over 30 min daily for5 days, repeated every 21 daystrastuzumabHerceptinTo treat breast cancer4 mg/kg I.V. over 90 min, followedby 2 mg/kg I.V. over 30 min every 7daysvelcadeBortezomibTo treat multiple myeloma 1.3 mg/m 2 I.V. bolus on days 1, 4, 8,and 11 for 2 wk, followed by reston days 12–21; then repeat 3-wkcycle

1166Selected Antihypertensive CombinationsSelected Antihypertensive CombinationsAntihypertensive drugs are used along withlifestyle changes to manage hypertension.Antihypertensive combinations, which commonlyinclude one or two antihypertensivesand a diuretic, are used to simplify patients’drug regimens and, in some cases, to enhancedrug actions.The table below lists the generic and tradeANTIHYPERTENSIVECOMBINATIONTRADE NAMESAldoril-15Aldoril-25Aldoril D30Aldoril D50ANTIHYPERTENSIVEGENERIC NAMESmethyldopa 250 mgmethyldopa 250 mgmethyldopa 500 mgmethyldopa 500 mgDIURETICGENERIC NAMEShydrochlorothiazide (HCTZ)15 mgHCTZ 25 mgHCTZ 30 mgHCTZ 50 mgApresazide 25/25Apresazide 50/50Apresazide 100/50hydralazine hydrochloride (HCl)25 mghydralazine HCl 50 mghydralazine HCl 100 mgHCTZ 25 mgHCTZ 50 mgHCTZ 50 mgAtacand HCT 16/12.5Atacand HCT 32/12.5candesartan cilexetil 16 mgcandesartan cilexetil 32 mgHCTZ 12.5 mgHCTZ 12.5 mgAvalide-150Avalide-300irbesartan 150 mgirbesartan 300 mgHCTZ 12.5 mgHCTZ 12.5 mgAzor 5/20Azor 5/40Azor 10/20Azor 10/40amlopidine 5 mg, olmesartan 20 mgamlodipine 5 mg, olmesartan 40 mgamlodipine 10 mg, olmesartan 20 mgamlodipine 10 mg, olmesartan 40 mgNoneBenicar HCT 20/12.5Benicar HCT 40/12.5Benicar HCT 40/25olmesartan medoxomil 20 mgolmesartan medoxomil 40 mgolmesartan medoxomil 40 mgHCTZ 12.5 mgHCTZ 12.5 mgHCTZ 25 mgCapozide 25/15Capozide 25/25Capozide 50/15Capozide 50/25captopril 25 mgcaptopril 25 mgcaptopril 50 mgcaptopril 50 mgHCTZ 15 mgHCTZ 25 mgHCTZ 15 mgHCTZ 25 mg

Selected Antihypertensive Combinations 1167names; functional classes; usual adult dosages;and onset, peak, and duration for commonlyused antihypertensive combinations. For informationabout the mechanisms of action, interactions,adverse reactions, and nursing considerationsrelated to antihypertensive combinations,review the entries for the specific antihypertensivesand diuretics that they contain.FUNCTIONAL CLASSESCentrally acting antiadrenergicand thiazide diureticUSUAL ADULT DOSAGES1 tab b.i.d or t.i.d1 tab b.i.d.1 tab daily1 tab dailyONSET, PEAK,AND DURATIONOnset: UnknownPeak: 4 to 6 hrDuration: 12 to 24 hrPeripherally acting arterialdilator and thiazide diuretic1 cap once or twice daily1 cap once or twice daily1 cap once or twice dailyOnset: 20 to 30 minPeak: 1 to 2 hrDuration: 2 to 4 hrAngiotensin II receptorantagonist and thiazidediuretic1 tab once or twice daily1 tab dailyOnset: 1 to 2 wkPeak: Within 4 wkDuration: UnknownACE inhibitor and thiazidediuretic1 tab daily1 tab dailyOnset: UnknownPeak: UnknownDuration: UnknownCalcium channel blocker andangiotensin II receptorantagonist1 tab daily1 tab daily1 tab daily1 tab dailyOnset: UnknownPeak: 1 to 6 hrDuration: 24 hrAngiotensin II receptorantagonist and thiazidediuretic1 tab daily1 tab daily1 tab dailyOnset: UnknownPeak: UnknownDuration: UnknownACE inhibitor and thiazidediuretic1 tab daily to t.i.d.1 tab once or twice daily1 tab once daily to t.i.d.1 tab once or twice dailyOnset: 15 to 60 minPeak: 60 to 90 minDuration: 6 to 12 hr(continued)

1168Selected Antihypertensive CombinationsSelected Antihypertensive Combinations (continued)ANTIHYPERTENSIVECOMBINATIONTRADE NAMESANTIHYPERTENSIVEGENERIC NAMESDIURETICGENERIC NAMESDiovan HCT 80/12.5Diovan HCT 160/12.5Diovan HCT 160/25Diovan HCT 320/12.5Diovan HCT 320/25valsartan 80 mgvalsartan 160 mgvalsartan 160 mgvalsartan 320 mgvalsartan 320 mgHCTZ 12.5 mgHCTZ 12.5 mgHCTZ 25 mgHCTZ 12.5 mgHCTZ 25 mgDyazidetriamterene 37.5 mgHCTZ 25 mgExforgeamlodipine 5 mg, valsartan 160 mgNoneExforge HCT 5/160/12.5Exforge HCT 10/160/12.5Exforge HCT 5/160/25Exforge HCT 10/160/25Exforge HCT 10/320/25amlodipine 5 mg, valsartan 160 mgamlodipine 10 mg, valsartan 160 mgamlodipine 5 mg, valsartan 160 mgamlodipine 10 mg, valsartan 160 mgamlodipine 10 mg, valsartan 320 mgHCTZ 12.5 mgHCTZ 12.5 mgHCTZ 25 mgHCTZ 25 mgHCTZ 25 mgHyzaar 50/12.5Hyzaar 100/25losartan potassium 50 mglosartan potassium 100 mgHCTZ 12.5 mgHCTZ 25 mgInderide 80/25Inderide LA 80/50Inderide LA 120/50Inderide LA 160/50propranolol HCl 80 mgpropranolol HCl 80 mgpropranolol HCl 120 mgpropranolol HCl 160 mgHCTZ 25 mgHCTZ 50 mgHCTZ 50 mgHCTZ 50 mgLopressor HCT 50/25Lopressor HCT 100/25Lopressor HCT 100/50metoprolol tartrate 50 mgmetoprolol tartrate 100 mgmetoprolol tartrate 100 mgHCTZ 25 mgHCTZ 25 mgHCTZ 50 mgLotensin HCT 5/6.25Lotensin HCT 10/12.5Lotensin HCT 20/12.5Lotensin HCT 20/25benazepril HCl 5 mgbenazepril HCl 10 mgbenazepril HCl 20 mgbenazepril HCl 20 mgHCTZ 6.25 mgHCTZ 12.5 mgHCTZ 12.5 mgHCTZ 25 mg

Selected Antihypertensive Combinations 1169FUNCTIONAL CLASSESACE inhibitor and thiazidediureticUSUAL ADULT DOSAGES1 or 2 tabs daily1 tab daily1 tab daily1 tab daily1 tab dailyONSET, PEAK,AND DURATIONOnset: 2 hrPeak: 6 hrDuration: 24 hrPotassium-sparing diureticand thiazide diuretic1 or 2 caps or tabs dailyOnset: 2 to 4 hrPeak: 1 dayDuration: 7 to 9 hrDihydropyridine and tetrazole1 or 2 tabs dailyOnset: UnknownPeak: 6 to 12 hrDuration: 24 hrCalcium channel blocker, ACEinhibitor, and thiazide diuretic1 tab daily1 tab daily1 tab daily1 tab daily1 tab dailyOnset: UnknownPeak: 2 to 6 hrDuration: UnknownACE inhibitor and thiazidediuretic1 or 2 tabs daily1 tab dailyOnset: UnknownPeak: 6 hrDuration: 24 hr or moreBeta blocker and thiazidediuretic1 or 2 tabs b.i.d.1 cap daily1 cap daily1 cap dailyOnset: UnknownPeak: 1 to 1.5 hrDuration: UnknownBeta blocker and thiazidediuretic1 or 2 tabs daily or 1 tab b.i.d.1 or 2 tabs daily or 1 tab b.i.d.1 or 2 tabs daily or 1 tab b.i.d.Onset: 1 hrPeak: 1 to 2 hrDuration: UnknownACE inhibitor and thiazidediuretic1 tab daily1 tab daily1 tab daily1 tab dailyOnset: 1 hrPeak: 2 to 4 hrDuration: 24 hr(continued)

1170Selected Antihypertensive CombinationsSelected Antihypertensive Combinations (continued)ANTIHYPERTENSIVECOMBINATIONTRADE NAMESANTIHYPERTENSIVEGENERIC NAMESDIURETICGENERIC NAMESLotrel 2.5/10Lotrel 5/10Lotrel 5/20Lotrel 10/20amlodipine 2.5 mg, benazeprilHCl 10 mgamlodipine 5 mg, benazeprilHCl 10 mgamlodipine 5 mg, benazeprilHCl 10 mgamlodipine 10 mg, benazeprilHCl 20 mgNoneNoneNoneNoneMaxzide 37.5/25Maxzide 75/50triamterene 37.5 mgtriamterene 75 mgHCTZ 25 mgHCTZ 50 mgMicardis HCT 40/12.5Micardis HCT 80/12.5telmisartan 40 mgtelmisartan 80 mgHCTZ 12.5 mgHCTZ 12.5 mgModureticamiloride 5 mgHCTZ 50 mgPrinzide 10/12.5Prinzide 20/12.5Prinzide 20/25lisinopril 10 mglisinopril 20 mglisinopril 20 mgHCTZ 12.5 mgHCTZ 12.5 mgHCTZ 25 mgTekturnaaliskiren 150 mgHCTZ 12.5 mgTekturna HCT 150/12.5Tekturna HCT 150/25Tekturna HCT 300/12.5aliskiren 150 mgaliskiren 150 mgaliskiren 300 mgHCTZ 12.5 mgHCTZ 25 mgHCTZ 12.5 mgTimolide 10/25timolol maleate 10 mgHCTZ 25 mg

Selected Antihypertensive Combinations 1171FUNCTIONAL CLASSESACE inhibitor and calciumchannel blockerUSUAL ADULT DOSAGES1 or 2 caps daily1 cap daily1 cap daily1 cap dailyONSET, PEAK,AND DURATIONOnset: UnknownPeak: UnknownDuration: 24 hrPotassium-sparing diureticand thiazide diuretic1 tab daily1 tab dailyOnset: 2 to 4 hrPeak: 1 dayDuration: 7 to 9 hrAngiotensin II receptor antagonistand thiazide diuretic1 tab once or twice daily1 tab once or twice dailyOnset: Within 3 hrPeak: In 4 wkDuration: Several days to1 wkPotassium-sparing diureticand thiazide diuretic1 or 2 tabs dailyOnset: 2 hrPeak: 6 to 10 hrDuration: 24 hrACE inhibitor and thiazidediuretic1 or 2 tabs daily1 or 2 tabs daily1 or 2 tabs dailyOnset: 1 hrPeak: 6 hrDuration: 24 hrHemifumarate salt and thiazidediuretic1 tab dailyOnset: UnknownPeak: 1 to 3 hrDuration: UnknownDirect renin inhibitor andthiazide diuretic1 tab daily1 tab daily1 tab dailyOnset: UnknownPeak: 1 to 2.5 hrDuration: UnknownBeta blocker and thiazidediuretic1 tab b.i.d. or 2 tabs dailyOnset: UnknownPeak: 1 to 2 hrDuration: Unknown(continued)

1172Selected Antihypertensive CombinationsSelected Antihypertensive Combinations (continued)ANTIHYPERTENSIVECOMBINATIONTRADE NAMESANTIHYPERTENSIVEGENERIC NAMESDIURETICGENERIC NAMESTwynsta 40/5Twynsta 40/10Twynsta 80/5Twynsta 80/10telmisartan 40 mg, amlodipine 5 mgtelmisartan 40 mg, amlodipine 10 mgtelmisartan 80 mg, amlodipine 5 mgtelmisartan 80 mg, amlodipine 10 mgNoneNoneNoneNoneUniretic 15/25moexipril HCl 15 mgHCTZ 25 mgValturna 150/160Valturna 300/320aliskiren 150 mg, valsartan 160 mgaliskiren 300 mg, valsartan 320 mgNoneNoneVaseretic 5/12.5Vaseretic 10/25enalapril maleate 5 mgenalapril maleate 10 mgHCTZ 12.5 mgHCTZ 25 mgZestoretic 10/12.5Zestoretic 20/12.5Zestoretic 20/25lisinopril 10 mglisinopril 20 mglisinopril 20 mgHCTZ 12.5 mgHCTZ 12.5 mgHCTZ 25 mgZiac 2.5/6.25Ziac 5/6.25Ziac 10/6.25bisoprolol fumarate 2.5 mgbisoprolol fumarate 5 mgbisoprolol fumarate 10 mgHCTZ 6.25 mgHCTZ 6.25 mgHCTZ 6.25 mg

Selected Antihypertensive Combinations 1173FUNCTIONAL CLASSESAngiotensin II receptorantagonist and calciumchannel blockerUSUAL ADULT DOSAGES1 tab daily1 tab daily1 tab daily1 tab dailyONSET, PEAK,AND DURATIONOnset: UnknownPeak: 1 to 6 hrDuration: UnknownPotassium-sparing diureticand thiazide diuretic1 or 2 tabs dailyOnset: 1 hrPeak: 3 to 6 hrDuration: 24 hrDirect renin inhibitor andACE inhibitor1 tab daily1 tab dailyOnset: UnknownPeak: 1 to 3 hrDuration: UnknownACE inhibitor and thiazidediuretic1 tab once or twice daily1 tab once or twice dailyOnset: 1 hrPeak: 4 to 6 hrDuration: 24 hrACE inhibitor and thiazidediuretic1 or 2 tabs daily1 or 2 tabs daily1 or 2 tabs dailyOnset: 1 hrPeak: 6 hrDuration: 24 hrBeta blocker and thiazidediuretic1 or 2 tabs daily1 or 2 tabs daily1 or 2 tabs dailyOnset: UnknownPeak: UnknownDuration: Unknown

1174VitaminsVitaminsAs you know, an adequate daily intake of vitaminsis essential to vital bodily functions, suchas embryonic development (vitamin A), regulationof serum calcium and phosphate (vitaminD), and blood clotting (vitamin K).Vitamins are classified as one of two types:fat soluble (vitamins A, D, E, and K) and watersoluble (vitamin C and all forms of vitamin B).Fat-soluble vitamins can accumulate in bodytissue over time; when excessive amounts areingested through diet or supplementation,severe and life-threatening toxicity can devel-GENERIC AND TRADE NAMESvitamin A(retinol)Aquasol ARECOMMENDED DAILY INTAKEAdult men and boys over age 10. 1,000 mcg/day.Adult women and girls over age 10. 800 mcg/day.Pregnant women. 800 mcg/day. (900 mcg/day [CAN].)Breast-feeding women. 1,200 to 1,300 mcg/day. (1,200 mcg/day [can].)Children ages 7 to 10. 700 mcg/day. (700 to 800mcg/day [CAN].)Children ages 4 to 7. 500 mcg/day.Neonates and children to age 4. 375 to400 mcg/day. (400 mcg/day [CAN].)vitamin B 1(thiamine hydrochloride)Betaxin (CAN), Bewon (CAN), BiamineAdult men and boys over age 10. 1.2 to 1.5 mg/day. (0.8 to 1.3 mg/day [CAN].)Adult women and girls over age 10. 1 to 1.1 mg/day. (0.8 to 0.9 mg/day [CAN].)Pregnant women. 1.5 mg/day. (0.9 to 1 mg/day. [CAN].)Breast-feeding women. 1.6 mg/day. (1 to 1.2 mg/day [CAN].)

Vitamins 1175op. Water-soluble vitamins don’t accumulate inthe body; they are excreted daily so that toxicityis not usually a concern with excessiveintake.The following chart lists the generic andtrade names of fat-soluble and water-solubleOTHER INDICATIONS AND DOSAGESvitamins, the recommended daily intake to preventvitamin deficiency, dosages when deficiencyoccurs, other indications and dosagesfor vitamin therapy, and guidelines for parenteraladministration of vitamins.PARENTERAL ADMINISTRATIONGUIDELINESTO TREAT VITAMIN A DEFICIENCYCAPSULES, ORAL SOLUTION, TABLETSAdults and adolescents. Dosage individualized basedon severity of deficiency, as prescribed.I.M. INJECTIONAdults and children age 8 and over. 15,000 to30,000 retinol equivalent (RE)/day (50,000 to100,000 international units (IU)/day) for 3 days, followedby 15,000 RE/day (50,000 IU/day) for 2 wk.Children ages 1 to 8. 1,500 to 4,500 RE/day (5,000 to15,000 IU/day) for 10 days; for severe deficiency,5,250 to 10,500 RE/day (17,500 to 35,000 IU/day) for10 days.Infants to age 1 year. 1,500 to 3,000 RE/day (5,000 to10,000 IU/day) for 10 days; for severe deficiency,2,250 to 4,500 RE/day (7,500 to 15,000 IU/day) for10 days.I.V. INFUSIONAdults and children. Dosage individualized as part oftotal parenteral nutrition solution, as prescribed.TO TREAT XEROPHTHALMIACAPSULES, ORAL SOLUTION, TABLETSChildren age 1 and over. 60,000 RE (200,000 IU) as asingle dose. Dose repeated on day 2 and again in 4 wk.Children ages 6 months to 1 year. 30,000 RE(100,000 IU) as a single dose. Dose repeated on day2 and again in 4 wk.AS AN ADJUNCT TO TREAT MEASLESCAPSULES, ORAL SOLUTION, TABLETSChildren age 1 and over. 60,000 RE (200,000 IU) as asingle dose when measles are diagnosed.Children ages 6 months to 1 year. 30,000 RE(100,000 IU) as a single dose when measles are diagnosed.TO TREAT VITAMIN B 1 DEFICIENCY (BERIBERI)ELIXIR, TABLETSAdults. 5 to 10 mg t.i.d.Children and infants. 10 mg/day.I.V. OR I.M. INJECTIONAdults. Initial: 5 to 100 mg every 8 hr, switched to P.O.vitamin B 1 therapy as soon as possible and continuedfor total of 1 mo.•Be aware that anaphylaxis and deathhave occurred after I.V. administration ofvitamin A; I.V. administration is restrictedto special solutions, such as in totalparenteral nutrition solution. Typically,parenteral administration of vitamin A isby I.M. injection.•Take precautions to protect vitamin Asolution from exposure to light becauseit’s light sensitive.•Be aware that I.V. administration of vitaminB 1 has caused severe and lifethreateningreactions, especially withrepeat administration. Monitor patientclosely for angioedema, GI bleeding, respiratorydistress, throat tightness,urticaria, vascular collapse, and weaknessduring and after administration.(continued)

1176VitaminsVitamins (continued)GENERIC AND TRADE NAMESvitamin B 1 (continued)RECOMMENDED DAILY INTAKEChildren ages 7 to 10. 1 mg/day. (0.8 to 1 mg/day [CAN].)Children ages 4 to 7. 0.9 mg/day. (0.7 mg/day [CAN].)Children ages 1 to 4. 0.3 to 0.7 mg/day. (0.3 to0.6 mg/day [CAN].)vitamin B 3(niacin)Endur-Acin, Nia-Bid, Niac, Niacels,Niacor, Nico-400, Nicobid Tempules,Nicolar, Nicotinex Elixir, Novo-Niacin(CAN), Slo-NiacinAdult men and boys age 11 and over. 15 to 20 mg/day.(14 to 23 mg/day [CAN].)Adult women and girls age 11 and over. 13 to 15mg/day. (14 to 16 mg/day [CAN].)Pregnant women. 17 mg/day. (14 to 16 mg/day [CAN].)Breast-feeding women. 20 mg/day. (14 to16 mg/day [CAN].)Children ages 7 to 11. 13 mg/day. (14 to 18 mg/day [CAN].)Children ages 4 to 7. 12 mg/day. (13 mg/day [can].)Neonates and children to age 4. 5 to 9 mg/day. (4 to 9 mg/day [CAN].)vitamin B 6(pyridoxine hydrochloride)Beesix, Doxine, Nestrex, Pyri, Rodex,Vita-bee 6Adult men and boys age 11 and over. 1.7 to2 mg/day.Adult women and girls age 11 and over. 1.4 to1.6 mg/day.Pregnant women. 2.2 mg/day.Breast-feeding women. 2.1 mg/day.Children ages 7 to 10. 1.4 mg/day.Children ages 4 to 6. 1.1 mg/day.Neonates and children to age 3. 0.3 to 1 mg/day.

Vitamins 1177OTHER INDICATIONS AND DOSAGESTO TREAT WERNICKE’S ENCEPHALOPATHYI.V. OR I.M. INJECTIONAdults. Initial: 100 mg I.V. Maintenance: 50 to 100 mgI.V. or I.M. daily until normal recommended daily intakeis achieved.TO TREAT VITAMIN B 3 DEFICIENCYE.R. CAPSULES, E.R. TABLETS, ORAL SOLUTION, TABLETSAdults and children age 11 and over. Dosage individualizedbased on severity of deficiency, as prescribed.Maximum: 6 g/day.I.V. INJECTIONAdults and children age 11 and over. 25 to 100 mg atleast b.i.d.Children to age 11. Up to 300 mg dailyI.M. INJECTIONAdults and children age 11 and over. 50 to 100 mg atleast 5 times/day.Children to age 11. Dosage individualized based onseverity of deficiency.TO TREAT HYPERLIPIDEMIA (NIACIN ONLY)E.R. CAPSULES, E.R. TABLETS, ORAL SOLUTION, TABLETSAdults. Initial: 1,000 mg t.i.d. Dosage increased by500 mg/day every 2 to 4 wk, as needed. Maintenance:1 to 2 g t.i.d. Maximum: 6 g/day.Dosage Adjustment To reduce or preventfacial flushing, initial dosage reduced to 100 mg/day (tab) or 500 mg/day (E.R. tab), and then graduallyincreased to 3 to 4 g/day.TO TREAT VITAMIN B 6 DEFICIENCYE.R. CAPSULES, TABLETSAdults and children. Dosage individualized based onseverity of deficiency, as prescribed.E.R. TABLETSAdults. Dosage individualized based on severity ofdeficiency, as prescribed.I.V. INFUSIONAdults and children. Dosage individualized as part oftotal parenteral nutrition.PARENTERAL ADMINISTRATIONGUIDELINES•Rotate sites for I.M. administration ofvitamin B 1 to help prevent tendernessand induration that may occur followingadministration.•I.M. administration may be painful; usethe Z-track method of administration.•Because of incompatibilities, don’t addparenteral vitamin B 1 to alkaline or neutralsolutions; also, don’t mix it with oxidizingand reducing agents, includingbarbiturates, carbonates, citrates, andcopper•Take precautions to protect vitamin B 1solution from exposure to light becauseit’s light sensitive.•Be aware that I.V. administration of vitaminB 3 may cause CNS or CV adversereactions, such as arrhythmias, dizziness,headache, peripheral vasodilation, andsyncope. Rate of I.V. administrationshouldn’t exceed 2 mg/min, regardlessof method of I.V. administration.•Vitamin B 3 must be diluted for I.V. use.For direct injection, dilute to 2 mg/ml;for intermittent or continuous infusion,dilute dose in 500 ml of normal saline orother compatible solution•Give I.M. injection following routine I.M.administration guidelines. Vitamin B 3doesn’t need to be diluted for I.M. injection.•Be aware that parenteral administrationshouldn’t be used to treat hyperlipidemia.•Be aware that SubQ or I.M. administrationof vitamin B 6 may cause injectionsite burning or stinging. Before givinginjection, alert patient that this adverseeffect may occur.•Know that I.V. administration is given aspart of a multivitamin solution; followthe guidelines for administering an I.V.multivitamin solution as recommendedfor the product being used.(continued)

1178VitaminsVitamins (continued)GENERIC AND TRADE NAMESvitamin B 6 (continued)RECOMMENDED DAILY INTAKEAdult men and boys age 11 and over. 1.7 to 2 mg/day.Adult women and girls age 11 and over. 1.4 to1.6 mg/day.Pregnant women. 2.2 mg/day.Breast-feeding women. 2.1 mg/day.Children ages 7 to 10. 1.4 mg/day.Children ages 4 to 6. 1.1 mg/day.Neonates and children to age 3. 0.3 to 1 mg/day.vitamin B 9(folic acid)Apo-Folic (CAN), Folvite,Novo-Folacid (CAN)Adult men and boys age 11 and over. 150 to400 mcg/day. (150 to 220 mcg/day [CAN].)Adult women and girls age 11 and over. 150 to400 mcg/day. (145 to 190 mcg/day [CAN].)Pregnant women. 400 to 800 mcg/day. (445 to475 mcg/day [CAN].)Breast-feeding women. 260 to 800 mcg/day. (245 to275 mcg/day [CAN].)Children ages 7 to 11. 100 to 400 mcg/day. (125 to180 mcg/day [CAN].)Children ages 4 to 7. 75 to 400 mcg/day.(90 mcg/day [CAN].)Neonates and children to age 4. 25 mcg/day. (50 to80 mcg/day [CAN].)vitamin B 12(cyanocobalamin, hydroxycobalamin)Adults age 19 and over. 2.4 mcg/day.Pregnant women. 2.6 mcg/day.Breast-feeding women. 2.8 mcg/day.Adolescents ages 14 to 19. 2.4 mcg/day.Children ages 9 to 14. 1.8 mcg/day.Children ages 4 to 9. 1.2 mcg/day.Children ages 1 to 4. 0.9 mcg/day.Infants ages 6 to 12 months. 0.4 mcg/day.Neonates and infants to 6 months. 0.5 mcg/day.

Vitamins 1179OTHER INDICATIONS AND DOSAGESTO TREAT PYRIDOXINE DEPENDENCY SYNDROMEI.V. OR I.M. INJECTIONAdults and children age 11 and over. 30 to 600 mgdaily.Infants with seizures. Initial: 10 to 100 mg, then individualizedbased on severity of deficiency, as prescribed.TO TREAT DRUG-INDUCED PYRIDOXINE DEFICIENCYI.V. OR I.M. INJECTIONAdults and children age 11 and over. 50 to 200 mg/day for 3 wk, then 25 to 100 mg/day, as needed.TO TREAT VITAMIN B 9 DEFICIENCYTABLETSAdults and children. Dosage individualized based onseverity of deficiency, as prescribed.I.V. INFUSION, I.M. OR SUBCUTANEOUS INJECTIONAdults and children. 0.25 to 1 mg daily until hematologicresponse occurs.TO TREAT VITAMIN B 12 DEFICIENCYCaused by nutritional intake imbalance(not for use to treat pernicious anemia)LOZENGES, TABLETSAdults and children. Dosage individualized based onseverity of deficiency, as prescribed.Caused by pernicious anemia; malabsorption disorders(tropical or nontropical sprue, partial or total gastrectomy,regional enteritis, gastroenterostomy, ileal resection);or malignancies, granulomas, strictures, or anastomosesinvolving the ileum.SUBCUTANEOUS INJECTION (CYANOCOBALAMIN)Adults. Initial: 30 mcg daily for 5 to 10 days, thenswitched to I.M. administration for maintenancetherapy.PARENTERAL ADMINISTRATIONGUIDELINES•Vitamin B 6 may increase AST (SGOT) levels.Be aware that at least one manufacturerwarns against I.V. administration ofvitamin B 6 to patients with heart disease.•Take precautions to protect vitamin B 6solution from exposure to light becauseit’s light sensitive.•Be aware that some vitamin B 9 solutionscontain benzyl alcohol. Don’t administerthese solutions to neonates or immatureinfants because of a risk of fatal toxicsyndrome, which may include CNS, respiratory,circulatory, and renal impairmentand metabolic acidosis.•Unless ordered otherwise, dilute 5 mg/ml of vitamin B 9 with with 49 ml of sterilewater for injection to provide a solutioncontaining 0.1 mg of vitamin/ml.•Know that parenteral administrationmay cause anaphylaxis. Parenteraladministration should be used only inpatients with severe vitamin deficiencyor in those with severely impaired GIabsorption.•Be aware that SubQ administrationshould be injected deep.•Take precautions to protect vitamin B 9solution from exposure to light becauseit’s light sensitive.•Be aware that parenteral vitamin B 12solution is incompatible with manydrugs, including ascorbic acid, chlorpromazinehydrochloride, dextrose, heavymetals, phytonadione, prochlorperazineedisylate, warfarin sodium, oxidizing orreducing agents, and alkaline or stronglyacidic solutions. Do not administer vitaminwith other drugs.•Know that both cyanocobalamin andhydroxycobalamin may be administeredby I.M. injection, but only cyanocobalaminmay be administered as an SubQinjection. Be alert to which form is beingadministered to ensure correct route ofadministration.(continued)

1180VitaminsVitamins (continued)GENERIC AND TRADE NAMESRECOMMENDED DAILY INTAKEvitamin B 12 (continued)vitamin C(ascorbic acid)Ascorbic Acid, Cecon Drops, Cenolate,Cevi-Bid, Vicks Vitamin C DropsAdult men. 90 mg/day.Adult women. 75 mg/day.Pregnant women age 19 and over. 85 mg/day.Breast-feeding women age 19 and over.120 mg/day.Adolescent boys ages 14 to 19. 75 mg/day.Adolescent girls ages 14 to 19. 65 mg/day.Pregnant girls ages 14 to 19. 80 mg/day.Breast-feeding girls ages 14 to 19. 115 mg/day.Children ages 9 to 14. 45 mg/day.Children ages 4 to 9. 25 mg/day.Children ages 1 to 4. 15 mg/day.Infants ages 7 to 12 months. 50 mg/day.Neonates and infants to age 7 months.40 mg/day.Dosage Adjustment Recommended daily intake forpeople who smoke is 100 mg/day because of anincreased utilization of vitamin C. Recommended dailyintake should be increased to promote wound healingand for those with a chronic illness, fever, hemovasculardisorder, or infection; the amount of vitamin C increasedepends on the severity of the underlying condition.

Vitamins 1181OTHER INDICATIONS AND DOSAGESChildren. Initial: 1,000 to 5,000 mcg given in singledaily doses of 100 mcg over 2 or more wk.Maintenance: 60 or more mcg/mo.I.M. INJECTION (CYANOCOBALAMIN OR HYDROXYCOBALAMIN)Adults. Initial: 30 mcg daily for 5 to 10 days.Maintenance: 100 to 200 mcg every mo.Children. Initial: 1,000 to 5,000 mcg, given in singledaily doses of 100 mcg over 2 or more wk.Maintenance: 60 or more mcg/mo.Dosage Adjustment Dosage adjusted, as needed, tomaintain normal hematologic morphology and an erythrocytecount greater than 4.5 million/mm 3 .TO TREAT FAMILIAL SELECTIVE B 12 MALABSORPTIONI.M. INJECTION (CYANOCOBALAMIN)Adults. Initial. 1 mg/wk for 3 wk. Maintenance:250 mcg/mo.TO TREAT HEREDITARY DEFICIENCY OFTRANSCOBALAMIN III.M. INJECTION (CYANOCOBALAMIN)Adults. 1 to 2 mg/wk.TO TREAT VITAMIN C DEFICIENCY (SCURVY)E.R. CAPSULES; LOZENGES; ORAL SOLUTION;E.R. TABLETS; TABLETS; SUBCUTANEOUS, I.M.,OR I.V. INJECTIONAdults. 100 to 250 mg once or twice daily until skeletalchanges and signs and symptoms of hemorrhagic disorderare reversed (usually within 2 to 21 days).ORAL SOLUTION; TABLETS; SUBCUTANEOUS, I.M.,OR I.V. INJECTIONInfants and children. 100 to 300 mg/day in divideddoses until skeletal changes and signs and symptomsof hemorrhagic disorder are reversed (usually withindays).PARENTERAL ADMINISTRATIONGUIDELINES•Be aware that SubQ administration ofcyanocobalamin should be injecteddeeply.•Know that vitamin B 12 is excreted morerapidly after I.V. injection; I.V. administrationisn’t recommended.•Take precautions to protect vitamin B 12solution from exposure to light becauseit’s light sensitive.•Be aware that I.M. injection is the preferredparenteral route for administeringvitamin C, although it may be administeredI.V. or SubQ when necessary.•Rotate sites for I.M. and SubQ administrationto help prevent transient mildsoreness that may occur followingadministration. Inform patient that thisadverse effect may occur.•If giving I.V. vitamin C, avoid rapidadministration to prevent faintness ordizziness.•Administer vitamin C solution by itselfbecause it’s incompatible with manydrugs.•Be aware that vitamin C solution rapidlyoxidizes in air and in alkaline solutions.Take precautions to protect vitaminsolution from exposure to air and light.•Open vitamin C ampules carefullybecause increased pressure may developafter prolonged storage.(continued)

1182VitaminsVitamins (continued)GENERIC AND TRADE NAMESvitamin D 2(ergocalciferol)Calciferol, Calciferol Drops, Drisdol,Drisdol Drops, Ostoforte (CAN),Radiostol Forte (CAN)RECOMMENDED DAILY INTAKEAdults and children ages 11 and over. 200 to 400 internationalunits (IU)/day. (100 to 200 IU/day [CAN].)Pregnant and breast-feeding women. 400 IU/day. (200 to 300 IU/day [CAN].)Children ages 7 to 11. 400 IU/day. (100 to200 IU/day [CAN].)Children ages 4 to 7. 400 IU/day. (200 IU/day [CAN].)Neonates and children to age 4. 300 to 400 IU/day. (200 to 400 IU/day [CAN].)vitamin E(alpha tocopherol)Amino-Opti-E, Aquasol E,E-Complex 600, E-Vitamin succinate,Liqui-E, Pheryl E, Vita-Plus E, WebberVitamin E (CAN)Adult men and adolescent boys. 16.7 internationalunits (IU)/day. (10 to 16.7 IU/day [CAN].)Adult women and adolescent girls. 13 IU/day. (8.3 to11.7 IU/day [CAN].)Pregnant women. 16.7 IU/day. (13 to 15 IU/day [CAN].)Breast-feeding women. 18 to 20 IU/day. (15 to16.7 IU/day [CAN].)Children ages 7 to 10. 11.7 IU/day. (10 to 13 IU/day [CAN].)Children ages 4 to 7. 11.7 IU/day. (8.3 IU/day [CAN].)Infants and children to age 4. 5 to 10 IU/day. (5 to6.7 IU/day [CAN].)

Vitamins 1183OTHER INDICATIONS AND DOSAGESTO TREAT VITAMIN D 2 DEFICIENCYCAPSULES, ORAL SOLUTION, TABLETSAdults and children. Dosage individualized based onseverity of deficiency, as prescribed.TO TREAT VITAMIN D-RESISTANT RICKETSCAPSULES, ORAL SOLUTION, TABLETSAdults. 12,000 to 150,000 international units dailyTO TREAT VITAMIN D-DEPENDENT RICKETSCAPSULES, ORAL SOLUTION, TABLETSAdults. 10,000 to 60,000 international units dailyMaximum: 150,000 international units daily.Children. 3,000 to 10,000 international units daily.Maximum: 50,000 international units daily.TO TREAT OSTEOMALACIA CAUSED BY LONG-TERMANTICONVULSANT USECAPSULES, ORAL SOLUTION, TABLETSAdults. 1,000 to 4,000 international units daily.Children. 1,000 international units daily.TO TREAT FAMILIAL HYPOPHOSPHATEMIACAPSULESAdults. 50,000 to 100,000 international units daily.To treat hypoparathyroidismCAPSULESAdults. 50,000 to 150,000 international units daily.Children. 50,000 to 200,000 international units daily.TO TREAT INTESTINAL MALABSORPTIONI.M. INJECTIONAdults and children. 10,000 international units daily.TO TREAT VITAMIN E DEFICIENCYCAPSULES (ADULTS ONLY), ORAL SOLUTION, TABLETSAdults and children. Dosage individualized based onseverity of deficiency, as prescribed.PARENTERAL ADMINISTRATIONGUIDELINES•Be aware that vitamin D 2 is usually givenorally. However, I.M. injection may berequired for patients with GI, liver, or biliarydisease associated with malabsorptionof vitamin D analogues.•Take precautions to protect parenteralvitamin D 2 solution from exposure tolight because light causes it to decompose.Vitamin E isn’t administered parenterally.(continued)

1184VitaminsVitamins (continued)GENERIC AND TRADE NAMESvitamin K 1(phytonadione)AquaMEPHYTON, MephytonRECOMMENDED DAILY INTAKERecommended daily intake hasn’t been established forvitamin K 1 . However, adequate intake is suggested as follows:Adult men age 19 and over. 120 mcg/day.Adult women age 19 and over, pregnant and breastfeedingwomen. 90 mcg/day.Adolescents ages 14 to 19. 75 mcg/day.Children ages 9 to 14. 60 mcg/day.Children ages 4 to 9. 55 mcg/day.Children ages 1 to 4. 30 mcg/day.Infants ages 7 to 12 months. 2.5 mcg/day.Neonates and infants to age 7 months. 2 mcg/day.

Vitamins 1185OTHER INDICATIONS AND DOSAGESTO PREVENT HYPOPROTHROMBINEMIA DURINGPROLONGED USE OF TOTAL PARENTERAL NUTRITIONI.M. INJECTIONAdults. 5 to 10 mg/wk.Children. 2 to 5 mg/wk.TO PREVENT HYPOPROTHROMBINEMIA IN INFANTSWITH DIETS DEFICIENT IN VITAMIN K(LESS THAN 100 MCG/L)I.M. INJECTIONInfants. 1 mg/mo.TO TREAT ANTICOAGULANT-INDUCEDHYPOPROTHROMBINEMIATABLETS, I.M. OR SUBCUTANEOUS INJECTIONAdults. 2.5 to 25 mg, repeated 12 to 48 hr after P.O.dose or 6 to 8 hr after SubQ or I.M. dose, as prescribed.Maximum: 50 mg/dose.Children. 2.5 to 10 mg SubQ or I.M., repeated in 6 to8 hr, as prescribed.Infants. 1 to 2 mg SubQ or I.M., repeated in 4 to 8 hr, asprescribed.TO TREAT HYPOPROTHROMBINEMIAFROM OTHER CAUSESTABLETS, I.M. OR SUBCUTANEOUS INJECTIONAdults. 2 to 25 mg. Usual: 25 mg. Maximum: 50 mg/dose.Children. 5 to 10 mg SubQ or I.M.Infants. 2 mg SubQ or I.M.TO PREVENT HEMORRHAGIC DISEASE IN NEONATESI.M. OR SUBCUTANEOUS INJECTIONNeonates. 0.5 to 1 mg within 1 hr after birth, repeatedin 6 to 8 hr, as prescribed.TO TREAT HEMORRHAGIC DISEASE IN NEONATESI.M. OR SUBCUTANEOUS INJECTIONNeonates. 1 mg (or higher dose if mother took an oralanticoagulant or anticonvulsant during pregnancy).PARENTERAL ADMINISTRATIONGUIDELINES•Be aware that severe adverse reactions,including anaphylaxis, cardiac and respiratoryarrest, hypersensitivity, and shock,may occur during or immediately afterI.M. or I.V. administration of vitamin K 1 ,even if it’s diluted to avoid rapid infusion.Administer vitamin by SubQ routewhenever possible.•If vitamin K 1 must be administered I.V.,do not exceed rate of 1 mg/min, as prescribed.•Be aware that some vitamin K 1 solutionscontain benzyl alcohol. Don’t administerthese solutions to neonates or immatureinfants because of a risk of fatal toxicsyndrome, which may include CNS, respiratory,circulatory, and renal impairmentand metabolic acidosis.•Take precautions to protect vitamin K 1solution from exposure to light becauseit’s light sensitive.

1186InterferonsInterferonsInterferons are classified as biological responsemodifiers or antineoplastics. They fall into threemajor categories—alpha, beta, and gamma—which are described below.The table on the following pages lists thetrade names, indications, usual adult dosages,adverse reactions, and nursing considerationsfor these interferons.Interferon alphaHighly purified proteins produced by a recombinantDNA process, drugs in this categoryexhibit antiviral and antitumor activity. Antiviralactivity depends on their inhibition of viral proteinsynthesis. Antitumor activity results fromtheir ability to exert a cytostatic effect, reducingthe rate of cell proliferation by delaying RNAand protein production. This delay induces cellsto enter a resting stage. These drugs alsoincrease the activity of human natural killer(NK) cells, which have the ability to lyse certaintumor cells and normal targets. They also selectivelyincrease the number of cytotoxic T-cells,thereby affecting tumor growth. Phagocyticactivity of macrophages also is increased.INTERFERON ALFACONThis specific form of interferon is produced byfermentation of genetically engineeredEscherichia coli. It’s structurally and functionallyrelated to interferon beta and has greater biologicalactivity than other interferon alfas.Interferon betaProduced by fibroblasts and epithelial cells,drugs in this category neutralize the activity ofendogenous interferon gamma (IFNG), the sub-GENERIC ANDTRADE NAMESINDICATIONS ANDUSUAL ADULT DOSAGESInterferon alpha drugsinterferon alfa-n3Alferon Npeginterferon alfa-2aPEGASYSTo treat condyloma acuminatum: 250,000 units intralesionallyat base of wart 2 times/wk for up to 8 wk.As monotherapy to treat patients with chronic heptatitis C whohave compensated liver disease and have never received aninterferon alpha: 180 mcg/wk SubQ for 48 wk.As adjunct to treat patients with chronic hepatitis C who havecompensated liver disease and have never received an interferonalpha: 180 mcg/wk SubQ with ribavirin (Copegus) 800 to1,200 mg/day P.O. in 2 divided doses with food for 48 wk.peginterferon alfa-2bPEG-IntronTo treat patients with chronic hepatitis C: 1 mcg/kg/wk SubQevery wk on the same day of the wk for 1 year.To treat patients with chronic hepatitis C in combination withribvarin: 1.5 mcg/kg SubQ every wk on the same day of thewk for 48 wk.recombinant interferon alfa-2bIntron ATo treat hairy cell leukemia: 2 million units/m 2 I.M. or SubQ 3times/wk.

Interferons 1187stance believed to be responsible for triggeringthe autoimmune process that leads to multiplesclerosis. In multiple sclerosis, an initial viralinfection may stimulate IFNG production by Tcells. Then IFNG induces macrophages to produceproteinases that degrade the myelinsheath around the nerves and spinal cord.Cytotoxic T cells then move to the site ofinflammation, recognizing antigens as receptorsites, where they attack the tissue affected byIFNG, resulting in progressive neurologic dysfunction.Interferon beta drugs interfere withIFNG production by lymphocytes and themRNA transcription caused by IFNG. As a result,cytotoxic T cells can’t locate receptor sites andcause further damage in the CNS.Interferon gammaProduced from genetically engineered E. coli,this type of interferon is chemically and therapeuticallydistinct from interferon alpha. Drugsin this category have potent phagocyteactivatingproperties. By enhancing oxidativemetabolism, they produce toxic oxygenmetabolites in phagocytes, which permits moreefficient killing of certain fungi, bacteria, andprotozoal microbes. Enhanced antibodydependentcellular cytotoxicity and NK-cellactivity reduce the risk of developing a seriousinfection in patients with chronic disease. Thesedrugs also stimulate production of cytokines,such as interleukin-1-beta, and regulate theimmune system by suppressing the IgE leveland inhibiting collagen production.ADVERSEREACTIONSNURSINGCONSIDERATIONSCNS: Dizziness, fatigue, headache,homicidal ideation, psychosis,seizures, peripheral neuropathy,vertigoCV: Hypertriglyceridemia, hypertension,hypotension, palpitationsEENT: Dry mouth, hearing loss, retinaldetachment (with ribavirin)GI: Anorexia, diarrhea, hepatotoxicity,nausea, vomitingGU: Renal failureHEME: Anemia, leukopenia, pure redcell aplasia, thrombocytopenia,thrombotic thrombocytopenic purpuraMS: Myositis, rhabdomyolysisSKIN: Alopecia, rash, Stevens-Johnson syndrome, toxic epidermalnecrolysis, urticariaOther: Anaphylaxis, angioedema,bacterial infections, flulike symptoms,sepsis, systemic lupus erythematosus•Use interferon alpha drugs cautiously in patients withrenal impairment and in elderly patients.•Be aware that cross-sensitivity may occur among interferonalpha drugs.•Be aware that interferon alpha drugs aren’t interchangeable.•Be aware that patients who are sensitive to mouseimmunoglobulin also may be sensitive to recombinantinterferon alfa-2a.•Unless contraindicated, ensure that patient is well hydratedat the start of and throughout therapy to reduce therisk of hypotension.•Reconstitute by adding 3 ml of diluent provided by manufacturerand swirling gently to dissolve.•Be aware that reconstitution of peginterferon alfa-2a andinterferon alfa-n3 is not necessary.•Don’t shake vial.•Be aware that cross-sensitivity with interferon alfa-n3 tomouse immunoglobulin, egg protein, or neomycin mayoccur.WARNING Because interferon alpha drugs may cause oraggravate fatal or life-threatening autoimmune, ischemic,infectious, or neuropsychiatric disorders, monitor patientperiodically with clinical and laboratory evaluations andexpect drug to be discontinued if he develops severe orworsening signs and symptoms of these conditions.(continued)

1188InterferonsInterferons (continued)GENERIC ANDTRADE NAMESINDICATIONS ANDUSUAL ADULT DOSAGESInterferon alpha drugs (continued)recombinant interferon alfa-2bIntron A(continued)To treat condyloma acuminatum: 1 million units (using onlythe 10-million units/ml strength) intralesionally at base ofwart (up to 5 warts/course) 3 times/wk on alternate days for3 wk. If response is inadequate 12 to 16 wk after initial treatment,repeat course, as prescribed.To treat AIDS-related Kaposi’s sarcoma: 30 million units/m 2(using 50 million units/ml) I.M. or SubQ 3 times/wk.To treat chronic, active hepatitis B and C: 3 million units I.M. orSubQ 3 times/wk.To treat chronic hepatitis B: 5 million units/day or 10 millionunits 3 times/wk I.M. or SubQ for 16 wk.To treat malignant melanoma: 20 million units/m 2 as I.V.infusion for 5 consecutive days/wk for 4 wk, followed by10 million units/m 2 SubQ 3 times/wk for 48 wk.Interferon alphacon drugsinterferon alfacon-1InfergenTo treat chronic, active hepatitis C: 9 mcg SubQ 3 times/wk, at intervals of at least 48 hours, for 24 wk. If inadequateresponse or relapse occurs, 15 mcg 3 times/wk for 6 mo.Interferon beta drugsinterferon beta-1aAvonexRebifinterferon beta-1bBetaseron, ExtaviaTo treat initial attack or relapsing forms of multiple sclerosis:30 mcg I.M. once/wk.To treat relapsing forms of multiple sclerosis: 44 mcg SubQ3 times/wk.To treat relapsing forms of multiple sclerosis: 0.25 mg SubQevery other day.

Interferons 1189ADVERSEREACTIONSNURSINGCONSIDERATIONS•Obtain CBC before and regularly during treatment, asordered, because interferon alpha drugs may cause bonemarrow suppression. Expect drug to be discontinued ifpatient develops severe decreases in platelet or neutrophilcount.•Implement bleeding and infection-control measures,according to facility policy.•Use gamma interferon cautiously in patients previouslyexposed to cytotoxic drugs or radiation therapy.•Be aware that cross-sensitivity may occur with Escherichiacoli–derived products.•Discard vial if left at room temperature for more than12 hours.•Implement bleeding and infection-control measures,according to facility policy.•Administer acetaminophen, as prescribed, to prevent ortreat headache and fever.CNS: Anxiety, confusion, decreasedconcentration, depression, insomnia,nervousnessEENT: Abnormal visionHEME: Leukopenia, thrombocytopenia•Be aware that use of interferon alfacon-1 isn’t recommendedfor patients with autoimmune hepatitis or psychiatricdisorders.•Be aware that cross-sensitivity may occur with other interferonalfa drugs or Escherichia coli–derived products.•Don’t shake vial.•Implement bleeding and infection-control measures,according to facility policy.•Monitor patient for signs and symptoms of vision abnormalities.CNS: Depression, fatigue, headache,suicidal ideation, weaknessGI: Diarrhea, elevated liver enzymelevels, nauseaHEME: Anemia, leukopenia, thrombocytopeniaOther: Anaphylaxis,flulike symptoms,infection, injection site reactions(including necrosis)•Use beta interferons with extreme caution in patientswith depression or seizure disorder.•Be aware that cross-sensitivity may occur with natural orrecombinant interferon beta or human albumin.•Reconstitute following manufacturer’s directions andrefrigerate. Use interferon beta-1a within 6 hours ofreconstitution. Use interferon beta-1b within 3 hours ofreconstitution.•Implement bleeding and infection-control measures,according to facility policy.(continued)

1190InterferonsInterferons (continued)GENERIC ANDTRADE NAMESINDICATIONS ANDUSUAL ADULT DOSAGESInterferon gamma drugsinterferon gamma-1bActimmuneTo treat chronic granulomatous disease or to delayprogression of severe, malignant osteopetrosis in patientswith body surface area greater than 0.5 m 2 : 50 mcg/m 2(1 million international units/m 2 ) SubQ 3 times/wk.To treat chronic granulomatous disease or to delayprogression of severe, malignant osteopetrosis in patientswith body surface area of 0.5 m 2 or less: 1.5 mcg/kg/doseSubQ 3 times/wk.

Interferons 1191ADVERSEREACTIONSNURSINGCONSIDERATIONSCNS: Fatigue, headacheGI: Diarrhea, nausea, vomitingHEME: LeukopeniaSKIN: RashOther: Flulike symptoms•Use gamma interferon cautiously in patients previouslyexposed to cytotoxic drugs or radiation therapy.•Be aware that cross-sensitivity may occur with Escherichiacoli–derived products.•Discard vial if left at room temperature for more than12 hours.•Implement bleeding and infection-control measures,according to facility policy.•Administer acetaminophen, as prescribed, to prevent ortreat headache and fever.

1192Compatible Drugs in a SyringeCompatible Drugs in a SyringeThe table below lets you know at a glancewhether particular drugs are compatible for atleast 15 minutes when mixed together in asyringe for immediate administration. However,keep in mind that drugs listed as compatiblewhen mixed in a syringe may not be compatiblewhen prepared for other routes of administration.Drug combinations prepared for immediateadministration usually require a moreconcentrated solution than those prepared forinfusion.Key: C = Compatible; I = Incompatible; n/a =Compatibility information not available; no recommendationscan be given.atropinechlorpromazinedexamethasonediazepamdiphenhydraminedroperidolfurosemideglycopyrrolatehaloperidolatropine C n/a n/a C C n/a C Ichlorpromazine C n/a n/a C C n/a C n/adexamethasone n/a n/a n/a I n/a n/a n/a n/adiazepam n/a n/a n/a n/a n/a n/a I n/adiphenhydramine C C I n/a C n/a C Idroperidol C C n/a n/a C I C n/afurosemide n/a n/a n/a n/a n/a I n/a n/aglycopyrrolate C C I C C C n/a Chaloperidol n/a n/a n/a n/a C n/a n/a n/aheparin C I n/a I n/a I C n/a Ihydromorphone C C n/a n/a C n/a n/a C Chydroxyzine C C n/a n/a C C n/a C Iketorolac n/a n/a n/a I n/a n/a n/a n/a Ilidocaine n/a n/a n/a n/a n/a n/a n/a C n/alorazepam n/a n/a n/a n/a n/a n/a n/a n/a n/ameperidine C C n/a C C C n/a C n/ametoclopramide C C n/a n/a C C I n/a n/amidazolam C C n/a n/a C n/a n/a C Cmorphine C C n/a n/a C C n/a C Ipentobarbital C I n/a n/a I I n/a I n/aprochlorperazine C n/a n/a n/a C C n/a C n/aranitidine C I C n/a C n/a n/a C n/ascopolamine C C n/a n/a C C n/a C n/a

Compatible Drugs in a Syringe 1193heparinhydromorphoinehydroxyzineketorolaclidocainelorazepammeperidinemetoclopramidemidazolammorphinepentobarbitalprochlorperazineranitidinescopolaminen/a C C n/a n/a n/a C C C C C C C CI C C n/a n/a n/a C C C I I C C Cn/a C n/a n/a n/a n/a n/a C n/a n/a n/a n/a C n/aI n/a n/a I n/a n/a n/a n/a n/a n/a n/a n/a I n/an/a C C n/a n/a n/a C C C C I C C CI n/a C n/a n/a n/a C C C C I C n/a CC n/a n/a n/a n/a n/a n/a I n/a n/a n/a n/a n/a n/an/a C C n/a C n/a C n/a C C I C C CI C I I n/a n/a n/a n/a n/a I n/a n/a n/a n/an/a n/a n/a C n/a I C n/a C n/a n/a n/a n/an/a C I n/a C n/a n/a C n/a C I C Cn/a C I C n/a C C C C I C C Cn/a I I n/a n/a n/a n/a n/a n/a n/a I n/a n/aC n/a C n/a n/a n/a C n/a n/a n/a n/a n/a n/an/a C n/a n/a n/a n/a n/a n/a n/a n/a n/a I n/aI n/a C n/a n/a n/a C I I C C C CC C n/a n/a C n/a C C C n/a C C Cn/a C C n/a n/a n/a C C C I I I CC* n/a C n/a n/a n/a n/a C C I C C Cn/a C I n/a n/a n/a I I I I I I Cn/a I C I n/a n/a C C I C I C Cn/a C I n/a n/a I C C I C I C Cn/a C C n/a n/a n/a C C C C C C C* Compatible only with morphine doses of 1 mg, 2 mg, and 5 mg.

1194Drug Formulas and CalculationsDrug Formulas and CalculationsWhen giving drugs, you must be familiarwith drug formulas and calculation methodsto make sure your patient receives the prescribeddrug in the correct dosage, strength,or flow rate. This appendix offers a quickreview of ways to calculate the strength of asolution, drug dosages, and I.V. flow rates.Calculating the Strengthof a SolutionMost solutions are prepared in the requiredstrength by the pharmacy or medical supplysource. But sometimes only a concentratedform is available, and you’ll need to dilutethe solution or solid to administer the prescribedstrength.Method 1: Calculating percentage and volumeUse the following formula:When a solid form of a drug is used toprepare a solution, the drug must be completelydissolved. Solid drug forms, such astablets, crystals, and powders, are considered100% strength. (An exception to this is boricacid, which is only 5% at full strength.) Thefinal diluted solution is stated in terms of liquidmeasurement. To prepare a solution,you’ll need to add the prescribed solid or liquidform of the drug (the solute) to the prescribedamount of diluent (the solvent). Twoof the most common clinical diluents arenormal saline solution and sterile water.You can use two formulas to calculate thestrength of a solution, as shown in the examplesbelow.Example: You need to dilute a stock solution of 100% strength to a 5% solution.How much solute will you need to add to obtain 500 ml of the 5% solution?100 X (500)(5) or 2,500X 25 gAnswer: You’ll need to add 25 g of solute to each 500 ml of solventto prepare a 5% solution.Method 2: Calculating percentage and volumeUse the following formula:(Desired strength)(Available strength)Weaker solution Stronger solutionCalculate as follows:5 (%) (weaker solution) 100 (%) (stronger solution)Total amount ofdesired solution XExample: You need to make 100 ml of a 20% solution, using an 80% solution.How much of the 80% solution must you add to the sterile water to yielda final volume of 100 ml of a 20% solution?Calculate as follows:20 (%) (Desired strength) 80 (%) (Available strength)Solute Solvent0.20 0.250.800.25 100 (ml) XX 25 ml of 80% solutionX (g) (solute)500 ml (solvent)(amount of undiluted drugneeded to make solution)100 ml (Total amountof desired solution) XAnswer: You’ll need to add 25 ml of the 80% solution to the waterto make a final volume of 100 ml of a 20% solution.

Drug Formulas and Calculations 1195Drug Formulas and Calculations (continued)Calculating Drug DosagesYou may be required to calculate drug dosages when you need to administer a drug that’savailable only in one measure, but prescribed in another. You should also be prepared to convertvarious units of measure, such as milligrams (mg) to grains (gr), and dry measurementsto liquid. You can use three common methods of ratio and proportion to calculate drugdosages, as shown in the examples below.CALCULATING ORAL DRUG DOSAGESExample: You need to give a patient 0.25 mg of digoxin, which comes only in 0.125-mg tablets.How many tablets will you need to give him to attain the proper dosage?Method 1: Using labeled amount of drugIn this method, true proportions between the drug label and the prescribed dose are usedto determine ratio and proportion. The drug label, which states the amount of drug in oneunit of measurement—in this case, 0.125-mg in each tablet of digoxin—is the first ratio,expressed as follows:milligrams : tablets milligrams : tablets0.125 mg (amount of drug) : 1 tablet (unit of measure)The prescribed dose—in this case, 0.25-mg—is the second ratio; it must be stated in thesame order and units of measure as the first, as follows:Calculate as follows:0.125 mg : 1 tablet 0.25 mg : X (tablets)0.125 X 0.250.25X 0.125X 2Answer: You’ll need to give the patient 2 tablets of digoxin 0.125 mg.Be sure to use critical thinking to assess whether your answer is correct. Because theamount of drug prescribed is greater than the amount of drug in one tablet, it’s reasonableto expect the required number of tablets to be greater than one.Method 2: Using an established formulaTo determine the correct number of digoxin tablets to give using this method, use the followingformula:Prescribed dose Quantity (unit of measure) X (unknown quantity to be given)Dose availableCalculate as follows:0.25 mg 1 tablet X (number of 0.125-mg tablets)0.125 mg0.25 2X0.1252 XAnswer: You’ll need to give the patient 2 tablets of digoxin 0.125 mg.(continued)

1196Drug Formulas and CalculationsDrug Formulas and Calculations (continued)Method 3: Calculating according to proportion sizeThis method uses the same components as method #1, but the ratio is based on proportionsaccording to size. To determine the correct number of digoxin tablets to give usingthis method, use the following formula:smaller smaller larger largerSubstitute 0.125 into the smaller part and 0.25 into the greater part of the first ratio.Critical thinking leads us to believe that you’ll need more than 1 tablet of the weaker0.125-mg strength to equal the stronger 0.25 mg. Set up the proportion as follows:0.125 mg 1 (tablet) 0.25 mg X (tablets)Calculate as follows:0.125 X 0.250.25X 0.125X 2 tabletsAnswer: You’ll need to give the patient 2 tablets of digoxin 0.125 mg.CALCULATING PARENTERAL DRUG DOSAGESThe same methods used for calculating oral drugs and solutions can be used for preparingparenteral injections.Example: You need to administer a prescribed dose of 1 mg morphine sulfate from aunit-dose cartridge containing 4 mg per 2 ml. How many milliliters will you need to giveto equal the prescribed dose of 1 mg?Method 1: Using labeled amount of drugUsing the same ratio as for oral drugs, the drug label—in this case, 4 mg—is the firstratio, and the prescribed dose—in this case, 1 mg—is the second ratio, expressed as follows:4 mg (the amount of drug) : 2 ml (the unit of measure)Calculate as follows:4 mg : 2 ml 1 mg : X ml4X 2X 24X 0.5 mlAnswer: You’ll need to give 0.5 ml of morphine sulfateto equal the prescribed dose of 1 mg.Method 2: Using an established formulaUse this formula:Prescribed dose Quantity (unit of measure) X (unknown quantity to be given)Dose available

Drug Formulas and Calculations 1197Drug Formulas and Calculations (continued)Calculate as follows:1 mg 4 mg 2 ml X (number of ml)42 0.5Answer: You’ll need to give 0.5 ml of morphine sulfateto equal the prescribed dose of 1 mg.Method 3: Calculating according to proportion sizeTo determine the correct amount of morphine sulfate to give using this method, use thefollowing formula:smaller : greater smaller : greatermilligrams : milligrams milliliters : millilitersCritical thinking leads us to believe that 1 mg is less than 4 mg and that you’ll need lessthan 2 ml to give 1 mg of drug; therefore, 1 mg goes into the smaller part of the first ratio,and X goes into the smaller part of the second ratio. Set up the proportion as follows:1 mg : 4 mg X (ml) : 2 ml4X 22X 4X 0.5Answer: You’ll need to give 0.5 ml of morphine sulfateto equal the prescribed dose of 1 mg.Calculating I.V. Flow RatesWhen an I.V. solution is delivered by gravity, you must calculate the number of dropsneeded per minute for proper infusion. To calculate I.V. flow rates, you need to knowthree things:•the drip factor—or the number of drops contained in 1 ml for the type of I.V. set you’ll beusing. This information is provided on the individual package label.•the amount and type of fluid that you’ll be infusing based on the medication order.•the infusion duration time in minutes.Once you’ve gathered this information, you can calculate the I.V. flow rate using thefollowing equation:Total number of ml drip factor (gtt/ml) flow rate (gtt/min)Total number of minutesExample 1: If the physician prescribes 1,000 ml of D 5 W to infuse over 10 hours, andthe drip rate for your administration set is 15 drops (gtt) per ml, calculate as follows:1,000 ml 15 gtt/ml X gtt/minute10 hours x 60 minutes1,000 ml600 minutes 15 gtt/ml X gtt/minute

1198Drug Formulas and CalculationsDrug Formulas and Calculations (continued)1.67 ml/minute 15 gtt/ml X gtt/minute25.05 gtt/minute XAnswer: To infuse, round off 25.05 to 25 gtt/minuteor according to your institution’s policy.Example 2: If the physician prescribes 500 ml ofhalf-normal (0.45%) saline solution to infuse over 2 hours,and the drip rate for your administration set delivers 10 gtt/ml,calculate as follows:500 ml2 hours 60 minutes 10 gtt/ml X gtt/minute500 ml120 minutes 10 gtt/ml X gtt/minute4.17 ml/minute 10 gtt/ml X gtt/minute41.7 gtt/minute XAnswer: To infuse, round off 41.7 to 42 gtt/minuteor according to your institution’s policy.Note: When preparing for I.V. administration using a controlled infusion device, the electronicflow-regulator will either count drops using an electronic eye or use a controlledpumping action to deliver the fluid in milliliters. Your final calculation will be based onthe unit of measure used by the device: drops per minute, or ml per hour.

Weights and Equivalents 1199Weights and EquivalentsThe following three tables show approximate equivalents among systems of measurement.Table 1. Liquid Equivalents Among Household, Apothecaries’, and Metric SystemsHOUSEHOLD APOTHECARIES’ METRIC1 teaspoon (tsp)1 tablespoon (tbs)2 tbs (1 ounce [oz])1 cupful1 pint1 quart (qt)1 fluid dram0.5 fluid oz1 fluid oz8 fluid oz16 fluid oz32 fluid oz5 milliliters (ml)15 ml30 ml240 ml473 ml946 ml (1 liter)Table 2. Solid Equivalents AmongApothecaries’ and Metric SystemsAPOTHECARIES’15 grains (gr)10 gr7.5 gr5 gr3 gr1.5 gr1 gr0.75 gr0.5 gr0.25 gr1/60 gr1/100 gr1/120 gr1/150 grMETRIC1 gram (g) (1,000 milligrams [mg])0.6 g (600 mg)0.5 g (500 mg)0.3 g (300 mg)0.2 g (200 mg)0.1 g (100 mg)0.06 g (60 mg) or 0.065 g (65 mg)0.05 g (50 mg)0.03 g (30 mg)0.015 g (15 mg)0.001 g (1 mg)0.6 mg0.5 mg0.4 mg(continued)

1200Weights and EquivalentsWeights and Equivalents (continued)Table 3. Solid Equivalents Among Avoirdupois, Apothecaries’, and Metric SystemsAVOIRDUPOIS APOTHECARIES’ METRIC1 gr1 gr0.065 g15.4 gr15 gr1 g1 ounce (oz)480 gr28.35 g437.5 gr1 oz31 g1 pound (lb)1.33 lb454 g0.75 lb1 lb373 g2.2 lb2.7 lb1 kg

Equianalgesic Doses for Opioid AgonistsEquianalgesic Doses for Opioid Agonists 1201An equianalgesic dose of a synthetic opioidagonist is the dose that produces the samelevel of analgesia as 10 mg of I.M. or SubQmorphine, the prinicipal opioid obtained fromopium poppies. If your patient is switched fromone opioid to another, expect to use theequianalgesic dose to decrease the risk ofadverse reactions while increasing the likelihoodof adequate pain relief. The chart belowcompares equianalgesic doses (oral and parenteral)for adults and children who weigh 50kg (110 lb) or more.OPIOID ORAL DOSE PARENTERAL DOSEcodeine200 mg(not recommended)120 to 130 mghydrocodone30 mgNot applicablehydromorphone7.5 mg1.5 mglevorphanol4 mg2 mgmeperidine300 mg75 to 100 mgmorphine (around-the-clockdosing)30 mg10 mgmorphine (single orintermittent dosing)60 mg10 mgoxycodone30 mgNot applicable

1202AbbreviationsAbbreviationsThe following abbreviations, which are common to nursing practice, may be used throughoutthe book.ABGa.c.ACEADHAIDSALTANAAPTTASTATPAVb.i.d.BUN°CcAMP(CAN)capCBCcGMPCKClcmCMVCNSCOPDC.R.CSFCVCVAD 5 LRD 5 NSD 5 /0.2NSD 5 /0.45NSD 5 WD 10 WD 50 WdlDNADSECarterial blood gasbefore mealsangiotensin-converting enzymeantidiuretic hormoneacquired immunodeficiencysyndromealanine aminotransferaseantinuclear antibodiesactivated partial thromboplastintimeaspartate aminotransferaseadenosine triphosphateatrioventriculartwice a dayblood urea nitrogendegrees Celsiuscyclic adenosine monophosphateCanadian drug trade namecapsulecomplete blood countcyclic guanosine monophosphatecreatine kinasechloridecentimetercytomegaloviruscentral nervous systemchronic obstructive pulmonarydiseasecontrolled-releasecerebrospinal fluidcardiovascularcerebrovascular accidentdextrose 5% in lactated Ringer’ssolutiondextrose 5% in normal salinesolutiondextrose 5% in quarter-normalsaline solutiondextrose 5% in half-normalsaline solutiondextrose 5% in waterdextrose 10% in waterdextrose 50% in waterdeciliterdeoxyribonucleic aciddouble-strengthenteric-coatedECGEEGEENTENDOE.R.°FFDAgGABAGFRGIgttGUH 1H 2HDLHEMEHIVHMG-CoAHPVhrHSVHZVICPI.D.IgAIgEI.M.INRI.V.IVPBkgKIULLAlbLDLDLLOCLRMm 2MAOmcgmEqmgMIelectrocardiogramelectroencephalogrameyes, ears, nose, and throatendocrineextended-releasedegrees FahrenheitFood and Drug Administrationgramgamma aminobutyric acidglomerular filtration rategastrointestinaldropgenitourinaryhistamine 1histamine 2high-density lipoproteinhematologichuman immunodeficiency virushydroxymethylglutarylcoenzymeAhuman papilloma virushourherpes simplex virusherpes zoster virusintracranial pressureintradermalimmunoglobulin Aimmunoglobulin Eintramuscularinternational normalized ratiointravenousintravenous piggybackkilogramkallikrein inactivator unitsliterlong-actingpoundlactate dehydrogenaselow-density lipoproteinlevel of consciousnesslactated Ringer’s solutionmolarsquare metermonoamine oxidasemicrogrammilliequivalentmilligrammyocardial infarction

Abbreviations 1203Abbreviations (continued)minmlmmmm 3mmolmoMSmsecNaNaClNGngNPHNPONS0.225NS0.45NSNSAIDNYHAOTCozp.c.PCAP.O.P.R.p.r.n.PSVTPTPTCAPTTPVCq.i.d.RBCREMRESPRNARSVSAsecS.L.S.R.statSubQsupptabT 3minutemillilitermillimetercubic millimetermillimolemonthmusculoskeletalmillisecondsodiumsodium chloridenasogastricnanogramhuman isophane insulinnothing by mouthnormal saline solutionquarter-normal saline (0.225%)solutionhalf-normal saline (0.45%) solutionnonsteroidal anti-inflammatorydrugNew York Heart Associationover the counterounceafter mealspatient-controlled analgesiaby mouthby rectumas neededparoxysmal supraventriculartachycardiaprothrombin timepercutaneous transluminal coronaryangioplastypartial thromboplastin timepremature ventricular contractionfour times a dayred blood cellrapid eye movementrespiratoryribonucleic acidrespiratory syncytial virussinoatrialsecondsublingualsustained-releaseimmediatelysubcutaneoussuppositorytablettriiodothyronineT 4t.i.d.USPUTIVLDLWBCwkthyroxinethree times a dayUnited States Pharmacopeiaurinary tract infectionvery-low-density lipoproteinwhite blood cellweek

Index

Index 1207• Generic and alternate names: lowercase initial letter• Trade names: uppercase initial letter• Illustrations: i after page number• Tables: t after page numberIndexAabacavir sulfate, 1142tabacavir sulfate andlamivudine, 1142tabacavir sulfate, lamivudine,and zidovudine, 1142tabatacept, 17–18Abbokinase, 1070Abbokinase Open-Cath,1070abciximab, 18–19Abelcet, 78Abenol, 23Abilify, 99Abilify Discmelt, 99Abitrate, 252Abreva, 1133tAbsorbine Footcare, 1133tAbsorption, 2–4acamprosate calcium, 19–21,20iacarbose, 21–22Accolate, 1093Accretropin, 951AccuNeb, 37Accupril, 888Accutane, 551acebutolol hydrochloride,22–23Aceon, 810Acephen, 23Acetadote, 29Aceta Elixir, 23acetaminophen, 23–25Acetaminophen Uniserts, 23Aceta Tablets, 23Acetazolam, 25acetazolamide, 25–26Acetocot, 1051acetohexamide, 26–28acetohydroxamic acid, 28–29acetylcholine chloride, 1119tacetylcysteine, 29–30acetylsalicylic acid, 104–106Achromycin, 996, 1128tAchromycin V, 996Acilac, 565AcipHex, 892acitretin, 30–32Aclovate, 1133tAcova, 98acrivastine, 1124tAct, 410Actemra, 1030Acticin, 1141tActicort 100, 1135tActigall, 1071Actimmune, 1190tactinomycin-D, 1152tActiprofen Caplets, 515Actiq, 432Activase, 52Activase rt-PA, 52Actonel, 911Actos, 828Actron, 558Acular, 1117tAcuvail, 1117tacyclovir, 1133t, 1145tAdalat, 738Adalat CC, 738Adalat PA, 738Adalat XL, 738adalimumab, 32–34adamantanaminehydrochloride, 55–57adapalene, 1137tAdcirca, 979adefovir dipivoxil, 1147tAdenocard, 34Adenoscan, 34adenosine, 34–35ADH, 1081–1082, 1081iAdministration routes, 2–4,9–11Adrenalin, 374Adrenalin Chloride Solution,374adrenaline, 374–376Adriamycin PFS, 1153tAdriamycin RDF, 1153tAdrucil, 1155tAdsorbocarpine, 1119tAdsorbonac, 1122tAdvate, 90Adverse reaction, 5Advil, 515AeroBid, 447AeroBid-M, 447Aerolate, 999Aerolate III, 999Aerolate Jr., 999Aerolate Sr., 999Aerosporin, 835Afinitor, 1153tAfko-Lube, 336Afko-Lube Lax, 336Aftate for Athlete’s Foot,1133tAftate for Jock Itch, 1133tAggrastat, 1025Agonists, 5Agrylin, 84A-hydroCort, 507Airet, 37Akarpine, 1119tAKBeta, 1122tAk-Con, 1120tAK-Dex, 1117tAk-Dilate, 1120tAK-Fluor, 1122tAkineton, 142Akineton Lactate, 142AK-NaCl, 1122tAk-Nefrin, 1120tAkne-Mycin, 1127tAK-Pentolate, 1119tAK-Pred, 1118tAK-Sulf, 1116tAKTob, 1116t

1208IndexAK-Tracin, 1114tAk-Zol, 25Ala-Cort, 1135tAla-Scalp HP, 1135talatrofloxacin mesylate, 36Albalon Liquifilm, 1120tAlbert Docusate, 336Albert Glyburide, 486albuterol, 37–38, 38ialbuterol sulfate, 37–38, 38iAlcaine, 1120talclometasone dipropionate,1133tAlconefrin Nasal Drops 12,820Alconefrin Nasal Drops 25,820Alconefrin Nasal Drops 50,820Alconefrin Nasal Spray 25,820Aldactone, 957Aldara, 1140taldesleukin, 1158tAldomet, 654Aldoril-15, 1166–1167tAldoril-25, 1166–1167tAldoril D30, 1166–1167tAldoril D50, 1166–1167talefacept, 38–40alemtuzumab, 1158talendronate sodium, 40–41Aleve, 718Alferon N, 1186talfuzosin hydrochloride,41–42alglucerase, 42–43Alimta, 1156tAlinia, 741aliskiren, 43–44, 1170t, 1172tAlkeran, 1151tAlkylating drugs,1149–1152tAllegra, 1125tAllegra-D, 1125tAllercort, 1135tAllerdryl, 329Allerest, 1120tAllergic reaction, 5–6AllerNaze, 1051Alli, 766allopurinol, 44–45allopurinol sodium, 44–45Almora, 613almotriptan malate, 45–47Alocril, 1122tAloprim, 44Alora, 396alosetron hydrochloride,47–48Aloxi, 786Alphacaine, 588Alphaderm, 1135talpha-difluoromethylornithine,364Alphagan, 1121tAlphagan P, 1121tAlphanate, 90alpha1-proteinase inhibitor(human), 48–49alpha tocopherol,1182–1183talprazolam, 49–50alprostadil, 50–52, 51iAlrex, 1118tAltace, 895alteplase, 52–54AlternaGEL, 54Alti-Bromocriptine, 150Alti-Doxycycline, 349Alti-Minocycline, 681Alti-MPA, 866Alti-Sulfasalazine, 966Alti-Triazolam, 1055Alti-Valproic, 1073Altoprev, 608Alu-Cap, 54Alugel, 54aluminum carbonate, 54aluminum hydroxide, 54Alupent, 636Alustra, 1140tAlu-Tab, 54Alvesco, 236alvimopan, 54–55amantadine hydrochloride,55–57Amaryl, 481ambenonium chloride, 58Ambien, 1104Ambien CR, 1104AmBisome, 78ambrisentan, 59–60amcinonide, 1133tAmcort, 1051Amen, 866Amerge, 721A-methaPred, 659amethopterin, 650–651,1156tAmevive, 38Amicar, 62Amidrine, 310Amigesic, 925amikacin sulfate, 60–61Amikin, 60amiloride hydrochloride,61–62, 1170taminocaproic acid, 62–63aminoglutethimide, 63Amino-Opti-E, 1182taminophylline, 63–65aminosalicylate sodium,65–66amiodarone hydrochloride,66–68Amitiza, 611amitriptyline hydrochloride,68–70, 69iamlodipine besylate, 70–71,1166t, 1168t, 1170t, 1172tammonium chloride, 71–72ammonium lactate, 12%,1138tamobarbital sodium, 72–73amoxapine, 73–74amoxicillin trihydrate, 75–76Amoxil, 75amoxycillin, 75–76amphetamine sulfate, 76–78Amphocin, 78Amphojel, 54Amphotec, 78amphotericin B, 78–81amphotericin B cholesterylsulfate complex, 78–81amphotericin B lipidcomplex, 78–81amphotericin B liposomalcomplex, 78–81ampicillin, 81–83ampicillin sodium, 81–83ampicillin trihydrate, 81–83Ampicin, 81Ampyra, 281amrinone, 528amyl nitrite, 83–84Amytal, 72Anadrol-50, 780

Anaflex 750, 925Anafranil, 253anagrelide hydrochloride,84–85Ana-Guard, 374anakinra, 85–86Anandron, 1161tAnaphylactic reaction, 6Anapolon-50, 780Anaprox, 718Anaprox DS, 718Anaspaz, 514anastrozole, 86–87, 87i,1159tAncalixir, 816Ancasal, 104Ancef, 185Anergan 25, 869Anergan 50, 869Anestacon, 588Anexate, 446Angiomax, 146Aniflex, 767anisindione, 87–88anisoylated plasminogenstreptokinaseactivatorcomplex, 88–90anistreplase, 88–90Ansaid, 453Antabuse, 333Antagonists, 5anthralin, 1138tAnthranol 1, 1138tAntibacterials, topical, 1126,1127–1128tAntibiotic antineoplastics,1149, 1152–1154tantidiuretic hormone,1081–1082, 1081iAntifungals, topical, 1126,1129–1133tantihemophilic factor(human), 90–93antihemophilic factor(recombinant), plasma/albumin-free method,90–93antihemophilic factor–vonWillebrand factorcomplex (human, dried,pasteurized), 90–93Antihistamines, 1124–1125tAntihypertensive combinations,selected, 1166–1173tAntilirium, 825Antimetabolites, 1149,1154–1157tAntimitotic antineoplastics,1149, 1157–1158tAntinaus 50, 869Antineoplastic drugs,selected, 1149–1165tAntineoplastic enzymes,1149, 1158tantithrombin III, human,93–94Anti-Tuss, 492Antivert, 619Antivirals, selected,1142–1148tAntivirals, topical, 1126,1133tAnturane, 967Anusol-HC, 1135tAnzemet, 339Apacet Capsules, 23Apacet Elixir, 23Apacet Extra StrengthTablets, 23Apacet Regular StrengthTablets, 23Apidra (insulin glulisine),1111tAplenzin, 157Apo-Acetazolamide, 25Apo-Allopurinol, 44Apo-Alpraz, 49Apo-amitriptyline, 68Apo-Amoxi, 75Apo-Ampi, 81Apo-As, 104Apo-ASEN, 104Apo-Atenol, 106Apo-Baclofen, 125Apo-Benztropine, 134Apo-Bromocriptine, 150Apo-Cal, 168Apo-Carbamazepine, 174Apo-Cefaclor, 182Apo-Cephalex, 214Apo-Chlordiazepoxide, 223Apo-Chlorpropamide, 230Apo-Chlorthalidone, 232Apo-Cimetidine, 239Apo-Clonazepam, 254Index 1209Apo-Clorazepate, 258Apo-Cloxi, 259Apo-Cromolyn, 273Apo-Diazepam, 306Apo-Diclo, 312Apo-Diflunisal, 318Apo-Diltiaz, 325Apo-Dipyridamole FC, 330Apo-Dipyridamole SC, 330Apo-Doxy, 349Apo-Erythro, 386Apo-Erythro-ES, 386Apo-Erythro-S, 387Apo-Famotidine, 421Apo-Ferrous Gluconate, 436Apo-Ferrous Sulfate, 436Apo-Fluphenazine, 450Apo-Flurazepam, 452Apo-Folic, 460, 1178–1179tApo-Furosemide, 472Apo-Gain, 683Apo-Gemfibrozil, 477Apo-Glyburide, 486Apo-Guanethidine, 494Apo-Haloperidol, 498Apo-Hydralazine, 503Apo-Hydroxyzine, 513Apo-Ibuprofen, 515Apo-Imipramine, 522Apo-Indapamide, 528Apo-Indomethacin, 530Apo-Ipravent, 536Apo-ISDN, 549Apo-K, 838Apo-Keto, 558Apokyn, 94Apo-Lorazepam, 606Apo-Megestrol, 866Apo-Meprobamate, 631Apo-Methyldopa, 654Apo-Metoclop, 662Apo-Metoprolol, 665Apo-Metronidazole, 667Apo-Minocycline, 681apomorphine hydrochloride,94–95Apo-Napro-Na, 718Apo-Naproxen, 718Apo-Nifed, 738Apo-Nitrofurantoin, 742Apo-Nizatidine, 747Apo-Oxazepam, 773Apo-Oxtriphylline, 776

1210IndexApo-Pen-VK, 802Apo-Perphenazine, 811Apo-Piroxicam, 832Apo-Prednisone, 855Apo-Primidone, 858Apo-Propranolol, 876Apo-Quinidine, 889Apo-Ranitidine, 896Apo-Selegiline, 931Apo-sucralfate, 961Apo-Sulfamethoxazole, 965Apo-Sulfinpyrazone, 967Apo-Sulfisoxazole, 969Apo-Sulin, 970Apo-Tamox, 981, 1161tApo-Temazepam, 988Apo-Tetra, 996Apo-Theo LA, 999Apo-Thioridazine, 1005Apo-Timol, 1019Apo-Timop, 1122tApo-Tolbutamide, 1103Apo-Triazo, 1055Apo-Trifluoperazine, 1057Apo-Trihex, 1061Apo-Trimip, 1063Apo-Verap, 1084Apo-Zidovudine, 1144tapraclonidine hydrochloride,1120taprepitant, 95–97Apresazide 25/25,1166–1167tApresazide 50/50,1166–1167tApresazide 100/50,1166–1167tApresoline, 503Aptivus, 1144tAquachloral Supprettes, 221AquaMEPHYTON, 1184tAquasol A, 1174tAquasol E, 1182tARA-C, 1154tAranesp, 287Arava, 572Aredia, 787arformoterol, 97–98argatroban, 98–99Argesic-SA, 925Aricept, 340Arimidex, 86, 1159taripiprazole, 99–101Aristocort, 1051, 1136t,1137tAristocort A, 1136t, 1137tAristocort C, 1137tAristocort D, 1136tAristocort Forte, 1051Aristocort R, 1137tAristopak, 1051Aristospan, 1051Arixtra, 461Arm-a-Med Isoetharine(0.062%, 0.125%, 0.167%,0.2%, 0.25%), 544Arm-a-Med Metaproterenol,636Arm and Hammer PureBaking Soda, 944armodafinil, 102–103Armour Thyroid, 1010Aromasin, 1160tarsenic trioxide, 1161tArtane, 1061Arthrinol, 104Arthrisin, 104Arthropan, 235Articulose-50, 852Articulose-LA, 1051ASA, 104–106Asacol, 633ascorbic acid, 1180–1181tAscorbic Acid, 1180tasenapine, 103–104Asendin, 73Asmalix, 999asparaginase, 1158tA-Spas S/L, 514Aspergum, 104aspirin, 104–106Aspirin, 104Aspirin Free Pain Relief, 23Astelin, 117, 1124tAstepro 0.1%, 1124tAstepro 0.15%, 1124tAsthmahaler Mist, 374AsthmaNefrin, 374Astramorph PF, 698Atacand, 171Atacand HCT 16/12.5,1166–1167tAtacand HCT 32/12.5,1166–1167tAtarax, 513atazanavir sulfate, 1142tatenolol, 106–108AT-III, 93–94Ativan, 606ATnativ, 93Atolone, 1051atomoxetine hydrochloride,108–109atorvastatin calcium,109–111atovaquone, 111–112atracurium besylate, 112–113Atretol, 174Atria S.R., 104Atromid-S, 252AtroPen, 113atropine, 113–115,1192–1193tatropine sulfate, 113–115,1118tAtropisol, 1118tAtrovent, 536A/T/S, 1127tauranofin, 115–116Avage, 1137tAvalide-150, 1166–1167tAvalide-300, 1166–1167tAvandia, 920Avapro, 537Avastin, 1162tAvelox, 701Avelox IV, 701Aventyl, 751Avinza, 698Avita, 1137tAvodart, 359Avonex, 1188tAxert, 45Axid, 747Axid AR, 747Ayercillin, 802Aygestin, 866Azactam, 120azatadine, 1124tazathioprine, 116–117azathioprine sodium,116–117azelaic acid cream, 1127tazelastine, 1124tazelastine hydrochloride,117–118azelastine hydrochloride0.05%, 1121tAzelex, 1127t

Azilect, 899azithromycin, 118–120Azmacort, 1051Azopt, 1121tAzor 5/20, 1166–1167tAzor 5/40, 1166–1167tAzor 10/20, 1166–1167tAzor 10/40, 1166–1167tAzo-Standard, 813aztreonam, 120–122AZT, 1143t, 1144tAzulfidine, 966Azulfidine EN-Tabs, 966Bbacampicillin hydrochloride,123–124Baci-IM, 124bacillus Calmette-Guérinlive, Connaught strain,1158tbacillus Calmette-Guérin,Tice strain, 1158tbacitracin, 124–125, 1114t,1127tbaclofen, 125–127Bactine, 1135tBactocill, 768Bactroban, 1128tBactroban Cream, 1128tBactroban Nasal, 1128tBalminil Expectorant, 492balsalazide disodium,127–128Banflex, 767Banophen, 329Banzel, 922Barbita, 816Baridium, 813Barriere-HC, 1135tBasaljel, 54basiliximab, 128–129Bayer, 104Bayer Select Ibuprofen PainRelief Formula Caplets,515Bayer Time Release(8 Hour), 104BayGam, 524BCG live, Connaught strain,1158tBCNU, 1150tB-D Glucose, 304Beben, 1133tbecaplermin, 1138tBeclodisk, 129beclomethasonedipropionate, 129–131Beclovent Rotacaps, 129Beconase, 129Beconase AQ, 129Beepen-VK, 802Beesix, 1176tbelladonna alkaloids,131–132Bell/ans, 944Benadryl, 329Benadryl Allergy, 329benazepril hydrochloride,132–133, 1168t, 1170tbendamustine, 1150tBenemid, 860Benicar, 759Benicar HCT 20/12.5,1166–1167tBenicar HCT 40/12.5,1166–1167tBenicar HCT 40/25,1166–1167tBenoquin, 1140tBentyl, 316Bentylol, 316Benuryl, 860Benylin-E, 492Benzac AC Wash, 1127tBenzaclin gel DUAC, 1127tBenzacot, 1062Benzamycin, 1127tbenzonatate, 133–134Benzonatate Softgels, 133benzoyl peroxide, 1127tbenzquinamide hydrochloride,134benztropine mesylate,134–136bepotastine besilate 1.5%,1121tBepreve, 1121tbepridil hydrochloride,136–137Berinert, 163Beta-2 (1%), 544Betadine, 1128tBetadine Cream, 1128tIndex 1211Betadine Spray, 1128tBetagan, 1122tBeta-HC, 1135tBetaloc, 665Betaloc Durules, 665betamethasone, 137–139betamethasone acetate–betamethasone sodiumphosphate, 137–139betamethasone benzoate,1133tbetamethasonedipropionate, 1133tbetamethasone sodiumphosphate, 137–139betamethasone valerate,1134tBetapace, 954Betapace AF, 954Betapen-VK, 802Betaseron, 1188tBetaxin, 1174tbetaxolol hydrochloride,140–141, 1121tbethanechol chloride,141–142Betimol, 1122tBetnesol, 137Betoptic, 1121tBetoptic S, 1121tbevacizumab, 1162tBewon, 1174tbexarotene, 1162tBiamine, 1174tBiaxin, 247Biaxin XL, 247Biaxin XL-PAK, 247bicalutamide, 1159tBicillin C-R, 802Bicillin C-R 900/300, 802Bicillin L-A, 802BiCNU, 1150tBilax, 336bimatoprost 0.03%, 1121tBiological response modifiers,1149, 1158–1159tBio-Syn, 1134tBiotransformation, 4Bio-Well, 591biperiden hydrochloride,142–143biperiden lactate, 142–143

1212Indexbisoprolol fumarate,143–145, 1172tbitolterol mesylate, 145–146bivalirudin, 146–147Blenoxane, 1152tbleomycin sulfate, 1152tBleph-10, 1116tBlocadren, 1019Body mass index calculation,inside back coverBoldex, 1117tBonamine, 619Bonine, 619Bortezomib, 1165tbosentan, 147–149, 148iBreonesin, 492Brethaire, 993Brethine, 993Bretylate, 149bretylium tosylate, 149–150,150iBretylol, 149Brevibloc, 392Bricanyl, 993Bricanyl Turbuhaler, 993brimonidine tartrate, 1121tbrinzolamide 1%, 1121tbromfenac 0.09%, 1116tbromocriptine mesylate,150–152Bronalide, 447Bronkaid Mist, 374Bronkaid Mistometer, 374Bronkaid Suspension Mist,374Bronkometer (0.61%), 544Bronkosol (1%), 544Brovana, 97budesonide, 152–154bumetanide, 155–156Bumex, 155Buphenyl, 947Buprenex, 156buprenorphine hydrochloride,156–157bupropion hydrobromide,157–158bupropion hydrochloride,157–158Busodium, 159BuSpar, 158BuSpar DIVIDOSE, 158buspirone hydrochloride,158–159Bustab, 158busulfan, 1150tBusulfex, 1150tbutabarbital sodium,159–161Butalan, 159butenafine hydrochloride1%, 1129tButisol, 159butoconazole nitrate, 1129tbutorphanol tartrate,161–162Byetta, 418Bystolic, 725CC1 esterace inhibitor(human), 163–164cabergoline, 164–165Caelyx, 1153tCalan, 1084Calan SR, 1084calcifediol, 165–166Calciferol, 1182tCalciferol Drops, 1182tCalciject, 168Calcijex, 167Calcilean, 500Calcimar, 166Calci-Mix, 168Calcionate, 168Calciparine, 500calcipotriene, 1138tcalcipotriene hydrate0.005% and betamethasonedipropionate 0.064%,1138tcalcitonin, human, 166–167calcitonin, salmon, 166–167calcitriol, 167–168calcium acetate, 168–171calcium carbonate, 168–171calcium chloride, 168–171calcium citrate, 168–171calcium glubionate, 168–171calcium gluceptate, 168–171calcium gluconate, 168–171calcium lactate, 168–171Calcium-Sandoz, 168Calcium Stanley, 169Calderol, 165Caldolor, 515Calmylin Expectorant, 492Calsan, 168Campath, 1158tCampral, 19Camptosar, 1163tCanasa, 633Cancidas, 180candesartan cilexetil,171–172, 1166tCanesten, 1129tCapastat, 172capecitabine, 1154tCapitrol, 1138tCapoten, 173Capozide 25/15, 1166–1167tCapozide 25/25, 1166–1167tCapozide 50/15, 1166–1167tCapozide 50/25, 1166–1167tcapreomycin sulfate,172–173capsaicin, 1138tCapsin, 1138tCapsules, 9captopril, 173–174, 1166tCapzacin-P, 1138tCarac, 1139t, 1155tCarafate, 961carbachol 0.01%, 1119tcarbachol 0.75%, 1.5%,2.25%, 3%, 1119tCarbacot, 649carbamazepine, 174–177,175icarbamide, 1069–1070Carbastat, 1119tCarbatrol, 174Carbex, 931Carbolith, 601Carboptic, 1119tCardene, 733Cardene IV, 733Cardene SR, 733Cardioquin, 889Cardizem, 325Cardizem CD, 325Cardizem LA, 325Cardizem SR, 325Cardura, 345Cardura-1, 345Cardura-2, 345

Cardura-4, 345carisoprodol, 177–178carmustine, 1150tcarteolol hydrochloride,178–179, 1121tCartrol, 178carvedilol, 179–180Casodex, 1159tcaspofungin acetate,180–182, 181iCataflam, 312Catapres, 255Catapres-TTS, 255Caverject, 50CCNU, 1151t2-CdA, 1154tCeclor, 182Ceclor CD, 182Cecon Drops, 1180tCedax, 205Cedocard-SR, 549CeeNU, 1151tcefaclor, 182–183cefadroxil, 183–185Cefadyl, 216cefazolin sodium, 185–186cefdinir, 186–188cefditoren pivoxil, 188–189cefepime hydrochloride,189–191cefixime, 191–192Cefizox, 206cefmetazole sodium, 192–193Cefobid, 195cefonicid sodium, 193–195cefoperazone sodium,195–196Cefotan, 198cefotaxime sodium, 196–198cefotetan disodium, 198–199cefoxitin sodium, 199–200cefpodoxime proxetil,201–202cefprozil, 202–203ceftazidime, 203–205ceftibuten, 205–206Ceftin, 210ceftizoxime sodium,206–208ceftriaxone sodium, 208–210cefuroxime axetil, 210–212cefuroxime sodium, 210–212Cefzil, 202Celebrex, 212celecoxib, 212–214Celestone, 137Celestone Phosphate, 137Celestone Soluspan, 137Celexa, 245CellCept, 703CellCept Intravenous, 703CellCept Oral Suspension,703Celontin, 653Cena-K, 838Cenestin, 402Cenocort A-40, 1051Cenocort Forte, 1051Cenolate, 1180tcephalexin hydrochloride,214–216, 215icephalexin monohydrate,214–216, 215icephapirin sodium, 216–217cephradine, 217–218Cephulac, 565Ceptaz, 203Cerebyx, 467Ceredase, 42certolizumab pegol, 218–220Cerubidine, 1153tC.E.S., 402Cetacort, 1135tcetirizine, 1124tCevi-Bid, 1180tcevimeline hydrochloride,220–221Chantix, 1079Children, specialconsiderations for, 6–7Children’s Advil, 515Children’s Motrin, 515chloral hydrate, 221–222chlorambucil, 1150tchloramphenicol, 222–223,1114tchloramphenicol palmitate,222–223chloramphenicol sodiumsuccinate, 222–223chlordiazepoxide hydrochloride,223–225chlorhexidine, 1138t2-chlorodeoxyadenosine,1154tChloromag, 613Index 1213Chloromycetin, 222chlorothiazide, 225–226chlorothiazide sodium,225–226chloroxine, 1138tchlorphenesin carbamate,226–227Chlorpromanyl, 227chlorpromazine, 227–230,1192–1193tchlorpromazine hydrochloride,227–230chlorpropamide, 230–232chlorthalidone, 232–233chlorzoxazone, 233–234Cholac, 565Choledyl, 776Choledyl SA, 776cholestyramine, 234–235choline salicylate, 235–236Chronulac, 565Cialis, 979Cibacalcin, 166Cibalith-S, 601ciclesonide, 236–238ciclopirox olamine 1%,1129tciclopirox olamine 8%,1129tcidofovir, 1146tCidomycin, 480cilostazol, 238–239Ciloxan, 1114tcimetidine, 239–240cimetidine hydrochloride,239–240Cimzia, 218cinacalcet hydrochloride,240–241Cinalone 40, 1051Cinobac, 241Cinonide-40, 1051cinoxacin, 241–242Cipro, 242ciprofloxacin, 242–245ciprofloxacin hydrochloride0.3%, 1114tCipro I.V., 242Cipro XR, 242cisplatin, 1152tcitalopram hydrobromide,245–247Citracal, 168

1214IndexCitracal Liquitabs, 168citrate of magnesia, 613–616Citrocarbonate, 944Citroma, 613Citro-Mag, 613cladribine, 1154tClaforan, 196Claravis, 551Clarinex, 1125tClarinex Reditabs, 1125tClaripel, 1140tClaripex, 252clarithromycin, 247–249Claritin, 1125tClaritin-D12, 1125tClaritin-D24, 1125tClearasil MaximumStrength, 1127tClear Eyes, 1120tCleocin, 250, 1127tCleocin Pediatric, 250Cleocin T Gel, 1127tCleocin T Lotion, 1127tclidinium bromide, 249–250Climara, 396Clinacort, 1051Clinagen LA 40, 396Clinda-Derm, 1127tclindamycin 1% and benzoylperoxide 5%, 1127tclindamycin hydrochloride,250–252clindamycin palmitatehydrochloride, 250–252clindamycin phosphate,250–252, 1127tClindesse, 250Clinoril, 970clobetasol propionate, 1134tclofibrate, 252–253clomipramine hydrochloride,253–254Clonapam, 254clonazepam, 254–255clonidine, 255–257clonidine hydrochloride,255–257clopidogrel bisulfate,257–258clorazepate dipotassium,258–259clotrimazole, 1129tclotrimazole and betamethasonedipropionate 0.05%,1%, 1138tcloxacillin sodium 259–260Cloxapen, 259clozapine, 260–262Clozaril, 260coagulation factor VIIa(recombinant), 262–263coal tar, 1139tcodeine phosphate, 263–264codeine sulfate, 263–264Cogentin, 134Cognex, 975Colace, 336Colaspase, 1158tColax, 336Colazal, 127colchicine, 264–267, 265iColcrys, 264colesevelam hydrochloride,267–268Colestid, 268colestipol hydrochloride,268–269colistimethate sodium,269–270Collyrium Fresh Eye Drops,1120tColprone, 866Coly-Mycin M, 269Combivir, 1143tComfort Eye Drops, 1120tCompatible drugs insyringe, 1192–1193tCompazine, 863Compazine Spansule, 863Comtan, 373Concerta, 657Condylox, 1141tCongest, 402conivaptan hydrochloride,270–271Constilac, 565Constulose, 565Controlled substance schedules,xviCopegus, 1148tCoradur, 549Cordarone, 66Cordran, 1134tCordran Tape, 1134tCoreg, 179Coreg CR, 179Corgard, 708Corlopam, 429Coronex, 549Correctol Stool Softener SoftGels, 336Cortacet, 1135tCortaid, 1135t, 1136tCortastat, 297Cortastat LA, 297Cortate, 1135tCort-Dome, 1135tCortef, 507Cortef Feminine Itch, 1136tCortenema, 507Corticaine, 1135tCorticosteroids, topical,1126, 1133–1137tCorticreme, 1135t, 1136tCortifair, 1135tCortifoam, 507cortisol, 507–509cortisone acetate, 271–273Cortisone Acetate-ICN, 271Cortisporin, 1136t, 1140tCortoderm, 1135t, 1136tCortone, 271Cortone Acetate, 271Cortril, 1135tCorvert, 518Cosmegen, 1152tCotanol-65, 875Cotazym, 789Cotazym-S, 789Cotolone, 852Coumadin, 1090Cozaar, 607Creon, 789Crestor, 921Crinone, 866Crixivan, 1143tcromolyn sodium, 273–275,274icrotamiton, 275crotamiton 10%, 1139tCrysticillin 300 AS, 802Cubicin, 286Culture, specialconsiderations for, 6Cuprimine, 800Curretab, 866

Cutivate, 1134tcyanocobalamin,1178–1181tcyclizine hydrochloride,275–276cyclizine lactate, 275–276cyclobenzaprine hydrochloride,276–277Cyclocort, 1133tCyclogyl, 1119tcyclopentolate hydrochloride,1119tcyclophosphamide, 1150tcycloserine, 277–278Cycloset, 150cyclosporin A, 278–280cyclosporine, 278–280cyclosporine emulsion0.05%, 1121tCycrin, 866Cymbalta, 357Cystospaz, 514Cystospaz-M, 514Cytadren, 63cytarabine, liposomal, 1155tcytarabine, 1154tCytomel, 595Cytosar, 1154tCytosar-U, 1154tcytosine arabinoside, 1154tCytotec, 686Cytovene, 1146tCytoxan, 1150tDdacarbazine, 1162tdacliximab, 281daclizumab, 281Dacogen, 290dactinomycin, 1152tDalacin, 1127tDalacin C, 250Dalacin C FlavoredGranules, 250Dalacin C Phosphate, 250Dalacin T Topical Solution,1127tDalalone, 297Dalalone D.P., 297Dalalone L.A., 297dalfampridine, 281–282Dalgan, 305Dalmane, 452dalteparin sodium, 282–283D-Amp, 81danaparoid sodium, 283–284Dantrium, 284Dantrium Intravenous, 284dantrolene sodium, 284–286daptomycin, 286–287Daranide, 311darbepoetin alfa, 287–289darifenacin, 289–290Darvon, 875Darvon-N, 875darunavir, 1142tdaunorubicin, liposomal,1153tdaunorubicin hydrochloride,1153tDaunoXome, 1153tDaypro, 771Daytrana Ritalin LA, 657Dazamide, 25DC Softgels, 336DDAVP Injection, 295DDAVP Nasal Spray, 295DDAVP Rhinal Tube, 295DDAVP Rhinyle NasalSolution, 295DDAVP Tablets, 296Decadrol, 297Decadron, 297Decadron Elixir, 297Decadron-LA, 297Decadron Respihaler, 297Decaject, 297Decaject L.A., 297decitabine, 290–291Declomycin, 293deferasirox, 291–293degarelix, 1160tDegest 2, 1120tDelacort, 1135tdelavirdine, 1142tDelestrogen, 396Delta-Cortef, 852Deltasone Liquid Pred, 855delta-9-tetrahydrocannabinol,352–353Delta-Tritex, 1137tDemadex, 1041Index 1215demeclocycline hydrochloride,293–294Demerol, 625Demser, 6669Denavir, 1133t, 1145tdenileukin diftitox, 1159t2-deoxycoformycin, 1154tDepacon, 1073Depakene, 1073Depakote, 1073Depakote ER, 1073Depakote Sprinkle, 1073Depen, 800depGynogen, 396depMedalone, 659DepoCyt, 1155tDepoDur, 698Depo-Estradiol, 396Depogen, 396Depoject, 659Depo-Medrol, 659Deponit, 743Depopred, 659Depo-Predate, 659Depo-Provera, 866, 1160tDeproic, 1073Depro Tech, 1155tDermacort, 1135tDermaFlex, 588Derma Smooth FS, 1134tDermatop, 1136tDermiCort, 1135tDermovate, 1134tDermtex HC, 1135tDeronil, 297desipramine hydrochloride,284–285Desired effect, 5desloratadine, 1125tdesmopressin acetate,295–297desonide, 1134tDesowen, 1134tdesoximetasone, 1139tDesoxyn, 643Desoxyn Gradumet, 643Desquam-E 2.5 Gel, 1127tdesvenlafaxine succinate,1082–1084Detensol, 876Detrol, 1037Detrol LA, 1037Dexacen-4, 297

1216IndexDexacen LA-8, 297Dexacorten, 297Dexacorten-LA, 297Dexacort Turbinaire, 297dexamethasone, 297–301,1117t, 1192–1193tdexamethasone acetate,297–301Dexamethasone Intensol,297dexamethasone sodiumphosphate, 297–301, 1117tdexamphetamine sulfate,76–78Dexasone, 297Dexasone L.A., 297Dexchlor, 301dexchlorpheniraminemaleate, 301–302DexFerrum, 539DexIron, 539dexlansoprazole, 569–571dexmethylphenidatehydrochloride, 302–303Dexone, 297Dexone LA, 297dexrazoxane, 303–304dextrose, 304–3052.5% Dextrose Injection, 3045% Dextrose Injection, 30410% Dextrose Injection, 30420% Dextrose Injection, 30425% Dextrose Injection, 30450% Dextrose Injection, 30460% Dextrose Injection, 30470% Dextrose Injection, 304Dey-Lute Isoetharine(0.08%, 0.1%, 0.17%,0.25%), 544Dey-Lute Metaproterenol,636dezocine, 305–306DFMO, 364d-glucose, 304–305D.H.E. 45, 323DHT, 324DHT Intensol, 324DiaBeta, 486Diabinese, 230Dialose, 336Dialume, 54Diamox, 25Diamox Sequels, 25Diapid, 612Diastat, 306diazepam, 306–309,1192–1193tDiazepam Intensol, 306diazoxide, 309–310dichloralphenazone, 310–311dichlorphenamide, 311–312diclofenac potassium,312–314diclofenac sodium, 312–314diclofenac sodium 0.1%,1117tdiclofenac sodium 3%, 1139tdicloxacillin sodium,314–315dicumarol, 315–316dicyclomine hydrochloride,316–317Didronel, 415Differin, 1137tdiflorasone diacetate, 1134tDiflucan, 443diflunisal, 318–319difluprednate, 1117tDigibind, 321digoxin, 319–321digoxin immune Fab(ovine), 321–323dihydroergotamine mesylate,323–324Dihydroergotamine-Sandoz,323dihydrogenated ergotalkaloids, 383dihydromorphinone,509–511dihydrotachysterol, 324–3251,25-dihydroxycholecalciferol,167–168Dilacor XR, 325Dilantin, 822Dilantin-30, 822Dilantin-125, 822Dilantin Infatabs, 822Dilantin Kapseals, 822Dilatrate-SR, 549Dilaudid, 509Dilaudid-5, 509Dilaudid-HP, 509Dilocaine, 588Dilor, 360diltiazem hydrochloride,325–327, 326iDimelor, 26dimenhydrinate, 327–328Dinate, 327Diochloram, 1114tDiocto, 336Diocto-K, 336dioctyl calciumsulfosuccinate, 336–337dioctyl potassium sulfosuccinate,336–337dioctyl sodium sulfosuccinate,336–337Dioeze, 336Dioptic, 1114tDioval 40, 396Dioval XX, 396Diovan, 1075Diovan HCT 80/12.5,1168–1169tDiovan HCT 160/12.5,1168–1169tDiovan HCT 160/25,1168–1169tDiovan HCT 320/12.5,1168–1169tDiovan HCT 320/25,1168–1169tDipentum, 760Diphenhist CapTabs, 329diphenhydramine,1192–1193tdiphenhydraminehydrochloride, 329–330dipivefrin hydrochloride,1121tDiprivan, 874Diprolene, 1133tDiprolene AF, 1133tDiprosone, 1133tdipyridamole, 330–331dirithromycin, 331–332Disalcid, 925Disipal, 767disodium cromoglycate,273–275, 274idisoprofol, 874–875disopyramide, 332–333disopyramide phosphate,332–333DisperMox, 75Distribution, 4

disulfiram, 333–335Ditropan, 777Ditropan XL, 777Diulo, 664Diuril, 225divalproex sodium,1073–1075Dixarit, 255Dizac, 306Dizmiss, 619dobutamine hydrochloride,335–336Dobutrex, 335docetaxel, 1157tdocosanol, 1133tDocucal-P, 336docusate calcium, 336–337docusate potassium,336–337docusate sodium, 336–337dofetilide, 337–339DOK, 337Doktors, 820dolasetron mesylate,339–340Dolgesic, 515Dolobid, 318Dolophine, 640Dom-Proic, 1073donepezil hydrochloride,340–341Donnamar, 514Donnazyme, 788Dopamet, 654dopamine hydrochloride,341–343Dopar, 580Dopram, 344Doral, 885Doribax, 343doripenem, 343–344Doryx, 349dorzolamide hydrochloride,1121tD.O.S. Softgels, 337Dostinex, 164Dovonex, 1138tdoxapram hydrochloride,344–345doxazosin mesylate, 345–346doxepin hydrochloride,346–347, 1139tdoxercalciferol, 347–349Doxidan, 336Doxil, 1153tDoxine, 1176tdoxorubicin, liposomal,1153tdoxorubicin hydrochloride,1153tDoxycin, 349doxycycline calcium,349–352doxycycline hyclate, 349–352doxycycline monohydrate,349–352Dramamine II, 619Dramanate, 327Drenison, 1134tDrisdol, 1182tDrisdol Drops, 1182tDrithocreme, 1138tDritho-Scalp, 1138tdronabinol, 352–353dronaderone, 353–354droperidol, 354–356,1192–1193tdrotrecogin alfa (activated),356–357Droxia, 1155tDr. Scholl’s Athlete’s Foot,1133tDrug administrationprinciples of, 8–11“rights of,” 8–9routes of, 9–11Drug classification, 1Drug disposal, xviiiDrug calculations,1194–1198Drug interaction, 6Drug nomenclature, 1Drug therapynurse’s responsibilities in,xixnursing process and, 12–15teaching patient about, xviiDTIC, 1162tDTIC-Dome, 1162tduloxetine hydrochloride,357–359Duphalac, 565Duraclon, 255Dura-Estrin, 396Duragen-20, 396Duragesic, 432Index 1217Duralith, 601Duramorph, 698Duration, 820Durezol, 1117tDuricef, 183dutasteride, 359–360, 360iDuvoid, 141Dyazide, 1168–1169tDycill, 314Dymelor, 26Dynabac, 331Dynacin, 681DynaCirc, 552Dynapen, 314dyphylline, 360–361Dyrenium, 1054Dyspep HB, 421EEasprin, 104ecallantide, 363EC-Naprosyn, 718E-Complex 600, 1182teconazole nitrate, 1130tEconopred Plus, 1118tEcostatin, 1130tEcotrin, 104Ecotrin Maximum Strength,104E-Cypionate, 396Edecrin, 408Edex, 50ED-SPAZ, 514E.E.S., 386efavirenz, 1142tEffer-K, 838Effexor, 1082Effexor XR, 1082Effient, 849Eflone, 1117teflornithine, 1139teflornithine hydrochloride,364Efudex, 1139t, 1155tEldepryl, 931Elderly patients, specialconsiderations for, 6Eldopaque, 1140tEldoquin, 1140teletriptan hydrobromide,364–365

1218IndexElidel, 1141tEligard 7.5 mg, 575Eligard 22.5 mg, 575Elimite, 1141tElitek, 901Elixophyllin, 999Ellence, 1153tElmiron, 808Elocom, 1136tElocon, 1136tEloxatin, 1151tElspar, 1158teltrombopag olamine,365–367Eltroxin, 586Emadine, 1121tEmbeline, 1134tEmcyt, 1160temedastine difumarate,1121tEmend, 95Emend for Injection, 95Emete-Con, 134Eminase, 88EMLA, 1140tEmo-Cort, 1135tEmpirin, 104Emsam, 931emtricitabine, 1142tEmtriva, 1142tE-Mycin, 386Enablex, 289enalaprilat, 367–369enalapril maleate, 367–369,1172tEnbrel, 406Endantadine, 55Endep, 68End Lice, 1141tEndur-Acin, 1176tenfuvirtide, 1142tEnjuvia, 402enoxacin, 369–370, 370ienoxaparin sodium, 371–373entacapone, 373–374Enteral administration, 2–3,9–10Entereg, 54Entocort EC, 152Enulose, 565Epifoam, 1136tEpimorph, 698epinephrine, 374–376epinephrine bitartrate,374–376EpiPen, 374EpiPen Auto-Injector, 374EpiPen Jr., 374EpiPen Jr. Auto-Injector, 374epirubicin hydrochloride,1153tEpitol, 174Epival, 1073Epivir, 1143tEpivir HBV, 1147teplerenone, 376–377EPO, 377–379epoetin alfa, 377–379Epogen, 377epoprostenol sodium,379–381Eprex, 377eprosartan mesylate, 381eptifibatide, 381–383Epzicom, 1142tEquanil, 631Equetro, 174Equianalgesic doses foropioid agonists, 1201tEquivalents, 1199–1200Ergamisol, 1159tergocalciferol, 1182–1183tergoloid mesylates, 383Ergomar, 383Ergostat, 383ergotamine tartrate, 383–384Eridium, 813ertapenem sodium, 384–386Erybid, 386ERYC, 386Erycette, 1127tEryDerm, 1127tErygel, 1127tErymax, 1127tEryPed, 386Ery-Sol, 1127tEry-Tab, 386Erythro, 386Erythrocin, 387Erythrocot, 387Erythrogel, 1127terythromycin, 386–390,1114t, 1127terythromycin 3% and benzoylperoxide 5%, 1127terythromycin estolate,386–390erythromycin ethylsuccinate,386–390erythromycin gluceptate,386–390erythromycin lactobionate,386–390erythromycin stearate,386–390erythropoietin alfa, 377–379escitalopram oxalate,390–392Esclim, 396Esidrix, 505Eskalith, 601Eskalith CR, 601esmolol hydrochloride,392–393esomeprazole magnesium,393–395estazolam, 395–396Estinyl, 396Estrace, 396Estraderm, 396estradiol, 396–402estradiol acetate, 396–402estradiol cypionate, 396–402estradiol transdermal system,396–402estradiol valerate, 396–402Estragyn LA 5, 396Estra-L 40, 396estramustine phosphatesodium, 1160tEstrasorb, 396Estring, 396Estro-Cyp, 396Estrofem, 396Estrogel, 396estrogens (conjugated),402–405estrogens (conjugated) andmedroxyprogesterone,402–405Estro-L.A., 396Estro-Span, 396eszopiclone, 405–406etanercept, 406–408, 407iethacrynate sodium,408–409ethacrynic acid, 408–409

ethambutol hydrochloride,410ethchlorvynol, 411ethinyl estradiol, 396–402ethionamide, 411–412Ethnicity, special considerationsfor, 6ethosuximide, 412–413ethotoin, 413–415Etibi, 410etidronate disodium,415–416etodolac, 416–418Etopophos, 1163tetoposide, 1162tetoposide phosphate, 1163tetravirine, 1143tETS, 1127tEuflex, 1160tEuflexxa, 503Euglucon, 486Eulexin, 1160tEurax, 275, 1139tEvalose, 565Evamist, 396everolimus, 1153tEvista, 893E-Vitamin succinate, 1182tEvoclin, 250Evoxac, 220Excedrin IB, 515Excretion, 4Exdol, 23Exelderm, 1132tExelon, 914Exelon Patch, 914exemestane, 1160texenatide, 418–420, 419iExforge, 1168–1169tExforge HCT 5/160/12.5,1168–1169tExforge HCT 10/160/12.5,1168–1169tExforge HCT 5/160/25,1168–1169tExforge HCT 10/160/25,1168–1169tExforge HCT 10/320/25,1168–1169tExjade, 291Ex-Lax Light Formula, 337Extavia, 1188tEyesine, 1120tEZE-DS, 233ezetimibe, 420–421, 421iFFactive, 478famciclovir, 1145tfamotidine, 421–424, 423iFamvir, 1145tFanapt, 519Fareston, 1161tFazaclo, 260febuxostat, 424–425felbamate, 425–426Felbatol, 425Feldene, 832felodipine, 426–427Femara, 1160tFemiron, 436Femizol-M, 1131tFemogex, 396FemPatch, 396Femring, 396Femstat, 1129tFemstat One, 1129tFemtrace, 396fenofibrate, 427–429fenofibric acid, 427–429fenoldopam mesylate,429–430fenoprofen calcium, 430–432fentanyl citrate, 432–435fentanyl transdermal system,432–435fentanyl iontophoretictransdermal, 432–435Feosol, 436Feostat, 436Feostat Drops, 436Feratab, 436Fer-gen-sol, 436Fergon, 436Fer-In-Sol Capsules, 436Fer-In-Sol Drops, 436Fer-In-Sol Syrup, 436Fer-Iron Drops, 436Fero-Grad, 436Fero-Gradumet, 436Ferospace, 436Ferralet, 436Ferralet Slow Release, 436Index 1219Ferralyn Lanacaps, 436Ferra-TD, 436Ferretts, 436Ferrlecit, 946ferrous fumarate, 435–438ferrous gluconate, 436–438ferrous salts, 435–438ferrous sulfate, 436–438Fertinic, 436fesoterodine fumarate,438–439Feverall, 23Feverall Sprinkle Caps, 23fexofenadine, 1125tfilgrastim, 439–440Finacea, 1127tfinasteride, 440–441Finevin, 1127tFirmagon, 1160tFlagyl, 667Flagyl I.V., 667Flagyl I.V. RTU, 667Flamazine, 1128tFlarex, 1117tflavoxate hydrochloride,441–442flecainide acetate, 442–443Flexeril, 276Flexoject, 767Flolan, 379Flomax, 982Flonase, 455Flo-Pred, 852Florinef, 445Florone, 1134tFlovent, 455Floxin, 755floxuridine, 1155tfluconazole, 443–444Fludara, 1155tfludarabine phosphate, 1155tfludrocortisone acetate,445–446flumazenil, 446–447flunisolide, 447–448Fluocet, 1134tfluocinolone acetonide,1134tfluocinolone acetonide0.01%, hydroquinone 4%,tretinoin 0.05%, 1139tfluocinonide, 1134tFluoderm, 1134t

1220IndexFluolar, 1134tFluonid, 1134tFluonide, 1134tfluorescein sodium, 1122tFluorescite, 1122tFluor-I-Strip, 1122tFluor-I-Strip-A.T., 1122tfluorodeoxyuridine, 1155tfluorometholone, 1117tfluorometholone acetate,1117tFluor-Op, 1117tFluoroplex, 1139t, 1155tfluorouracil, 1155t5-fluorouracil, 1155tfluorouracil cream, 1139tfluoxetine hydrochloride,448–450fluphenazine decanoate,450–452fluphenazine enanthate,450–452fluphenazine hydrochloride,450–452flurandrenolide, 1134tflurazepam hydrochloride,452–453flurbiprofen, 453–455flurbiprofen sodium, 1117tFlurosyn, 1134tflutamide, 1160tFlutex, 1136t, 1137tfluticasone furoate, 455–457fluticasone propionate,455–457, 1134tfluvastatin sodium, 457–458fluvoxamine maleate,458–460FML Forte, 1117tFML Liquifilm, 1117tFML S.O.P., 1117tFocalin, 302Focalin XR, 302FoilleCort, 1135tFolex, 650Folex PFS, 650folic acid, 460–461,1178–1179tFolotyn, 1157tFolvite, 460, 1178tfondaparinux sodium,461–463Foradil Aerolizer, 463formoterol fumaratedihydrate, 463–464Formulas for drugcalculations, 1194–1198Formulex, 316Fortamet, 638Fortaz, 203Forteo, 994Fortovase, 1144tFosamax, 40fosamprenavir calcium,1143tfosaprepitant dimeglumine,95–97foscarnet, 1145t, 1146tFoscavir, 1145t, 1146tfosfomycin tromethamine,464–465fosinopril sodium, 465–467fosphenytoin sodium,467–470Fosrenol, 571Fostex 10 BPO Gel, 1127tFragmin, 282Froben, 453Froben SR, 453Frova, 470frovatriptan succinate,470–4715-FU, 1155tFUDR, 1155tFul-Glo, 1122tFumasorb, 436Fumerin, 436Funduscein-10, 1122tFunduscein-25, 1122tFungizone Intravenous, 78Fungoid, 1131tFuracin, 1128tFuradantin, 742furazolidone, 471–472furosemide, 472–474,1192–1193tFuroside, 472Furoxone, 471Fuzeon, 1142tGgabapentin, 475–476Gabitril, 1012galantamine hydrobromide,476–477Galzin, 1098Gamimune N 5% S/D, 524Gamimune N 10% S/D, 524Gammagard Liquid, 524Gammagard S/D, 524Gammagard S/D 0.5 g, 524gamma globulin, 524–528Gammar-P IV, 524Gamunex 10%, 524ganciclovir, 1146tganciclovir 0.15%, 1114tGantanol, 965Gantrisin, 969Garamycin, 480, 1115t, 1127tGastrocrom, 273Gastrosed, 514gatifloxacin 0.3%, 1115tGBH, 591Gee-Gee, 492Gefitinib, 1164tGelnique 10%, 777gemcitabine hydrochloride,1163tgemfibrozil, 477–478gemifloxacin mesylate,478–480gemtuzumab ozogamicin,1163tGemzar, 1163tGenahist, 329Gen-Amantadine, 55Genapap Infants’ Drops, 23Genapax, 1130tGenaspore, 1033tGenatuss, 492Gen-Cimetidine, 239Gen-Clonazepam, 254Genebs Extra Strength, 23Gen-Famotidine, 421Gen-Fibro, 477Gen-Glybe, 486Gen-Indapamide, 528Gen-K, 838Gen-Medroxy, 866Gen-Metformin, 638Gen-Minocycline, 681Gen-Minoxidil, 683Genoptic, 1115tGenotropin, 951Genpril, 515

Genprin, 104Gen-Ranitidine, 896Gen-Salbutamol, 37Gen-Selegiline, 931Gentacidin, 1115tGentak, 1115tgentamicin sulfate, 480–481,1115t, 1127tGen-Tamoxifen, 981, 1161tgentian violet, 1130tGen Triazolam, 1055Gentropin, 951Geodon, 1100Geodon for Injection, 1100Geridium, 813Gerimal, 383Gesterol 50, 866Gesterol LA 250, 866GG-CEN, 492Gleevec, 1163tGliadel Wafer, 1150tglibenclamide, 486–488glimepiride, 481–483glipizide, 483–484GlucaGen, 485glucagon, 485–486Glucagon Diagnostic Kit,485Glucagon Emergency Kit,485Glucophage, 638Glucophage XR, 638glucose, 304–305Glucotrol, 483Glucotrol XL, 483Glu-K, 839Glumetza, 638Glutose, 304glyburide, 486–488glyceryl trinitrate, 743–746Glycon, 638glycopyrrolate, 488–490,1192–1193tGly-Cort, 1135tGlycotuss, 492Glynase PresTab, 486Glyquin, 1140tGlyset, 677Glytuss, 492G-Mycin, 480G-myticin, 1127tgolimumab, 490–491goserelin acetate, 1160tgranisetron hydrochloride,491–492granulocyte colonystimulatingfactor, 439–440Gravol, 327guaifenesin, 492–493Guaituss, 492guanadrel sulfate, 493–494guanethidine monosulfate,494–496guanfacine hydrochloride,496–497G-well, 591Gynazole-1, 1129tGynecort, 1135tGyneCure Ovules, 1132tGyne-Lotrimin, 1129tGyne-Lotrimin 3, 1129tGynergen, 383Gynogen L.A. 20, 396Gynogen L.A. 40, 396HHabitrol, 736halazepam, 497–498halcinonide, 1134tHalcion, 1055Haldol, 498Haldol Concentrate, 498Haldol Decanoate, 498Haldol LA, 498Halenol Children’s JuniorStrength, 23Half-life, 4halobetasol propionate,1134tHalog, 1134thaloperidol, 488–500,1192–1193thaloperidol decanoate,498–500haloperidol lactate, 498–500haloprogin, 1130tHalotex, 1130tHalotussin, 492Haltran, 515Hectorol, 347Hemocyte, 436Hepalean, 500heparin, 1192–1193tIndex 1221heparin calcium, 500–503heparin co-factor I, 93–94Heparin Leo, 500Heparin Lock Flush, 500heparin sodium, 500–503Hepsera, 1147tHeptalac, 565Herceptin, 1165tHerplex Liquifilm, 1145thexachlorophene, 1140tHexadrol, 297Hexadrol Phosphate, 297Hexit, 591Hibiclens, 1138tHi-Cor 1.0, 1135tHi-Cor 2.5, 1135tHiprex, 645Histantil, 869Hi-Vegi-Lip, 788HMS Liquifilm, 1118thomatropine hydrobromide,1119tHormonal antineoplastics,1149, 1159–1161tHumalog (insulin lispro),1111tHumalog Mix 50/50, 1113tHumalog Mix 75/25, 1113tHumate-P, 90Humatrope, 951HUMIRA, 32Humulin 10/90, 1113tHumulin 20/80, 1113tHumulin 30/70, 1113tHumulin 40/60, 1113tHumulin 70/30, 1113tHumulin N, 1112tHumulin-R, 1111tHumulin-U, 1112thyaluronan (highmolecular-weight),503Hycamtin, 1165tHydergine, 383Hydergine LC, 383Hyderm, 1135t, 1136thydralazine hydrochloride,503–505, 1166tHydrate, 327Hydrea, 1155tHydro-chlor, 505hydrochlorothiazide,505–506, 506i, 1166t,1168t, 1170t, 1172t

1222Indexhydrocortisone, 507–509hydrocortisone 0.25%, 1135thydrocortisone 0.5%, 1135thydrocortisone 1%, 1135thydrocortisone 2%, 1135thydrocortisone 2.5%, 1135thydrocortisone acetate,507–509hydrocortisone acetate 0.1%,1135thydrocortisone acetate 0.5%,1135thydrocortisone acetate 1%,2%, 2.5%, 1136thydrocortisone acetatedental paste, 1136thydrocortisone acetate,polymyxin B sulfate, andneomycin sulfate, 1136t,1140thydrocortisone acetatetopical aerosol foam, 1136thydrocortisone andiodoquinol, 1136thydrocortisone butyrate,1136thydrocortisone cypionate,507–509hydrocortisone sodiumphosphate, 507–509hydrocortisone sodiumsuccinate, 507–509hydrocortisone valerate,1136tHydrocortone, 507Hydrocortone Acetate, 507Hydrocortone Phosphate,505Hydro-D, 505Hydro-DIURIL, 505hydromorphone, 1192–1193thydromorphone hydrochloride,509–511hydroquinone, 1140tHydrostat IR, 509Hydro-Tex, 1135thydroxychloroquine sulfate,511–513hydroxycobalamin,1178–1181thydroxyprogesteronecaproate, 866–869hydroxyurea, 1155thydroxyzine, 1192–1193thydroxyzine hydrochloride,513–514hydroxyzine pamoate,513–514Hy/Gestrone, 866Hygroton, 232Hylorel, 493Hylutin, 866hyoscyamine sulfate,514–515Hyperstat, 309Hyrexin, 329Hytakerol, 324Hytone, 1135tHytrin, 991Hytuss, 492Hytuss 2X, 492Hyzaar 50/12.5, 1168–1169tHyzaar 100/25, 1168–1169tIIbifon 600 Caplets, 515Ibuprin, 515ibuprofen, 515–518Ibuprohm Caplets, 515Ibu-Tab, 515ibutilide fumarate, 518–519I.D.A., 310Idamycin, 1153tidarubicin hydrochloride,1153tIdiosyncratic response, 5idoxuridine, 1145tIFEX, 1151tifosfamide, 1151tIG, 524–528IGIV, 524–528iloperidone, 519–521iloprost, 521–522Ilosone, 386Ilotycin, 386, 1114tIlozyme, 789IL-2, 1158timatinib mesylate, 1163tIMDUR, 549imipramine hydrochloride,522–524imipramine pamoate,522–524imiquimod 5%, 1140tImitrex, 973ImmuCyst, 1158timmune globulin intramuscular(human),524–528immune globulin intravenous(human), 524–528immune serum globulin,524–528Impril, 522Imuran, 116inamrinone, 528Inapsine, 354Indameth, 530indapamide, 528–530Inderal, 876Inderal LA, 876Inderide 80/25, 1168–1169tInderide LA 80/50,1168–1169tInderide LA 120/50,1168–1169tInderide LA 160/50,1168–1169tindinavir, 1143tIndocid, 530Indocid PDA, 530Indocin, 530Indocin I.V., 530Indocin SR, 530indomethacin, 530–533indomethacin sodiumtrihydrate, 530–533InFeD, 539Infergen, 1188tInflamase Forte, 1118tInflamase Mild, 1118tinfliximab, 533–535INH, 545–546Inhalation route, 3, 11Innohep, 1021Innopran XL, 876Inocor, 528Inspra, 376Insta-Glucose, 304Insulin preparations,1111–1113tInsulin Reaction, 304Intal Syncroner, 273Integrilin, 381Intelence, 1143t

interferon alfa-2a,recombinant, 1159tinterferon alfa-2b, recombinant,1159t, 1186–1187tinterferon alfacon-1,1188–1189tinterferon alfa-n3,1186–1187tinterferon beta-1a,1188–1189tinterferon beta-1b,1188–1189tinterferon gamma-1b,1190–1191tInterferons, 1186–1191tinterleukin-2, 1158tIntradermal route, 3, 10Intramuscular route, 3, 10Intravenous route, 3, 10Intron A, 1159t, 1186t, 1188tIntropin, 341Intuniv, 496Invanz, 384Invega, 785Invirase, 1144tIonsys, 432Iopidine, 1120tipecac syrup, 535–536Ipecac Syrup, 535ipratropium bromide,536–537, 537iirbesartan, 537–538, 1166tIrcon, 436iressa, 1164tirinotecan hydrochloride,1163tiron, carbonyl, 436–438iron dextran, 539–540iron sucrose, 540–541Isentress, 1144tISG, 524–528Ismelin, 494ISMO, 549Iso-Acetozone, 310isocarboxazid, 541–544Isocom, 310isoetharine hydrochloride,544–545isoetharine mesylate,544–545isoniazid, 545–546isonicotinic acid hydrazide,545–546isoprenaline, 547–548isoproterenol, 557–548isoproterenol hydrochloride,547–548isoproterenol sulfate,547–548Isoptin, 1084Isoptin SR, 1084Isopto Atropine, 1118tIsopto Carbachol, 1119tIsopto Carpine, 1119tIsopto Cetamide, 1116tIsopto Frin, 1120tIsopto Homatropine, 1119tIsopto Hyoscine, 1119tIsordil Tembids, 549Isordil Titradose, 549isosorbide dinitrate,549–550, 549iisosorbide mononitrate,549–550, 549iIsotamine, 545isotretinoin, 551–552isradipine, 552–554Istodax, 1154tIsuprel, 547Isuprel Mistometer, 547itraconazole, 554–556Iveegam EN, 524I.V. flow rates, calculating,1197–1198IVIG, 524–528ixabepilone, 1157t, 1164tIxempra, 1157t, 1164tJJanuvia, 943Jenamicin, 480KK-8, 838K-10, 839K+ 10, 839Kabikinase, 959Kadian, 698Kalbitor, 363Kaletra, 1143tKalium Durules, 839Index 1223kanamycin sulfate, 557–558Kantrex, 557Kaochlor 10%, 839Kaochlor S-F 10%, 839Kaon, 839Kaon-Cl, 839Kapidex, 569Kasof, 336Kato, 839Kay Ciel, 839Kayexalate, 948Kaylixir, 839K+ Care, 839K+Care ET, 838KCL 5%, 839K-Dur, 839Keflex, 214Keftab, 214K-Electrolyte, 838Kenacort, 1051Kenacort Diacetate, 1051Kenac, 1136t, 1137tKenaject-40, 1051Kenalog, 1136t, 1137tKenalog-10, 1051Kenalog-40, 1051Kenalog-H, 1137tKenalog in Orabase, 1137tKendral-Ipratropium, 536Ken-Jec-40, 1051Kenonel, 1097t, 1136tkeoxifene hydrochloride,893–894Keppra, 578Keppra XR, 578Kerlone, 140Ketek, 986ketoconazole 2%, 1130tketoprofen, 558–560ketorolac, 1192t, 1193tketorolac tromethamine,560–562, 1117tketotifen fumarate, 1122tK-Exit, 948Key-Pred, 852K-G Elixir, 839KI, 821–842K-Ide, 838, 839Kidrolase, 1158tKildane, 591Kineret, 85Kionex, 948Klaron, 1128t

1224IndexK-Lease, 839K-Long, 839Klonopin, 254K-Lor, 839Klor-Con 10, 839Klor-Con/EF, 838Klor-Con Powder, 839Klor-Con/25 Powder, 839Klorvess 10% Liquid, 839Klorvess EffervescentGranules, 838K-Lyte, 838K-Lyte/Cl, 838K-Lyte/Cl 50, 838K-Lyte/Cl Powder, 839K-Lyte DS, 838K-Med 900, 839K-Norm, 839Kogenate FS, 90Kolyum, 839K-Phos M.F., 843K-Phos-Neutral, 843K-Phos No. 2, 843K-Phos Original, 842K-Sol, 839K-Tab, 839Kuvan, 926Ku-Zyme HP, 789K-Vescent, 838Kwell, 591Kwellada, 591Kwildane, 591Kytril, 491Llabetalol hydrochloride,563–564Lac-Hydrin, 1138tlacosamide, 564–565LactiCare-HC, 1135tLactulax, 565lactulose, 565–566Lamictal, 566Lamisil, 992Lamisil AT Cream, 1132tLamisil AT Solution, 1132tLamisil DermGel, 1132tLamisil Solution, 1132tlamivudine, 1143t, 1147tlamivudine and zidovudine,1143tlamivudine triphosphate,1143tlamotrigine, 566–568Lanacort, 1135tLaniazid, 545Lanophyllin, 999Lanoxicaps, 319Lanoxin, 319Lanoxin Elixir Pediatric, 319Lanoxin Injection, 319Lanoxin Injection Pediatric,319lanreotide, 568–569lansoprazole, 569–571lanthanum carbonate,571–572, 572iLantus (insulin glargine),1112tLanvis, 1157tLargactil, 227Larodopa, 580Lasix, 472Lasix Special, 472latanoprost, 1122tLaxilose, 565L-Caine, 588Ledercillin VK, 802leflunomide, 572–573Lemoderm, 1135tlepirudin, 574–575Lescol, 457Lescol XL, 457Letairis, 59letrozole, 1160tLeukeran, 1150tleuprolide acetate, 575–577,1160tLeustatin, 1154tlevalbuterol hydrochloride,577–578levamisole hydrochloride,1159tLevaquin, 582levarterenol bitartrate,748–749Levate, 68Levatol, 798Levbid, 514Levemir (insulin detemir),1112tlevetiracetam, 578–579Levitra, 1078levobunolol hydrochloride,1122tlevocabastine hydrochloride0.05%, 1122tlevocetirizine, 579–580,1125tlevodopa, 580–582, 581iLevo-Dromoran, 585levofloxacin, 582–585levofloxacin 0.5%, 1115tlevonorgestrel, 866–869Levophed, 748levorphanol tartrate,585–586Levo-T, 586Levothroid, 586levothyroxine sodium,586–588Levoxyl, 586Levsin, 514Levsin/SL, 514Levsinex Timecaps, 514Lexapro, 390Lexiva, 1143tLialda, 633Librium, 223Lidemol, 1134tLidex, 1134tlidocaine, 1192-1193tlidocaine and prilocaine,1140ttlidocaine hydrochloride,588–589Lidoderm, 588lignocaine hydrochloride,588–589Lincocin, 590lincomycin hydrochloride,590–591lindane, 591–592linezolid, 592–595, 593iLioresal, 125Lioresal Intrathecal, 125liothyronine sodium,595–596Lipitor, 109Lipofen, 427Liquadd, 76Liquaemin, 500Liqui-Cal, 168Liquid Cal-600, 168Liquid equivalents, 1199tLiqui-E, 1182t

Liquiprin Elixir, 23Liquiprin Infants’ Drops, 23liraglutide, 596–597lisdexamphetaminedimesylate, 597–599lisinopril, 599–601, 1170t,1172tLithane, 601lithium carbonate, 601–603lithium citrate, 601–603Lithizine, 601Lithobid, 601Lithonate, 601Lithostat, 28Lithotabs, 601Livalo, 834Livostin, 1122tLocoid, 1136tLodine, 416Lodine XL, 416lomefloxacin hydrochloride,603–605lomustine, 1151tLoniten, 683Lopid, 477lopinavir and ritonavir,1143tLopresor, 665Lopresor SR, 665Lopressor, 665Lopressor HCT 50/25,1168–1169tLopressor HCT 100/25,1168–1169tLopressor HCT 100/50,1168–1169tLoprox 0.77%, 1129tLopurin, 44Lorabid, 605loracarbef, 605–606loratadine, 1125tlorazepam, 606–607,1192–1193tLorazepam Intensol, 606losartan potassium,607–608, 1168tLosec, 763Lotemax, 1118tLotensin, 132Lotensin HCT 5/6.25,1168–1169tLotensin HCT 10/12.5,1168–1169tLotensin HCT 20/12.5,1168–1169tLotensin HCT 20/25,1168–1169tloteprednol etabonate, 1118tLotrel 2.5/10, 1170–1171tLotrel 5/10, 1170–1171tLotrel 5/20, 1170–1171tLotrel 10/20, 1170–1171tLotrimin, 1129tLotrimin Antifungal, 1129tLotrimin Ultra, 1129tLotrisone, 1138tLotronex, 47lovastatin, 608–610Lovaza, 762Lovenox, 371Loxapac, 610loxapine hydrochloride,610–611loxapine succinate, 610–611Loxitane, 610Loxitane C, 610Loxitane IM, 610Lozide, 528Lozol, 528L-phenylalanine mustard,1151tL-thyroxine sodium,586–588L-triiodothyronine, 595–596lubiprostone, 611–612Ludiomil, 617Lufyllin, 360Lumigan, 1121tLuminal, 816Lunesta, 405Lupron, 575, 1160tLupron Depot, 575, 1160tLupron Depot-3 Month,1160tLupron Depot-3 Month11.25 mg, 575Lupron Depot-3 Month22.5 mg, 575Lupron Depot-4 Month,1160tLupron Depot-4 Month30 mg, 575Lupron Depot-Ped, 575Lupron-3 Month SR Depot22.5 mg, 575Luvox, 458Luvox CR, 458Luxiq, 1134tlypressin, 612Lyrica, 857Lysodren, 1164tLysteda, 1045MIndex 1225Macrobid, 742Macrodantin, 742mafenide gel 1%, 1127tMag-200, 613Mag-L-100, 613Maglucate, 613magnesium chloride,613–616magnesium citrate, 613–616magnesium gluconate,613–616magnesium hydroxide,613–616magnesium lactate, 613–616magnesium oxide, 613–616magnesium sulfate, 613–616Magonate, 613Mag-Ox 400, 613Mag-Tab SR Caplets, 613Magtrate, 613malathion lotion 0.5%,1140tMandelamine, 645mannitol, 616–617Maolate, 226Maox, 613maprotiline hydrochloride,617–619maraviroc,1143t, 1145tMarezine, 275Marinol, 352Marplan, 541Marthritic, 925Marzine, 275Matulane, 1164tMavik, 1043Maxair, 831Maxair Autohaler, 831Maxalt, 916Maxalt-MLT, 916Maxaquin, 603Maxeran, 662Maxidex, 1117t

1226IndexMaxiflor, 1134tMaximum Bayer, 104Maximum Strength Cortaid,1136tMaxipime, 189Maxzide 37.5/25,1170–1171tMaxzide 75/50, 1170–1171tMB-Tab, 631Mebaral, 630mechlorethaminehydrochloride, 1151tMeclicot, 619meclizine hydrochloride,619–620meclofenamate sodium,620–621Meclomen, 620meclozine hydrochloride,619–620Meda Cap, 23Medi-Glybe, 486Medihaler Ergotamine, 383Medihaler-Iso, 547Medipren, 515Medivert, 619medrogestone, 866–869Medrol, 659medroxyprogesteroneacetate, 866–869, 1160tmedrysone, 1118tMed-Valproic, 1073Mefoxin, 199Megace, 866, 1161tMegace OS, 866Megacillin, 802megestrol acetate, 866–869,1161tMelanex, 1140tMellaril, 1005Mellaril Concentrate, 1005Mellaril-S, 1005meloxicam, 622–623melphalan, 1151tmelphalan hydrochloride,1151tmemantine hydrochloride,623–625, 624iMenaval-20, 396Meni-D, 619Menostar, 396Mentax, 1129tmeperidine, 1192–1193tmeperidine hydrochloride,625–626mephentermine sulfate,626–628mephenytoin, 628–630mephobarbital, 630–631Mephyton, 1184tmeprobamate, 631–632Meprolone, 659Mepron, 111Meprospan, 631mequinol 2%, retinol 0.01%,1140tmercaptopurine, 1156t6-mercaptopurine, 1156tMeridia, 936meropenem, 632–633Merrem I.V., 632mesalamine, 633–635Mesantoin, 628Mesasal, 633M-Eslon, 698mesoridazine besylate,635–636Mestinon, 883Mestinon-SR, 883Mestinon Timespans, 883Metabolism, 4Metadate, 657Metadate CD, 657Metadate ER, 657metaproterenol sulfate,636–637metaxalone, 637–638metformin hydrochloride,638–640methadone hydrochloride,640–643Methadose, 640methamphetaminehydrochloride, 643–644methazolamide, 645methenamine hippurate,645–646methenamine mandelate,645–646methicillin sodium, 646–647methimazole, 647–648methocarbamol, 649–650methotrexate, 650–651,1156tmethotrexate sodium,650–651, 1156tmethoxypolyethylene glycolepoetinbeta, 651–652methscopolamine bromide,653methsuximide, 653–654Methylcotolone, 659methyldopa, 654–656, 1166tmethyldopate hydrochloride,654–656Methylin, 657Methylin ER, 657methylnaltrexone bromide,656–657methylphenidate hydrochloride,657–659methylprednisolone,659–662methylprednisolone acetate,659–662methylprednisolone sodiumsuccinate, 659–662Meticorten, 855metipranolol hydrochloride,1122tmetoclopramide,1192–1193tmetoclopramide hydrochloride,662–664Metoclopramide Intensol,662metolazone, 664–665metoprolol succinate,665–667metoprolol tartrate,665–667, 1168tMetric 21, 667MetroCream, 1128tMetroGel, 667, 1128tMetroGel-Vaginal, 667,1128tmetronidazole, 667–669,1128tmetronidazole hydrochloride,667–669metyrosine, 669–670Mevacor, 608mevinolin, 608–610Mexate, 650Mexate-AQ, 650mexiletine hydrochloride,670–672Mexitil, 670

Mezlin, 672mezlocillin sodium, 672–673Miacalcin, 166micafungin sodium, 673–674Micardis, 987Micardis HCT 40/12.5,1170–1171tMicardis HCT 80/12.5,1170–1171tMicatin, 1131tmiconazole nitrate, 1131tMicort HC-Lipocream,1136tMicro-K, 839Micro-K 10, 839Micronase, 486MicroNefrin, 374Microzide, 505Midamor, 61midazolam, 1192–1193tmidazolam hydrochloride,674–676Midchlor, 310midodrine hydrochloride,676–677Midol IB, 515Midrin, 310miglitol, 677–678Migquin, 310Migragap, 310Migranal, 323Migratine, 310Migrazone, 310Migrend, 310Migrex, 310milk of magnesia, 613–616milnacipran hydrochloride,678–679milrinone lactate, 679–681,680iMiltown, 631Minims Atropine, 1118tMinims Cyclopentolate,1119tMinims Homatropine, 1119tMinims Pilocarpine, 1119tMinipress, 851Minitran, 743Minocin, 681minocycline, 681–683minocycline hydrochloride,681–683Minox, 683minoxidil (oral), 683–685minoxidil (topical),683–685, 1140tMinoxigaine, 683Miocarpine, 1119tMiochol-E, 1119tMiolin, 767Mio-Rel, 767Miostat, 1119tMiradon, 87Mirapex, 845Mircera, 651mirtazapine, 685–686misoprostol, 686–687Mithracin, 1154tmithramycin, 1154tmitomycin, 1153tmitomycin-C, 1153tmitotane, 1164tmitoxantrone hydrochloride,687–690, 1164tMitride, 310Moban Concentrate, 693Mobic, 622modafinil, 690–691Modane Soft, 337Modecate, 450Modecate Concentrate, 450Moditen Enanthate, 450Moditen HCl, 450Moduretic, 1170–1171tmoexipril hydrochloride,691–693, 1172tmolindone hydrochloride,693–695Mol-Iron, 436mometasone furoate, 1136tmometasone furoatemonohydrate, 695–696Monistat 3, 1131tMonistat 7, 1131tMonistat-Derm, 1131tMonitan, 22monobenzone 20%, 1140tMonocid, 193Monodox, 349Mono-Gesic, 925Monoket, 549Monopril, 465montelukast sodium,696–698Monurol, 464morphine, 1192–1193tIndex 1227Morphine Extra-Forte, 698Morphine Forte, 698Morphine H.P., 698morphine sulfate, 698–701Morphitec, 698Motrin, 515Motrin-IB, 515Moxatag, 75moxifloxacin 0.5%, 1115tmoxifloxacin hydrochloride,701–7036-MP, 1156tMS Contin, 698MSIR, 698MS/L, 698MS/L Concentrate, 698MS/S, 698Mucinex, 492Mucomyst, 29Mucosil, 29Multaq, 353Multipax, 513mupirocin 2%, 1128tMurine Plus, 1120tMuro-128, 1122tMuroptic-5, 1122tMuse, 50Mustargen, 1151tMutamycin, 1153tMyambutol, 410Mycamine, 673Mycelex, 1129tMycelex 3, 1129tMycelex-7, 1129tMycelex-G, 1129tMycelex OTC, 1129tMycifradin, 728Myciguent, 1128tMycobutin, 907mycophenolate mofetil,703–706mycophenolate mofetilhydrochloride, 703–706mycophenolic acid, 703–706MyCort, 1135tMycostatin, 752, 1131tMydfrin, 1120tMydriacyl, 1119tMy-E, 387Myfortic, 703Myidone, 858Mykrox, 664Mylanta-AR, 421

1228IndexMyleran, 1150tMylotarg, 1163tMyotrol, 767Myrosemide, 472Mysoline, 858Mytelase, 58MZM, 645M-Zole 3, 1131tNnabumetone, 707–708nadolol, 708–710Nadopen-V 200, 802Nadopen-V 400, 802Nadostine, 752, 1131tnafarelin acetate, 710–711Nafcil, 711nafcillin sodium, 711–712naftifine hydrochloride,1131tNaftin, 1131tnalbuphine hydrochloride,712–714Nalcrom, 273Nalfon, 430nalidixic acid, 714–715Nallpen, 711naloxone hydrochloride,715–716naltrexone hydrochloride,716–718Namenda, 623naphazoline hydrochloride,1120tNaprelan, 718Naprosyn, 718Naprosyn-E, 718Naprosyn-SR, 718naproxen, 718–721naproxen sodium, 718–721naratriptan hydrochloride,721–722Narcan, 715Nardil, 814Nasacort, 1051Nasacort AQ, 1051Nasacort HFA, 1051Nasalcrom, 273Nasalide, 447Nasal route, 3–4, 11Nasarel, 447Nasogastric route, 2, 9–10Nasonex, 695natalizumab, 722–724nateglinide, 724–725, 724iNatrecor, 730Natulan, 1164tNavane, 1008Navelbine, 1158tNaxen, 718nebivolol hydrochloride,725–726NebuPent, 804nedocromil sodium 2%,1122tnefazodone hydrochloride,726–728NegGram, 714nelfinavir, 1143tnelfinavir mesylate, 1143tNemasol Sodium, 65Nembutal, 807Neo-Calglucon, 168Neo-Codema, 505Neo-Fer, 436Neo-Fradin, 728Neo-K, 838neomycin sulfate, 728–729,1128tNeopap, 23Neoral, 278Neosar, 1150tneostigmine bromide,729–730neostigmine methylsulfate,729–730Neo-Synephrine, 820Neo-Synephrine NasalDrops, 820Neo-Synephrine Nasal Jelly,820Neo-Synephrine NasalSpray, 820Neo-Synephrine PediatricNasal Drops, 820Nephro-Fer, 436Nephron, 374Neptazane, 645nesiritide, 730–732Nestrex, 1176tnetilmicin sulfate, 732–733Netromycin, 732Neulasta, 796Neupogen, 439Neuramate, 631Neurontin, 475Neutra-Phos, 843Neutra-Phos-K, 842nevirapine, 1144tNexavar, 1165tNexium, 393Nexium I.V., 393Nexterone, 66Nia-Bid, 1176tNiac, 1176tNiacels, 1176tniacin, 1176–1177tNiacor, 1176tnicardipine hydrochloride,733–735Niclocide, 735niclosamide, 735–736Nico-400, 1176tNicobid Tempules, 1176tNicoderm, 736NicoDerm CQ, 736Nicolar, 1176tNicorette, 736Nicorette Plus, 736nicotine for inhalation,736–738nicotine nasal solution,736–738nicotine polacrilex, 736–738nicotine transdermal system,736–738Nicotinex Elixir, 1176tNicotrol, 736Nicotrol Inhaler, 736Nicotrol NS, 736Nidagel, 667nifedipine, 738–740Nilandron, 1161tnilotinib, 1164tNilstat, 752, 1131tnilutamide, 1161t9-1-1, 1135tNipent, 1154tNipride, 746nisoldipine, 740–741nitazoxanide, 741–742Nitro-Bid, 743Nitrocot, 743Nitro-Dur, 743nitrofurantoin, 742–743nitrofurazone, 1128t

Nitrogard, 743nitrogen mustard, 1151tnitroglycerin, 743–746Nitroglyn E-R, 743Nitroject, 743Nitrol, 743Nitrolingual, 743NitroMist, 743Nitrong SR, 743Nitro-par, 743Nitropress, 746nitroprusside sodium,746–747Nitrostat, 743Nitro-time, 743Nix, 1141tnizatidine, 747–748Nizoral, 1130tNolvadex, 981, 1161tNolvadex-D, 1161tNorditropin, 951norepinephrine bitartrate,748–749norethindrone, 866–869Norflex, 767norfloxacin, 749–751Norfranil, 522norgestrel, 866–869Norlutate, 866Normodyne, 563Noroxin, 749Norpace, 332Norpace CR, 332Norplant System, 866Norpramin, 294Nor-Pred T.B.A., 852nortriptyline hydrochloride,751–752Norvasc, 70Norvir, 1144tNorwich Extra-Strength, 104Nostril Spray Pump, 820Nostril Spray Pump Mild,820Novamobarb, 72Novamoxin, 75Novantrone, 687, 1164tNova Rectal, 807Novasen, 105Novo-Alprazol, 49Novo-Ampicillin, 81Novo-Atenol, 106Novo-AZT, 1144tNovo-Baclofen, 125Novo-Butamide, 1033Novo-Carbamaz, 174Novo-Chlorhydrate, 221Novochlorocap, 222Novo-Chlorpromazine, 227Novo-Cimetine, 239Novo-Clopate, 258Novo-Cloxin, 259Novo-cromolyn, 273Novo-Difenac, 312Novo-Diflunisal, 318Novo-Digoxin, 319Novo-Diltiazem, 325Novo-Dipam, 306Novo-Dipiradol, 330Novo-Doxepin, 346Novo-Famotidine, 421Novoferrogluc, 436Novoferrosulfa, 436Novofibrate, 252Novo-Flupam, 452Novo-Flurprofen, 453Novo-Folacid, 460, 1178tNovofumar, 436Novo-Furantoin, 742Novo-Gemfibrozil, 477Novo-Glyburide, 486Novo-Hydrazide, 505Novohydrocort, 1135t, 1136tNovo-Hydroxyzin, 513Novo-Hylazin, 503Novo-Indapamide, 528Novo-Levobunolol, 1122tNovo-Lexin, 214Novolin 70/30, 1113tNovolin ge 10/90, 1113tNovolin ge 20/80, 1113tNovolin ge 30/70, 1113tNovolin ge 40/60, 1113tNovolin ge 50/50, 1113tNovolin ge Lente, 1112tNovolin ge NPH, 1112tNovolin ge Toronto, 1111tNovolin ge Ultralente, 1112tNovolin N, 1112tNovolin N Prefilled, 1112tNovolin R, 1111tNovolin R Prefilled, 1111tNovoLog (insulin aspart),1111tNovoLog Mix 50/50, 1113tNovoLog Mix 70/30, 1113tNovo-Lorazem, 606Index 1229Novo-Medrone, 866Novo-Metformin, 638Novo-Methacin, 530Novomethacin, 530Novometoprol, 665Novo-Minocycline, 681Novo-Naprox, 718Novo-Naprox Sodium, 718Novo-Niacin, 1176tNovonidazol, 667Novo-Nifedin, 738Novopentobarb, 807Novo-Pen-VK, 802Novo-Peridol, 498NovoPindol, 826Novo-Pirocam, 832Novo-Poxide, 223Novopramine, 522Novopranol, 876Novo-Profen, 515Novo-Propamide, 230Novopyrazone, 967Novoquinidin, 889Novo-Ranitidine, 896Novoreserpine, 905Novo-Ridazine, 1005Novo-Rythro, 386, 387Novo-Rythro Encap, 386Novo-Salmol, 37Novosecobarb, 930Novo-Selegiline, 931Novosemide, 472Novoseven, 262Novoseven RT, 262Novo-Soxazole, 969Novospiroton, 957Novo-Sundac, 970Novo-Tamoxifen, 981, 1161tNovo-Temazepam, 988Novo-Tetra, 996Novo-Thalidone, 232Novo-Timol, 1019Novo-Tolmetin, 1035Novo-Triolam, 1055Novo-Tripramine, 1063Novotriptyn, 68Novo-Valproic, 1073Novo-Veramil, 1084Novoxapam, 773Noxafil, 837Nplate, 917NP-27, 1133tNu-Alpraz, 49

1230IndexNu-Amoxi, 75Nu-Ampi, 81Nubain, 712Nu-Cephalex, 214Nu-Cimet, 239Nu-Cloxi, 259Nucynta, 983Nu-Diclo, 312Nu-Diltiaz, 325Nu-Famotidine, 421Nu-Gemfibrozil, 477Nu-Glyburide, 486Nu-Ibuprofen, 515Nu-Indapamide, 528Nu-Indo, 530Nu-Loraz, 606Nu-Medopa, 654Numorphan, 781Nu-Naprox, 718Nu-Nifed, 738Nu-Pen VK, 802Nu-Pirox, 832Nuprin, 515Nu-Prochlor, 863Nu-Ranit, 896Nursing process, drugtherapy and, 12–15Nu-Selegiline, 931Nu-Tetra, 996Nutracort, 1135tNutropin, 951Nutropin AQ, 951Nu-Valproic, 1073Nu-Verap, 1084Nuvigil, 102Nydrazid, 545nystatin, 752–753, 1131tNystex, 752Nystop, 752Nytol QuickCaps, 329OOctagam 5%, 524Octamide, 662Octostim, 296octreotide acetate, 753–755OcuClear, 1120tOcufen, 1117tOcuflox, 1115tOcupress, 1121tOcusert Pilo-20, 1119tOcusert Pilo-40, 1119tOcusulf-10, 1116tofloxacin, 755–757ofloxacin 0.3%, 1115tolanzapine, 757–759olmesartan medoxomil,759–760, 759i, 1166tolopatadine, 1125tolopatadine hydrochloride0.1%, 1118tolsalazine sodium, 760–761Olux, 1134tomalizumab, 761–762omega-3-acid ethyl esters,762–763omeprazole, 763–765, 764iOmnicef, 186Omnipen, 81Omnipen-N, 81Omnitrope, 951OMS Concentrate, 698Oncaspar, 1158tOncovin, 1157tondansetron hydrochloride,765–766Onglyza, 927Onset of action, xiiiOnsolis, 432Ontak, 1118tOny-Clear Nail, 1131tOpana, 781Opana ER, 781o,p-DDD, 1164tOphthaine, 1120tOphthalmic antibiotics,1114–1116tOphthalmic antiinflammatorydrugs,1116–1118tOphthalmic cyloplegicmydriatics, 1118–1119tOphthalmic drugs, selected,1114–1123tOphthalmic miotics, 1119tOphthalmic route, 3, 11Ophthalmicvasoconstrictors, 1120tOphthetic, 1120tOphthifluor, 1122tOphto-Dipivefrin, 1121tOpticyl, 1119tOptigene 3, 1120tOptimine, 1124tOptiPranolol, 1122tOptivar, 1120tOrabase-HCA, 1136tOracort, 1137tOradexon, 297Oralone, 1137tOral route, 2, 9Oramorph SR, 698Oraphen-PD, 23Orapred ODT, 852Orasone 1, 855Orasone 5, 855Orasone 10, 855Orazinc, 1098Orbenin, 259Orencia, 17Oretic, 505Orfro, 767Organidin NR, 492Orgaran, 283Orinase, 1033orlistat, 766–767, 767iOrnidyl, 364orphenadrine citrate,767–768orphenadrine hydrochloride,767–768Orphenate, 767Orthovisc, 503Orudis, 558Orudis KT, 558Orudis-SR, 558Oruvail, 558oseltamivir phosphate, 1147tOsmitrol, 616Ostoforte, 1182tOtic route, 3, 11Ovide, 1140tOvrette, 866oxacillin sodium, 768–770oxaliplatin, 1151tOxandrin, 770oxandrolone, 770–771oxaprozin, 771–773oxazepam, 773–774oxcarbazepine, 774–776Oxeze Turbuhaler, 463oxiconazole nitrate, 1131tOxistat, 1131tOxizold, 1131toxtriphylline, 776–777

oxybutynin chloride,777–778oxycodone hydrochloride,778–780OxyContin, 778oxymetazoline hydrochloride,1120toxymetholone, 780–781oxymorphone hydrochloride,781–783oxytetracycline, 783–784oxytetracycline hydrochloride,783–784PPacerone, 66paclitaxel, 1157tPalafer, 436Palladone, 509paliperidone, 785–786palonosetron hydrochloride,786–787, 786i2-PAM chloride, 844–845Pamelor, 751pamidronate disodium,787–788Pamine, 653Pamine Forte, 653Pamprin-IB, 515Panadol, 23Panadol Infants’ Drops, 23Pancrease, 789Pancrease MT 4, 789Pancrease MT 10, 789Pancrease MT 16, 789Pancrease MT 20, 789pancreatin, 788–790Pancreatin (4x), 788Pancreatin (8x), 788pancrelipase, 789–790Pancrezyme 4X, 788Panmycin, 996Pantoloc, 790pantoprazole sodium,790–792para-aminosalicylate, 65Paraflex, 233Parafon Forte DSC, 233Parenteral administration,3, 10paricalcitol, 792–793Parlodel, 150Parlodel SnapTabs, 150Parnate, 1046paroxetine hydrochloride,793–796paroxetine mesylate,793–796PAS, 65Patanase, 1125tPatanol, 1118tPathocil, 314Paxil, 793Paxil CR, 793Paxipam, 497PCE, 386Peak therapeutic effect, xviPediaphen, 23Pediapred, 852Pedi-Dri, 752Peganone, 413pegaspargase, 1158tPEGASYS, 1186tpegfilgrastim, 796–797peginterferon alfa-2a,1186–1187tpeginterferon alfa-2b,1186–1187tPEG-Intron, 1186tPEG-l-asparaginase, 1158tpegvisomant, 797–798, 798ipemetrexed disodium, 1156tPenbritin, 81penbutolol sulfate, 798–800penciclovir, 1133tPenecort, 1135tPenetrex, 369Penglobe, 123penicillamine, 800–802penicillin G benzathine,802–804penicillin G potassium,802–804penicillin G procaine,802–804penicillin G sodium,802–804penicillin V potassium,802–804Penlac, 1129tPentacarinat, 804Pentam 300, 804pentamidine isethionate,804–805Index 1231Pentamycetin, 1114tPentasa, 633Pentazine, 869pentazocine lactate, 805–807Pentids, 802pentobarbital, 1192–1193tpentobarbital sodium,807–808Pentolair, 1119tpentosan polysulfatesodium, 808–809pentostatin, 1154tPentothal, 1004pentoxifylline, 809–810Pen Vee, 802Pen Vee K, 802Pepcid, 421Pepcid AC, 421Pepcid RPD, 421Perforomist, 463Peridol, 498perindopril erbumine,810–811Permapen, 802permethrin 1%, 1141tpermethrin 5%, 1141tPermitil, 450Permitil Concentrate, 450perphenazine, 811–813Persantine, 330Pertofrane, 294pethidine hydrochloride,625–626Pexeva, 793Pfizerpen, 802Pfizerpen-AS, 802PGI 2 , 379–381PGX, 379–381Pharmacodynamics, 4–5Pharmacokinetics, 2–4Pharma-Cort, 1135tPharmacotherapeutics, 5–6Phenazine 25, 869Phenazine 50, 869Phenazo, 813Phenazodine, 813phenazopyridine hydrochloride,813–814Phencen-50, 869phenelzine sulfate, 814–816,815iPhenerzine, 869

1232Indexphenobarbital, 816–819phenobarbital sodium,816–819Phenoject-50, 869Phenoptic, 1120tphentolamine mesylate,819–820phenylephrine hydrochloride,820–822, 1120tPhenytex, 822phenytoin, 822–825phenytoin sodium, 822–825Pheryl E, 1182tPhillips’ Chewable Tablets,613Phillips’ Magnesia Tablets,613Phillips’ Milk of Magnesia,613Phillips’ Milk of MagnesiaConcentrate, 613pHisoHex, 1140tPhosLo, 168Photofrin, 1164tPhyllocontin, 63physostigmine salicylate,825–826phytonadione, 1184–1185tPilagan, 1119tPilocar, 1119tpilocarpine, 1119tpilocarpine hydrochloride,1119tpilocarpine nitrate, 1119tPilopine HS, 1119tPilostat, 1119tPima, 842pimecrolimus 1%, 1141tpindolol, 826–828pioglitazone hydrochloride,828–829piperacillin sodium, 829–831Pipracil, 829pirbuterol acetate, 831–832piroxicam, 832–834pitavastatin, 834–835Pitressin, 1081Pitrex, 1133tPlacidyl, 411Plaquenil, 511Platinol, 1152tPlatinol-AQ, 1152tPlavix, 257Plendil, 426Pletal, 238plicamycin, 1154tPMS Benztropine, 134PMS-Bethanechol Chloride,141PMS-Cephalexin, 214PMS-Chloral Hydrate, 221PMS-Cimetidine, 239PMS-Ferrous Sulfate, 436PMS Fluphenazine, 450PMS-Hydromorphone, 509PMS-HydromorphoneSyrup, 509PMS-Isoniazid, 545PMS-Lactulose, 565PMS-LevothyroxineSodium, 586PMS-Lindane, 591PMS-Methylphenidate, 657PMS-Metoclopramide, 662PMS Perphenazine, 811PMS-Piroxicam, 832PMS Primidone, 858PMS-Progesterone, 866pms Propranolol, 876pms-Pyrazinamide, 882PMS-Sodium PolystyreneSulfonate, 948PMS-Sulfasalazine, 966PMS-Sulfasalazine E.C., 966PMS Theophylline, 999PMS Thioridazine, 1005PMS-Trifluoperazine, 1057PMS Trihexyphenidyl, 1061PMS-Valproic Acid, 1073Pneumopent, 804podofilox, 1141tPolaramine, 301Polaramine Repetabs, 301Polycillin, 81Polycillin-N, 81Polygam S/D, 524Polymox, 75polymyxin B sulfate,835–837, 1116tPontocaine, 1120tporfimer sodium, 1164tPortalac, 565posaconazole, 837–838Potasalan, 839potassium acetate, 838–841potassium and sodiumphosphates, 842–844potassium bicarbonate,838–841potassium bicarbonate andpotassium chloride,838–841potassium bicarbonate andpotassium citrate, 838–841potassium chloride, 838–841potassium gluconate,838–841potassium gluconate andpotassium chloride,838–841potassium gluconate andpotassium citrate, 838–841potassium iodide, 842potassium phosphates,842–844Potassium-Rougier, 839Potassium Sandoz, 838povidone-iodine, 1128tPP-Cap, 875pralatrexate, 1157tpralidoxime chloride,844–845pramipexole dihydrochloride,845–847pramlintide acetate, 847–849Prandin, 903prasugrel, 849–850Pravachol, 850pravastatin sodium, 850–851prazosin hydrochloride,851–852Precose, 21Predacort 50, 852Predalone 50, 852Predalone T.B.A. 852Predate 50, 852Predate TBA, 852Predcor-25, 852Predcor-50, 852Predcor-TBA, 852Pred Forte, 1118tPred-Ject 50, 852Pred Mild, 1118tprednicarbate, 1136tPrednicen-M, 855Prednicot, 855

prednisolone, 852–855prednisolone acetate,852–855prednisolone acetatesuspension, 1118tprednisolone sodiumphosphate, 852–855prednisolone sodiumphosphate solution, 1118tprednisolone tebutate,852–855prednisone, 855–857Prednisone Intensol, 855pregabalin, 857–858Pregnancy, specialconsiderations for, 7Pregnancy risk categories, xvPrelone, 852Premarin, 402Premarin Vaginal Cream,402Premphase, 402Prempro, 402Pressyn, 1081Prevacid, 569Prevacid I.V., 569Prevacid SoluTab, 569Prevex-HC, 1135tPrezista, 1142tPrialt, 1095Prilosec, 763Primacor, 679Primatene Mist, 374Primethasone, 297primidone, 858–859Principen-250, 81Principen-500, 81Prinivil, 599Prinzide 10/12.5,1170–1171tPrinzide 20/12.5,1170–1171tPrinzide 20/25, 1170–1171tPristiq, 1082Pro-50, 869Proair HFA, 37ProAmatine, 676Probalan, 860Pro-Banthine, 873probenecid, 860–861procainamide hydrochloride,861–863Pro-Cal-Sof, 336Procan SR, 861procarbazine hydrochloride,1164tProcardia, 738Procardia XL, 738prochlorperazine, 863–866,1192–1193tprochlorperazine edisylate,863–866prochlorperazine maleate,863–866Procrit, 377Procytox, 1150tProdrox, 866progesterone, 866–869progestins, 866–869Proglycem, 309Prograf, 976Prolastin, 48Prolastin-C, 48Proleukin, 1158tProlixin, 450Prolixin Concentrate, 450Prolixin Decanoate, 450Prolixin Enanthate, 450Proloprim, 1062Promacot, 869Promacta, 365Pro-Med 50, 869Promet, 869promethazine hydrochloride,869–872Prometrium, 866Promine, 861Pronestyl, 861Pronestyl-SR, 861propafenone hydrochloride,872–873Propanthel, 873propantheline bromide,873–874proparacaine hydrochloride,1120tPropecia, 440Propine, 1121tpropofol, 874–875propoxyphene hydrochloride,875–876propoxyphene napsylate,875–876propranolol hydrochloride,876–879, 1168tpropylthiouracil, 879–880Index 1233Propyl-Thyracil, 879Proquin XR, 242Prorex-25, 869Prorex-50, 869Proscar, 440Pro-Span, 866prostacyclin, 379–381Prostaphlin, 768ProStep, 736Prostigmin, 729protamine sulfate, 880–881Prothazine, 869Protilase, 789Protonix, 790Protopam Chloride, 844Protopic, 1141tProtostat, 667protriptyline hydrochloride,881–882Proventil, 37Proventil HPA, 37Proventil Repetabs, 37Proventil Syrup, 37Provera, 866Provigil, 690Prozac, 448Prozac Weekly, 448Psorcon, 1134tPTU, 879–880Pulmicort Flexhaler, 152Pulmicort Respules, 152Pulmicort Turbuhaler, 152Pulmophylline, 999Purinethol, 1156tPurinol, 44P.V. Carpine Liquifilm, 1119tpyrazinamide, 882–883pyrethrum extract andpiperonyl butoxide, 1141tPyri, 1176tPyridiate, 8132-pyridine aldoximemethochloride, 844–845Pyridium, 813pyridostigmine bromide,883–884pyridoxine hydrochloride,1176–1179t

1234QQ-Profen, 515Quarzan, 249quazepam, 885–886Questran, 234Questran Light, 234quetiapine fumarate,886–888Quibron-T Dividose, 999Quibron-T/SR Dividose, 999Quinaglute Dura-tabs, 889quinapril hydrochloride,888–889Quinate, 889Quinidex Extentabs, 889quinidine gluconate,889–891quinidine polygalacturonate,889–891quinidine sulfate, 889–891quinine sulfate, 891–892Quin-Release, 889Quinsana Plus, 1133tQuixin, 1115tQVAR, 129RIndexrabeprazole sodium,892–893racepinephrine, 374–376Radiostol Forte, 1182trAHF-PFM, 90–93raloxifene hydrochloride,893–894raltegravir, 1144tramelteon, 894–895ramipril, 895–896Ranexa, 898Raniclor, 182ranitidine, 1192–1193tranitidine hydrochloride,896–898ranolazine, 898–899Rapaflo, 939Rapamune, 941rapamycin, 941–943rasagiline, 899–901rasburicase, 901–902Razadyne, 476Razadyne ER, 476Rebetol, 1148tRebif, 1188tReclast, 1101recombinant erythropoietin,377–379recombinant human activatedprotein C, 356–357recombinant interferonalfa-2b, 1186–1189tRectal route, 2–3, 10Rederm, 1135tRedutemp, 23Refludan, 574Regitine, 819Reglan, 662Regonol, 883Regranex, 1138tRegular (concentrated)insulin, Iletin II, U-500,1111tRegulax SS, 337Relafen, 707Relaxazone, 233Relenza, 1147tRelief Eye Drops for RedEyes, 1120tRelistor, 656–657Relpax, 364Remeron, 685Remeron SolTab, 685Remicade, 533remifentanil hydrochloride,902–903, 903iRemodulin, 1049Remular, 233Remular-S, 233Renagel, 935Renedil, 426Renova, 1137tRenvela, 935ReoPro, 18repaglinide, 903–905Requip, 918Rescriptor, 1142tRescudose, 698Rescula, 1123tResectisol, 616Reserfia, 905reserpine, 905–906, 905iRespbid, 999Restasis, 1121tRestoril, 988Resyl, 492Retavase, 906reteplase, 906–907Retin-A, 1137tRetin-A Micro, 1137tretinol, 1174–1075tRetrovir, 1144tRevatio, 938ReVia, 716Revimine, 341Rexolate, 949Reyataz, 1142trG-CSF, 439–440Rheumatrex, 650Rhinalar, 447Rhinall, 820Rhinall-10 Children’sFlavored Nose Drops, 820Rhinocort, 152Rhinocort Aqua, 152Rhinocort Turbuhaler, 152Rhodis, 558Rhophylac, 524Rhotrimine, 1063r-HuEPO, 377–379Ribasphere, 1148tribavirin, 1148tRidaura, 115RID, 1141trifabutin, 907–908Rifadin, 908Rifadin IV, 908rifampicin, 908–910rifampin, 908–910Rilutek, 910riluzole, 910–911Rimactane, 908rimexolone, 1118tRiomet, 638Riphenidate, 657risedronate sodium, 911–912Risperdal, 912Risperdal Consta, 912risperidone, 912–914Ritalin, 657Ritalin-LA, 657Ritalin SR, 657Ritalin-SR, 657ritonavir, 1144tRituxan, 1164trituximab, 1164trivastigmine tartrate,914–916

Rivotril, 254rizatriptan benzoate,916–917RMS Uniserts, 698Robalog, 1051Robaxin, 649Robaxin 750, 649Robigesic, 23Robinul, 488Robinul Forte, 488Robitet, 996Robitussin, 492Rocaltrol, 167Rocephin, 208R.O. Dexasone, 1117tRodex, 1176tRofact, 908Roferon-A, 1159tRogaine, 683Rogaine 2% and 5%, 1140tRogaine ES for Men, 683Rogaine for Men, 683Rogaine for Women, 683Romazicon, 446romidepsin, 1154tromiplostim, 917–918ropinirole hydrochloride,918–920rosiglitazone maleate,920–921rosuvastatin calcium,921–922Rowasa, 633Roxanol, 698Roxanol 100, 698Roxanol UD, 698Roxicodone, 778Roychlor 10%, 839Rozerem, 894Rubex, 1153tRufen, 515rufinamide, 922–923Rum-K, 839Rythmodan, 332Rythmodan-LA, 332Rythmol, 872SSabril, 1086Saizen, 951Sal-Adult, 105Salazopyrin EN-Tabs, 966salbutamol, 37-38, 38isalbutamol sulphate, 37–38,38iSalflex, 925salicylsalicylic acid, 925–926Sal-Infant, 105salmeterol xinafoate,923–925Salofalk, 633salsalate, 925–926Salsitab, 925Samsca, 1038Sanctura, 1066Sanctura XR, 1066Sancuso, 491Sandimmune, 278Sandoglobulin, 524Sandostatin, 753Sandostatin LAR Depot, 753SangCya, 278Sans-Acne, 1127tSaphris, 103sapropterin dihydrochloride,926–927saquinavir, 1144tSarafem, 448Sarisol No. 2, 159Sarna HC, 1135tS.A.S.-500, 965S.A.S. Enteric-500, 965Savella, 678saxagliptin monohydrate,927–928Scabene, 591SCE-A, 402scopolamine, 1192–1193tscopolamine hydrobromide,928–930, 1119tscopolamine transdermalsystem, 928–930Scot-tussin Expectorant, 492SD Deprenyl, 931secobarbital sodium,930–931Seconal, 930Sectral, 22Selegiline-5, 931selegiline hydrochloride,931–933selegiline transdermalsystem, 931–933selenium sulfide, 1132tSelestoject, 137Index 1235Selsun, 1132tSelzentry, 1143t, 1145tSemprex-D, 1124tSensipar, 240Sential, 1135tSerax, 773Serentil, 635Serevent Diskus, 923Seromycin, 278Seroquel, 886Seroquel XR, 886Serostim, 951Serpalan, 905Serpasil, 905Sertan, 858sertraline hydrochloride,933–935Serzone, 726sevelamer carbonate,935–936sevelamer hydrochloride,935–936Shogan, 869sibutramine hydrochloridemonohydrate, 936–938Silace, 337Siladryl, 329sildenafil citrate, 938–939silodosin, 939–940Silvadene, 1128tsilver sulfadiazine, 1128tSimponi, 490Simron, 436Simulect, 128simvastatin, 940–941Sinequan, 346Singulair, 696sirolimus, 941–943sitagliptin, 943–944Skelaxin, 637Skelex, 649Skelid, 1018Sleep-Eze D Extra Strength,329Slo-Bid Gyrocaps, 999Slo-Niacin, 1176tSlo-Phyllin, 999Slow-Fe, 436Slow-K, 839Slow-Mag, 613Soda Mint, 944sodium bicarbonate,944–946

1236Indexsodium chloride, hypertonic,1122tsodium cromoglycate,273–275, 274isodium ferric gluconate,946–947sodium l-triiodothyronine,595–596sodium phenylbutyrate,947–948sodium phosphates, 842–844sodium polystyrenesulfonate, 948–949Sodium Sulamyd 10%, 1116tsodium thiosalicylate,949–950Solage, 1140tSolaraze, 1139tSolfoton, 816Solid equivalents,1199–1200tsolifenacin succinate,950–951Solodyn, 681Solu-Cortef, 507Solu-Medrol, 659Solurex, 297Solurex LA, 297Solutions, 9calculating the strength of,1194–1198Soma, 177somatropin, 951–953Somatulin Depot, 568Somavert, 797Somnol, 452Sonata, 1093Sopamycetin, 1114tsorafenib, 1165tSorbitrate, 549Soriatane, 30Sotacor, 954sotalol hydrochloride,954–955Span-FF, 436sparfloxacin, 955–956Spasmoban, 316Spectazole, 1130tspectinomycin hydrochloride,956–957Spectracef, 188Spectrobid, 123Spiriva HandiHaler, 1023spironolactone, 957–959,958iSporanox, 554SPS Suspension, 948SSKI, 842Stadol, 161Stadol NS, 161Staphcillin, 646Starlix, 724Statex, 698Staticin, 1127tstavudine, 1144tStavzor, 1073S-T Cort, 1135tStelara, 1072Stemetil, 863Sterapred, 855Sterapred DS, 855Stieva-A, 1137tStimate, 296Stimate Nasal Spray, 296St. Joseph Aspirin-FreeInfant Drops, 23St. Joseph Children’s, 105Storzolamide, 25Stoxil, 1145tStrattera, 108Streptase, 959streptokinase, 959–960streptomycin sulfate,960–961streptozocin, 1151tStrifon Forte DSC, 233Subcutaneous route, 3, 10Sublimaze, 432Sublingual route, 3, 11Subutex, 156sucralfate, 961–962Sular, 740sulconazole nitrate, 1132tSulcrate, 961Sulcrate Suspension Plus,961Sulf-10, 1116tsulfacetamide sodium 10%,1116t, 1128tsulfacetamide sodium 10%and sulfur 5%, 1128tsulfacetamide sodium 15%,1116tsulfacetamide sodium 30%,1116tSulfacet-R, 1128tsulfadiazine, 962–963sulfamethizole, 963–964sulfamethoxazole, 965–966Sulfamylon, 1127tsulfasalazine, 966–967sulfinpyrazone, 967–969sulfisoxazole, 969–970sulfisoxazole acetyl, 969–970Sulfizole, 969Sulfolax, 336sulindac, 970–972sumatriptan succinate,973–974Sumycin, 996sunitinib malate, 1165tSupasa, 105Supeudol, 778Suprax, 191Surfak, 336Surmontil, 1063Suspensions, 9Sustiva, 1142tSutent, 1165tSymax SL, 514Symax SR, 514Symlin, 847Symmetrel, 55Synacort, 1135tSynalar, 1134tSynalar-HP, 1134tSynamol, 1134tSynarel, 710Synemol, 1134tSyn-Nadolol, 708SynPindol, 826Synthetic ConjugatedEstrogens A (SCE-A)Vaginal Cream, 402synthetic estrogens, A (conjugated),402–405synthetic estrogens, B (conjugated),402–405Synthroid, 586TT 3 , 595–596T 4 , 586–588Tablets, 9Tabloid, 1157tTac-3, 1051

Taclonex, 1138tTaclonex Scalp, 1138ttacrine hydrochloride,975–976, 975itacrolimus, 976–979, 1141ttadalafil, 979–980Tagamet, 239Tagamet HB, 239Talwin, 805Tambocor, 442Tamiflu, 1147tTamofen, 981, 1161tTamone, 981, 1161ttamoxifen citrate, 981–982,1161ttamsulosin hydrochloride,982–983Tapanol Extra Strength, 23Tapazole, 647tapentadol, 983–984Targretin, 1162tTargretin Gel, 1162tTasaigna, 1164tTasmar, 1034Taxol, 1157tTaxotere, 1157ttazarotene 0.05%, 0.1%,1137tTazicef, 203Tazidime, 203Tazorac, 1137tTebamide, 1062Tebrazid, 882tedelparin, 282–283Tegopen, 259Tegretol, 174Tegretol-XR, 174Tegrin-LT, 1141tTekturna, 43, 1170–1171tTekturna HCT 150/12.5,1170–1171tTekturna HCT 150/25,1170–1171tTekturna HCT 300/12.5,1170–1171ttelavancin, 984–986telbivudine, 1147ttelithromycin, 986–987telmisartan, 987–988, 1170t,1172ttemazepam, 988–989Temodar, 1151tTemovate, 1134ttemozolomide, 1151tTempra, 24Tempra Drops, 24tenecteplase, 989–991Tenex, 496Ten-K, 839tenofovir, 1144ttenofovir and emtricitabine,1144tTenormin, 106Terazol 3, 1132tTerazol 7, 1132tterazosin hydrochloride,991–992terbinafine hydrochloride,992–993, 1132tterbutaline sulfate, 993–994terconazole, 1132tteriparatide, 994–996, 995iTerramycin, 783Terramycin I.M., 783Teslac, 1161tTESPA, 1152tTessalon Perles, 133testolactone, 1161ttetracaine, 1120tTetracap, 996tetracycline hydrochloride,996–997, 1128tTetracyn, 996Tetracyn 500, 996tetrahydroaminoacridine,975–976, 975itetrahydrozoline hydrochloride,1120tTetrasine, 1120tTeveten, 381Tev-Tropin, 9516-TG, 1157tTHA, 975–976, 975ithalidomide, 997–999Thalitone, 232Thalomid, 997Tham, 1065THC, 352–353Theo-24, 999Theobid Duracaps, 999Theochron, 999Theoclear, 999Theoclear LA, 999Theo-Dur, 999Theolair, 999Theolair-SR, 999Index 1237theophylline, 999–1002theophylline ethylenediamine,63–65Theo-SR, 999Theovent Long-Acting, 999TheraCys, 1158tTherapy Bayer, 105Thermazine, 1128tthiamine hydrochloride,1174–1177tthiethylperazine maleate,1002–1003thioguanine, 1157t6-thioguanine, 1157tThiola, 1023Thionex, 591thiopental sodium,1004–1005Thioplex, 1152tthioridazine, 1005–1007thioridazine hydrochloride,1005–1007Thiosulfil Forte, 963thiotepa, 1152tthiothixene, 1008–1010Thiothixene HCl Intensol,1008thiothixene hydrochloride,1008–1010Thorazine, 227Thorazine Spansule, 2273TC, 1143t3TC/AZT, 1143t3TC/ZDV, 1143tThrive, 736Thrombate III, 93Thyrar, 1010Thyro-Block, 842Thyrogen, 1011thyroid-stimulatinghormone, 1011–1012Thyroid Strong, 1010thyroid USP, 1010–1011thyronine sodium, 595–596thyrotropin, 1011–1012thyrotropin alfa, 1011–1012thyroxine sodium, 586–588Thytropar, 1011tiagabine hydrochloride,1012–1013Ticar, 1013ticarcillin disodium,1013–1014

1238IndexTICE BCG, 1158tTiclid, 1014ticlopidine hydrochloride,1014–1016, 1015iTigan, 1062tigecycline, 1016–1017Tikosyn, 337Tilone, 1051tiludronate disodium, 1018Timolide 10/25, 1170–1171ttimolol hemihydrate, 1122ttimolol maleate, 1019–1020,1122t, 1170ttimolol maleate extendedreleasesolution, 1122tTimoptic, 1122tTimoptic-XE, 1122tTinactin, 1133tTindamax, 1020Ting, 1133ttinidazole, 1020–1021tinzaparin sodium,1021–1023tioconazole, 1132ttiopronin, 1023tiotropium bromide,1023–1025Tipramine, 522tipranavir, 1144ttirofiban hydrochloride,1025–1026tissue plasminogen activator,recombinant, 52–54Titralac, 168tizanidine hydrochloride,1026–1027TNKase, 989Tobi, 1027TobraDex, 1116ttobramycin, 1116ttobramycin 0.3% (3 mg)and dexamethasone 0.1%(1 mg), 1116ttobramycin sulfate,1027–1029Tobrex, 1116ttocainide hydrochloride,1029–1030tocilizumab, 1030–1032Tofranil, 522Tofranil-PM, 522tolazamide, 1032–1033tolbutamide, 1033–1034tolcapone, 1034–1035Tolectin 200, 1035Tolectin 400, 1035Tolectin 600, 1035Tolectin DS, 1035Tolinase, 1032tolmetin, 1035–1037tolnaftate, 1133ttolterodine tartrate,1037–1038tolvaptan, 1038–1039Tonocard, 1029Topamax, 1039Topical drugs, selected,1126–1141tTopical route, 11Topicort, 1139tTopicycline, 1128tTopilene, 1133ttopiramate, 1039–1040Toposar, 1162ttopotecan hydrochloride,1165tToprol-XL, 665Toradol, 560Torecan, 1002toremifene citrate, 1161tTornalate, 145torsemide, 1041–1042Totacillin, 81Totacillin-N, 81Tovalt, 1104Toviaz, 438T-Phyl, 999Tracleer, 147Tracrium, 112Tramacort-D, 1051tramadol hydrochloride,1042–1043Trandate, 563trandolapril, 1043–1045tranexamic acid, 1045–1046Transcutaneous administration,3–4, 10–11Transderm-Nitro, 743Transderm-Scōp, 928Transderm-V, 928Tranxene, 258Tranxene-SD, 258Tranxene-SD Half Strength,258tranylcypromine sulfate,1046–1048trastuzumab, 1165tTravatan, 1123ttravoprost 0.004%, 1123ttrazodone hydrochloride,1048–1049Trazon, 1048Treanda, 1150tTrecator-SC, 411Trelstar LA, 1161tTrendar, 515Trental, 809treprostinil sodium,1049–1051tretinoin, 1137tTriacet, 1136t, 1137tTriadapin, 346Triaderm, 1136t, 1137tTrialodine, 1048Triam-A, 1051triamcinolone, 1051–1054triamcinolone acetonide,1051–1054triamcinolone acetonide0.025%, 0.5%, 1136ttriamcinolone acetonide0.1%, 1137ttriamcinolone acetonide0.5%, 1137ttriamcinolone acetonidedental paste, 1137ttriamcinolone acetonidetopical aerosol, 1137ttriamcinolone diacetate,1051–1054triamcinolone hexacetonide,1051–1054Triam-Forte, 1051Triamolone 40, 1051Triamonide, 1051triamterene, 1054–1055,1168t, 1170tTrianide Mild, 1136tTrianide Regular, 1137ttriazolam, 1055–1057Triaz, 1127tTribenzagan, 1062Tricor, 427Tridesilon, 1134tTridil, 743triethylenethiophosphoramide,1152t

trifluoperazine hydrochloride,1057–1059triflupromazine, 1059–1061Trihexane, 1061Trihexy, 1061trihexyphenidyl hydrochloride,1061–1062Tri-K, 839Trikacide, 667trikates, 838–841Tri-Kort, 1051Trilafon, 811Trilafon Concentrate, 811Trileptal, 774Trilipix, 427Trilog, 1051TRI-LUMA Cream, 1139tTrimazide, 1062trimethobenzamidehydrochloride, 1062–1063trimethoprim, 1062–1063trimipramine maleate,1063–1065Trimox, 75Trimpex, 1062Trinalin Repetabs, 1124tTriostat, 595Triptil, 881triptorelin pamoate, 1161tTrisenox, 1161tTristoject, 1051Trivagizole 3, 1129tTrizivir, 1142tTrobicin, 956tromethamine, 1065–1066Tropicacyl, 1119ttropicamide, 1119ttrospium chloride,1066–1067trovafloxacin mesylate, 36Trovan, 36Trovan I.V., 36Truphylline, 63Trusopt, 1121tTruvada, 1144tTruxophyllin, 999TSH, 1011–1012TSPA, 1152tT-Stat, 1088ttubocurarine chloride,1067–1068, 1067iTusal, 949Twin-K, 839Twynsta 40/5, 1172–1173tTwynsta 40/10, 1172–1173tTwynsta 80/5, 1172–1173tTwynsta 80/10, 1172–1173tTygacil, 1016Tylenol, 24Tylenol Caplets, 24Tylenol Children’s ChewableTablets, 24Tylenol Extra Strength, 24Tylenol Gelcaps, 24Tylenol Infants’ Drops, 24Tysabri, 722Tyvaso, 1049Tyzeka, 1147tUUloric, 424Ultiva, 902Ultram, 1042Ultram ER, 1042Ultrase MT 12, 789Ultrase MT 20, 789Ultravate, 1134tUnicort, 1135tUni-Dur, 999Unipen, 711Uniphyl, 999Uniretic 15/25, 1172–1173tUnisom SleepGelsMaximum Strength, 329Unithroid, 586Uni-tussin, 492Univasc, 691unoprostone isopropyl0.15%, 1123tUrabeth, 141urea, 1069–1070Ureaphil, 1069Urecholine, 141Urex, 645Uridon, 232Urispas, 441Uritol, 472Urobak, 965Urocit-K, 839Urodine, 813Urogesic, 813urokinase, 1070–1071Uro-Mag, 613Index 1239Uroxatral, 41Urozide, 505URSO 250, 1071ursodeoxycholic acid,1071–1072ursodiol, 1071–1072Ursofalk, 1071Urso Forte, 1071ustekinumab, 1072–1073Uticort, 1133tVVagifem, 396Vaginal route, 4, 11Vagistat-1, 1132tvalacyclovir, 1146tValcyte, 1146tValergen 10, 396Valergen 20, 396Valergen 40, 396valganciclovir hydrochloride,1146tValisone, 1134tValium, 306valproate sodium,1073–1075valproic acid, 1073–1075valrubicin, 1154tvalsartan, 1075–1076, 1168t,1172tValstar, 1154tValtrex, 1146tValturna 150/160,1172–1173tValturna 300/320,1172–1173tVanadom, 177Vancenase, 129Vanceril, 129Vancocin, 1076vancomycin hydrochloride,1076–1078Vaniqa, 1139tVantin, 201Vaponefrin, 374Vaprisol, 270vardenafil hydrochloride,1078–1079varenicline, 1079–1081Vascor, 136

1240IndexVaseretic 5/12.5, 1172–1173tVaseretic 10/25, 1172–1173tVasocon Regular, 1120tvasopressin, 1081–1082,1081iVasotec, 367Vasotec I.V., 367V-Cillin K, 802VCR, 1157tVectrin, 681Veetids, 802Velban, 1157tVelbe, 1157tvelcade, 1165tVelosef, 217Velosulin BR, 1111tVelosulin Human, 1111tvenlafaxine hydrochloride,1082–1084Venofer, 540Venoglobulin-I, 524Venoglobulin-S 5%, 524Venoglobulin-S 10%, 524Ventavis, 521Ventolin HFA, 37Ventolin Syrup, 37VePesid, 1162tVeramyst, 455verapamil, 1084–1086verapamil hydrochloride,1084–1086Verazinc, 1098Verelan, 1084Versed, 674VESIcare, 950Vesprin, 1059Vexol, 1118tVfend, 1088V-Gan-25, 869V-Gan-50, 869Viadur, 571, 1160tViagra, 938Vibativ, 984Vibramycin, 349Vibra-Tabs, 349Vicks Sinex, 820Vicks Vitamin C Drops,1180tVictoza, 596vidarabine, 1146tvigabatrin, 1086–1087Vigamox, 1115tVimpat, 564vinblastine sulfate, 1157tVincasar PFS, 1157tvincristine sulfate, 1157tvinorelbine tartrate, 1158tViokase Powder, 789Viokase Tablets, 789Vira-A, 1146tViracept, 1143tViramune, 1144tViread, 1144tViridium, 813Visine Extra, 1120tVisine L.R., 1120tVisine Moisturizing, 1120tVisken, 826Vistaril, 513Vistide, 1146tVita-bee 6, 1176tvitamin A, 1174–1075tvitamin B 1 , 1174–1177tvitamin B 3 , 1176–1177tvitamin B 6 , 1176–1179tvitamin B 9 , 460–461,1178–1179tvitamin B 12 , 1178–1181tvitamin C, 1180–1181tvitamin D 2 , 1182–1183tvitamin E, 1182-1183tvitamin K 1 , 1184–1185tVitamins, 1174–1185tVita-Plus E, 1182tVivactil, 881Vivelle, 396Vivelle-Dot, 396Vivitrol, 716Vivol, 306VLB, 1157tVolmax, 37Voltaren, 312, 1117tVoltaren Ophtha, 1117tVoltaren Rapide, 312Voltaren SR, 312voriconazole, 1088–1090VP-16, 1162tVytone, 1136tVyvanse, 597Wwarfarin sodium, 1090–1092Webber Vitamin E, 1182tWeights and equivalents,1199–1200tWelchol, 267Wellbutrin, 157Wellbutrin SR, 157Wellbutrin XL, 157Westcort, 1136tWesthroid, 1010Winpred, 855WinRho SDF, 524Wintrocin, 387Wyamine, 626Wycillin, 802Wymox, 75XYXalatan, 1122tXanax, 49Xanax XR, 49Xeloda, 1154tXenical, 766Xibram, 1116tXigris, 356Xolair, 761Xopenex, 577Xopenex HFA, 577Xylocaine, 588Xylocard, 588Xyntha, 90Xyzal, 579, 1125tZZaditor, 1122tzafirlukast, 1093Zagam, 955zaleplon, 1093–1095Zanaflex, 1026zanamivir, 1147tZanosar, 1151tZantac,896

Index 1241Zantac EFFERdose Tablets,896Zantac 150 GELdose, 896Zantac 300 GELdose, 896Zarontin, 412Zaroxolyn, 664ZDV, 1144tZeasorb-AF, 1133tZebeta, 143Zefazone, 192Zegerid, 763Zelapar, 931Zemaira, 48Zemplar, 792Zenapax, 281Zenpep, 789Zerit, 1144tZerit XR, 1144tZestoretic 10/12.5,1172–1173tZestoretic 20/12.5,1172–1173tZestoretic 20/25, 1172–1173tZestril, 599Zetar, 1139tZetar Shampoo, 1139tZetia, 420Ziac 2.5/6.25, 1172–1173tZiac 5/6.25, 1172–1173tZiac 10/6.25, 1172–1173tZiagen, 1142tziconotide, 1095–1097, 1096izidovudine, 1144tzileuton, 1097–1098Zinacef, 210Zinc 15, 1098Zinc-220, 1098zinc acetate, 1098–1099Zinca-Pak, 1098Zincate, 1098zinc chloride, 1098–1099zinc gluconate, 1098–1099zinc sulfate, 1098–1099Zinecard, 303Zingo, 588ziprasidone hydrochloride,1100–1101ziprasidone mesylate,1100–1101Zipsor, 312Zirgan, 1114tZithromax, 118Zmax, 118Zocor, 940Zofran, 765Zofran ODT, 765Zoladex, 1160tZoladex LA, 1160tZoladex 3-Month, 1160tzoledronic acid, 1101–1103zolmitriptan, 1103–1104Zoloft, 933zolpidem tartrate,1104–1106Zometa, 1101Zomig, 1103Zomig ZMT, 1103Zonalon, 1139tZonegran, 1106zonisamide, 1106–1107ZORprin, 105Zostrix, 1138tZovirax, 1133t, 1145tZyban, 157Zydis, 757Zyflo CR, 1097Zyloprim, 44Zymar, 1115tZymase, 789Zyprexa, 757Zyrtec, 1124tZyrtec D, 1124tZyvox, 592

Body Mass Index CalculationBody mass index (BMI) is a formula used todetermine obesity; it’s calculated by dividing aperson’s weight in kilograms by height inmeters squared (kg/m 2 ). A BMI of 25 or higherincreases your patient’s risk of developinghypertension, cardiovascular disease, type 2diabetes mellitus, and stroke. It also increasesthe risk that he won’t respond effectively to theusual drug dosages. If your patient has anabnormal BMI, be prepared to make dosageadjustments that are individualized based onbody weight, as prescribed.The table below will help you find yourpatient’s BMI easily. The table converts poundsto kilograms and inches to meters, and then itshows the BMI. To use it, simply find thepatient’s height on either side of the table, thenmove across the row to the weight that matchesyour patient’s most closely. At the bottom ofthe column containing the weight, you’ll findthe BMI for that patient. For example, the BMIfor a patient who is 70 inches tall and weighs208 lb is 30.HEIGHT (INCHES)WEIGHT (POUNDS)58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 17259 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 17860 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 18461 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 19062 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 19663 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 20364 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 20965 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 21666 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 22367 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 23068 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 23669 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 24370 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 25071 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 25772 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 26573 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 27274 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 28075 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 28776 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 29519 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36BODY MASS INDEX

WEIGHT (POUNDS)177 181 186 191 196 201 205 210 215 220 224 229 234 239 244 248 253 258 58183 188 193 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267 59189 194 199 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276 60195 201 206 211 217 222 227 232 238 243 248 254 259 264 269 275 280 285 61202 207 213 218 224 229 235 240 246 251 256 262 267 273 278 284 289 295 62208 214 220 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304 63215 221 227 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314 64222 228 234 240 246 252 258 264 270 276 282 288 294 300 306 312 318 324 65229 235 241 247 253 260 266 272 278 284 291 297 303 309 315 322 328 334 66236 242 249 255 261 268 274 280 287 293 299 306 312 319 325 331 338 344 67243 249 256 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354 68250 257 263 270 277 284 291 297 304 311 318 324 331 338 345 351 358 365 69257 264 271 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376 70265 272 279 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386 71272 279 287 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397 72280 288 295 302 310 318 325 333 340 348 355 363 371 378 386 393 401 408 73287 295 303 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420 74295 303 311 319 327 335 343 351 359 367 375 383 391 399 407 415 423 431 75304 312 320 328 336 344 353 361 369 377 385 394 402 410 418 426 435 443 7637 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54HEIGHT (INCHES)BODY MASS INDEX

Mechanism of Action IllustrationsFor your reference, this table lists all the drugs whose mechanisms of action are illustrated in thisbook, along with drugs that have the same mechanism of action as the illustrated ones.Drugs with illustratedmechanisms of actionacamprosate calciumalbuterol, albuterol sulfatealprostadilamitriptyline hydrochlorideanastrozolebosentanbretylium tosylatecarbamazepinecaspofungin acetatecephalexin hydrochloride,cephalexin monohydratecolchicinecromolyn sodiumdiltiazem hydrochloridedutasterideDrugs with similarmechanisms of actionnonebitolterol mesylate, formoterol fumarate dihydrate,levalbuterol hydrochloride, pirbuterol acetate, salmeterolxinafoate, terbutaline sulfatenoneamoxapine, clomipramine hydrochloride, desipraminehydrochloride, doxepin hydrochloride, imipramine hydrochloride,imipramine pamoate, nortriptyline hydrochloride,protriptyline hydrochloride, trimipramine maleatenonenonenoneethotoin, fosphenytoin, lamotrigine, mephenytoin,oxcarbazepine, phenytoin, phenytoin sodiumnoneamoxicillin trihydrate, amoxicillin and clavulanate potassium,ampicillin, ampicillin sodium, ampicillin sodium and sulbactamsodium, ampicillin trihydrate, aztreonam, carbenicillin indanylsodium, cefaclor, cefadroxil, cefamandole nafate, cefazolin sodium,cefdinir, cefditoren pivoxil, cefepime hydrochloride,cefixime, cefmetazole sodium, cefonicid sodium, cefoperazonesodium, cefotaxime sodium, cefotetan disodium, cefoxitinsodium, cefpodoxime proxetil, cefprozil, ceftazidime, ceftibuten,ceftizoxime sodium, ceftriaxone sodium, cefuroxime axetil,cefuroxime sodium, cephapirin sodium, cephradine, cloxacillinsodium, dicloxacillin sodium, imipenem and cilastatin sodium,loracarbef, meropenem, methicillin sodium, mezlocillin sodium,nafcillin sodium, oxacillin sodium, penicillin G benzathine,penicillin G potassium, penicillin G procaine, penicillin Gsodium, penicillin V potassium, piperacillin sodium, piperacillinsodium and tazobactam sodium, ticarcillin disodium, ticarcillindisodium and clavulanate potassiumnonenedocromil sodiumbepridil hydrochloride, felodipine, isradipine, nicardipinehydrochloride, nifedipine, verapamil, verapamil hydrochloridenone

Mechanism of Action Illustrations (cont’d)Drugs with illustratedDrugs with similarmechanisms of actionmechanisms of actionenoxacinetanerceptexenatideezetimibefamotidinehydrochlorothiazideipratropium bromideisosorbide dinitrate,isosorbide mononitratelanthanum carbonatelevodopalinezolidmemantine hydrochloridemilrinone lactatenateglinideolmesartan medoxomilomeprazoleorlistatpalonosetronpegvisomantphenelzine sulfatealatrofloxacin mesylate, cinoxacin, ciprofloxacin, gatifloxacin,levofloxacin, lomefloxacin hydrochloride, moxifloxacinhydrochloride, nalidixic acid, norfloxacin, ofloxacin,sparfloxacin, trovafloxacin mesylateinfliximabnonenonecimetidine, nizatidine, ranitidine hydrochloridechlorothiazide, chlorothiazide sodium, chlorthalidone,indapamide, metolazonenonenitroglycerinsevelamer hydrochloridenonenonenoneinamrinone (formerly amrinone lactate)repaglinideirbesartan, losartan potassium, valsartanesomeprazole magnesium, lansoprazole, pantoprazolesodium, rabeprazole sodiumnonealosetron, dolasetron, granisetron, ondansetronnoneisocarboxazid, tranylcypromine sulfate(continued)

Mechanism of Action Illustrations (cont’d)Drugs with illustratedDrugs with similarmechanisms of actionmechanisms of actionremifentanil hydrochloridereserpinespironolactonetacrine hydrochlorideteriparatideticlopidine hydrochloridetubocurarine chloridevasopressinziconitidecodeine phosphate, codeine sulfate, fentanyl citrate,fentanyl transdermal, fentanyl transmucosal,hydrocodone bitartrate and acetaminophen,hydrocodone and ibuprofen, hydromorphone hydrochloride,levomethadyl acetate hydrochloride, levorphanoltartrate, meperidine hydrochloride, methadonehydrochloride, morphine sulfate, oxycodone and acetaminophen,oxycodone hydrochloride, oxymorphonehydrochloride, propoxyphene hydrochlorideguanadrel sulfate, guanethidine monosulfatenonedonepezil hydrochloride, galantamine hydrobromide,rivastigmine tartratenoneclopidogrel bisulfateatracurium besylatedesmopressin acetate, lypressinnone