Drugs
acetazolamide
ah-set-a-ZOLE-ah-mide
Acetazolam†, Diamox Sequels
acetazolamide sodium
Pharmacologic class: carbonic anhydrase inhibitor
Pregnancy risk category C
AVAILABLE FORMS
acetazolamide
Capsules (extended-release): 500 mg
Tablets: 125 mg, 250 mg
acetazolamide sodium
Powder for injection: 500-mg vial
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Secondary glaucoma; preoperative treatment of acute angle-closure glaucoma
Adults: 250 mg P.O. every 4 hours or 250 mg P.O. b.i.d. for short-term therapy. In acute cases, 500 mg P.O.; then 125 to 250 mg P.O. every 4 hours. To rapidly lower intraocular pressure (IOP), initially, 500 mg I.V.; may repeat in 2 to 4 hours, if needed, followed by 125 to 250 mg P.O. every 4 to 6 hours.
Children: 10 to 15 mg/kg P.O. daily in divided doses every 6 to 8 hours. For acute angle-closure glaucoma, 5 to 10 mg/kg I.V. every 6 hours.
[black right-pointing arrowhead] Chronic open-angle glaucoma
Adults: 250 mg to 1 g P.O. daily in divided doses q.i.d., or 500 mg extended-release P.O. b.i.d.
[black right-pointing arrowhead] To prevent or treat acute mountain sickness (high-altitude sickness)
Adults: 500 mg to 1 g (regular or extended-release) P.O. daily in divided doses every 12 hours. Start 24 to 48 hours before ascent and continue for 48 hours while at high altitude. When rapid ascent is required, start with 1,000 mg P.O. daily.
[black right-pointing arrowhead] Adjunct for epilepsy and myoclonic, refractory, generalized tonic-clonic, absence, or mixed seizures
Adults and children: 8 to 30 mg/kg P.O. daily in divided doses. For adults, 375 mg to 1 g daily is ideal. If given with other anticonvulsants, start at 250 mg P.O. once daily, and increase to 375 mg to 1 g daily.
[black right-pointing arrowhead] Edema caused by heart failure; drug-induced edema
Adults: 250 mg to 375 mg (5 mg/kg) P.O. daily in the morning. For best results, use every other day or 2 days on followed by 1 to 2 days off.
Children: 5 mg/kg or 150 mg/m2 P.O. or I.V. daily in the morning.
ADMINISTRATION
P.O.
• Give drug with food to minimize GI upset.
• Don’t crush or open extended-release capsules.
• If patient can’t swallow oral form, pharmacist may make a suspension using crushed tablets in a highly flavored syrup, such as cherry, raspberry, or chocolate to mask the bitter flavor. Although concentrations up to 500 mg/5 ml are possible, concentrations of 250 mg/5 ml are more palatable.
• Refrigeration improves palatability but doesn’t improve stability. Suspensions are stable for 1 week.
I.V.
• Reconstitute drug in 500-mg vial with at least 5 ml of sterile water for injection. Use within 12 hours of reconstitution.
• Inject 100 to 500 mg/minute into a large vein using a 21G or 23G needle.
• Direct I.V. injection is the preferred route.
• Intermittent and continuous infusions aren’t recommended.
• Incompatibilities: Multivitamins.
ACTION
Promotes renal excretion of sodium, potassium, bicarbonate, and water. As anticonvulsant, drug normalizes neuronal discharge. In mountain sickness, drug stimulates ventilation and increases
cerebral blood flow. In glaucoma, drug reduces intraocular pressure (IOP).
cerebral blood flow. In glaucoma, drug reduces intraocular pressure (IOP).
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | 60-90 min | 1-4 hr | 8-12 hr |
P.O. (extended-release) | 2 hr | 3-6 hr | 18-24 hr |
I.V. | 2 min | 15 min | 4-5 hr |
Half-life: 10 to 15 hours. | |||
ADVERSE REACTIONS
CNS: seizures, drowsiness, paresthesia, confusion, depression, weakness, ataxia.
EENT: transient myopia, hearing dysfunction, tinnitus.
GI: nausea, vomiting, anorexia, metallic taste, diarrhea, black tarry stools, constipation.
GU: polyuria, hematuria, crystalluria, glycosuria, phosphaturia, renal calculus.
Hematologic: aplastic anemia, leukopenia, thrombocytopenia, hemolytic anemia.
Metabolic: hypokalemia, asymptomatic hyperuricemia, hyperchloremic acidosis.
Skin: pain at injection site, Stevens-Johnson syndrome, rash, urticaria.
Other: sterile abscesses.
INTERACTIONS
Drug-drug. Amphetamines, anticholinergics, mecamylamine, procainamide, quinidine: May decrease renal clearance of these drugs, increasing toxicity. Monitor patient for toxicity.
Cyclosporine: May increase cyclosporine level, causing nephrotoxicity and neurotoxicity. Monitor patient for toxicity.
Diflunisal: May increase acetazolamide adverse effects; may significantly decrease IOP. Use together cautiously.
Lithium: May increase lithium excretion, decreasing its effect. Monitor lithium level.
Methenamine: May reduce methenamine effect. Avoid using together.
Primidone: May decrease serum and urine primidone levels. Monitor patient closely.
Salicylates: May cause accumulation and toxicity of acetazolamide, including CNS depression and metabolic acidosis. Monitor patient for toxicity.
Drug-lifestyle. Sun exposure: May increase risk of photosensitivity reactions. Advise patient to avoid excessive sunlight exposure.
EFFECTS ON LAB TEST RESULTS
• May increase uric acid level. May decrease potassium and hemoglobin levels and hematocrit.
• May decrease WBC and platelet counts.
• May decrease iodine uptake by the thyroid in hyperthyroid and euthyroid patients. May cause false-positive urine protein test result.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug and in those with hyponatremia or hypokalemia, renal or hepatic disease or dysfunction, renal calculi, adrenal gland failure, hyperchloremic acidosis, or severe pulmonary obstruction.
• Contraindicated in those receiving long-term treatment for chronic noncongestive angle-closure glaucoma.
• Use cautiously in patients receiving other diuretics and in those with respiratory acidosis or COPD.
NURSING CONSIDERATIONS
• Cross-sensitivity between antibacterial sulfonamides and sulfonamide-derivative diuretics such as acetazolamide has been reported.
• Monitor fluid intake and output, glucose, and electrolytes, especially potassium, bicarbonate, and chloride. When drug is used in diuretic therapy, consult prescriber and dietitian about providing a high-potassium diet.
• Monitor elderly patients closely because they are especially susceptible to excessive diuresis.
• Weigh patient daily. Rapid or excessive fluid loss may cause weight loss and hypotension.
• Diuretic effect decreases when acidosis occurs but can be reestablished by using intermittent administration schedules.
• Monitor patient for signs of hemolytic anemia (pallor, weakness, and palpitations).
• Drug may increase glucose level and cause glycosuria.
• Look alike-sound alike: Don’t confuse acetazolamide with acetaminophen or acyclovir.
PATIENT TEACHING
• Tell patient to take oral form with food to minimize GI upset.
• Tell patient not to crush, chew, or open capsules.
• Caution patient not to perform hazardous activities if adverse CNS reactions occur.
• Instruct patient to avoid prolonged exposure to sunlight because drug may cause phototoxicity.
• Instruct patient to notify prescriber of any unusual bleeding, bruising, tingling, or tremors.
acetylcysteine
a-se-teel-SIS-tay-een
Acetadote, Mucomyst
Pharmacologic class: L-cysteine derivative
Pregnancy risk category B
AVAILABLE FORMS
Solution: 10%, 20%
I.V. injection: 200 mg/ml
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Adjunct therapy for abnormal viscid or thickened mucous secretions in patients with pneumonia, bronchitis, bronchiectasis, primary amyloidosis of the lung, tuberculosis, cystic fibrosis, emphysema, atelectasis, pulmonary complications of thoracic surgery, or CV surgery
Adults and children: 1 to 2 ml 10% or 20% solution by direct instillation into trachea as often as every hour. Or, 1 to 10 ml of 20% solution or 2 to 20 ml of 10% solution by nebulization every 2 to 6 hours, p.r.n.
[black right-pointing arrowhead] Acetaminophen toxicity
Adults and children: Initially, 140 mg/kg P.O.; then 70 mg/kg P.O. every 4 hours for 17 doses (total). Or, a loading dose of 150 mg/kg I.V. over 60 minutes; then I.V. maintenance dose of 50 mg/kg infused over 4 hours, followed by 100 mg/kg infused over 16 hours.
ADMINISTRATION
P.O.
• Dilute oral dose (used for acetaminophen overdose) with cola, fruit juice, or water. Dilute 20% solution to 5% (add 3 ml of diluent to each milliliter of drug). If patient vomits within 1 hour of receiving loading or maintenance dose, repeat dose. Use diluted solution within 1 hour.
• Drug smells strongly of sulfur. Mixing oral form with juice or cola improves its taste.
• Drug delivered through nasogastric tube may be diluted with water.
• Store opened, undiluted oral solution in the refrigerator for up to 96 hours.
I.V.
• Drug may turn from a colorless liquid to a slight pink or purple color once the stopper is punctured. This color change doesn’t affect the drug.
• Drug is hyperosmolar and is compatible with D5W, half-normal saline, and sterile water for injection.
• Adjust total volume given for patients who weigh less than 40 kg or who are fluid restricted.
• For patients who weigh 40 kg (88 lb) or more, dilute loading dose in 200 ml of D5W, second dose in 500 ml, and third dose in 1,000 ml.
• For patients who weigh 25 to 40 kg (55 to 88 lb), dilute loading dose in 100 ml, second dose in 250 ml, and third dose in 500 ml.
• For patients who weigh 20 kg (44 lb), dilute loading dose in 60 ml, second dose in 140 ml, and third dose in 280 ml.
• For patients who weigh 15 kg (33 lb), dilute loading dose in 45 ml, second dose in 105 ml, and third dose in 210 ml.
• For patients who weigh 10 kg (22 lb), dilute loading dose in 30 ml, second dose in 70 ml, and third dose in 140 ml.
• Reconstituted solution is stable for 24 hours at room temperature.
• Vials contain no preservatives; discard after opening.
• Incompatibilities: Incompatible with rubber and metals, especially iron, copper, and nickel.
Inhalational
• Use plastic, glass, stainless steel, or another nonreactive metal when giving by nebulization. Hand-bulb nebulizers aren’t recommended because output is too small and particle size too large.
• Incompatibilities: Physically or chemically incompatible with inhaled
tetracyclines, erythromycin lactobionate, amphotericin B, and ampicillin sodium. If given by aerosol inhalation, nebulize these drugs separately. Iodized oil, trypsin, and hydrogen peroxide are physically incompatible with acetylcysteine; don’t add to nebulizer.
tetracyclines, erythromycin lactobionate, amphotericin B, and ampicillin sodium. If given by aerosol inhalation, nebulize these drugs separately. Iodized oil, trypsin, and hydrogen peroxide are physically incompatible with acetylcysteine; don’t add to nebulizer.
ACTION
Reduces the viscosity of pulmonary secretions by splitting disulfide linkages between mucoprotein molecular complexes. Also, restores liver stores of glutathione to treat acetaminophen toxicity.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O., I.V., inhalation | Unknown | Unknown | Unknown |
Half-life: 6¼ hours. | |||
ADVERSE REACTIONS
CNS: abnormal thinking, fever, drowsiness, gait disturbances.
CV: chest tightness, flushing, hypertension, hypotension, tachycardia.
EENT: rhinorrhea, ear pain, eye pain, pharyngitis, throat tightness.
GI: nausea, stomatitis, vomiting.
Respiratory: bronchospasm, cough, dyspnea, rhonchi.
Skin: clamminess, diaphoresis, pruritus, rash, urticaria.
Other: anaphylactoid reaction, angioedema, chills.
INTERACTIONS
Drug-drug. Activated charcoal: May limit acetylcysteine’s effectiveness. Avoid using activated charcoal before or with acetylcysteine.
EFFECTS ON LAB TEST RESULTS
None reported.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug.
• Use cautiously in elderly or debilitated patients with severe respiratory insufficiency. Use I.V. form cautiously in patients with asthma or a history of bronchospasm.
NURSING CONSIDERATIONS
• Monitor cough type and frequency.
• Alert: Monitor patient for bronchospasm, especially if he has asthma.
• Ingestion of more than 150 mg/kg of acetaminophen may cause liver toxicity. Measure acetaminophen level 4 hours after ingestion to determine risk of liver toxicity.
• Alert: Drug is used for acetaminophen overdose within 24 hours of ingestion. Start drug immediately; don’t wait for results of acetaminophen level. Give within 10 hours of acetaminophen ingestion to minimize hepatic injury.
• If you suspect acetaminophen overdose, obtain baseline AST, ALT, bilirubin, PT, BUN, creatinine, glucose, and electrolyte levels.
• Alert: Monitor patient receiving I.V. form for anaphylactoid reactions. If anaphylactoid reaction occurs, stop infusion and treat anaphylaxis. Once anaphylaxis treatment starts, restart infusion. If anaphylactoid symptoms return, stop drug. Contact the Poison Control Center at (800) 222-1222 for more information.
• Facial erythema may occur within 30 to 60 minutes of start of I.V. infusion and usually resolves without stopping infusion.
• When acetaminophen level is below toxic level according to nomogram, stop therapy.
• Look alike-sound alike: Don’t confuse acetylcysteine with acetylcholine.
• The vial stopper doesn’t contain natural rubber latex, dry natural rubber, or blends of natural rubber.
PATIENT TEACHING
• Warn patient that drug may have a foul taste or smell that may be distressing.
• For maximum effect, instruct patient to cough to clear his airway before aerosol administration.
acyclovir
ay-SYE-kloe-ver
Zovirax
acyclovir sodium
Zovirax
Pharmacologic class: synthetic purine nucleoside
Pregnancy risk category B
AVAILABLE FORMS
Capsules: 200 mg
Injection: 500 mg/vial, 1 g/vial
Suspension: 200 mg/5 ml
Tablets: 400 mg, 800 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] First and recurrent episodes of mucocutaneous herpes simplex virus (HSV-1 and HSV-2) infections in immunocompromised patients; severe first episodes of genital herpes in patients who aren’t immunocompromised
Adults and children age 12 and older: 5 mg/kg given I.V. over 1 hour every 8 hours for 7 days. Give for 5 to 7 days for severe first episode of genital herpes.
Children younger than age 12: Give 10 mg/kg I.V. over 1 hour every 8 hours for 7 days.
[black right-pointing arrowhead] First genital herpes episode
Adults: 200 mg P.O. every 4 hours while awake, five times daily; or 400 mg P.O. every 8 hours. Continue for 7 to 10 days.
[black right-pointing arrowhead] Intermittent therapy for recurrent genital herpes
Adults: 200 mg P.O. every 4 hours while awake, five times daily. Continue for 5 days. Begin therapy at first sign of recurrence.
[black right-pointing arrowhead] Long-term suppressive therapy for recurrent genital herpes
Adults: 400 mg P.O. b.i.d. for up to 12 months. Or, 200 mg P.O. three to five times daily for up to 12 months.
[black right-pointing arrowhead] Varicella (chickenpox) infections in immunocompromised patients
Adults and children age 12 and older: 10 mg/kg I.V. over 1 hour every 8 hours for 7 days. Dosage for obese patients is 10 mg/kg based on ideal body weight every 8 hours for 7 days. Don’t exceed maximum dosage equivalent of 20 mg/kg every 8 hours.
Children younger than age 12: Give 20 mg/kg I.V. over 1 hour every 8 hours for 7 days.
[black right-pointing arrowhead] Varicella infection in immunocompetent patients
Adults and children who weigh more than 40 kg (88 lb): 800 mg P.O. q.i.d. for 5 days.
Children age 2 and older, who weigh less than 40 kg: 20 mg/kg (maximum 800 mg/dose) P.O. q.i.d. for 5 days. Start therapy as soon as symptoms appear.
[black right-pointing arrowhead] Acute herpes zoster infection in immunocompetent patients
Adults and children age 12 and older: 800 mg P.O. every 4 hours five times daily for 7 to 10 days.
[black right-pointing arrowhead] Herpes simplex encephalitis
Adults and children age 12 and older: 10 mg/kg I.V. over 1 hour every 8 hours for 10 days.
Children ages 3 months to 12 years: 20 mg/kg I.V. over 1 hour every 8 hours for 10 days.
[black right-pointing arrowhead] Neonatal herpes simplex virus infection
Neonates to 3 months old: 10 mg/kg I.V. over 1 hour every 8 hours for 10 days.
Adjust-a-dose: For patients receiving the I.V. form, if creatinine clearance is 25 to 50 ml/minute, give 100% of dose every 12 hours; if clearance is 10 to 24 ml/minute, give 100% of dose every 24 hours; if clearance is less than 10 ml/minute, give 50% of dose every 24 hours.
For patients receiving the P.O. form, if normal dose is 200 mg every 4 hours five times daily and creatinine clearance is less than 10 ml/minute, give 200 mg P.O. every 12 hours. If normal dose is 400 mg every 12 hours and clearance is less than 10 ml/minute, give 200 mg every 12 hours. If normal dose is 800 mg every 4 hours five times daily and clearance is 10 to 25 ml/minute, give 800 mg every 8 hours; if clearance is less than 10 ml/minute, give 800 mg every 12 hours.
ADMINISTRATION
P.O.
• Give drug without regard for meals, but give with food if stomach irritation occurs.
• Patient should take drug as prescribed, even after he feels better.
I.V.
• Solutions concentrated at 7 mg/ml or more may cause a higher risk of phlebitis.
• Encourage fluid intake because patient must be adequately hydrated during infusion.
• Bolus injection, dehydration (decreased urine output), renal disease, and use with other nephrotoxic drugs increase the risk of renal toxicity. Don’t give by bolus injection.
• Give I.V. infusion over at least 1 hour to prevent renal tubular damage.
• Monitor intake and output, especially during the first 2 hours after administration.
• Alert: Don’t give I.M. or subcutaneously.
• Incompatibilities: Amifostine, aztreonam, biological or colloidal solutions, cefepime, cisatracurium besylate, diltiazem hydrochloride, dobutamine hydrochloride, dopamine hydrochloride, fludarabine phosphate, foscarnet sodium, gemcitabine hydrochloride, idarubicin hydrochloride, levofloxacin, meperidine hydrochloride, meropenem, morphine sulfate, ondansetron hydrochloride, parabens, piperacillin sodium and tazobactam sodium, sargramostim, tacrolimus, vinorelbine tartrate.
ACTION
Interferes with DNA synthesis and inhibits viral multiplication.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 2½ hr | Unknown |
I.V. | Immediate | Immediate | Unknown |
Half-life: 2 to 3½ hours with normal renal function; up to 19 hours with renal impairment. | |||
ADVERSE REACTIONS
CNS: headache, malaise, encephalopathic changes (including lethargy, obtundation, tremor, confusion, hallucinations, agitation, seizures, coma).
GI: nausea, vomiting, diarrhea.
GU: acute renal failure, hematuria.
Hematologic: leukopenia, thrombocytopenia, thrombocytosis.
Skin: inflammation or phlebitis at injection site, itching, rash, urticaria.
INTERACTIONS
Drug-drug. Interferon: May have synergistic effect. Monitor patient closely.
Probenecid: May increase acyclovir level. Monitor patient for possible toxicity.
Zidovudine: May cause drowsiness or lethargy. Use together cautiously.
EFFECTS ON LAB TEST RESULTS
• May increase BUN and creatinine levels.
• May decrease WBC count. May increase or decrease platelet count.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug.
• Use cautiously in patients with neurologic problems, renal disease, or dehydration, and in those receiving other nephrotoxic drugs.
• Adequate studies haven’t been done in pregnant women; use only if potential benefits outweigh risks to fetus.
NURSING CONSIDERATIONS
• In patients with renal disease or dehydration and in those taking other nephrotoxic drugs, monitor renal function.
• Encephalopathic changes are more likely to occur in patients with neurologic disorders and in those who have had neurologic reactions to cytotoxic drugs.
• Look alike-sound alike: Don’t confuse acyclovir sodium (Zovirax) with acetazolamide sodium (Diamox) vials, which may look alike.
• Look alike-sound alike: Don’t confuse Zovirax with Zyvox.
PATIENT TEACHING
• Tell patient to take drug as prescribed, even after he feels better.
• Tell patient drug is effective in managing herpes infection but doesn’t eliminate or cure it. Warn patient that drug won’t prevent spread of infection to others.
• Tell patient to avoid sexual contact while visible lesions are present.
adefovir dipivoxil
ah-DEF-oh-veer
Hepsera
Pharmacologic class: acyclic nucleotide analogue
Pregnancy risk category C
AVAILABLE FORMS
Tablets: 10 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Chronic hepatitis B infection
Adults: 10 mg P.O. once daily.
Adjust-a-dose: In patients with creatinine clearance of 20 to 49 ml/minute, give 10 mg P.O. every 48 hours. In patients with clearance of 10 to 19 ml/minute, give 10 mg P.O. every 72 hours. In patients receiving hemodialysis, give 10 mg P.O. every 7 days, after dialysis session.
ADMINISTRATION
P.O.
• Give drug without regard for meals.
ACTION
An acyclic nucleotide analogue that inhibits hepatitis B virus reverse transcription via viral DNA chain termination.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 1-4 hr | Unknown |
Half-life: Unknown. | |||
ADVERSE REACTIONS
CNS: asthenia, fever, headache.
EENT: pharyngitis, sinusitis.
GI: abdominal pain, diarrhea, dyspepsia, flatulence, nausea, vomiting.
GU: renal failure, renal insufficiency, hematuria, glycosuria.
Hepatic: hepatic failure, hepatomegaly with steatosis.
Metabolic: lactic acidosis.
Respiratory: cough.
Skin: pruritus, rash.
INTERACTIONS
Drug-drug. Ibuprofen: May increase adefovir bioavailability. Monitor patient for adverse effects.
Nephrotoxic drugs (aminoglycosides, cyclosporine, NSAIDs, tacrolimus, vancomycin): May increase risk of nephrotoxicity. Use together cautiously.
EFFECTS ON LAB TEST RESULTS
• May increase ALT, amylase, AST, CK, creatinine, and lactate levels.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to any component of the drug.
• Use cautiously in patients with renal dysfunction, in those receiving nephrotoxic drugs, and in those with known risk factors for hepatic disease.
• In elderly patients, use cautiously because they’re more likely to have decreased renal and cardiac function.
• Safety and effectiveness in children haven’t been established.
NURSING CONSIDERATIONS
• Monitor renal function, especially in patients with renal dysfunction or those taking nephrotoxic drugs.
• Alert: Patients may develop lactic acidosis and severe hepatomegaly with steatosis during treatment. Women, obese patients, and those taking antiretrovirals are at higher risk.
• Monitor hepatic function. Notify prescriber if patient develops signs or symptoms of lactic acidosis and severe hepatomegaly with steatosis. Stop drug, if needed.
• Stopping adefovir may cause severe worsening of hepatitis. Monitor hepatic function closely in patients who stop antihepatitis B therapy.
• The ideal length of treatment hasn’t been established.
• Offer patients HIV antibody testing; drug may promote resistance to antiretrovirals in patients with unrecognized or untreated HIV infection.
• For pregnant women, call the Antiretroviral Pregnancy Registry at 1-800-258-4263 to monitor fetal outcome.
PATIENT TEACHING
• Inform the patient that drug may be taken without regard to meals.
• Tell patient to immediately report weakness, muscle pain, trouble breathing, stomach pain with nausea and vomiting, dizziness, light-headedness, fast or irregular heartbeat, and feeling cold, especially in arms and legs.
• Warn patient not to stop taking this drug unless directed because it could cause hepatitis to become worse.
• Instruct woman to tell her prescriber if she becomes pregnant or is breast-feeding. It’s unknown if drug appears in breast milk. Use cautiously in breast-feeding women.
albuterol sulfate
al-BYOO-ter-ole
AccuNeb, ProAir HFA, Proventil, Proventil HFA, Ventolin, Ventolin HFA, VoSpire ER
Pharmacologic class: adrenergic
Pregnancy risk category C
AVAILABLE FORMS
Inhalation aerosol: 90 mcg/metered spray
Solution for inhalation: 0.083% (2.5 mg/3 ml), 0.5% (5 mg/ml), 0.042% (1.25 mg/3 ml), 0.021% (0.63 mg/3 ml)
Syrup: 2 mg/5 ml
Tablets: 2 mg, 4 mg
Tablets (extended-release): 4 mg, 8 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] To prevent or treat bronchospasm in patients with reversible obstructive airway disease
Tablets (extended-release)
Adults and children age 12 and older: 4 to 8 mg P.O. every 12 hours. Maximum, 32 mg daily.
Children ages 6 to 11: 4 mg P.O. every 12 hours. Maximum, 24 mg daily.
Tablets
Adults and children age 12 and older: 2 to 4 mg P.O. t.i.d. or q.i.d. Maximum, 32 mg daily.
Children ages 6 to 11: 2 mg P.O. t.i.d. or q.i.d. Maximum, 24 mg daily.
Solution for inhalation
Adults and children age 12 and older: 2.5 mg t.i.d. or q.i.d. by nebulizer, given over 5 to 15 minutes. To prepare solution, use 0.5 ml of 0.5% solution diluted with 2.5 ml of normal saline solution. Or, use 3 ml of 0.083% solution.
Children ages 2 to 12 weighing more than 15 kg (33 lb): 2.5 mg by nebulizer given over 5 to 15 minutes t.i.d. or q.i.d., with subsequent doses adjusted to response. Don’t exceed 2.5 mg t.i.d. or q.i.d.
Children ages 2 to 12 weighing 15 kg or less: 0.63 mg or 1.25 mg by nebulizer given over 5 to 15 minutes t.i.d. or q.i.d. with subsequent doses adjusted to response. Don’t exceed 2.5 mg t.i.d. or q.i.d.
Syrup
Adults and children older than age 14: 2 to 4 mg (1 to 2 tsp) P.O. t.i.d. or q.i.d. Maximum, 32 mg daily.
Children ages 6 to 13: 2 mg (1 tsp) P.O. t.i.d. or q.i.d. Maximum, 24 mg daily.
Children ages 2 to 5: Initially, 0.1 mg/kg P.O. t.i.d. Starting dose shouldn’t exceed 2 mg (1 tsp) t.i.d. Maximum, 12 mg daily.
Adjust-a-dose: For elderly patients and those sensitive to sympathomimetic amines, 2 mg P.O. t.i.d. or q.i.d. as oral tablets or syrup. Maximum, 32 mg daily
Inhalation aerosol
Adults and children age 4 and older: 1 to 2 inhalations every 4 to 6 hours as needed. Regular use for maintenance therapy to control asthma symptoms isn’t recommended.
[black right-pointing arrowhead] To prevent exercise-induced bronchospasm
Adults and children age 4 and older: 2 inhalations using the inhalation aerosol 15 minutes before exercise; up to 12 inhalations may be taken in 24 hours.
ADMINISTRATION
P.O.
• When switching patient from regular to extended-release tablets, remember that a regular 2-mg tablet every 6 hours is equivalent to an extended-release 4-mg tablet every 12 hours.
• Give drug whole; don’t break or crush extended-release tablets or mix them with food.
Inhalational
• If more than 1 inhalation is ordered, wait at least 2 minutes between inhalations.
• Use spacer device to improve drug delivery, if appropriate.
• Shake the inhaler before use.
ACTION
Relaxes bronchial, uterine, and vascular smooth muscle by stimulating beta2 receptors.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | 15-30 min | 2-3 hr | 4-8 hr |
P.O. (extended) | Unknown | 6 hr | 12 hr |
Inhalation | 5-15 min | 30-120 min | 2-6 hr |
Half-life: About 4 hours. | |||
ADVERSE REACTIONS
CNS: tremor, nervousness, headache, hyperactivity, insomnia, dizziness, weakness, CNS stimulation, malaise.
CV: tachycardia, palpitations, hypertension.
EENT: dry and irritated nose and throat with inhaled form, nasal congestion, epistaxis, hoarseness.
GI: nausea, vomiting, heartburn, anorexia, altered taste, increased appetite.
Metabolic: hypokalemia.
Musculoskeletal: muscle cramps.
Respiratory: bronchospasm, cough, wheezing, dyspnea, bronchitis, increased sputum.
Other: hypersensitivity reactions.
INTERACTIONS
Drug-drug. CNS stimulants: May increase CNS stimulation. Avoid using together.
Digoxin: May decrease digoxin level. Monitor digoxin level closely.
MAO inhibitors, tricyclic antidepressants: May increase adverse CV effects. Monitor patient closely.
Propranolol and other beta blockers: May cause mutual antagonism. Monitor patient carefully.
EFFECTS ON LAB TEST RESULTS
• May decrease potassium level.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or its ingredients.
• Use cautiously in patients with CV disorders (including coronary insufficiency and hypertension), hyperthyroidism, or diabetes mellitus and in those who are unusually responsive to adrenergics.
• Use extended-release tablets cautiously in patients with GI narrowing.
NURSING CONSIDERATIONS
• Drug may decrease sensitivity of spirometry used for diagnosis of asthma.
• Syrup contains no alcohol or sugar and may be taken by children as young as age 2.
• In children, syrup may rarely cause erythema multiforme or Stevens-Johnson syndrome.
• The HFA form uses the propellant hydrofluoroalkane (HFA) instead of chlorofluorocarbons.
• Alert: Patient may use tablets and aerosol together. Monitor these patients closely for signs and symptoms of toxicity.
• Look alike-sound alike: Don’t confuse albuterol with atenolol or Albutein.
PATIENT TEACHING
• Warn patient about risk of paradoxical bronchospasm and to stop drug immediately if it occurs.
• Teach patient to perform oral inhalation correctly. Give the following instructions for using the MDI:
– Shake the inhaler.
– Clear nasal passages and throat.
– Breathe out, expelling as much air from lungs as possible.
– Place mouthpiece well into mouth, seal lips around mouthpiece, and inhale deeply as you release a dose from inhaler. Or, hold inhaler about 1 inch (two fingerwidths) from open mouth; inhale while dose is released.
– Hold breath for several seconds, remove mouthpiece, and exhale slowly.
• If prescriber orders more than 1 inhalation, tell patient to wait at least 2 minutes before repeating procedure.
• Tell patient that use of a spacer device may improve drug delivery to lungs.
• If patient is also using a corticosteroid inhaler, instruct him to use the
bronchodilator first and then to wait about 5 minutes before using the corticosteroid. This lets the bronchodilator open the air passages for maximal effectiveness of the corticosteroid.
bronchodilator first and then to wait about 5 minutes before using the corticosteroid. This lets the bronchodilator open the air passages for maximal effectiveness of the corticosteroid.
• Tell patient to remove canister and wash inhaler with warm, soapy water at least once a week.
• Advise patient to contact prescriber if using more than 4 inhalations per day for 2 or more days or more than one canister in 8 weeks.
• Advise patient not to chew or crush extended-release tablets or mix them with food.
SAFETY ALERT!
alprazolam
al-PRAH-zoe-lam
Apo-Alpraz†, Apo-Alpraz TS†, Niravam, Novo-Alprazol†, Xanax, Xanax XR
Pharmacologic class: benzodiazepine
Pregnancy risk category D Controlled substance schedule IV
AVAILABLE FORMS
Oral solution: 1 mg/ml (concentrate)
Orally disintegrating tablets (ODTs): 0.25 mg, 0.5 mg, 1 mg, 2 mg
Tablets: 0.25 mg, 0.5 mg, 1 mg, 2 mg
Tablets (extended-release): 0.5 mg, 1 mg, 2 mg, 3 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Anxiety
Adults: Usual first dose, 0.25 to 0.5 mg P.O. t.i.d. Maximum, 4 mg daily in divided doses.
Elderly patients: Usual first dose, 0.25 mg P.O. b.i.d. or t.i.d. Maximum, 4 mg daily in divided doses.
[black right-pointing arrowhead] Panic disorders
Adults: 0.5 mg P.O. t.i.d., increased at intervals of 3 to 4 days in increments of no more than 1 mg. Maximum, 10 mg daily in divided doses. If using extended-release tablets, start with 0.5 to 1 mg P.O. once daily. Increase by no more than 1 mg every 3 to 4 days. Maximum daily dose is 10 mg.
Adjust-a-dose: For debilitated patients or those with advanced hepatic disease, usual first dose is 0.25 mg P.O. b.i.d. or t.i.d. Maximum, 4 mg daily in divided doses.
ADMINISTRATION
P.O.
• Don’t break or crush extended-release tablets.
• Mix oral solution with liquids or semisolid food, such as water, juices, carbonated beverages, applesauce, and puddings. Use only calibrated dropper provided with this product.
• Use dry hands to remove ODTs from bottle. Discard cotton from inside bottle.
• Discard unused portion if breaking scored ODT.
ACTION
Unknown. Probably potentiates the effects of GABA, depresses the CNS, and suppresses the spread of seizure activity.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 1-2 hr | Unknown |
P.O. (extended-release) | Unknown | Unknown | Unknown |
Half-life: Immediate-release, 12 to 15 hours; extended-release, 11 to 16 hours. | |||
ADVERSE REACTIONS
CNS: insomnia, irritability, dizziness, headache, anxiety, confusion, drowsiness, light-headedness, sedation, somnolence, difficulty speaking, impaired coordination, memory impairment, fatigue, depression, suicide, mental impairment, ataxia, paresthesia, dyskinesia, hypoesthesia, lethargy, decreased or increased libido, vertigo, malaise, tremor, nervousness, restlessness, agitation, nightmare, syncope, akathisia, mania.
CV: palpitations, chest pain, hypotension.
EENT: sore throat, allergic rhinitis, blurred vision, nasal congestion.
GI: diarrhea, dry mouth, constipation, nausea, increased or decreased appetite, anorexia, vomiting, dyspepsia, abdominal pain.
GU: dysmenorrhea, sexual dysfunction, premenstrual syndrome, difficulty urinating.
Metabolic: increased or decreased weight.
Musculoskeletal: arthralgia, myalgia, arm or leg pain, back pain, muscle rigidity, muscle cramps, muscle twitch.
Respiratory: upper respiratory tract infection, dyspnea, hyperventilation.
Skin: pruritus, increased sweating, dermatitis.
Other: influenza, injury, emergence of anxiety between doses, dependence, feeling warm.
INTERACTIONS
Drug-drug. Anticonvulsants, antidepressants, antihistamines, barbiturates, benzodiazepines, general anesthetics, narcotics, phenothiazines: May increase CNS depressant effects. Avoid using together.
Azole antifungals (including fluconazole, itraconazole, ketoconazole, miconazole): May increase and prolong alprazolam level, CNS depression, and psychomotor impairment. Avoid using together.
Carbamazepine, propoxyphene: May induce alprazolam metabolism and may reduce therapeutic effects. May need to increase dose.
Cimetidine, fluoxetine, fluvoxamine, hormonal contraceptives, nefazodone: May increase alprazolam level. Use cautiously together, and consider alprazolam dosage reduction.
Tricyclic antidepressants: May increase levels of these drugs. Monitor patient closely.
Drug-herb. Kava, valerian root: May increase sedation. Discourage use together.
St. John’s wort: May decrease drug level. Discourage use together.
Drug-food. Grapefruit juice: May increase drug level. Discourage use together.
Drug-lifestyle. Alcohol use: May cause additive CNS effects. Discourage use together.
Smoking: May decrease effectiveness of drug. Monitor patient closely.
EFFECTS ON LAB TEST RESULTS
• May increase ALT and AST levels.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other benzodiazepines and in those with acute angle-closure glaucoma.
• Use cautiously in patients with hepatic, renal, or pulmonary disease.
NURSING CONSIDERATIONS
• The optimum duration of therapy is unknown.
• Alert: Don’t withdraw drug abruptly; withdrawal symptoms, including seizures, may occur. Abuse or addiction is possible.
• Monitor hepatic, renal, and hematopoietic function periodically in patients receiving repeated or prolonged therapy.
• Look alike-sound alike: Don’t confuse alprazolam with alprostadil. Don’t confuse Xanax with Zantac or Tenex.
PATIENT TEACHING
• Warn patient to avoid hazardous activities that require alertness and good coordination until effects of drug are known.
• Tell patient to avoid use of alcohol while taking drug.
• Advise patient that smoking may decrease drug’s effectiveness.
• Warn patient not to stop drug abruptly because withdrawal symptoms or seizures may occur.
• Tell patient to swallow extended-release tablets whole.
• Tell patient using ODT to remove it from bottle using dry hands and to immediately place it on his tongue where it will dissolve and can be swallowed with saliva.
• Tell patient taking half a scored ODT to discard the unused half.
• Advise patient to discard the cotton from the bottle of ODTs and keep it tightly sealed to prevent moisture from dissolving the tablets.
SAFETY ALERT!
alteplase (tissue plasminogen activator, recombinant; t-PA)
al-ti-PLAZE
Activase, Cathflo Activase
Pharmacologic class: enzyme
Pregnancy risk category C
AVAILABLE FORMS
Cathflo Activase injection: 2-mg singlepatient vials
Injection: 50-mg (29 million international units), 100-mg (58 million international units) vials
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Lysis of thrombi obstructing coronary arteries in acute MI
3-hour infusion
Adults who weigh 65 kg (143 lb) or more: 100 mg by I.V. infusion over 3 hours, as follows: 60 mg in first hour, 6 to 10 mg of which is given as a bolus over first 1 to 2 minutes. Then 20 mg/hour infused for 2 hours.
Adults who weigh less than 65 kg: Give 1.25 mg/kg in a similar fashion (60% in first hour, 10% of which is given as a bolus; then 20% of total dose per hour for 2 hours. Don’t exceed total dose of 100 mg.
Accelerated infusion
Adults who weigh more than 67 kg (147 lb): 100 mg maximum total dose. Give 15 mg I.V. bolus over 1 to 2 minutes, followed by 50 mg infused over the next 30 minutes; then 35 mg infused over the next hour.
Adults who weigh 67 kg or less: 15 mg I.V. bolus over 1 to 2 minutes, followed by 0.75 mg/kg (not to exceed 50 mg) infused over the next 30 minutes; then 0.5 mg/kg (not to exceed 35 mg) infused over the next hour. Don’t exceed total dose of 100 mg.
[black right-pointing arrowhead] To manage acute massive pulmonary embolism
Adults: 100 mg by I.V. infusion over 2 hours. Begin heparin at end of infusion when PTT or thrombin time returns to twice normal or less. Don’t exceed 100-mg dose. Higher doses may increase risk of intracranial bleeding.
[black right-pointing arrowhead] Acute ischemic stroke
Adults: 0.9 mg/kg by I.V. infusion over 1 hour with 10% of total dose given as an initial I.V. bolus over 1 minute. Maximum total dose is 90 mg.
[black right-pointing arrowhead] To restore function to central venous access devices
Cathflo Activase
Adults and children older than age 2: For patients who weigh more than 30 kg (66 lb), instill 2 mg in 2 ml sterile water into catheter. For patients who weigh 10 kg (22 lb) to 30 kg, instill 110% of the internal lumen volume of the catheter, not to exceed 2 mg in 2 ml sterile water. After 30 minutes of dwell time, assess catheter function by aspirating blood. If function is restored, aspirate 4 ml to 5 ml of blood to remove drug and residual clot, and gently irrigate the catheter with normal saline solution. If catheter function isn’t restored after 120 minutes, instill a second dose.
[black right-pointing arrowhead] Lysis of arterial occlusion in a peripheral vessel or bypass graft ♦
Adults: 0.05 to 0.1 mg/kg/hour infused intra-arterially for 1 to 8 hours.
ADMINISTRATION
I.V.
• Immediately before use, reconstitute solution with unpreserved sterile water for injection. Check manufacturer’s labeling for specific information.
• Don’t use 50-mg vial if vacuum isn’t present; 100-mg vials don’t have a vacuum.
• Using an 18G needle, direct stream of sterile water at lyophilized cake. Don’t shake.
• Slight foaming is common. Let it settle before giving drug. Solution should be colorless or pale yellow.
• Drug may be given reconstituted (at 1 mg/ml) or diluted with an equal volume of normal saline solution or D5W to yield 0.5 mg/ml.
• Give drug using a controlled infusion device.
• Discard any unused drug after 8 hours.
Cathflo Activase
• Assess the cause of catheter dysfunction before using drug. Possible causes of occlusion include catheter malposition, mechanical failure, constriction by a suture, and lipid deposits or drug precipitates in the catheter lumen. Don’t try to suction the catheter because you risk damaging the vessel wall or collapsing a soft-walled catheter.
• Reconstitute Cathflo Activase with 2.2 ml sterile water to yield 1 mg/ml. Dissolve completely to produce a colorless to pale yellow solution.
• Don’t use excessive pressure while instilling drug into catheter; doing so could rupture the catheter or expel a clot into circulation.
• Solution is stable up to 8 hours at room temperature.
• Incompatibilities: None reported, but don’t mix with other drugs.
ACTION
Converts plasminogen to plasmin by directly cleaving peptide bonds at two sites, causing fibrinolysis.
Route | Onset | Peak | Duration |
|---|---|---|---|
I.V. | Unknown | Unknown | Unknown |
Half-life: Less than 10 minutes. | |||
ADVERSE REACTIONS
CNS: cerebral hemorrhage, fever.
CV: arrhythmias, hypotension, edema, cholesterol embolization, venous thrombosis.
GI: bleeding (Cathflo Activase), nausea, vomiting.
GU: bleeding.
Hematologic: spontaneous bleeding.
Skin: ecchymosis.
Other: anaphylaxis, sepsis (Cathflo Activase), bleeding at puncture sites, hypersensitivity reactions.
INTERACTIONS
Drug-drug. Aspirin, clopidogrel, dipyridamole, drugs affecting platelet activity (abciximab), heparin, warfarin anticoagulants: May increase risk of bleeding. Monitor patient carefully.
Nitroglycerin: May decrease alteplase antigen level. Avoid using together. If use together is unavoidable, use the lowest effective dose of nitroglycerin.
EFFECTS ON LAB TEST RESULTS
• May alter coagulation and fibrinolytic test results.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients with active internal bleeding, intracranial neoplasm, arteriovenous malformation, aneurysm, severe uncontrolled hypertension, or history or current evidence of intracranial hemorrhage, suspicion of subarachnoid hemorrhage, or seizure at onset of stroke when used for acute ischemic stroke.
• Contraindicated in patients with history of stroke, intraspinal or intracranial trauma or surgery within 2 months, or known bleeding diathesis.
• Use cautiously in patients having major surgery within 10 days (when bleeding is difficult to control because of its location); organ biopsy; trauma (including cardiopulmonary resuscitation); GI or GU bleeding; cerebrovascular disease; systolic pressure of 180 mm Hg or higher or diastolic pressure of 110 mm Hg or higher; mitral stenosis, atrial fibrillation, or other conditions that may lead to left heart thrombus; acute pericarditis or subacute bacterial endocarditis; hemostatic defects caused by hepatic or renal impairment; septic thrombophlebitis; or diabetic hemorrhagic retinopathy.
• Use cautiously in patients receiving anticoagulants, in patients age 75 and older, and during pregnancy and the first 10 days postpartum.
NURSING CONSIDERATIONS
• Alert: When used for acute ischemic stroke, give drug within 3 hours after symptoms occur and only when intracranial bleeding has been ruled out.
• Drug may be given to menstruating women.
• To recanalize occluded coronary arteries and to improve heart function, begin treatment as soon as possible after symptoms start.
• Anticoagulant and antiplatelet therapy is commonly started during or after treatment, to decrease risk of another thrombosis.
• Monitor vital signs and neurologic status carefully. Keep patient on strict bed rest.
• Coronary thrombolysis is linked with arrhythmias caused by reperfusion of ischemic myocardium. Such arrhythmias don’t differ from those commonly linked with MI. Have antiarrhythmics readily available, and carefully monitor ECG.
• Avoid invasive procedures during thrombolytic therapy. Closely monitor patient for signs of internal bleeding, and frequently check all puncture sites. Bleeding is the most common adverse effect and may occur internally and at external puncture sites.
• If uncontrollable bleeding occurs, stop infusion (and heparin) and notify prescriber.
• Avoid I.M. injections.
PATIENT TEACHING
• Explain use and administration of drug to patient and family.
• Tell patient to report adverse reactions promptly.
amantadine hydrochloride
a-MAN-ta-deen
Symmetrel
Pharmacologic class: synthetic cyclic primary amine
Pregnancy risk category C
AVAILABLE FORMS
Capsules: 100 mg
Syrup: 50 mg/5 ml
Tablets: 100 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Parkinson disease
Adults: Initially, if used as monotherapy, 100 mg P.O. b.i.d. In patients with serious illness or in those already receiving high doses of other antiparkinsonians, begin dose at 100 mg P.O. once daily. Increase to 100 mg b.i.d. if needed after at least 1 week. Some patients may benefit from 400 mg daily in divided doses.
[black right-pointing arrowhead] To prevent or treat symptoms of influenza type A virus and respiratory tract illnesses
Children age 13 or older and adults up to age 65: 200 mg P.O. daily in a single dose or 100 mg P.O. b.i.d.
Children ages 9 to 12: 100 mg P.O. b.i.d.
Children ages 1 to 8 or who weigh less than 45 kg (99 lb): 4.4 to 8.8 mg/kg P.O. as a total daily dose given once daily or divided equally b.i.d. Maximum daily dose is 150 mg.
Elderly patients: 100 mg P.O. once daily in patients older than age 65 with normal renal function.
Begin treatment within 24 to 48 hours after symptoms appear and continue for 24 to 48 hours after symptoms disappear (usually 2 to 7 days). Start prophylaxis as soon as possible after exposure and continue for at least 10 days after exposure. May continue prophylactic treatment up to 90 days for repeated or suspected exposures if influenza vaccine is unavailable. If used with influenza vaccine, continue dose for 2 to 3 weeks until antibody response to vaccine has developed.
Adjust-a-dose: For patients with creatinine clearance of 30 to 50 ml/minute, 200 mg the first day and 100 mg thereafter; if clearance is 15 to 29 ml/minute, 200 mg the first day and then 100 mg on alternate days; if clearance is less than 15 ml/minute or if patient is receiving hemodialysis, 200 mg every 7 days.
[black right-pointing arrowhead] Drug-induced extrapyramidal reactions
Adults: 100 mg P.O. b.i.d. May increase to 300 mg daily in divided doses.
ADMINISTRATION
P.O.
• Give drug without regard for food.
ACTION
May exert its antiparkinsonian effect by causing the release of dopamine in the substantia nigra. As an antiviral, may prevent release of viral nucleic acid into the host cell, reducing duration of fever and other systemic symptoms.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 1-4 hr | Unknown |
Half-life: About 24 hours; with renal dysfunction, as long as 10 days. | |||
ADVERSE REACTIONS
CNS: dizziness, insomnia, irritability, light-headedness, depression, fatigue, confusion, hallucinations, anxiety, ataxia, headache.
CV: heart failure, peripheral edema, orthostatic hypotension.
EENT: blurred vision.
GI: nausea, anorexia, constipation, vomiting, dry mouth.
Skin: livedo reticularis.
INTERACTIONS
Drug-drug. Anticholinergics: May increase anticholinergic effects. Use together cautiously; reduce dosage of anticholinergic before starting amantadine.
CNS stimulants: May increase CNS stimulation. Use together cautiously.
Co-trimoxazole, quinidine, thiazide diuretics, triamterene: May increase amantadine
level, increasing the risk of toxicity. Use together cautiously.
level, increasing the risk of toxicity. Use together cautiously.
Thioridazine: May worsen Parkinson disease tremor. Monitor patient closely.
Drug-herb. Jimsonweed: May adversely affect CV function. Discourage use together.
Drug-lifestyle. Alcohol use: May increase CNS effects, including dizziness, confusion, and orthostatic hypotension. Discourage use together.
EFFECTS ON LAB TEST RESULTS
• May increase CK, BUN, creatinine, alkaline phosphatase, LDH, bilirubin, GGT, AST, and ALT levels.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug.
• Use cautiously in elderly patients and in patients with seizure disorders, heart failure, peripheral edema, hepatic disease, mental illness, eczematoid rash, renal impairment, orthostatic hypotension, and CV disease. Monitor renal and liver function tests.
NURSING CONSIDERATIONS
• Patients with Parkinson disease who don’t respond to anticholinergics may respond to this drug.
• Begin treatment for influenza within 24 to 48 hours after symptoms appear and continue for 24 to 48 hours after symptoms disappear (usually 2 to 7 days of therapy).
• Start influenza prophylaxis as soon as possible after first exposure and continue for at least 10 days after exposure. For repeated or suspected exposures, if influenza vaccine is unavailable, may continue prophylaxis for up to 90 days. If used with influenza vaccine, continue dose for 2 to 3 weeks until antibody response to vaccine has developed.
• Alert: Elderly patients are more susceptible to adverse neurologic effects. Monitor patient for mental status changes.
• Suicidal ideation and attempts may occur in any patient, regardless of psychiatric history.
• Drug can worsen mental problems in patients with a history of psychiatric disorders or substance abuse.
• Look alike-sound alike: Don’t confuse amantadine with rimantadine.
PATIENT TEACHING
• Alert: Tell patient to take drug exactly as prescribed because not doing so may result in serious adverse reactions or death.
• If insomnia occurs, tell patient to take drug several hours before bedtime.
• If patient gets dizzy when he stands up, instruct him not to stand or change positions too quickly.
• Instruct patient to notify prescriber of adverse reactions, especially dizziness, depression, anxiety, nausea, and urine retention.
• Caution patient to avoid activities that require mental alertness until effects of drug are known.
• Encourage patient with Parkinson disease to gradually increase his physical activity as his symptoms improve.
• Advise patient to avoid alcohol while taking drug.
SAFETY ALERT!
NEW DRUGambrisentan
am-bree-SEN-tan
Pharmacologic class: endothelinreceptor antagonist
Pregnancy risk category X
AVAILABLE FORMS
Tablets: 5 mg, 10 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Pulmonary arterial hypertension in patients with World Health Organization class II (with significant exertion) or III (with mild exertion) symptoms to improve exercise tolerance and decrease rate of clinical worsening
Adults: 5 mg P.O. once daily; may increase to 10 mg P.O. once daily if tolerated.
Adjust-a-dose: Don’t start therapy in patients with elevated aminotransferase levels (ALT and AST) of more than three times the upper limit of normal (ULN) at baseline. If ALT elevations during therapy are between three and five times the ULN, remeasure. If confirmed level is in the
same range, reduce dose or stop therapy and remeasure every 2 weeks until levels are less than three times ULN. If ALT and AST are between five and eight times the ULN, stop therapy and monitor until the levels are less than three times ULN. Restart therapy with more frequent monitoring. If ALT and AST exceed eight times the ULN, stop therapy and don’t restart.
same range, reduce dose or stop therapy and remeasure every 2 weeks until levels are less than three times ULN. If ALT and AST are between five and eight times the ULN, stop therapy and monitor until the levels are less than three times ULN. Restart therapy with more frequent monitoring. If ALT and AST exceed eight times the ULN, stop therapy and don’t restart.
ADMINISTRATION
P.O.
• Give drug without regard for food.
• Give drug whole; don’t crush or split tablets.
ACTION
Blocks endothelin-1 receptors on vascular endothelin and smooth muscle. Stimulation of these receptors in smooth muscle cells is associated with vasoconstriction and PAH.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Rapid | 2 hr | Unknown |
Half-life: 9 hours. | |||
ADVERSE REACTIONS
CNS: headache.
CV: peripheral edema, flushing, palpitations.
EENT: nasal congestion, sinusitis, nasopharyngitis.
GI: abdominal pain, constipation.
Hematologic: anemia.
Hepatic: hepatic impairment.
Respiratory: dyspnea.
INTERACTIONS
Drug-drug. CYP enzyme inducers, such as carbamazepine, phenobarbital, phenytoin, and rifampin: May decrease effects of ambrisentan. Use together cautiously.
CYP enzyme inhibitors, such as atanazavir, clarithromycin, fluvoxamine, fluconazole, indinavir, itraconazole, ketoconazole, nefazodone, nelfinavir, omeprazole, ritonavir, saquinavir, telithromycin, and ticlopidine: May increase the effects of ambrisentan. Use together cautiously.
Cyclosporine: May increase ambrisentan levels. Use together cautiously and monitor patient for increased adverse effects.
EFFECTS ON LAB TEST RESULTS
• May increase AST, ALT, and bilirubin levels. May decrease hemoglobin level and hematocrit.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or its components.
• Contraindicated in pregnant women because it may harm the fetus.
• Contraindicated in those with moderate to severe hepatic impairment; don’t begin therapy in those with elevated baseline ALT and AST levels of more than three times the ULN.
• Use cautiously in those with mild hepatic impairment.
• Use cautiously in those with renal impairment; drug hasn’t been studied in those with severe renal impairment.
PATIENT TEACHING
• Inform female patient that she’ll need to have a pregnancy test done monthly and to report suspected pregnancy to her prescriber immediately.
• Alert: Teach woman of childbearing age to use two reliable birth control methods unless she has had tubal sterilization or has a Copper T 380A intrauterine device (IUD) or an LNg 20 IUD inserted.
• Tell patient that monthly blood tests will be done to monitor for adverse effects.
• Advise patient to take the pill whole and not to split, crush, or chew the tablet.
• Alert: Teach patient to notify prescriber immediately of signs or symptoms of liver injury, including anorexia, nausea, vomiting, fever, malaise, fatigue, right upper quadrant abdominal discomfort, itching, and jaundice.
• Tell the patient to report edema and weight gain.
amikacin sulfate
am-i-KAY-sin
Amikin
Pharmacologic class: aminoglycoside
Pregnancy risk category D
AVAILABLE FORMS
Injection: 50 mg/ml (pediatric) vial, 250 mg/ml vial, 250 mg/ml disposable syringe
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Serious infections caused by sensitive strains of Pseudomonas aeruginosa, Escherichia coli, Proteus, Klebsiella, or Staphylococcus
Adults and children: 15 mg/kg/day I.M. or I.V. infusion, in divided doses every 8 to 12 hours for 7 to 10 days.
Neonates: Initially, loading dose of 10 mg/kg I.V.; then 7.5 mg/kg every 12 hours for 7 to 10 days.
[black right-pointing arrowhead] Uncomplicated UTI caused by organisms not susceptible to less toxic drugs
Adults: 250 mg I.M. or I.V. b.i.d.
[black right-pointing arrowhead] Active tuberculosis, with other antituberculotics ♦
Adults and children age 15 and older: 15 mg/kg (up to 1 g) I.M. or I.V. once daily five to seven times per week for 2 to 4 months or until culture conversion. Then reduce dose to 15 mg/kg daily given two or three times weekly depending on other drugs in regimen. Patients older than age 59 may receive a reduced dose of 10 mg/kg (up to 750 mg) daily.
Children younger than age 15: Give 15 to 30 mg/kg (up to 1 g) I.M. or I.V. once daily or twice weekly.
[black right-pointing arrowhead] Mycobacterium avium complex (MAC) infection ♦
Adults: 15 mg/kg/day I.V. in divided doses every 8 to 12 hours as part of a multiple-drug regimen.
Adjust-a-dose: For adults with impaired renal function, initially, 7.5 mg/kg I.M. or I.V. Subsequent doses and frequency determined by amikacin levels and renal function studies. For adults receiving hemodialysis, give supplemental doses of 50% to 75% of initial loading dose at end of each dialysis session. Monitor drug levels and adjust dosage accordingly.
ADMINISTRATION
I.V.
• Obtain specimen for culture and sensitivity tests before giving first dose. Begin therapy while awaiting results.
• For adults, dilute I.V. drug in 100 to 200 ml of D5W or normal saline solution. For children, the amount of fluid will depend on the ordered dose.
• In adults and children, infuse over 30 to 60 minutes. In infants, infuse over 1 to 2 hours.
• After infusion, flush line with normal saline solution or D5W.
• Incompatibilities: Allopurinol, aminophylline, amphotericin B, ampicillin, azithromycin, bacitracin, cefazolin, ceftazidime, chlorothiazide sodium, cisplatin, heparin sodium, hetastarch in 0.9% sodium chloride, oxacillin, phenytoin, propofol, thiopental, vancomycin, vitamin B complex with C.
I.M.
• Obtain specimen for culture and sensitivity tests before giving first dose. Begin therapy while awaiting results.
• Obtain blood for peak level 1 hour after I.M. injection and 30 minutes to 1 hour after I.V. infusion ends; for trough levels, draw blood just before next dose. Don’t collect blood in a heparinized tube; heparin is incompatible with aminoglycosides.
ACTION
Inhibits protein synthesis by binding directly to the 30S ribosomal subunit; bactericidal.
Route | Onset | Peak | Duration |
|---|---|---|---|
I.V. | Immediate | 30 min | 8-12 hr |
I.M. | Unknown | 1 hr | 8-12 hr |
Half-life: Adults, 2 to 3 hours. Patients with severe renal damage, 30 to 86 hours. | |||
ADVERSE REACTIONS
CNS: neuromuscular blockade.
EENT: ototoxicity.
GU: azotemia, nephrotoxicity, increase in urinary excretion of casts.
Musculoskeletal: arthralgia.
Respiratory: apnea.
INTERACTIONS
Drug-drug. Acyclovir, amphotericin B, bacitracin, cephalosporins, cidofovir, cisplatin, methoxyflurane, vancomycin, other aminoglycosides: May increase nephrotoxicity. Use together cautiously, and monitor renal function test results.
Atracurium, pancuronium, rocuronium, vecuronium: May increase effects of nondepolarizing muscle relaxants, including prolonged respiratory depression. Use together only when necessary, and expect to reduce dosage of nondepolarizing muscle relaxant.
Dimenhydrinate: May mask ototoxicity symptoms. Monitor patient’s hearing.
General anesthetics: May increase neuromuscular blockade. Monitor patient for increased effects.
Indomethacin: May increase trough and peak amikacin levels. Monitor amikacin level.
I.V. loop diuretics such as furosemide: May increase ototoxicity. Use together cautiously, and monitor patient’s hearing.
Parenteral penicillins: May inactivate amikacin in vitro. Don’t mix.
EFFECTS ON LAB TEST RESULTS
• May increase BUN, creatinine, nonprotein nitrogen, and urine urea levels.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other aminoglycosides.
• Use cautiously in patients with impaired renal function or neuromuscular disorders, in neonates and infants, and in elderly patients.
NURSING CONSIDERATIONS
• Alert: Evaluate patient’s hearing before and during therapy if he’ll be receiving the drug for longer than 2 weeks. Notify prescriber if patient has tinnitus, vertigo, or hearing loss.
• Weigh patient and review renal function studies before therapy begins.
• Correct dehydration before therapy because of increased risk of toxicity.
• Peak drug levels more than 35 mcg/ml and trough levels more than 10 mcg/ml may be linked to a higher risk of toxicity.
• Alert: Monitor renal function: urine output, specific gravity, urinalysis, BUN and creatinine levels, and creatinine clearance. Report to prescriber evidence of declining renal function.
• Watch for signs and symptoms of superinfection (especially of upper respiratory tract), such as continued fever, chills, and increased pulse rate.
• Alert: Neuromuscular blockage and respiratory paralysis have been reported after aminoglycoside administration. Monitor patient closely.
• Therapy usually continues for 7 to 10 days. If no response occurs after 3 to 5 days, stop therapy and obtain new specimens for culture and sensitivity testing.
• Look alike-sound alike: Don’t confuse Amikin with Amicar. Don’t confuse amikacin with anakinra.
PATIENT TEACHING
• Instruct patient to promptly report adverse reactions to prescriber.
• Encourage patient to maintain adequate fluid intake.
amlodipine besylate
am-LOE-di-peen
Norvasc
Pharmacologic class: calcium channel blocker
Pregnancy risk category C
AVAILABLE FORMS
Tablets: 2.5 mg, 5 mg, 10 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Chronic stable angina, vasospastic angina (Prinzmetal’s or variant angina)
Adults: Initially, 5 to 10 mg P.O. daily. Most patients need 10 mg daily.
Elderly patients: Initially, 5 mg P.O. daily.
Adjust-a-dose: For patients who are small or frail or have hepatic insufficiency, initially, 5 mg P.O. daily.
[black right-pointing arrowhead] Hypertension
Adults: Initially, 2.5 to 5 mg P.O. daily. Dosage adjusted according to patient response and tolerance. Maximum daily dose is 10 mg.
Elderly patients: Initially, 2.5 mg P.O. daily.
Adjust-a-dose: For patients who are small or frail, are taking other antihypertensives, or have hepatic insufficiency, initially, 2.5 mg P.O. daily.
ADMINISTRATION
P.O.
• Give drug without regard for food.
ACTION
Inhibits calcium ion influx across cardiac and smooth-muscle cells, dilates coronary arteries and arterioles, and decreases blood pressure and myocardial oxygen demand.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 6-12 hr | 24 hr |
Half-life: 30 to 50 hours. | |||
ADVERSE REACTIONS
CNS: headache, somnolence, fatigue, dizziness, light-headedness, paresthesia.
CV: edema, flushing, palpitations.
GI: nausea, abdominal pain.
GU: sexual difficulties.
Musculoskeletal: muscle pain.
Respiratory: dyspnea.
Skin: rash, pruritus.
INTERACTIONS
None reported.
EFFECTS ON LAB TEST RESULTS
None reported.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug.
• Use cautiously in patients receiving other peripheral vasodilators, especially those with severe aortic stenosis, and in those with heart failure. Because drug is metabolized by the liver, use cautiously and in reduced dosage in patients with severe hepatic disease.
NURSING CONSIDERATIONS
• Alert: Monitor patient carefully. Some patients, especially those with severe obstructive coronary artery disease, have developed increased frequency, duration, or severity of angina or acute MI after initiation of calcium channel blocker therapy or at time of dosage increase.
• Monitor blood pressure frequently during initiation of therapy. Because drug-induced vasodilation has a gradual onset, acute hypotension is rare.
• Notify prescriber if signs of heart failure occur, such as swelling of hands and feet or shortness of breath.
• Alert: Abrupt withdrawal of drug may increase frequency and duration of chest pain. Taper dose gradually under medical supervision.
• Look alike-sound alike: Don’t confuse amlodipine with amiloride.
PATIENT TEACHING
• Caution patient to continue taking drug, even when he feels better.
• Tell patient S.L. nitroglycerin may be taken as needed when angina symptoms are acute. If patient continues nitrate therapy during adjustment of amlodipine dosage, urge continued compliance.
amoxicillin and clavulanate potassium (amoxycillin and clavulanate potassium)
a-mox-i-SILL-in
Aclavulanate†, Amoxiclav†, Augmentin, Augmentin ES-600, Augmentin XR, Clavamoxin†, Clavulin†
Pharmacologic class: aminopenicillin and beta-lactamase inhibitor
Pregnancy risk category B
AVAILABLE FORMS
Oral suspension: 125 mg amoxicillin trihydrate and 31.25 mg clavulanic acid/5 ml (after reconstitution); 200 mg amoxicillin trihydrate and 28.5 mg clavulanic acid/5 ml (after reconstitution); 250 mg amoxicillin trihydrate and 62.5 mg clavulanic acid/5 ml (after reconstitution); 400 mg amoxicillin trihydrate and 57 mg clavulanic acid/5 ml (after reconstitution); 600 mg amoxicillin trihydrate and 42.9 mg clavulanic acid/5 ml (after reconstitution)
Tablets (chewable): 125 mg amoxicillin trihydrate, 31.25 mg clavulanic acid;
200 mg amoxicillin trihydrate, 28.5 mg clavulanic acid; 250 mg amoxicillin trihydrate, 62.5 mg clavulanic acid; 400 mg amoxicillin trihydrate, 57 mg clavulanic acid
200 mg amoxicillin trihydrate, 28.5 mg clavulanic acid; 250 mg amoxicillin trihydrate, 62.5 mg clavulanic acid; 400 mg amoxicillin trihydrate, 57 mg clavulanic acid
Tablets (extended-release): 1,000 mg amoxicillin trihydrate, 62.5 mg clavulanic acid
Tablets (film-coated): 250 mg amoxicillin trihydrate, 125 mg clavulanic acid; 500 mg amoxicillin trihydrate, 125 mg clavulanic acid; 875 mg amoxicillin trihydrate, 125 mg clavulanic acid
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Recurrent or persistent acute otitis media caused by Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis in patients exposed to antibiotics within the previous 3 months, who are 2 years old or younger or in day care facilities
Children age 3 months and older: 90 mg/kg/day Augmentin ES-600 P.O., based on amoxicillin component, every 12 hours for 10 days.
[black right-pointing arrowhead] Lower respiratory tract infections, otitis media, sinusitis, skin and skin-structure infections, and UTIs caused by susceptible strains of gram-positive and gram-negative organisms
Adults and children weighing 40 kg (88 lb) or more: 250 mg P.O., based on amoxicillin component, every 8 hours; or 500 mg every 12 hours. For more severe infections, 500 mg every 8 hours or 875 mg every 12 hours.
Children age 3 months and older and weighing less than 40 kg: 20 to 45 mg/kg P.O., based on amoxicillin component and severity of infection, daily in divided doses every 8 to 12 hours.
Children younger than age 3 months: 30 mg/kg/day P.O., based on amoxicillin component of the 125-mg/5-ml oral suspension, in divided doses every 12 hours.
Adjust-a-dose: Don’t give the 875-mg tablet to patients with creatinine clearance less than 30 ml/minute. If clearance is 10 to 30 ml/minute, give 250 to 500 mg P.O. every 12 hours. If clearance is less than 10 ml/minute, give 250 to 500 mg P.O. every 24 hours. Give hemodialysis patients 250 to 500 mg P.O. every 24 hours with an additional dose both during and after dialysis.
[black right-pointing arrowhead] Community-acquired pneumonia or acute bacterial sinusitis caused by H. influenzae, M. catarrhalis, H. parain-fluenzae, Klebsiella pneumoniae, methicillin-susceptible Staphylococcus aureus, or S. pneumoniae with reduced susceptibility to penicillin
Adults and children age 16 and older: 2,000 mg/125 mg Augmentin XR tablets every 12 hours for 7 to 10 days for pneumonia; 10 days for sinusitis.
Adjust-a-dose: In patients with creatinine clearance less than 30 ml/minute and patients receiving hemodialysis, don’t use Augmentin XR.
ADMINISTRATION
P.O.
• Before giving drug, ask patient about allergic reactions to penicillin. A negative history of penicillin allergy is no guarantee against an allergic reaction.
• Obtain specimen for culture and sensitivity tests before giving first dose. Begin therapy while awaiting results.
• Give drug at least 1 hour before a bacteriostatic antibiotic.
• Avoid use of 250-mg tablet in children weighing less than 40 kg (88 lb). Use chewable form instead.
• After reconstitution, refrigerate the oral suspension; discard after 10 days.
ACTION
Prevents bacterial cell-wall synthesis during replication. Increases amoxicillin’s effectiveness by inactivating beta-lactamases, which destroy amoxicillin.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 1-2½ hr | 6-8 hr |
P.O. (Augmentin ES-600) | Unknown | 1-4 hr | Unknown |
P.O. (Augmentin XR) | Unknown | 1-6 hr | Unknown |
Half-life: 1 to 1½ hours. For patients with severe renal impairment, 7½ hours for amoxicillin and 4½ hours for clavulanate. | |||
ADVERSE REACTIONS
CNS: agitation, anxiety, behavioral changes, confusion, dizziness, insomnia.
GI: nausea, vomiting, diarrhea, indigestion, gastritis, stomatitis, glossitis, black hairy tongue, enterocolitis, pseudomembranous colitis, mucocutaneous candidiasis, abdominal pain.
GU: vaginal candidiasis, vaginitis.
Hematologic: anemia, thrombocytopenia, thrombocytopenic purpura, eosinophilia, leukopenia, agranulocytosis.
Other: hypersensitivity reactions, anaphylaxis, pruritus, rash, urticaria, angioedema, overgrowth of nonsusceptible organisms, serum sickness-like reaction.
INTERACTIONS
Drug-drug. Allopurinol: May increase risk of rash. Monitor patient for rash.
Hormonal contraceptives: May decrease hormonal contraceptive effectiveness. Advise use of additional form of contraception during penicillin therapy.
Probenecid: May increase levels of amoxicillin and other penicillins. Probenecid may be used for this purpose.
Drug-herb. Khat: May decrease antimicrobial effect of certain penicillins. Discourage khat chewing, or tell patient to take amoxicillin 2 hours after khat chewing.
EFFECTS ON LAB TEST RESULTS
• May increase eosinophil count.
• May falsely decrease aminoglycoside level. May alter results of urine glucose tests that use cupric sulfate, such as Benedict’s reagent and Clinitest.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other penicillins and in those with a history of amoxicillin-related cholestatic jaundice or hepatic dysfunction.
• Augmentin XR is contraindicated in patients receiving hemodialysis and those with creatinine clearance less than 30 ml/minute.
• Use cautiously in patients with other drug allergies (especially to cephalosporins) because of possible cross-sensitivity and in those with mononucleosis because of high risk of maculopapular rash.
• Use cautiously in breast-feeding women; it’s unknown if drug appears in breast milk.
• Use cautiously in hepatically impaired patients, and monitor the hepatic function of these patients.
NURSING CONSIDERATIONS
• Each Augmentin XR tablet contains 29.3 mg (1.27 mEq) of sodium.
• Augmentin XR isn’t indicated for treating infections caused by S. pneumoniae with penicillin minimum inhibitory concentration, or MIC, of 4 mcg/ml or greater.
• If large doses are given or therapy is prolonged, bacterial or fungal superinfection may occur, especially in elderly, debilitated, or immunosuppressed patients.
• Alert: Don’t interchange the oral suspensions because of varying clavulanic acid contents.
• Augmentin ES-600 is intended only for children ages 3 months to 12 years with persistent or recurrent acute otitis media.
• Alert: Both 250- and 500-mg film-coated tablets contain the same amount of clavulanic acid (125 mg). Therefore, two 250-mg tablets aren’t equivalent to one 500-mg tablet. Regular tablets aren’t equivalent to Augmentin XR.
• This drug combination is particularly useful in clinical settings with a high prevalence of amoxicillin-resistant organisms.
• Look alike-sound alike: Don’t confuse amoxicillin with amoxapine.
PATIENT TEACHING
• Tell patient to take entire quantity of drug exactly as prescribed, even after feeling better.
• Instruct patient to take drug with food to prevent GI upset. If he’s taking the oral suspension, tell him to keep drug refrigerated, to shake it well before taking it, and to discard remaining drug after 10 days.
• Tell patient to call prescriber if a rash occurs because rash is a sign of an allergic reaction.
amoxicillin trihydrate (amoxycillin trihydrate)
a-mox-i-SILL-in
Amoxil, Apo-Amoxi†, DisperMox, Novamoxin†, Nu-Amoxi†, Trimox
Pharmacologic class: aminopenicillin
Pregnancy risk category B
AVAILABLE FORMS
Capsules: 250 mg, 500 mg
Oral suspension: 50 mg/ml (pediatric drops), 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml (after reconstitution)
Tablets (chewable): 125 mg, 200 mg, 250 mg, 400 mg
Tablets (film-coated): 500 mg, 875 mg Tablets for oral suspension: 200 mg, 400 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Mild to moderate infections of the ear, nose, and throat; skin and skin structure; or GU tract
Adults and children who weigh 40 kg (88 lb) or more: 500 mg P.O. every 12 hours or 250 mg P.O. every 8 hours.
Children older than age 3 months who weigh less than 40 kg: 25 mg/kg/day P.O. divided every 12 hours or 20 mg/kg/day P.O. divided every 8 hours.
Neonates and infants up to age 3 months: Up to 30 mg/kg/day P.O. divided every 12 hours.
[black right-pointing arrowhead] Mild to severe infections of the lower respiratory tract and severe infections of the ear, nose, and throat; skin and skin structure; or genitourinary tract
Adults and children who weigh 40 kg or more: 875 mg P.O. every 12 hours or 500 mg P.O. every 8 hours.
Children older than age 3 months weighing less than 40 kg: 45 mg/kg/day P.O. divided every 12 hours or 40 mg/kg/day P.O. divided every 8 hours.
[black right-pointing arrowhead] Uncomplicated gonorrhea
Adults and children who weigh more than 45 kg (99 lb): 3 g P.O. with 1 g probenecid given as a single dose.
Children age 2 and older who weigh less than 45 kg: 50 mg/kg to a maximum of 3 g P.O. with 25 mg/kg, to a maximum of 1 g of probenecid as a single dose. Don’t give probenecid to children younger than age 2.
[black right-pointing arrowhead] To prevent endocarditis in patients having dental, oral, or respiratory tract procedures and in moderate-risk patients undergoing GI and GU procedures ♦
Adults: 2 g P.O. 1 hour before procedure.
Children: 50 mg/kg P.O. 1 hour before procedure.
[black right-pointing arrowhead] To prevent penicillin-susceptible anthrax after exposure ♦
Adults and children older than age 9: 500 mg P.O. t.i.d. for 60 days.
Children younger than age 9: 80 mg/kg daily P.O., divided b.i.d. or t.i.d. for 60 days.
[black right-pointing arrowhead] Early Lyme disease, localized or disseminated, associated with erythema migrans, without neurologic involvement or third-degree AV heart block ♦
Adults: 500 mg P.O. t.i.d. for 14 to 21 days.
ADMINISTRATION
P.O.
• Before giving, ask patient about allergic reactions to penicillin. A negative history of penicillin allergy is no guarantee against allergic reaction.
• Obtain specimen for culture and sensitivity tests before giving first dose. Begin therapy while awaiting results.
• Give drug with or without food.
• For a child, place drops directly on child’s tongue for swallowing or add to formula, milk, fruit juice, water, ginger ale, or a cold drink for immediate and complete consumption.
• For a child taking DisperMox, mix one tablet in about 10 ml of water, have the child drink the resulting solution, rinse container with a small amount of water, and have the child drink again to ensure the whole dose is taken. Mix tablet only in water. Don’t let child chew tablets, swallow them whole, or let them dissolve in mouth.
• Store Trimox oral suspension in refrigerator, if possible. It also may be stored at room temperature for up to 2 weeks. Be sure to check individual product labels for storage information.
ACTION
Inhibits cell-wall synthesis during bacterial multiplication.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 1-2 hr | 6-8 hr |
Half-life: 1 to 1½ hours (7½ hours in severe renal impairment). | |||
ADVERSE REACTIONS
CNS: seizures, lethargy, hallucinations, anxiety, confusion, agitation, depression, dizziness, fatigue.
GI: diarrhea, nausea, pseudomembranous colitis, vomiting, glossitis, stomatitis, gastritis, enterocolitis, abdominal pain, black hairy tongue.
GU: interstitial nephritis, nephropathy, vaginitis.
Hematologic: agranulocytosis, leukopenia, thrombocytopenia, thrombocytopenic purpura, anemia, eosinophilia, hemolytic anemia.
Other: anaphylaxis, hypersensitivity reactions, overgrowth of nonsusceptible organisms.
INTERACTIONS
Drug-drug. Allopurinol: May increase risk of rash. Monitor patient for rash.
Hormonal contraceptives: May decrease contraceptive effectiveness. Advise use of additional form of contraception during penicillin therapy.
Probenecid: May increase levels of amoxicillin and other penicillins. Probenecid may be used for this purpose.
Drug-herb. Khat: May decrease antimicrobial effect of certain penicillins. Discourage herb use, or tell patient to take drug 2 hours after herb use.
EFFECTS ON LAB TEST RESULTS
• May decrease hemoglobin level.
• May increase eosinophil count. May decrease granulocyte, platelet, and WBC counts.
• May falsely decrease aminoglycoside level. May alter results of urine glucose tests that use cupric sulfate, such as Benedict’s reagent and Clinitest.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other penicillins.
• Use cautiously in patients with other drug allergies (especially to cephalosporins) because of possible cross-sensitivity.
• Use cautiously in those with mononucleosis because of high risk of maculopapular rash.
NURSING CONSIDERATIONS
• If large doses are given or if therapy is prolonged, bacterial or fungal superinfection may occur, especially in elderly, debilitated, or immunosuppressed patients.
• Amoxicillin usually causes fewer cases of diarrhea than ampicillin.
• Look alike-sound alike: Don’t confuse amoxicillin with amoxapine.
PATIENT TEACHING
• Tell patient to take entire quantity of drug exactly as prescribed, even after he feels better.
• Instruct patient to take drug with or without food.
• Tell patient to notify prescriber if rash, fever, or chills develop. A rash is the most common allergic reaction, especially if allopurinol is also being taken.
• Tell parent to place drops directly on child’s tongue for swallowing or add to formula, milk, fruit juice, water, ginger ale, or a cold drink for immediate and complete consumption.
• If child takes DisperMox, tell parent to mix one tablet in about 10 ml of water, to have the child drink the resulting solution, to rinse container with a small amount of water, and to have the child drink again to ensure the whole dose is taken. Parent should mix tablet only in water. Caution parent against allowing child to chew tablets, to swallow them whole, or to let them dissolve in mouth.
ampicillin
am-pi-SILL-in
Apo-Ampi†, Nu-Ampi†
ampicillin sodium
ampicillin trihydrate
Principen
Pharmacologic class: aminopenicillin
Pregnancy risk category B
AVAILABLE FORMS
Capsules: 250 mg, 500 mg
Injection: 250 mg, 500 mg, 1 g, 2 g
Oral suspension: 125 mg/5 ml, 250 mg/5 ml
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Respiratory tract or skin and skin-structure infections
Adults and children who weigh 40 kg (88 lb) or more: 250 to 500 mg P.O. every 6 hours.
Children who weigh less than 40 kg: 25 to 50 mg/kg/day P.O. in equally divided doses every 6 to 8 hours. Pediatric dosages shouldn’t exceed recommended adult dosages.
[black right-pointing arrowhead] GI infections or UTIs
Adults and children who weigh 40 kg (88 lb) or more: 500 mg P.O. every 6 hours. For severe infections, larger doses may be needed.
Children who weigh less than 40 kg: 50 to 100 mg/kg/day P.O. in equally divided doses every 6 hours.
[black right-pointing arrowhead] Bacterial meningitis or septicemia
Adults: 150 to 200 mg/kg/day I.V. in divided doses every 3 to 4 hours. May be given I.M. after 3 days of I.V. therapy. Maximum recommended daily dose is 14 g.
Children: 150 to 200 mg/kg I.V. daily in divided doses every 3 to 4 hours. Give I.V. for 3 days; then give I.M.
[black right-pointing arrowhead] Uncomplicated gonorrhea
Adults and children who weigh more than 45 kg (99 lb): 3.5 g P.O. with 1 g probenecid given as a single dose.
[black right-pointing arrowhead] To prevent endocarditis in patients having dental, GI, and GU procedures ♦
Adults: 2 g I.M. or I.V. within 30 minutes before procedure. For high-risk patients, also give 1.5 mg/kg gentamicin 30 minutes before the procedure; 6 hours later, give 1 g ampicillin I.M. or I.V. or 1 g amoxicillin P.O.
Children: 50 mg/kg I.M. or I.V. within 30 minutes before procedure. For high-risk patients, also give 1.5 mg/kg gentamicin 30 minutes before the procedure; 6 hours later, give 25 mg/kg ampicillin I.M. or I.V. or 25 mg/kg amoxicillin P.O.
Adjust-a-dose: In patients with creatinine clearance of 10 to 50 ml/minute, use same dose but increase dosing interval to 6 to 12 hours; for those with a clearance less than 10 ml/minute, increase dosing interval to 12 to 24 hours.
ADMINISTRATION
P.O.
• Before giving drug, ask patient about allergic reactions to penicillin. A negative history of penicillin allergy is no guarantee against a future allergic reaction.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• Give drug 1 to 2 hours before or 2 to 3 hours after meals. When given orally, drug may cause GI disturbances. Food may interfere with absorption.
• Give drug I.M. or I.V. if infection is severe or if patient can’t take oral dose.
I.V.
• Before giving drug, ask patient about allergic reactions to penicillin. A negative history of penicillin allergy is no guarantee against a future allergic reaction.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• Give drug I.M. or I.V. only if infection is severe or if patient can’t take oral dose.
• Give drug intermittently to prevent vein irritation. Change site every 48 hours.
• For direct injection, reconstitute with bacteriostatic water for injection. Use 5 ml for 250-mg or 500-mg vials, 7.4 ml for 1-g vials, and 14.8 ml for 2-g vials. Give drug over 10 to 15 minutes to avoid seizures. Don’t exceed 100 mg/minute.
• For intermittent infusion, dilute in 50 to 100 ml of normal saline solution for injection. Give drug over 15 to 30 minutes.
• Use first dilution within 1 hour. Follow manufacturer’s directions for stability data when drug is further diluted for I.V. infusion.
• Incompatibilities: Amikacin, amino acid solutions, chlorpromazine, dextran solutions, dextrose solutions, dopamine, erythromycin lactobionate, 10% fat emulsions, fructose, gentamicin, heparin sodium, hetastarch, hydrocortisone sodium succinate, hydromorphone, kanamycin, lidocaine, lincomycin, polymyxin B, prochlorperazine edisylate, sodium bicarbonate, streptomycin, tobramycin.
I.M.
• Before giving drug, ask patient about allergic reactions to penicillin. A negative history of penicillin allergy is no guarantee against a future allergic reaction.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• Give drug I.M. or I.V. only if infection is severe or if patient can’t take oral dose.
ACTION
Inhibits cell-wall synthesis during bacterial multiplication.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 2 hr | 6-8 hr |
I.V. | Immediate | Immediate | Unknown |
I.M. | Unknown | 1 hr | Unknown |
Half-life: 1 to 1½ hours (10 to 24 hours in severe renal impairment). | |||
ADVERSE REACTIONS
CNS: seizures, agitation, anxiety, confusion, depression, dizziness, hallucinations, lethargy, fatigue.
CV: thrombophlebitis, vein irritation.
GI: diarrhea, nausea, pseudomembranous colitis, abdominal pain, black hairy tongue, enterocolitis, gastritis, glossitis, stomatitis, vomiting.
GU: interstitial nephritis, nephropathy, vaginitis.
Hematologic: leukopenia, thrombocytopenia, thrombocytopenic purpura, anemia, eosinophilia, hemolytic anemia, agranulocytosis.
Skin: pain at injection site.
Other: hypersensitivity reactions, overgrowth of nonsusceptible organisms.
INTERACTIONS
Drug-drug. Allopurinol: May increase risk of rash. Monitor patient for rash.
H2 antagonists, proton pump inhibitors: May decrease ampicillin absorption and level. Separate administration times. Monitor patient for continued antibiotic effectiveness.
Hormonal contraceptives: May decrease hormonal contraceptive effectiveness. Advise use of another form of contraception during therapy.
Oral anticoagulants: May increase risk of bleeding. Monitor PT and INR.
Probenecid: May increase levels of ampicillin and other penicillins. Probenecid may be used for this purpose.
EFFECTS ON LAB TEST RESULTS
• May decrease hemoglobin level.
• May increase eosinophil count. May decrease granulocyte, platelet, and WBC counts.
• May falsely decrease aminoglycoside level. May alter results of urine glucose tests that use cupric sulfate, such as Benedict reagent and Clinitest.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other penicillins.
• Use cautiously in patients with other drug allergies (especially to cephalosporins) because of possible cross-sensitivity, and in those with mononucleosis because of high risk of maculopapular rash.
NURSING CONSIDERATIONS
• Monitor sodium level because each gram of ampicillin contains 2.9 mEq of sodium.
• If large doses are given or if therapy is prolonged, bacterial or fungal superinfection may occur, especially in elderly, debilitated, or immunosuppressed patients.
• Watch for signs and symptoms of hypersensitivity, such as erythematous maculopapular rash, urticaria, and anaphylaxis.
• In patients with impaired renal function, decrease dosage.
• In pediatric meningitis, drug may be given with parenteral chloramphenicol for 24 hours, pending cultures.
• To prevent bacterial endocarditis in patients at high risk, give drug with gentamicin.
PATIENT TEACHING
• Tell patient to take entire quantity of drug exactly as prescribed, even after he feels better.
• Instruct patient to take oral form on an empty stomach 1 hour before or 2 hours after meals.
• Inform patient to notify prescriber if rash, fever, or chills develop. A rash is the most common allergic reaction, especially if allopurinol is also being taken.
• Advise patient to report discomfort at I.V. injection site.
arformoterol tartrate
arr-fohr-MOH-tur-ahl
Brovana
Pharmacologic class: long-acting selective beta2 agonist
Pregnancy risk category C
AVAILABLE FORMS
Solution for inhalation: 15 mcg/2-ml vials
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Long-term maintenance treatment of bronchoconstriction in patients with COPD, including chronic bronchitis and emphysema
Adults: 15 mcg, inhaled b.i.d. (morning and evening) via nebulizer. Maximum dose is 30 mcg daily.
ADMINISTRATION
Inhalational
• Use only the recommended nebulizer and compressor for treatment.
• Don’t mix drugs with other drugs or solutions in the nebulizer.
• Store vials in the foil pouches in the refrigerator and use immediately after opening.
ACTION
Relaxes bronchial and cardiac smooth muscle by acting on beta2-adrenergic receptors; stimulates the enzyme adenyl cyclase, which catalyzes the conversion from ATP to cAMP. This further relaxes bronchial smooth muscle and inhibits release of mediators (like histamine and leukotrienes) from mast cells.
Route | Onset | Peak | Duration |
|---|---|---|---|
Inhalation | Rapid | 30 min | Unknown |
Half-life: 26 hours. | |||
ADVERSE REACTIONS
CV: chest pain, AV block, atrial flutter, heart failure, MI, prolonged QT interval, supraventricular tachycardia, inverted T wave, peripheral edema.
EENT: sinusitis.
GI: diarrhea.
Metabolic: hypoglycemia, hypokalemia.
Musculoskeletal: back pain, leg cramps.
Respiratory: dyspnea, pulmonary or congestion, bronchospasm.
Skin: rash.
Other: hypersensitivity reaction, pain, flu syndrome.
INTERACTIONS
Drug-drug. Aminophylline, corticosteroids (such as dexamethasone, prednisone), theophylline: May increase the risk of hypokalemia. Monitor patient’s potassium level.
Beta blockers (such as metoprolol, atenolol): May decrease effectiveness of arformoterol and increase risk of bronchospasm. Avoid using together, if possible; otherwise, use with extreme caution.
Non-potassium-sparing diuretics (such as furosemide, hydrochlorothiazide): May increase the risk of hypokalemia and ECG changes. Use cautiously together and monitor patient’s ECG and potassium level.
Other beta2 adrenergics (such as albuterol, formoterol): May cause additive effects. Avoid using together.
QT interval-prolonging drugs (such as MAO inhibitors, tricyclic antidepressants): May increase risk of ventricular arrhythmias. Use cautiously together.
EFFECTS ON LAB TEST RESULTS
• May increase PSA levels. May decrease potassium levels. May increase or decrease glucose levels.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug, formoterol, or any other components of this drug.
• Don’t use in patients with acutely deteriorating COPD.
• Use cautiously in patients with seizure disorder; thyrotoxicosis; hepatic insufficiency; preexisting cardiovascular disease, including coronary insufficiency, arrhythmias and hypertension; or in those unresponsive to sympathomimetic amines.
NURSING CONSIDERATIONS
• Drug may increase the risk of asthma-related death.
• Drug is twice as potent as formoterol inhaler.
• Alert: Make sure patient has a rescue inhaler, such as albuterol, to treat an acute asthma attack or bronchospasm.
• Alert: Notify prescriber if patient experiences decreasing control of symptoms or begins using his short-acting beta2 agonist more often.
• If paradoxical bronchospasm occurs, stop drug immediately.
• Monitor blood pressure, pulse, and ECG, as indicated.
• Look alike-sound alike: Don’t confuse Brovana (arformoterol tartrate) with Boniva (ibandronate sodium).
PATIENT TEACHING
• Tell patient to store vials in the foil pouches in the refrigerator and use immediately after opening.
• Tell patient to use only the recommended nebulizer and compressor for treatment and not to mix drug with other inhaled drugs or solutions.
• Alert: Warn patient that drug is for maintenance treatment only and shouldn’t be used to stop an asthma attack or bronchospasm. For emergency treatment, use a short-acting rescue inhaler such as albuterol.
• Educate patient using a short-acting bronchodilator on a scheduled basis, to stop scheduled use and use only for rescue therapy.
• Alert: Warn patient that serious adverse effects, including death, can occur at higher than recommended doses and not to take more inhalations than prescribed.
• Tell patient to stop drug immediately and obtain medical help if life-threatening bronchospasm, severe rash, or swelling in throat occurs.
• Inform patient that he may experience palpitations, chest pain, rapid heartbeat, tremors, or nervousness.
• Tell patient not to swallow the inhalation solution.
• Caution patient to notify prescriber if he notices a decrease in symptom control or more frequent use of his rescue inhaler.
azathioprine
ay-za-THYE-oh-preen
Azasan, Imuran
Pharmacologic class: purine antagonist
Pregnancy risk category D
AVAILABLE FORMS
Powder for injection: 100 mg
Tablets: 25 mg, 50 mg, 75 mg, 100 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Immunosuppression in kidney transplantation
Adults: Initially, 3 to 5 mg/kg P.O. or I.V. daily, usually beginning on day of transplantation. Maintained at 1 to 3 mg/kg daily based on patient response and tolerance.
Adjust-a-dose: Give drug in lower doses to patients with oliguria in the posttransplant period and in those with impaired renal function. In patients receiving allopurinol, decrease azathioprine dose to one-fourth to one-third of the usual dose.
[black right-pointing arrowhead] Severe, refractory rheumatoid arthritis
Adults: Initially, 1 mg/kg P.O. as single dose or divided into two doses. Usual dose is 50 to 100 mg. If patient response isn’t satisfactory after 6 to 8 weeks, dosage may be increased by 0.5 mg/kg daily to maximum of 2.5 mg/kg daily at
4-week intervals. Maintenance therapy should be at lowest effective dose. Attempt gradual dose reduction once the patient is stable. Reduce dosage by 0.5 mg/kg (about 25 mg daily) every 4 weeks.
4-week intervals. Maintenance therapy should be at lowest effective dose. Attempt gradual dose reduction once the patient is stable. Reduce dosage by 0.5 mg/kg (about 25 mg daily) every 4 weeks.
ADMINISTRATION
P.O.
• Give drug after meals to minimize adverse GI effects.
I.V.
• Use only in patients who can’t tolerate oral drugs.
• Reconstitute drug in 100-mg vial with 10 ml of sterile water for injection.
• Inspect for particles before use.
• Give by direct I.V. injection, or further dilute in normal saline solution for injection or D5W solution and infuse over 30 to 60 minutes.
• Incompatibilities: None reported.
ACTION
May cause variable alterations in antibody production.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O., I.V. | Unknown | Unknown | Unknown |
Half-life: About 5 hours. | |||
ADVERSE REACTIONS
CNS: fever.
GI: nausea, vomiting, anorexia, pancreatitis, steatorrhea, diarrhea, abdominal pain.
Hematologic: LEUKOPENIA, myelosuppression, macrocytic anemia, anemia, pancytopenia, THROMBOCYTOPENIA, immunosuppression.
Hepatic: hepatotoxicity, jaundice.
Musculoskeletal: arthralgia, myalgia.
Skin: rash, alopecia.
Other: infections, increased risk of neoplasia.
INTERACTIONS
Drug-drug. ACE inhibitors: May cause severe leukopenia. Monitor patient closely.
Allopurinol: May impair inactivation of azathioprine. Avoid using if possible; decrease azathioprine to one-third to onefourth usual dose.
Co-trimoxazole and other drugs that interfere with myelopoiesis: May cause severe leukopenia, especially in renal transplant patients. Use cautiously together.
Cyclosporine: May decrease cyclosporine level. Monitor cyclosporine level closely.
Warfarin: May decrease action of warfarin. Monitor patient closely.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, ALT, AST, and bilirubin levels. May decrease hemoglobin and uric acid levels.
• May decrease platelet, RBC, and WBC counts.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or its components.
• Use cautiously in patients with hepatic or renal dysfunction.
• Benefits must be weighed against risk when giving to patient with systemic viral infection, such as chickenpox or herpes zoster.
• Patients with rheumatoid arthritis previously treated with alkylating drugs, such as cyclophosphamide, chlorambucil, or melphalan, may be at risk for tumor development if treated with this drug.
NURSING CONSIDERATIONS
• To prevent bleeding, avoid all I.M. injections when platelet count is below 100,000/mm3.
• Monitor CBC and platelet counts weekly for 1 month and then twice monthly. Notify prescriber if counts drop suddenly or become dangerously low. Drug may need to be temporarily withheld.
• Watch for early signs and symptoms of hepatotoxicity (such as clay-colored stools, dark urine, pruritus, and yellow skin and sclera) and for increased alkaline phosphatase, bilirubin, AST, and ALT levels.
• Therapeutic response usually occurs within 8 weeks. Patients not improved after 12 weeks can be considered refractory to treatment.
• Look alike-sound alike: Don’t confuse azathioprine with Azulfidine or azatadine. Don’t confuse Imuran with Inderal.
PATIENT TEACHING
• Warn patient to report even mild infections (colds, fever, sore throat, malaise),
because drug is a potent immunosuppressant.
because drug is a potent immunosuppressant.
• Instruct patient to avoid conception during therapy and for 4 months after therapy stops.
• Warn patient that some hair thinning is possible.
• Tell patient taking drug for refractory rheumatoid arthritis that it may take up to 12 weeks to be effective.
• Advise patient to report unusual bleeding or bruising.
• Tell patient that drug may be taken with food to decrease nausea.
• Advise patient to use soft toothbrush and perform oral care cautiously.
aztreonam
AZ-tree-oh-nam
Azactam
Pharmacologic class: monobactam Pregnancy risk category B
AVAILABLE FORMS
Injection: 500-mg vials, 1-g vials, 2-g vials
INDICATIONS & DOSAGES
[black right-pointing arrowhead] UTI; septicemia; infections of lower respiratory tract, skin, and skin structures; intra-abdominal infections, surgical infections, and gynecologic infections caused by susceptible Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Enterobacter cloacae, K. oxytoca, Citrobacter species, and Serratia marcescens; respiratory infections caused by Haemophilus influenzae
Adults: 500 mg to 2 g I.V. or I.M. every 8 to 12 hours. For severe systemic or life-threatening infections, 2 g every 6 to 8 hours. Maximum dose is 8 g daily.
Children ages 9 months to 15 years: 30 mg/kg every 6 to 8 hours I.V. Maximum dose is 120 mg/kg/day.
Neonates age 1 to 4 weeks who weigh more than 2 kg (4.4 lb) ♦: 30 mg/kg I.V. every 6 hours.
Neonates age 1 to 4 weeks who weigh 2 kg or less ♦: 30 mg/kg I.V. every 8 hours.
Neonates younger than 7 days who weigh more than 2 kg ♦: 30 mg/kg I.V. every 8 hours.
Neonates younger than 7 days who weigh 2 kg or less ♦: 30 mg/kg I.V. every 12 hours.
Adjust-a-dose: For adults with a creatinine clearance of 10 to 30 ml/minute, give 1 to 2 g; then give 50% of the usual dose at usual interval. If clearance is less than 10 ml/minute, give 500 mg to 2 g; then give 25% of the usual dose at usual interval. For serious infections, add 12½% of the initial dose to maintenance doses after each hemodialysis session. For adults with alcoholic cirrhosis, decrease dose by 20% to 25%.
ADMINISTRATION
I.V.
• Obtain specimen for culture and sensitivity tests before giving first dose. Begin therapy while awaiting results.
• For direct injection, reconstitute with 6 to 10 ml of sterile water for injection and immediately shake vial vigorously.
• To give a bolus, inject drug over 3 to 5 minutes, directly into a vein or I.V. tubing.
• For infusion, reconstitute with a compatible I.V. solution to yield 20 mg/ml or less.
• Give infusions over 20 minutes to 1 hour.
• Give thawed solutions only by I.V. infusion.
• Incompatibilities: Acyclovir, amphotericin B, ampicillin sodium, azithromycin, cephradine, chlorpromazine, daunorubicin, ganciclovir, lorazepam, metronidazole, mitomycin, mitoxantrone, nafcillin, prochlorperazine, streptozocin, vancomycin.
I.M.
• To prepare I.M. injection, add at least 3 ml of one of the following solutions per gram of aztreonam: sterile water for injection, bacteriostatic water for injection, normal saline solution, or bacteriostatic normal saline solution.
• Give I.M. injections deep into a large muscle, such as the upper outer quadrant of the gluteus maximus or the side of the thigh. Give doses more than 1 g by I.V. route.
• Alert: Don’t give I.M. injection to children.
• Pain and swelling may occur at injection site.
ACTION
Inhibits bacterial cell-wall synthesis, ultimately causing cell-wall destruction; bactericidal.
Route | Onset | Peak | Duration |
|---|---|---|---|
I.V. | Unknown | Immediate | Unknown |
I.M. | Unknown | < 1 hr | Unknown |
Half-life: 2 hours. | |||
ADVERSE REACTIONS
CNS: seizures, confusion, headache, insomnia.
CV: hypotension, thrombophlebitis.
GI: pseudomembranous colitis, diarrhea, nausea, vomiting.
Hematologic: neutropenia, pancytopenia, thrombocytopenia, anemia, leukocytosis, thrombocytosis.
Skin: discomfort and swelling at I.M. injection site, rash.
Other: hypersensitivity reactions.
INTERACTIONS
Drug-drug. Aminoglycosides: May have synergistic nephrotoxic effects. Monitor renal function.
Cefoxitin, imipenem: May have antagonistic effect. Avoid using together.
Probenecid: May increase aztreonam level. Avoid using together.
EFFECTS ON LAB TEST RESULTS
• May increase ALT, AST, BUN, creatinine, and LDH levels. May decrease hemoglobin level.
• May increase PT, PTT, and INR. May decrease neutrophil and RBC counts. May increase or decrease platelet and WBC counts.
• May cause false-positive Coombs’ test result. May alter urine glucose determinations using cupric sulfate (Clinitest or Benedict reagent).
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or any of its components.
• Use cautiously in elderly patients and in those with impaired renal or hepatic function. Dosage adjustment may be needed. Monitor renal function test results.
NURSING CONSIDERATIONS
• Observe patient for signs and symptoms of superinfection.
• Alert: Because drug is ineffective against gram-positive and anaerobic organisms, combine it with other antibiotics for immediate treatment of life-threatening illnesses.
• Alert: Patients allergic to penicillins or cephalosporins may not be allergic to this drug. Monitor closely those who have had an immediate hypersensitivity reaction to these antibiotics, especially to ceftazidime.
PATIENT TEACHING
• Warn patient receiving I.M. drug that pain and swelling may occur at injection site.
• Tell patient to report discomfort at I.V. insertion site.
• Instruct patient to report adverse reactions and signs and symptoms of superinfection promptly.
beclomethasone dipropionate
be-kloe-METH-a-sone
QVAR
Pharmacologic class: glucocorticoid Pregnancy risk category C
AVAILABLE FORMS
Oral inhalation aerosol: 40 mcg/metered spray, 80 mcg/metered spray
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Chronic asthma
Adults and children age 12 and older: Starting dose, 40 to 80 mcg b.i.d. when previously used bronchodilators alone, or 40 to 160 mcg b.i.d. when previously used inhaled corticosteroids. Maximum, 320 mcg b.i.d.
Children ages 5 to 12: Give 40 mcg b.i.d., up to 80 mcg b.i.d.
ADMINISTRATION
Inhalational
• Prime the inhaler before first use by depressing canister twice into the air.
• Allow 1 minute to elapse between inhalations.
ACTION
May decrease inflammation by decreasing the number and activity of inflammatory cells, inhibiting bronchoconstrictor mechanisms producing direct smooth-muscle relaxation, and decreasing airway hyperresponsiveness.
Route | Onset | Peak | Duration |
|---|---|---|---|
Inhalation | 1-4 wk | Unknown | Unknown |
Half-life: 2.8 hours. | |||
ADVERSE REACTIONS
EENT: hoarseness, throat irritation, fungal infection of throat.
GI: fungal infection of mouth, dry mouth.
Respiratory: bronchospasm, cough, wheezing.
Other: angioedema, facial edema, hypersensitivity reactions, adrenal insufficiency, suppression of hypothalamic-pituitary-adrenal function.
INTERACTIONS
None significant.
EFFECTS ON LAB TEST RESULTS
None reported.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or its ingredients and in those with status asthmaticus, nonasthmatic bronchial diseases, or asthma controlled by bronchodilators or other noncorticosteroids alone.
• Use cautiously, if at all, in patients with tuberculosis, fungal or bacterial infections, ocular herpes simplex, or systemic viral infections.
• Use cautiously in patients receiving systemic corticosteroid therapy.
NURSING CONSIDERATIONS
• Check mucous membranes frequently for signs and symptoms of fungal infection.
• During times of stress (trauma, surgery, or infection), systemic corticosteroids may be needed to prevent adrenal insufficiency in previously corticosteroid-dependent patients.
• Periodic measurement of growth and development may be needed during high-dose or prolonged therapy in children.
• Alert: Taper oral corticosteroid therapy slowly. Acute adrenal insufficiency and death may occur in patients with asthma who change abruptly from oral corticosteroids to beclomethasone.
PATIENT TEACHING
• Tell patient to prime the inhaler before first use, or after 10 days of not using it, by depressing canister twice into the air.
• Inform patient that drug doesn’t relieve acute asthma attacks.
• Tell patient who needs a bronchodilator to use it several minutes before beclomethasone.
• Instruct patient to carry or wear medical identification indicating his need for supplemental systemic corticosteroids during stress.
• Advise patient to allow 1 minute to elapse between inhalations of drug and to hold his breath for a few seconds to enhance drug action.
• Tell patient it may take up to 4 weeks to feel the full benefit of the drug.
• Tell patient to keep inhaler clean by wiping it weekly with a dry tissue or cloth; don’t get it wet.
• Advise patient to prevent oral fungal infections by gargling or rinsing his mouth with water after each use. Caution him not to swallow the water.
• Tell patient to report evidence of corticosteroid withdrawal, including fatigue, weakness, arthralgia, orthostatic hypotension, and dyspnea.
• Instruct patient to store drug at 77° F (25° C). Advise patient to ensure delivery of proper dose by gently warming canister to room temperature before using.
benzonatate
ben-ZOE-na-tate
Tessalon, Tessalon Perles
Pharmacologic class: local anesthetic Pregnancy risk category C
AVAILABLE FORMS
Capsules: 100 mg, 200 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Symptomatic relief of cough
Adults and children older than age 10: Give 100 to 200 mg P.O. t.i.d.; up to 600 mg daily.
ADMINISTRATION
P.O.
• Protect drug from light and moisture.
ACTION
Chemical relative of tetracaine that suppresses the cough reflex by direct action on the cough center in the medulla and through an anesthetic action on stretch receptors of vagal afferent fibers in the respiratory passages, lungs, and pleura.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | 15-20 min | Unknown | 3-8 hr |
Half-life: Unknown. | |||
ADVERSE REACTIONS
CNS: dizziness, headache, sedation.
EENT: nasal congestion, burning sensation in eyes.
GI: nausea, constipation, GI upset.
Other: chills, hypersensitivity reactions.
INTERACTIONS
None significant.
EFFECTS ON LAB TEST RESULTS
None reported.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or related compounds.
• Use cautiously in patients hypersensitive to PABA anesthetics (procaine, tetracaine) because cross-sensitivity reactions may occur.
NURSING CONSIDERATIONS
• Don’t use drug when cough is a valuable diagnostic sign or is beneficial (such as after thoracic surgery).
• Monitor cough type and frequency.
• Use with percussion and chest vibration.
PATIENT TEACHING
• Warn patient not to chew capsules or dissolve in mouth, which produces either local anesthesia that may result in aspiration, or CNS stimulation that may cause restlessness, tremor, and seizures.
• Instruct patient to report adverse reactions.
• Instruct patient to protect drug from light and moisture.
• Tell patient to contact his prescriber if cough lasts longer than 1 week, recurs frequently, or is accompanied by high fever, rash, or severe headache.
beractant (natural lung surfactant)
ber-AK-tant
Survanta
Pharmacologic class: bovine lung extract
Pregnancy risk category NR
AVAILABLE FORMS
Suspension for intratracheal instillation: 25 mg/ml
INDICATIONS & DOSAGES
[black right-pointing arrowhead] To prevent respiratory distress syndrome (RDS), also known as hyaline membrane disease, in premature neonates weighing 1,250 g (2 lb, 12 ounces) or less at birth, or having symptoms consistent with surfactant deficiency
Neonates: 4 ml/kg intratracheally. Divide each dose into four quarter-doses and give each quarter-dose with infant in a different position to ensure even distribution of drug; between quarter-doses, use a handheld resuscitation bag at 60 breaths/minute and sufficient oxygen to prevent cyanosis.
Give drug as soon as possible, preferably within 15 minutes of birth. Repeat in 6 hours if respiratory distress continues. Give no more than four doses in 48 hours.
[black right-pointing arrowhead] Rescue treatment of RDS in premature infants
Neonates: 4 ml/kg intratracheally; before giving, increase ventilator rate to 60 breaths/minute with an inspiratory time of 0.5 second and a fraction of inspired oxygen of 1. Divide each dose into four quarter-doses and give each quarter-dose with infant in a different position to ensure even distribution of drug; between quarter-doses, continue mechanical ventilation for at least 30 seconds or until stable.
Give dose as soon as RDS is confirmed by X-ray, preferably within 8 hours of birth. Repeat in 6 hours if respiratory distress continues. Give no more than four doses in 48 hours.
ADMINISTRATION
Inhalational
• Refrigerate at 36° to 46° F (2° to 8° C). Warm before use by allowing drug to stand at room temperature for at least 20 minutes or by holding in hand for at least 8 minutes. Don’t use artificial warming methods. Unopened vials that have been warmed to room temperature may be returned to the refrigerator within 24 hours; however, warm and return drug to the refrigerator only once. Vials are for single use only; discard unused drug.
• Beractant doesn’t need sonication or reconstitution before use. Inspect contents before giving; make sure color is off-white to light brown and that contents are uniform. If settling occurs, swirl vial gently; don’t shake. Some foaming is normal.
• Use a 20G or larger needle to draw up drug; don’t use a filter. Give drug using a #5 French end-hole catheter. Premeasure and shorten catheter before use. Fill catheter with beractant and discard excess drug so that only total dose to be given remains in the syringe. Insert catheter into neonate’s endotracheal tube; make sure catheter tip protrudes just beyond end of tube above neonate’s carina. Don’t instill drug into a mainstream bronchus.
• Even distribution of drug is important. Give each dose in four quarter-doses, with each quarter-dose being given over 2 to 3 seconds and with the patient positioned differently after each use. Between giving quarter-doses, remove the catheter and ventilate the patient. Give the first quarter-dose with the patient’s head and body inclined slightly downward, and the head turned to the right. Give the second quarter-dose with the head turned to the left. Then, incline the head and body slightly upward with the head turned to the right to give the third quarter-dose. Turn the head to the left for the fourth quarter-dose.
ACTION
Lowers alveolar surface tension during respiration and stabilizes alveoli against collapse. Drug contains neutral lipids, fatty acids, surfactant-related proteins, and phospholipids that mimic naturally occurring surfactant.
Route | Onset | Peak | Duration |
|---|---|---|---|
Intratracheal | 30-120 min | Unknown | 2-3 days |
Half-life: Unknown. | |||
ADVERSE REACTIONS
CV: TRANSIENT BRADYCARDIA, hypotension, vasoconstriction.
Respiratory: apnea, endotracheal tube reflux or blockage, decreased oxygen saturation, hypercapnia, hypocapnia.
Skin: pallor.
INTERACTIONS
None significant.
EFFECTS ON LAB TEST RESULTS
None reported.
CONTRAINDICATIONS & CAUTIONS
• In infants who weigh less than 600 g at birth or more than 1,750 g at birth, use hasn’t been studied.
NURSING CONSIDERATIONS
• Only staff experienced in treating clinically unstable premature neonates, including neonatal intubation and airway management, should give drug.
• Accurate weight determination is essential for proper measurement of dosage.
• Continuously monitor neonate before, during, and after giving beractant. The endotracheal tube may be suctioned before giving drug; allow neonate to stabilize before proceeding with administration.
• Immediately after giving, moist breath sounds and crackles can occur. Don’t suction the neonate for 1 hour unless he has other signs or symptoms of airway obstruction.
• Continuous monitoring of ECG and transcutaneous oxygen saturation are essential; frequent arterial blood pressure monitoring and frequent arterial blood gas sampling are highly desirable.
• Transient bradycardia and oxygen desaturation are common after dosing.
• Alert: Drug can rapidly affect oxygenation and lung compliance. Peak ventilator inspiratory pressures may need to be adjusted if chest expansion improves substantially after drug administration. Notify prescriber and adjust immediately as directed because failing to do so may cause lung overdistention and fatal pulmonary air leakage.
• Review manufacturer’s audiovisual materials that describe dosage and usage procedures.
• Look alike-sound alike: Don’t confuse Survanta with Sufenta.
PATIENT TEACHING
• Inform parents of neonate’s need for drug, and explain drug action and use.
• Encourage parents to ask questions, and address their concerns.
SAFETY ALERT!
bevacizumab
beh-vah-SIZZ-yoo-mab
Avastin
Pharmacologic class: monoclonal antibody
Pregnancy risk category C
AVAILABLE FORMS
Solution: 25 mg/ml in 4-ml and 16-ml vials
INDICATIONS & DOSAGES
[black right-pointing arrowhead] First- or second-line treatment, with fluorouracil-based chemotherapy, for metastatic colon or rectal cancer
Adults: If used with bolus irinotecan, fluorouracil, and leucovorin (IFL) regimen, give 5 mg/kg I.V. every 14 days. If used with oxaliplatin, fluorouracil, and leucovorin (known as FOLFOX 4) regimen, give 10 mg/kg I.V. every 14 days. Infusion rate varies by patient tolerance and number of infusions.
[black right-pointing arrowhead] With carboplatin and paclitaxel as first-line treatment of unresectable, locally advanced, recurrent, or metastatic nonsquamous, non-small cell lung cancer
Adults: 15 mg/kg I.V. infusion once every 3 weeks.
ADMINISTRATION
I.V.
• Don’t freeze or shake vials.
• Dilute drug using aseptic technique. Withdraw proper dose and mix in a total volume of 100 ml normal saline solution in an I.V. bag.
• Don’t give by I.V. push or bolus.
• Give the first infusion over 90 minutes and, if tolerated, the second infusion over 60 minutes. Later infusions can be given over 30 minutes if previous infusions were tolerated.
• Discard unused portion; drug is preservative-free.
• Drug is stable 8 hours if refrigerated at 36° to 46° F (2° to 8° C) and protected from light.
• Incompatibilities: Dextrose solutions.
ACTION
A recombinant humanized vascular endothelial growth factor (VEGF) inhibitor. Because VEGF promotes angiogenesis to tumors, it may contribute to metastatic tumor growth.
Route | Onset | Peak | Duration |
|---|---|---|---|
I.V. | Unknown | Unknown | Unknown |
Half-life: About 20 days. | |||
ADVERSE REACTIONS
CNS: asthenia, dizziness, headache, abnormal gait, confusion, pain, syncope.
CV: INTRA-ABDOMINAL THROMBOSIS, hypertension, thromboembolism, deep vein thrombosis, heart failure, hypotension.
EENT: epistaxis, excess lacrimation, gum bleeding, nasal septum perforation, taste disorder, voice alteration.
GI: anorexia, constipation, diarrhea, dyspepsia, flatulence, stomatitis, vomiting, GI hemorrhage, abdominal pain, colitis, dry mouth, nausea.
GU: vaginal hemorrhage, proteinuria, urinary urgency.
Hematologic: leukopenia, neutropenia, thrombocytopenia.
Metabolic: hypokalemia, weight loss, bilirubinemia.
Musculoskeletal: myalgia.
Respiratory: HEMOPTYSIS, dyspnea, upper respiratory tract infection.
Skin: alopecia, dermatitis, discoloration, dry skin, exfoliative dermatitis, nail disorder, skin ulcer.
Other: decreased wound healing, hypersensitivity.
INTERACTIONS
Drug-drug. Irinotecan: May increase level of irinotecan metabolite. Monitor patient.
EFFECTS ON LAB TEST RESULTS
• May increase bilirubin and urine protein levels. May decrease potassium level.
• May decrease neutrophil, platelet, and WBC counts.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients with recent hemoptysis or within 28 days after major surgery.
• Use cautiously in patients hypersensitive to drug or its components, in those who need surgery, are taking anticoagulants, or have significant CV disease.
NURSING CONSIDERATIONS
• Alert: Reversible posterior leukoencephalopathy syndrome (RPLS)-associated symptoms (hypertension, headache, visual disturbances, altered mental function, and seizures) may occur 16 hours to 1 year after starting the drug. Monitor patient closely. If syndrome occurs, stop drug and provide supportive care.
• RPLS can be confirmed only by MRI.
• Hypersensitivity reactions can occur during infusion. Monitor the patient closely.
• In patients who develop nephrotic syndrome, severe hypertension, hypertensive crisis, serious hemorrhage, GI perforation, or wound dehiscence that needs intervention, stop drug.
• Before elective surgery, stop drug, considering drug’s half-life is about 20 days. Don’t resume therapy until incision is fully healed.
• Alert: Drug may increase risk of serious arterial thromboembolic events including MI, TIAs, stroke, and angina. Those patients at highest risk are age 65 or older, have a history of arterial thromboembolism, and have taken the drug before. If patient has an arterial thrombotic event, permanently stop drug.
• Alert: Drug may cause fatal GI perforation. Monitor patient closely.
• Monitor urinalysis for worsening proteinuria. Patients with 2+ or greater urine dipstick test should undergo 24-hour urine collection.
• Monitor patient’s blood pressure every 2 to 3 weeks.
• It’s unknown whether drug appears in breast milk. Women shouldn’t breast-feed during therapy and for about 3 weeks after therapy ends.
• Adverse reactions occur more often in older patients.
PATIENT TEACHING
• Inform patient about potential adverse reactions.
• Tell patient to report adverse reactions immediately, especially abdominal pain, constipation, and vomiting.
• Advise patient that blood pressure and urinalysis will be monitored during treatment.
• Caution woman of childbearing age to avoid pregnancy during treatment.
• Urge patient to alert other health care providers about treatment and to avoid elective surgery during treatment.
SAFETY ALERT!
bleomycin sulfate
blee-oh-MYE-sin
Blenoxane
Pharmacologic class: cytotoxic glycopeptide antibiotic Pregnancy risk category D
AVAILABLE FORMS
Injection: 15-unit vials, 30-unit vials
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Squamous cell carcinoma (head, neck, skin, penis, cervix, and vulva), non-Hodgkin lymphoma, testicular carcinoma
Adults: 2 units or less of bleomycin for injection for the first two doses. If no acute reaction occurs, then 10 to 20 units/m2 I.V., I.M., or subcutaneously once or twice weekly to total of 400 units.
[black right-pointing arrowhead] Hodgkin lymphoma
Adults: 2 units or less of bleomycin for injection for the first two doses. If no acute reaction occurs, then 10 to 20 units/m2 I.V., I.M., or subcutaneously one or two times weekly. After 50% response, maintenance dose is 1 unit I.V. or I.M. daily or 5 units I.V. or I.M. weekly. Total cumulative dose is 400 units.
[black right-pointing arrowhead] Malignant pleural effusion
Adults: 60 units given as single-dose bolus intrapleural injection.
ADMINISTRATION
I.V.
• Preparing and giving parenteral form of drug may be mutagenic, teratogenic, and carcinogenic. Follow facility policy to reduce risks.
• Drug may adsorb to plastic I.V. bags. For prolonged infusions, use glass containers.
• Reconstitute drug with 5 or 10 ml of normal saline solution for injection to equal 3 units/ml solution.
• Use reconstituted solution within 24 hours.
• Refrigerate unopened vials containing dry powder.
• Incompatibilities: Amino acids; aminophylline; ascorbic acid injection; cefazolin; diazepam; drugs containing sulfhydryl groups; fluids containing dextrose; furosemide; hydrocortisone; methotrexate; mitomycin; nafcillin; penicillin G; riboflavin; solutions containing divalent and trivalent cations, especially calcium salts and copper; terbutaline sulfate.
I.M.
• Dilute drug in 1 to 5 ml of sterile water for injection, bacteriostatic water for injection, or normal saline solution for injection.
• Monitor injection site for irritation.
Subcutaneous
• Dilute drug in 1 to 5 ml of sterile water for injection, bacteriostatic water for injection, or normal saline solution for injection.
• Monitor injection site for irritation.
ACTION
May inhibit DNA synthesis and cause scission of single- and double-stranded DNA; also inhibits RNA and protein synthesis.
Route | Onset | Peak | Duration |
|---|---|---|---|
I.V., Subcut | Unknown | Unknown | Unknown |
I.M. | Unknown | 30-60 min | Unknown |
Half-life: 2 hours. | |||
ADVERSE REACTIONS
CNS: fever.
GI: stomatitis, anorexia, nausea, vomiting, diarrhea.
Metabolic: weight loss, hyperuricemia.
Respiratory: PNEUMONITIS, pulmonary fibrosis.
Skin: erythema, hyperpigmentation, acne, rash, striae, skin tenderness, pruritus, reversible alopecia, hyperkeratosis, nail changes.
Other: chills, anaphylactoid reactions.
INTERACTIONS
Drug-drug. Anesthesia: May increase oxygen requirements. Monitor patient closely.
Cardiac glycosides: May decrease digoxin level. Monitor digoxin level closely.
Fosphenytoin, phenytoin: May decrease phenytoin and fosphenytoin levels. Monitor drug levels closely.
EFFECTS ON LAB TEST RESULTS
• May increase uric acid level.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug.
• Use cautiously in patients with renal or pulmonary impairment.
NURSING CONSIDERATIONS
• Obtain pulmonary function tests. If tests show a marked decline, stop drug.
• Alert: Pulmonary toxicity appears to be dose-related, with an increase when total dose is more than 400 units. Give total doses of more than 400 units with caution.
• Alert: Adverse pulmonary reactions are more common in patients older than age 70. Pulmonary fibrosis is fatal in 1% of patients, especially when cumulative dosage exceeds 400 units. Also, in patients receiving radiation therapy, patients with lung disease, and patients who need oxygen therapy, pulmonary toxic adverse effects may be increased.
• Monitor chest X-ray and listen to lungs regularly.
• Obtain pulmonary function tests and chest X-rays before each course of therapy.
• Watch for fever, which may be treated with antipyretics. Fever usually occurs within 3 to 6 hours of administration.
• Alert: Watch for hypersensitivity reactions, which may be delayed for several hours, especially in patients with lymphoma. (Give test dose of 1 to 2 units before first two doses in these patients. If no reaction occurs, follow regular dosage schedule.)
• For intrapleural use, dilute 60 units of drug in 50 to 100 ml normal saline solution for injection; give drug through a thoracotomy tube.
• If patient’s condition requires sclerosis, instill drug when chest tube drainage is 100 to 300 ml/24 hours; ideally, drainage should be less than 100 ml. After instillation, clamp thoracotomy tube and move patient from his back to his left then right side for the next 4 hours. Remove clamp and reestablish suction. Amount of time chest tube is left in place after sclerosis depends on patient’s condition.
• Don’t use adhesive dressings.
PATIENT TEACHING
• Warn patient that hair loss may occur but is usually reversible.
• Tell patient to report adverse reactions promptly and to take infection-control and bleeding precautions.
• For patient who’s to receive anesthesia, tell him to inform anesthesiologist that he has taken this drug. High oxygen levels inhaled during surgery may enhance pulmonary toxicity of drug.
bosentan
bow-SEN-tan
Tracleer
Pharmacologic class: endothelinreceptor antagonist Pregnancy risk category X
AVAILABLE FORMS
Tablets: 62.5 mg, 125 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Pulmonary arterial hypertension in patients with World Health Organization class III (with mild exertion) or IV (at rest) symptoms, to improve exercise ability and decrease rate of clinical worsening
Adults: 62.5 mg P.O. b.i.d. in the morning and evening for 4 weeks. Increase to maintenance dosage of 125 mg P.O. b.i.d. in the morning and evening.
Adjust-a-dose: For patients who develop ALT and AST abnormalities, the dose may need to be decreased or the therapy stopped until ALT and AST levels return to normal. If therapy is resumed, begin with initial dose. Test levels within 3 days; then give using the following table. If liver function abnormalities are accompanied by symptoms of liver injury or if bilirubin level is at least twice the upper limit of normal (ULN), stop treatment and don’t restart. In patients who weigh less than 40 kg (88 lb), the initial and maintenance dosage is 62.5 mg b.i.d.
ADMINISTRATION
P.O.
• Give drug in morning and evening without regard for meals.
ALT and AST levels | Treatment and monitoring recommendations |
|---|---|
> 3 and < 5 times upper limit of normal (ULN) | Confirm with repeat test; if confirmed, reduce dose or interrupt treatment and retest every 2 wk. Once ALT and AST levels return to pretreatment levels, continue or reintroduce treatment at starting dose. |
> 5 and < 8 times ULN | Confirm with repeat test; if confirmed, stop treatment and retest at least every 2 wk. Once levels return to pretreatment levels, consider reintroduction of treatment. |
> 8 times ULN | Stop treatment; don’t consider restarting drug. |
ACTION
Specific and competitive antagonist for endothelin-1 (ET-1). ET-1 levels are elevated in patients with pulmonary arterial hypertension, suggesting a pathogenic role for ET-1 in this disease.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 3-5 hr | Unknown |
Half-life: About 5 hours. | |||
ADVERSE REACTIONS
CNS: headache, fatigue.
CV: edema, flushing, hypotension, palpitations.
EENT: nasopharyngitis.
GI: dyspepsia.
Hematologic: anemia.
Hepatic: HEPATOTOXICITY.
Skin: pruritus.
Other: leg edema.
INTERACTIONS
Drug-drug. Cyclosporine A: May increase bosentan level and decrease cyclosporine level. Use together is contraindicated.
Glyburide: May increase risk of elevated liver function test values and decrease levels of both drugs. Use together is contraindicated.
Hormonal contraceptives: May cause contraceptive failure. Advise use of an additional method of birth control.
Ketoconazole: May increase bosentan effect. Watch for adverse effects.
Simvastatin, other statins: May decrease levels of these drugs. Monitor cholesterol levels to assess need to adjust statin dose.
Tacrolimus: May increase bosentan levels. Use together cautiously.
EFFECTS ON LAB TEST RESULTS
• May increase liver aminotransferase level. May decrease hemoglobin level and hematocrit.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug, in pregnant patients, and in those taking cyclosporine A or glyburide.
• Generally avoid using in patients with moderate to severe liver impairment or in those with elevated aminotransferase levels greater than three times the ULN.
• Use cautiously in patients with mild liver impairment.
• Drug may harm fetus. Be sure woman isn’t pregnant before starting treatment.
• Because it’s unknown whether drug appears in breast milk, drug isn’t recommended for breast-feeding women.
• Safety and efficacy in children haven’t been established.
NURSING CONSIDERATIONS
• Use of this drug can cause serious liver injury. AST and ALT level elevations may be dose dependent and reversible, so measure these levels before treatment and monthly thereafter, adjusting dosage accordingly. If elevations are accompanied by symptoms of liver injury (nausea, vomiting, fever, abdominal pain, jaundice, or unusual lethargy or fatigue) or if bilirubin level increases by greater than twice the ULN, notify prescriber immediately.
• Fluid retention and heart failure may occur. Patient may require diuretics, fluid management, or hospitalization for decompensating heart failure.
• Monitor hemoglobin level after 1 and 3 months of therapy; then every 3 months.
• Gradually reduce dose before stopping drug.
PATIENT TEACHING
• Advise patient to take doses in the morning and evening, with or without food.
• Warn patient to avoid becoming pregnant while taking this drug. Hormonal contraceptives, including oral, implantable, and injectable methods, may not be effective when used with this drug. Advise patient to use a backup method of contraception. A monthly pregnancy test must be performed.
• Advise patient to have liver function tests and blood counts performed regularly.
budesonide
byoo-DES-oh-nide
Pulmicort Respules, Pulmicort Turbuhaler
Pharmacologic class: corticosteroid Pregnancy risk category B
AVAILABLE FORMS
Dry powder inhaler: 200 mcg/dose Inhalation suspension: 0.25 mg, 0.5 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] As a preventative in maintenance of asthma
All patients: Use lowest effective dose after stabilizing asthma.
Adults previously taking bronchodilator alone: Initially, inhaled dose of 200 to 400 mcg b.i.d. to maximum of 400 mcg b.i.d.
Adults previously taking inhaled corticosteroid: Initially, inhaled dose of 200 to 400 mcg b.i.d. to maximum of 800 mcg b.i.d.
Adults previously taking oral corticosteroid: Initially, inhaled dose of 400 to 800 mcg b.i.d. to maximum of 800 mcg b.i.d.
Children older than age 6 previously taking bronchodilator alone or inhaled corticosteroid: Initially, inhaled dose of 200 mcg b.i.d. to maximum of 400 mcg b.i.d.
Children older than age 6 previously taking oral corticosteroid: 400 mcg b.i.d., maximum.
Children ages 1 to 8: Give 0.25 mg Respules via jet nebulizer with compressor once daily. Increase to 0.5 mg daily or 0.25 mg b.i.d. in child not receiving systemic or inhaled corticosteroid or 1 mg daily or 0.5 mg b.i.d. in child receiving oral corticosteroid.
ADMINISTRATION
Inhalational
• Give inhalation suspension at regular intervals once a day or b.i.d., as directed.
• Give suspension with a jet nebulizer connected to a compressor with adequate airflow. Make sure that it’s equipped with a mouthpiece or suitable face mask.
• When aluminum foil envelope has been opened, the shelf-life of unused ampules is 2 weeks when protected from light.
ACTION
Exhibits potent glucocorticoid activity and weak mineralocorticoid activity. Drug inhibits mast cells, macrophages, and mediators (such as leukotrienes) involved in inflammation.
Route | Onset | Peak | Duration |
|---|---|---|---|
Inhalation, powder | 24 hr | 1-2 wk | Unknown |
Inhalation, Respules | 2-8 days | 4-6 wk | Unknown |
Half-life: 2 to 3 hours. | |||
ADVERSE REACTIONS
CNS: headache, asthenia, fever, hypertonia, insomnia, pain, syncope.
EENT: sinusitis, pharyngitis, rhinitis, voice alteration.
GI: abdominal pain, dry mouth, dyspepsia, gastroenteritis, nausea, oral candidiasis, taste perversion, vomiting.
Metabolic: weight gain.
Musculoskeletal: back pain, fractures, myalgia.
Respiratory: respiratory tract infection, bronchospasm, increased cough.
Skin: ecchymoses.
Other: flulike symptoms, hypersensitivity reactions.
INTERACTIONS
Drug-drug. Ketoconazole: May inhibit metabolism and increase level of budesonide. Monitor patient.
EFFECTS ON LAB TEST RESULTS
None reported.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug and in those with status asthmaticus or other acute asthma episodes.
• Use cautiously, if at all, in patients with active or inactive tuberculosis, ocular herpes simplex, or untreated systemic fungal, bacterial, viral, or parasitic infections.
NURSING CONSIDERATIONS
• When transferring from systemic corticosteroid to this drug, use caution and gradually decrease corticosteroid dose to prevent adrenal insufficiency.
• Drug doesn’t remove the need for systemic corticosteroid therapy in some situations.
• If bronchospasm occurs after use, stop therapy and treat with a bronchodilator.
• Lung function may improve within 24 hours of starting therapy, but maximum benefit may not be achieved for 1 to 2 weeks or longer.
• For Pulmicort Respules, lung function improves in 2 to 8 days, but maximum benefit may not be seen for 4 to 6 weeks.
• Watch for Candida infections of the mouth or pharynx.
• Alert: Corticosteroids may increase risk of developing serious or fatal infections in patients exposed to viral illnesses, such as chickenpox or measles.
• In rare cases, inhaled corticosteroids have been linked to increased intraocular pressure and cataract development. Stop drug if local irritation occurs.
PATIENT TEACHING
• Tell patient that budesonide inhaler isn’t a bronchodilator and isn’t intended to treat acute episodes of asthma.
• Instruct patient to use the inhaler at regular intervals because effectiveness depends on twice-daily use on a regular basis, by following these instructions:
— Keep Pulmicort Turbuhaler upright (mouthpiece on top) during loading, to provide the correct dose.
— Prime Turbuhaler when using it for the first time. To prime, hold unit upright and turn brown grip fully to the right, then fully to the left until it clicks. Repeat priming.
— Load first dose by holding unit upright and turning brown grip to the right and then to the left until it clicks.
— Turn your head away from the inhaler and breathe out.
— During inhalation, Turbuhaler must be in the upright or horizontal position.
— Don’t shake inhaler.
— Place mouthpiece between lips and inhale forcefully and deeply.
— You may not taste the drug or sense it entering your lungs, but this doesn’t mean it isn’t effective.
— Don’t exhale through the Turbuhaler. If more than one dose is required, repeat steps.
— Rinse your mouth with water and then spit out the water after each dose to decrease the risk of developing oral candidiasis.
— When 20 doses remain in the Turbuhaler, a red mark appears in the indicator window. When red mark reaches the bottom, the unit’s empty.
— Don’t use Turbuhaler with a spacer device and don’t chew or bite the mouthpiece.
— Replace mouthpiece cover after use and always keep it clean and dry.
• Tell patient that improvement in asthma control may be seen within 24 hours, although the maximum benefit may not appear for 1 to 2 weeks. If signs or symptoms worsen during this time, instruct patient to contact prescriber.
• Advise patient to avoid exposure to chickenpox or measles and to contact prescriber if exposure occurs.
• Instruct patient to carry or wear medical identification indicating need for supplementary corticosteroids during periods of stress or an asthma attack.
• Advise patient that unused Respules are good for 2 weeks after the foil envelope has been opened; however, unused Respules should be returned to the envelope to protect them from light.
• Tell patient to read and follow the patient information leaflet contained in the package.
bumetanide
byoo-MET-a-nide
Bumex
Pharmacologic class: loop diuretic Pregnancy risk category C
AVAILABLE FORMS
Injection: 0.25 mg/ml Tablets: 0.5 mg, 1 mg, 2 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Edema caused by heart failure or hepatic or renal disease
Adults: 0.5 to 2 mg P.O. once daily. If diuretic response isn’t adequate, a second or third dose may be given at 4- to 5-hour intervals. Maximum dose is 10 mg daily. May be given parenterally if oral route isn’t possible. Usual first dose is 0.5 to 1 mg given I.V. or I.M. If response isn’t adequate, a second or third dose may be given at 2- to 3-hour intervals. Maximum, 10 mg daily.
ADMINISTRATION
P.O.
• Give drug with food to minimize GI upset.
• To prevent nocturia, give drug in morning. If second dose is needed, give in early afternoon.
I.V.
• For direct injection, give drug over 1 to 2 minutes using a 21G or 23G needle.
• For intermittent infusion, give diluted drug through an intermittent infusion device or piggyback into an I.V. line containing a free-flowing, compatible solution.
• Incompatibilities: Dobutamine, fenoldopam, midazolam.
I.M.
• Document injection site.
ACTION
Inhibits sodium and chloride reabsorption in the ascending loop of Henle.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | 30-60 min | 1-2 hr | 4-6 hr |
I.V. | Within min | 15-30 min | 30-60 min |
I.M. | 40 min | Unknown | 5-6 hr |
Half-life: 1 to 1½ hours. | |||
ADVERSE REACTIONS
CNS: weakness, dizziness, headache, vertigo.
CV: orthostatic hypotension, ECG changes, chest pain.
EENT: transient deafness.
GI: nausea, vomiting, upset stomach, dry mouth, diarrhea.
GU: premature ejaculation, difficulty maintaining erection, oliguria.
Hematologic: thrombocytopenia, azotemia.
Metabolic: volume depletion and dehydration, hypokalemia, hypochloremic alkalosis, hypomagnesemia, asymptomatic hyperuricemia.
Musculoskeletal: arthritic pain, muscle cramps and pain.
Skin: rash, pruritus, diaphoresis.
INTERACTIONS
Drug-drug. Aminoglycoside antibiotics: May increase ototoxicity. Avoid using together if possible.
Antidiabetics: May decrease hypoglycemic effects. Monitor glucose level.
Antihypertensives: May increase hypotensive effects. Consider dosage adjustment.
Cardiac glycosides: May increase risk of digoxin toxicity from bumetanide-induced hypokalemia. Monitor potassium and digoxin levels.
Chlorothiazide, chlorthalidone, hydrochlorothiazide, indapamide, metolazone: May cause excessive diuretic response, causing serious electrolyte abnormalities or dehydration. Adjust doses carefully, and monitor patient closely for signs and symptoms of excessive diuretic response.
Cisplatin: May increase risk of ototoxicity. Monitor patient closely.
Lithium: May decrease lithium clearance, increasing risk of lithium toxicity. Monitor lithium level.
Neuromuscular blockers: May prolong neuromuscular blockade. Monitor patient closely.
NSAIDs, probenecid: May inhibit diuretic response. Use together cautiously.
Other potassium-wasting drugs (such as amphotericin B, corticosteroids): May increase risk of hypokalemia. Use together cautiously.
Warfarin: May increase anticoagulant effect. Use together cautiously.
Drug-herb. Dandelion: May interfere with drug activity. Discourage use together.
Licorice: May cause unexpected, rapid potassium loss. Discourage use together.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, ALT, AST, bilirubin, cholesterol, creatinine, glucose, LDH, and urine urea levels. May decrease calcium, magnesium, potassium, sodium, and chloride levels.
• May decrease platelet count.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or sulfonamides (possible cross-sensitivity) and in patients with anuria, hepatic coma, or severe electrolyte depletion.
• Use cautiously in patients with hepatic cirrhosis and ascites, in elderly patients, and in those with decreased renal function.
NURSING CONSIDERATIONS
• Safest and most effective dosage schedule is alternate days or 3 or 4 consecutive days with 1 or 2 days off between cycles.
• Monitor fluid intake and output, weight, and electrolyte, BUN, creatinine, and carbon dioxide levels frequently.
• Watch for evidence of hypokalemia, such as muscle weakness and cramps. Instruct patient to report these symptoms.
• Consult prescriber and dietitian about a high-potassium diet. Foods rich in potassium include citrus fruits, tomatoes, bananas, dates, and apricots.
• Monitor glucose level in diabetic patients.
• Monitor uric acid level, especially in patients with history of gout.
• Monitor blood pressure and pulse rate during rapid diuresis. Profound water and electrolyte depletion may occur.
• If oliguria or azotemia develops or increases, prescriber may stop drug.
• Drug can be safely used in patients allergic to furosemide; 1 mg of bumetanide equals about 40 mg of furosemide.
• Look alike-sound alike: Don’t confuse Bumex with Buprenex.
PATIENT TEACHING
• Instruct patient to take drug with food to minimize GI upset.
• Advise patient to take drug in morning to avoid need to urinate at night; if patient needs second dose, have him take it in early afternoon.
• Advise patient to avoid sudden posture changes and to rise slowly to avoid dizziness upon standing quickly.
• Instruct patient to notify prescriber about extreme thirst, muscle weakness, cramps, nausea, or dizziness.
• Instruct patient to weigh himself daily to monitor fluid status.
calfactant
kal-FAK-tant
Infasurf
Pharmacologic class: bovine lung extract Pregnancy risk category NR
AVAILABLE FORMS
Intratracheal suspension: 35 mg phospholipids and 0.65 mg proteins/ml; 6-ml vial
INDICATIONS & DOSAGES
[black right-pointing arrowhead] To prevent respiratory distress syndrome (RDS) in premature infants younger than 29 weeks’ gestational age at high risk for RDS; to treat infants younger than 72 hours of age, who develop RDS (confirmed by clinical and radiologic findings) and need an endotracheal tube (ETT)
Neonates: 3 ml/kg of body weight at birth intratracheally, given in two aliquots of 1.5 ml/kg each, every 12 hours for total of three doses.
ADMINISTRATION
Inhalational
• Suspension settles during storage. Gentle swirling or agitation of the vial is commonly needed for redispersion. Don’t shake vial. Visible flecks in the suspension and foaming at the surface are normal.
• Withdraw dose into a syringe from single-use vial using a 20G or larger needle; avoid excessive foaming.
• Give through a side-port adapter into the ETT. Make sure two medical staff are present while giving dose. Give dose in two aliquots of 1.5 ml/kg each. Place infant on one side after first aliquot and other side after second aliquot. Give while ventilation is continued over 20 to 30 breaths for each aliquot, with small bursts timed only during the inspiratory cycles. Evaluate respiratory status and reposition infant between each aliquot.
• Enter each single-use vial only once; discard unused material.
• Unopened, unused vials that have warmed to room temperature can be rerefrigerated within 24 hours for future use. Avoid repeated warming to room temperature.
• Store drug at 36° to 46° F (2° to 8° C). It isn’t necessary to warm drug before use.
ACTION
Modifies alveolar surface tension, which stabilizes the alveoli.
Route | Onset | Peak | Duration |
|---|---|---|---|
Intratracheal | Unknown | Unknown | Unknown |
Half-life: Unknown. | |||
ADVERSE REACTIONS
CV: BRADYCARDIA.
Respiratory: AIRWAY OBSTRUCTION, APNEA, cyanosis, hypoventilation.
Other: reflux of drug into ETT, dislodgment of ETT.
INTERACTIONS
None significant.
EFFECTS ON LAB TEST RESULTS
None reported
CONTRAINDICATIONS & CAUTIONS
• None known
NURSING CONSIDERATIONS
• Give drug under supervision of medical staff experienced in the acute care of neonates with respiratory failure who need intubation.
• Alert: Drug intended only for intratracheal use; to prevent RDS, give to infant as soon as possible after birth, preferably within 30 minutes.
• Monitor patient for reflux of drug into ETT, cyanosis, bradycardia, or airway obstruction during the procedure. If these occur, stop drug and take appropriate measures to stabilize infant. After infant is stable, resume drug with appropriate monitoring.
• After giving drug, carefully monitor infant so that oxygen therapy and ventilatory support can be modified in response to improvements in oxygenation and lung compliance.
PATIENT TEACHING
• Explain to parents the function of drug in preventing and treating RDS.
• Notify parents that, although infant may improve rapidly after treatment, he may continue to need intubation and mechanical ventilation.
• Notify parents of possible adverse effects of drug, including bradycardia, reflux into ETT, airway obstruction, cyanosis, dislodgment of ETT, and hypoventilation.
• Reassure parents that infant will be carefully monitored.
captopril
KAP-toe-pril
Capoten
Pharmacologic class: ACE inhibitor Pregnancy risk category C; D in 2nd and 3rd trimesters
AVAILABLE FORMS
Tablets: 12.5 mg, 25 mg, 50 mg, 100 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Hypertension
Adults: Initially, 25 mg P.O. b.i.d. or t.i.d. If dosage doesn’t control blood pressure satisfactorily in 1 or 2 weeks, increase it to 50 mg b.i.d. or t.i.d. If that dosage doesn’t
control blood pressure satisfactorily after another 1 or 2 weeks, expect to add a diuretic. If patient needs further blood pressure reduction, dosage may be raised to 150 mg t.i.d. while continuing diuretic. Maximum daily dose is 450 mg.
control blood pressure satisfactorily after another 1 or 2 weeks, expect to add a diuretic. If patient needs further blood pressure reduction, dosage may be raised to 150 mg t.i.d. while continuing diuretic. Maximum daily dose is 450 mg.
[black right-pointing arrowhead] Diabetic nephropathy
Adults: 25 mg P.O. t.i.d.
[black right-pointing arrowhead] Heart failure
Adults: Initially, 25 mg P.O. t.i.d. Patients with normal or low blood pressure who have been vigorously treated with diuretics and who may be hyponatremic or hypovolemic may start with 6.25 or 12.5 mg P.O. t.i.d.; starting dosage may be adjusted over several days. Gradually increase dosage to 50 mg P.O. t.i.d.; once patient reaches this dosage, delay further dosage increases for at least 2 weeks. Maximum dosage is 450 mg daily.
Elderly patients: Initially, 6.25 mg P.O. b.i.d. Increase gradually as needed.
[black right-pointing arrowhead] Left ventricular dysfunction after acute MI
Adults: Start therapy as early as 3 days after MI with 6.25 mg P.O. for one dose, followed by 12.5 mg P.O. t.i.d. Increase over several days to 25 mg P.O. t.i.d.; then increase to 50 mg P.O. t.i.d. over several weeks.
ADMINISTRATION
P.O.
• Give 1 hour before meals to enhance drug absorption.
ACTION
Inhibits ACE, preventing conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. Less angiotensin II decreases peripheral arterial resistance, decreasing aldosterone secretion, which reduces sodium and water retention and lowers blood pressure.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | 15-60 min | 60-90 min | 6-12 hr |
Half-life: Less than 2 hours. | |||
ADVERSE REACTIONS
CNS: dizziness, fainting, headache, malaise, fatigue, fever.
CV: tachycardia, hypotension, angina pectoris.
GI: abdominal pain, anorexia, constipation, diarrhea, dry mouth, dysgeusia, nausea, vomiting.
Hematologic: leukopenia, agranulocytosis, thrombocytopenia, pancytopenia, anemia.
Metabolic: hyperkalemia.
Respiratory: dry, persistent, nonproductive cough, dyspnea.
Skin: urticarial rash, maculopapular rash, pruritus, alopecia.
Other: angioedema.
INTERACTIONS
Drug-drug. Antacids: May decrease captopril effect. Separate dosage times.
Digoxin: May increase digoxin level by 15% to 30%. Monitor digoxin level, and observe patient for signs of digoxin toxicity.
Diuretics, other antihypertensives: May cause excessive hypotension. May need to stop diuretic or reduce captopril dosage.
Insulin, oral antidiabetics: May cause hypoglycemia when captopril therapy is started. Monitor patient closely.
Lithium: May increase lithium level; symptoms of toxicity possible. Monitor patient closely.
NSAIDs: May reduce antihypertensive effect. Monitor blood pressure.
Potassium-sparing diuretics, potassium supplements: May cause hyperkalemia. Avoid using together unless hypokalemia is confirmed.
Drug-herb. Black catechu: May cause additional hypotensive effect. Discourage use together.
Capsaicin: May worsen cough. Discourage use together.
Drug-food. Salt substitutes containing potassium: May cause hyperkalemia. Monitor patient closely.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, bilirubin, and potassium levels. May decrease hemoglobin level and hematocrit.
• May decrease granulocyte, platelet, RBC, and WBC counts.
• May cause false-positive urine acetone test results.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other ACE inhibitors.
• Use cautiously in patients with impaired renal function or serious autoimmune disease, especially systemic lupus erythematosus, and in those who have been exposed to other drugs that affect WBC counts or immune response.
NURSING CONSIDERATIONS
• Monitor patient’s blood pressure and pulse rate frequently.
• Alert: Elderly patients may be more sensitive to drug’s hypotensive effects.
• Assess patient for signs of angioedema.
• Drug causes the most frequent occurrence of cough, compared with other ACE inhibitors.
• In patients with impaired renal function or collagen vascular disease, monitor WBC and differential counts before starting treatment, every 2 weeks for the first 3 months of therapy, and periodically thereafter.
• Look alike-sound alike: Don’t confuse captopril with Capitrol.
PATIENT TEACHING
• Instruct patient to take drug 1 hour before meals; food in the GI tract may reduce absorption.
• Inform patient that light-headedness is possible, especially during first few days of therapy. Tell him to rise slowly to minimize this effect and to report occurrence to prescriber. If fainting occurs, he should stop drug and call prescriber immediately.
• Tell patient to use caution in hot weather and during exercise. Lack of fluids, vomiting, diarrhea, and excessive perspiration can lead to light-headedness and syncope.
• Advise patient to report signs and symptoms of infection, such as fever and sore throat.
• Tell women to notify prescriber if pregnancy occurs. Drug will need to be stopped.
• Urge patient to promptly report swelling of the face, lips, or mouth; or difficulty breathing.
cefaclor
SEF-ah-klor
Ceclor, Ceclor CD, Raniclor
Pharmacologic class: second-generation cephalosporin Pregnancy risk category B
AVAILABLE FORMS
Capsules: 250 mg, 500 mg
Oral suspension: 125 mg/5 ml, 187 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
Tablets (chewable): 125 mg, 187 mg, 250 mg, 375 mg
Tablets (extended-release): 375 mg, 500 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Respiratory tract infections, UTIs, skin and soft-tissue infections, and otitis media caused by Haemophilus influenzae, Streptococcus pneumoniae, S. pyogenes, Escherichia coli, Proteus mirabilis, Klebsiella species, and staphylococci
Adults: 250 to 500 mg P.O. every 8 hours. For pharyngitis or otitis media, daily dose may be given in two equally divided doses every 12 hours. For extended-release forms in bronchitis, 500 mg P.O. every 12 hours for 7 days; for extended-release forms in pharyngitis or skin and skin-structure infections, 375 mg P.O. every 12 hours for 10 days and 7 to 10 days, respectively.
Children: 20 mg/kg daily P.O. in divided doses every 8 hours. For pharyngitis or otitis media, daily dose may be given in two equally divided doses every 12 hours. In more serious infections, 40 mg/kg daily is recommended, not to exceed 1 g daily.
ADMINISTRATION
P.O.
• Before giving, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• Give drug with meals.
• Extended-release tablets shouldn’t be crushed, cut, or chewed.
• Store reconstituted suspension in refrigerator. Suspension is stable for 14 days if refrigerated. Shake well before use.
ACTION
Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 30-60 min | Unknown |
P.O. (extended) | Unknown | 1½-2½ hr | Unknown |
Half-life: ½ to 1 hour. | |||
ADVERSE REACTIONS
CNS: fever, dizziness, headache, somnolence, malaise.
GI: diarrhea, nausea, pseudomembranous colitis, vomiting, anorexia, dyspepsia, abdominal cramps, oral candidiasis.
GU: vaginal candidiasis, vaginitis.
Hematologic: thrombocytopenia, transient leukopenia, anemia, eosinophilia, lymphocytosis.
Skin: maculopapular rash, dermatitis, pruritus.
Other: anaphylaxis, hypersensitivity reactions, serum sickness.
INTERACTIONS
Drug-drug. Aminoglycosides: May increase risk of nephrotoxicity. Avoid using together.
Antacids: May decrease absorption of extended-release cefaclor if taken within 1 hour. Separate doses by 1 hour.
Anticoagulants: May increase anticoagulant effects. Monitor PT and INR.
Chloramphenicol: May cause antagonistic effect. Avoid using together.
Probenecid: May inhibit excretion and increase cefaclor level. Monitor patient for increased adverse reactions.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, ALT, AST, bilirubin, GGT, and LDH levels. May decrease hemoglobin level.
• May increase eosinophil count. May decrease platelet and WBC counts.
• May falsely increase serum or urine creatinine level in tests using Jaffe reaction. May cause false-positive results of Coombs’ test and urine glucose tests that use cupric sulfate, such as Benedict’s reagent and Clinitest.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other cephalosporins.
• Use cautiously in patients hypersensitive to penicillin because of the possibility of cross-sensitivity with other beta-lactam antibiotics.
• Use cautiously in breast-feeding women and in patients with a history of colitis or renal insufficiency.
NURSING CONSIDERATIONS
• If large doses are given, therapy is prolonged, or patient is at high risk, monitor patient for signs and symptoms of superinfection.
• Look alike-sound alike: Don’t confuse drug with other cephalosporins that sound alike.
PATIENT TEACHING
• Tell patient to take entire amount of drug exactly as prescribed, even after he feels better.
• Tell patient that drug may be taken with meals. If suspension is used, instruct him to shake container well before measuring dose and to keep the drug refrigerated.
• Advise patient to notify prescriber if rash develops or signs and symptoms of superinfection appear.
• Inform patient not to crush, cut, or chew extended-release tablets.
cefadroxil
sef-a-DROX-ill
Duricef
Pharmacologic class: firstgeneration cephalosporin Pregnancy risk category B
AVAILABLE FORMS
Capsules: 500 mg Oral suspension: 125 mg/5 ml, 250 mg/5 ml, 500 mg/5 ml Tablets: 1 g
INDICATIONS & DOSAGES
[black right-pointing arrowhead] UTIs caused by Escherichia coli, Proteus mirabilis, and Klebsiella species; skin and soft-tissue infections caused by staphylococci and streptococci; pharyngitis or tonsillitis caused by group A beta-hemolytic streptococci
Adults: 1 to 2 g P.O. daily, depending on infection being treated. Usually given once daily or in two divided doses.
Children: 30 mg/kg P.O. daily in two divided doses every 12 hours.
Adjust-a-dose: In patients with renal impairment, give first dose of 1 g. Reduce additional doses based on creatinine clearance. If clearance is 25 to 50 ml/minute, give 500 mg P.O. every 12 hours. If clearance is 10 to 25 ml/minute, give 500 mg P.O. every 24 hours; if clearance is less than 10 ml/minute, give 500 mg P.O. every 36 hours.
ADMINISTRATION
P.O.
• Before administration, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving first dose. Begin therapy while awaiting results.
• Give drug with food or milk to lessen GI discomfort.
ACTION
Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 1-2 hr | Unknown |
Half-life: About 1 to 2 hours. | |||
ADVERSE REACTIONS
CNS: seizures, fever, dizziness, headache.
GI: diarrhea, nausea, pseudomembranous colitis, vomiting, glossitis, abdominal cramps, oral candidiasis.
GU: genital pruritus, candidiasis, vaginitis, renal dysfunction.
Hematologic: transient neutropenia, leukopenia, agranulocytosis, thrombocytopenia, anemia, eosinophilia.
Respiratory: dyspnea.
Skin: maculopapular and erythematous rashes, urticaria.
Other: anaphylaxis, angioedema, hypersensitivity reactions.
INTERACTIONS
Drug-drug. Aminoglycosides: May increase risk of nephrotoxicity. Avoid using together.
Probenecid: May inhibit excretion and increase cefadroxil level. Use together cautiously.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, ALT, AST, bilirubin, GGT, and LDH levels. May decrease hemoglobin level.
• May increase eosinophil count. May decrease granulocyte, neutrophil, platelet, and WBC counts.
• May falsely increase serum or urine creatinine level in tests using Jaffe reaction. May cause false-positive results of Coombs’ test and urine glucose tests that use cupric sulfate, such as Benedict’s reagent and Clinitest.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other cephalosporins.
• Use cautiously in patients with a history of sensitivity to penicillin and in breast-feeding women.
• Use cautiously in patients with impaired renal function; adjust dosage as needed.
NURSING CONSIDERATIONS
• If creatinine clearance is less than 50 ml/minute, lengthen dosage interval so drug doesn’t accumulate. Monitor renal function in patients with renal dysfunction.
• If large doses are given, therapy is prolonged, or patient is high risk, monitor patient for superinfection.
• Look alike-sound alike: Don’t confuse drug with other cephalosporins that sound alike.
PATIENT TEACHING
• Instruct patient to take drug with food or milk to lessen GI discomfort.
• Tell patient to take entire amount of drug exactly as prescribed, even after he feels better.
• Advise patient to notify prescriber if rash develops or if signs and symptoms of superinfection appear, such as recurring fever, chills, and malaise.
cefazolin sodium
sef-AH-zoe-lin
Ancef
Pharmacologic class: firstgeneration cephalosporin Pregnancy risk category B
AVAILABLE FORMS
Infusion: 500 mg/50-ml bag, 1 g/50-ml bag Injection (parenteral): 500 mg, 1 g
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Perioperative prevention in contaminated surgery
Adults: 1 g I.M. or I.V. 30 to 60 minutes before surgery; then 0.5 to 1 g I.M. or I.V. every 6 to 8 hours for 24 hours. In operations lasting longer than 2 hours, give another 0.5- to 1-g dose I.M. or I.V. intraoperatively. Continue treatment for 3 to 5 days if life-threatening infection is likely.
[black right-pointing arrowhead] Infections of respiratory, biliary, and GU tracts; skin, soft-tissue, bone, and joint infections; septicemia; endocarditis caused by Escherichia coli, Enterobacteriaceae, gonococci, Haemophilus influenzae, Klebsiella species, Proteus mirabilis, Staphylococcus aureus, Streptococcus pneumoniae, and group A beta-hemolytic streptococci
Adults: 250 mg to 500 mg I.M. or I.V. every 8 hours for mild infections or 500 mg to 1.5 g I.M. or I.V. every 6 to 8 hours for moderate to severe or life-threatening infections. Maximum 12 g/day in life-threatening situations.
Children older than age 1 month: 25 to 50 mg/kg/day I.M. or I.V. in three or four divided doses. In severe infections, dose may be increased to 100 mg/kg/day.
Adjust-a-dose: For patients with creatinine clearance of 35 to 54 ml/minute, give full dose every 8 hours; if clearance is 11 to 34 ml/minute, give 50% of usual dose every 12 hours; if clearance is below 10 ml/minute, give 50% of usual dose every 18 to 24 hours.
ADMINISTRATION
I.V.
• Before giving first dose, obtain specimen for culture and sensitivity tests. Begin therapy while awaiting results.
• Before giving drug, ask patient if he’s allergic to penicillins or cephalosporins.
• Give commercially available frozen solutions in D5W only by intermittent or continuous I.V. infusion.
• Reconstitute drug with sterile water, bacteriostatic water, or normal saline solution as follows: Add 2 ml to 500-mg vial or 2.5 ml to 1-g vial, yielding 225 mg/ml or 330 mg/ml, respectively.
• Shake well until dissolved.
• For direct injection, further dilute with 5 ml of sterile water for injection.
• Inject into a large vein or into the tubing of a free-flowing I.V. solution over 3 to 5 minutes.
• For intermittent infusion, add reconstituted drug to 50 to 100 ml of compatible solution or use premixed solution.
• If I.V. therapy lasts longer than 3 days, alternate injection sites. Use of small I.V. needles in larger available veins may be preferable.
• Reconstituted drug is stable 24 hours at room temperature or 96 hours refrigerated.
• Incompatibilities: Aminoglycosides, amiodarone, amobarbital, ascorbic acid injection, bleomycin, calcium gluconate, cimetidine, colistimethate, hydrocortisone, idarubicin, lidocaine, norepinephrine, oxytetracycline, pentobarbital sodium, polymyxin B, ranitidine, tetracycline, theophylline, vitamin B complex with C.
I.M.
• Before giving first dose, obtain specimen for culture and sensitivity tests. Begin therapy while awaiting results.
• After reconstitution, inject drug I.M. without further dilution. This drug isn’t as painful as other cephalosporins. Give injection deep into a large muscle, such as the gluteus maximus or the side of the thigh.
ACTION
Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
Route | Onset | Peak | Duration |
|---|---|---|---|
I.V. | Immediate | Immediate | Unknown |
I.M. | Unknown | 1-2 hr | Unknown |
Half-life: About 1 to 2 hours. | |||
ADVERSE REACTIONS
CNS: seizures, headache, confusion.
CV: phlebitis, thrombophlebitis with I.V. injection.
GI: diarrhea, pseudomembranous colitis, nausea, anorexia, vomiting, glossitis, dyspepsia, abdominal cramps, anal pruritus, oral candidiasis.
GU: genital pruritus, candidiasis, vaginitis.
Hematologic: neutropenia, leukopenia, thrombocytopenia, eosinophilia.
Skin: maculopapular and erythematous rashes, urticaria, pruritus, pain, induration, sterile abscesses, tissue sloughing at injection site, Stevens-Johnson syndrome.
Other: anaphylaxis, hypersensitivity reactions, serum sickness, drug fever.
INTERACTIONS
Drug-drug. Aminoglycosides: May increase risk of nephrotoxicity. Avoid using together.
Anticoagulants: May increase anticoagulant effects. Monitor PT and INR.
Probenecid: May inhibit excretion and increase cefazolin level. Use together cautiously.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, ALT, AST, bilirubin, GGT, and LDH levels.
• May increase eosinophil count. May decrease neutrophil, platelet, and WBC counts.
• May falsely increase serum or urine creatinine level in tests using Jaffe reaction. May cause false-positive results of Coombs’ test and urine glucose tests that use cupric sulfate, such as Benedict’s reagent and Clinitest.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other cephalosporins.
• Use cautiously in patients hypersensitive to penicillin because of the possibility of cross-sensitivity with other beta-lactam antibiotics.
• Use cautiously in breast-feeding women and in patients with a history of colitis or renal insufficiency.
NURSING CONSIDERATIONS
• If creatinine clearance falls below 55 ml/minute, adjust dosage.
• If large doses are given, therapy is prolonged, or patient is at high risk, monitor patient for signs and symptoms of superinfection.
• Look alike-sound alike: Don’t confuse drug with other cephalosporins that sound alike.
PATIENT TEACHING
• Instruct patient to report adverse reactions promptly.
• Tell patient to report discomfort at I.V. injection site.
• Advise patient to notify prescriber if a rash develops or if signs and symptoms of superinfection appear, such as recurring fever, chills, and malaise.
cefdinir
sef-DIN-er
Omnicef
Pharmacologic class: thirdgeneration cephalosporin Pregnancy risk category B
AVAILABLE FORMS
Capsules: 300 mg
Suspension: 125 mg/5 ml, 250 mg/5 ml
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Mild to moderate infections caused by susceptible strains of microorganisms in community-acquired pneumonia, acute worsening of chronic bronchitis, acute maxillary sinusitis, acute bacterial otitis media, and uncomplicated skin and skin-structure infections
Adults and children age 12 and older: 300 mg P.O. every 12 hours or 600 mg P.O. every 24 hours for 10 days. Give every
12 hours for pneumonia and skin infections.
12 hours for pneumonia and skin infections.
Children ages 6 months to 12 years: 7 mg/kg P.O. every 12 hours or 14 mg/kg P.O. every 24 hours, for 10 days, up to maximum dose of 600 mg daily. Give every 12 hours for skin infections.
[black right-pointing arrowhead] Pharyngitis, tonsillitis
Adults and children age 12 and older: 300 mg P.O. every 12 hours for 5 to 10 days or 600 mg P.O. every 24 hours for 10 days.
Children ages 6 months to 12 years: 7 mg/kg P.O. every 12 hours for 5 to 10 days; or 14 mg/kg P.O. every 24 hours, for 10 days.
Adjust-a-dose: If creatinine clearance is less than 30 ml/minute, reduce dosage to 300 mg P.O. once daily for adults and 7 mg/kg up to 300 mg P.O. once daily for children. In patients receiving long-term hemodialysis, give 300 mg or 7 mg/kg P.O. at end of each dialysis session and then every other day.
ADMINISTRATION
P.O.
• Before administration, ask patient if he’s allergic to penicillins or cephalosporins.
• Give antacids and iron supplements 2 hours before or after a dose of cefdinir.
• Give drug without regard for meals.
ACTION
Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal. Some microorganisms resistant to penicillins and cephalosporins are susceptible to cefdinir. Active against a broad range of gram-positive and gram-negative aerobic microorganisms.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 2-4 hr | Unknown |
Half-life: 1¾ hours. | |||
ADVERSE REACTIONS
CNS: headache.
GI: diarrhea, pseudomembranous colitis, abdominal pain, nausea, vomiting.
GU: vaginal candidiasis, vaginitis, increased urine proteins, WBCs, and RBCs.
Skin: rash, cutaneous candidiasis.
Other: hypersensitivity reactions, anaphylaxis.
INTERACTIONS
Drug-drug. Aminoglycosides: May increase risk of nephrotoxicity. Avoid using together.
Antacids containing aluminum and magnesium, iron supplements, multivitamins containing iron: May decrease rate of absorption and bioavailability of cefdinir. Give such preparations 2 hours before or after cefdinir.
Probenecid: May inhibit renal excretion of cefdinir. Monitor patient for adverse reactions.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, GGT, and LDH levels. May decrease bicarbonate levels.
• May increase eosinophil, lymphocyte, and platelet counts.
• May falsely increase serum or urine creatinine level in tests using Jaffe reaction. May cause false-positive results of Coombs’ test and urine glucose tests that use cupric sulfate, such as Benedict’s reagent and Clinitest.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other cephalosporins.
• Use cautiously in patients hypersensitive to penicillin because of the possibility of cross-sensitivity with other beta-lactam antibiotics.
• Use cautiously in patients with history of colitis or renal insufficiency.
NURSING CONSIDERATIONS
• Prolonged drug treatment may result in emergence and overgrowth of resistant organisms. Monitor patient for signs and symptoms of superinfection.
• Pseudomembranous colitis has been reported with cefdinir and should be considered in patients with diarrhea after antibiotic therapy and in those with history of colitis.
• Look alike-sound alike: Don’t confuse drug with other cephalosporins that sound alike.
PATIENT TEACHING
• Instruct patient to take antacids and iron supplements 2 hours before or after a dose of cefdinir.
• Inform diabetic patient that each teaspoon of suspension contains 2.86 g of sucrose.
• Tell patient that drug may be taken without regard to meals.
• Tell patient to take drug as prescribed, even after he feels better.
• Advise patient to report severe diarrhea or diarrhea with abdominal pain.
• Tell patient to report adverse reactions or signs and symptoms of superinfection promptly.
cefditoren pivoxil
SEF-di-tore-en
Spectracef
Pharmacologic class: thirdgeneration cephalosporin Pregnancy risk category B
AVAILABLE FORMS
Tablets: 200 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Acute bacterial worsening of chronic bronchitis or community-acquired pneumonia caused by Haemophilus influenzae, H. parain-fluenzae, Streptococcus pneumoniae, or Moraxella catarrhalis
Adults and adolescents age 12 and older: 400 mg P.O. b.i.d. with meals for 10 days (chronic bronchitis) or 14 days (community-acquired pneumonia).
[black right-pointing arrowhead] Pharyngitis or tonsillitis caused by Streptococcus pyogenes; uncomplicated skin and skin-structure infections caused by S. pyogenes or Staphylococcus aureus
Adults and adolescents age 12 and older: 200 mg P.O. b.i.d. with meals for 10 days.
Adjust-a-dose: For patients with creatinine clearance of 30 to 49 ml/minute, don’t exceed 200 mg b.i.d. For patients with clearance less than 30 ml/minute, give 200 mg daily.
ADMINISTRATION
P.O.
• Before administration, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• Give drug with a fatty meal to increase its bioavailability.
ACTION
Adheres to bacterial penicillin-binding proteins, inhibiting cell-wall synthesis. Drug is active against many gram-positive and gram-negative organisms.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 1½-3 hr | Unknown |
Half-life: 1¼ to 2 hours. | |||
ADVERSE REACTIONS
CNS: headache.
GI: diarrhea, abdominal pain, dyspepsia, nausea, vomiting.
GU: vaginal candidiasis, hematuria.
Metabolic: hyperglycemia.
INTERACTIONS
Drug-drug. H2-receptor antagonists, magnesium, and aluminum antacids: May decrease cefditoren absorption. Avoid using together.
Probenecid: May increase cefditoren level. Avoid using together.
Drug-food. Moderate- or high-fat meal: May increase drug bioavailability. Advise patient to take drug with meals.
EFFECTS ON LAB TEST RESULTS
• May decrease glucose and hemoglobin level and hematocrit.
• May increase WBC count in urine.
• May cause a false-positive direct Coombs’ test result and a false-positive reaction for urine glucose in copper reduction tests (using Benedict’s or Fehling’s solution or Clinitest tablets).
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other cephalosporins.
• Contraindicated in patients with carnitine deficiency or inborn errors of metabolism that may result in significant carnitine deficiency.
• Because tablets contain sodium caseinate, a milk protein, don’t give drug to patients hypersensitive to milk protein (not lactose intolerance).
• Use cautiously in breast-feeding women because cephalosporins appear in breast milk, and safe use hasn’t been established.
• Use cautiously in patients with impaired renal function or penicillin allergy.
NURSING CONSIDERATIONS
• If patient develops diarrhea, keep in mind that this drug may cause pseudomembranous colitis.
• Don’t use this drug if patient needs prolonged treatment.
• Monitor patient for overgrowth of resistant organisms.
• Patients with renal or hepatic impairment, in poor nutritional state, receiving a protracted course of antibiotics, or previously stabilized on anticoagulants may be at risk for decreased prothrombin activity. Monitor PT in these patients.
PATIENT TEACHING
• Instruct patient to take drug exactly as prescribed.
• Tell patient to take drug with food to increase its absorption.
• Caution patient not to take drug with an H2-receptor antagonist or an antacid because either may reduce cefditoren absorption.
• Instruct patient not to stop drug before completing course and to call prescriber immediately if he experiences any unpleasant adverse reactions.
• Instruct patient to contact prescriber if signs and symptoms of infection don’t improve after several days of therapy.
• Inform patient of potential adverse reactions.
• Urge patient not to miss any doses. However, if he does, tell him to take the missed dose as soon as possible unless it’s within 4 hours of the next scheduled dose. In that case, tell him to skip the missed dose and go back to the regular dosing schedule. Tell him not to double the dose.
cefepime hydrochloride
SEF-ah-peem
Maxipime
Pharmacologic class: fourthgeneration cephalosporin Pregnancy risk category B
AVAILABLE FORMS
Injection: 500-mg vial, 1-g/100-ml piggyback bottle, 1-g ADD-Vantage vial, 1-g vial, 2-g/100-ml piggyback bottle, 2-g ADD-Vantage vial, 2-g vial
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Mild to moderate UTI caused by Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis, including concurrent bacteremia with these microorganisms
Adults and children age 12 and older: 0.5 to 1 g I.M. or I.V. over 30 minutes every 12 hours for 7 to 10 days. Use I.M. only for E. coli infection.
[black right-pointing arrowhead] Severe UTI, including pyelonephritis, caused by E. coli or K. pneumoniae
Adults and children age 12 and older: 2 g I.V. over 30 minutes every 12 hours for 10 days.
[black right-pointing arrowhead] Moderate to severe pneumonia caused by Streptococcus pneumoniae, Pseudomonas aeruginosa, K. pneumoniae, or Enterobacter species
Adults and children age 12 and older: 1 to 2 g I.V. over 30 minutes every 12 hours for 10 days.
[black right-pointing arrowhead] Moderate to severe skin infection, uncomplicated skin infection, and skin-structure infection caused by Streptococcus pyogenes or methicillin-susceptible strains of Staphylococcus aureus
Adults and children age 12 and older: 2 g I.V. over 30 minutes every 12 hours for 10 days.
[black right-pointing arrowhead] Complicated intra-abdominal infection caused by E. coli, viridans group streptococci, P. aeruginosa, K. pneumoniae, Enterobacter species, or Bacteroides fragilis
Adults: 2 g I.V. over 30 minutes every 12 hours for 7 to 10 days. Give with metronidazole.
[black right-pointing arrowhead] Empiric therapy for febrile neutropenia
Adults: 2 g I.V. every 8 hours for 7 days or until neutropenia resolves.
[black right-pointing arrowhead] Uncomplicated and complicated UTI (including pyelonephritis), uncomplicated skin and skin-structure infection, pneumonia, empiric therapy for febrile neutropenic children
Children ages 2 months to 16 years who weigh up to 40 kg (88 lb): 50 mg/kg/dose I.V. over 30 minutes every 12 hours, or every 8 hours for febrile neutropenia, for 7 to 10 days. Don’t exceed 2 g/dose.
Adjust-a-dose: Adjust dosage based on creatinine clearance, as shown in the table. For patients receiving hemodialysis, about 68% of drug is removed after a 3-hour dialysis session. Give a repeat dose, equivalent to the first dose, at the completion of dialysis. For patients receiving continuous ambulatory peritoneal dialysis, give normal dose every 48 hours.
ADMINISTRATION
I.V.
• Before giving drug, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• Follow manufacturer’s guidelines closely when reconstituting drug. They vary with concentration of drug ordered and how drug is packaged (piggyback vial, ADD-Vantage vial, or regular vial).
• The type of diluent varies with the product used. Use only solutions recommended by the manufacturer.
• Give intermittent I.V. infusion with a Y-type administration and compatible solutions.
• Stop the main I.V. fluid while infusing.
• Infuse over about 30 minutes.
• Incompatibilities: Aminophylline, amphotericin B, amphotericin B cholesteryl sulfate complex, ciprofloxacin, gentamicin, metronidazole, tobramycin, vancomycin.
I.M.
• Before giving drug, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• Reconstitute drug using sterile water for injection, normal saline solution for injection, D5W injection, 0.5% or 1% lidocaine hydrochloride, or bacteriostatic water for injection with parabens or benzyl alcohol. Follow manufacturer’s guidelines for quantity of diluent to use.
• Inspect solution for particulate matter before use. The powder and its solutions tend to darken, depending on storage conditions. If stored as recommended, potency isn’t adversely affected.
• Pain may occur at injection site.
ACTION
Inhibits bacterial cell-wall synthesis, promotes osmotic instability, and destroys bacteria.
Route | Onset | Peak | Duration |
|---|---|---|---|
I.V., I.M. | 30 min | 1-2 hr | Unknown |
Half-life: Adults: 2 to 2½ hours. Children: 1½ to 2 hours. | |||
ADVERSE REACTIONS
CNS: fever, headache.
CV: phlebitis.
GI: colitis, diarrhea, nausea, vomiting, oral candidiasis.
GU: vaginitis.
Skin: rash, pruritus, urticaria.
Other: anaphylaxis, pain, inflammation, hypersensitivity reactions.
INTERACTIONS
Drug-drug. Aminoglycosides: May increase risk of nephrotoxicity. Monitor renal function closely.
Potent diuretics: May increase risk of nephrotoxicity. Monitor renal function closely.
Probenecid: May inhibit renal excretion of cefepime. Monitor patient for adverse reactions.
Dosage adjustments for renal impairment | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| |||||||||||||||||||||||||
EFFECTS ON LAB TEST RESULTS
• May increase ALT and AST levels. May decrease phosphorus level.
• May increase eosinophil count. May alter PT and PTT.
• May falsely increase serum or urine creatinine level in tests using Jaffe reaction. May cause false-positive results of Coombs’ test and urine glucose tests that use cupric sulfate, such as Benedict’s reagent and Clinitest.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug, cephalosporins, beta-lactam antibiotics, or penicillins.
• Use cautiously in patients hypersensitive to penicillin because of possibility of cross-sensitivity with other beta-lactam antibiotics.
• Use cautiously in breast-feeding women and in patients with history of colitis or renal insufficiency.
NURSING CONSIDERATIONS
• Adjust dosage in patients with impaired renal function. If dosage isn’t adjusted, serious adverse reactions, including encephalopathy, myoclonus, seizures, and renal failure may occur.
• Monitor patient for superinfection. Drug may cause overgrowth of nonsusceptible bacteria or fungi.
• Drug may reduce PT activity. Patients at risk include those with renal or hepatic impairment or poor nutrition and those receiving prolonged therapy. Monitor PT and INR in these patients. Give vitamin K, as indicated.
• Look alike-sound alike: Don’t confuse drug with other cephalosporins that sound alike.
PATIENT TEACHING
• Warn patient receiving drug I.M. that pain may occur at injection site.
• Advise patient to notify prescriber if a rash develops or if signs and symptoms of superinfection appear, such as recurring fever, chills, and malaise.
• Instruct patient to report adverse reactions promptly.
cefotaxime sodium
sef-oh-TAKS-eem
Claforan
Pharmacologic class: thirdgeneration cephalosporin
Pregnancy risk category B
AVAILABLE FORMS
Infusion: 1-g, 2-g premixed package
Injection: 500-mg, 1-g, 2-g vials
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Perioperative prevention in contaminated surgery
Adults: 1 g I.M. or I.V. 30 to 90 minutes before surgery. In patients undergoing bowel surgery, provide preoperative mechanical bowel cleansing and give a nonabsorbable anti-infective, such as neomycin. In patients undergoing cesarean delivery, give 1 g I.M. or I.V. as soon as the umbilical cord is clamped; then 1 g I.M. or I.V. 6 and 12 hours later.
[black right-pointing arrowhead] Uncomplicated gonorrhea caused by penicillinase-producing strains or non-penicillinase-producing strains of Neisseria gonorrhoeae
Adults and adolescents: 500 mg I.M. as a single dose.
[black right-pointing arrowhead] Rectal gonorrhea
Men: 1 g I.M. as a single dose.
Women: 500 mg I.M. as a single dose.
[black right-pointing arrowhead] Serious infection of the lower respiratory and urinary tract, CNS, skin, bone, and joints; gynecologic and intra-abdominal infection; bacteremia; septicemia caused by susceptible microorganisms, such as streptococci (including Streptococcus pneumoniae and S. pyogenes, Staphylococcus aureus [penicillinaseand non-penicillinase-producing] and S. epidermidis), Escherichia coli, Klebsiella, Haemophilus influenzae, Serratia marcescens, and species of Pseudomonas (including P. aeruginosa), Enterobacter, Proteus, and Peptostreptococcus
Adults and children who weigh 50 kg (110 lb) or more: 1 to 2 g I.V. or I.M. every 6 to 8 hours. Up to 12 g daily can be given for life-threatening infections.
Children ages 1 month to 12 years who weigh less than 50 kg: 50 to 180 mg/kg/day I.M. or I.V. in four to six divided doses.
Neonates ages 1 to 4 weeks: 50 mg/kg I.V. every 8 hours.
Neonates to age 1 week: 50 mg/kg I.V. every 12 hours.
Adjust-a-dose: For patients with creatinine clearance less than 20 ml/minute, give half usual dose at usual interval.
ADMINISTRATION
I.V.
• Before giving drug, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• For direct injection, reconstitute drug in 500-mg, 1-g, or 2-g vials with 10 ml of sterile water for injection. Solutions containing 1 g/14 ml are isotonic.
• Inject drug over 3 to 5 minutes into a large vein or into the tubing of a free-flowing I.V. solution.
• For infusion, reconstitute drug in infusion vials with 50 to 100 ml of D5W or normal saline solution.
• Interrupt flow of primary I.V. solution, and infuse this drug over 20 to 30 minutes.
• Incompatibilities: Allopurinol, aminoglycosides, aminophylline, azithromycin, doxapram, filgrastim, fluconazole, hetastarch, pentamidine isethionate, sodium bicarbonate injection, vancomycin.
I.M.
• Before giving drug, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• For doses of 2 g, divide the dose and give at different sites.
• Inject deep into a large muscle, such as the gluteus maximus or the side of the thigh.
ACTION
Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
Route | Onset | Peak | Duration |
|---|---|---|---|
I.V. | Immediate | Immediate | Unknown |
I.M. | Unknown | 30 min | Unknown |
Half-life: 1 to 2 hours. | |||
ADVERSE REACTIONS
CNS: fever, headache, dizziness.
CV: phlebitis, thrombophlebitis.
GI: diarrhea, pseudomembranous colitis, nausea, vomiting.
GU: vaginitis, candidiasis, interstitial nephritis.
Hematologic: agranulocytosis, thrombocytopenia, transient neutropenia, eosinophilia, hemolytic anemia.
Skin: maculopapular and erythematous rashes, urticaria, pain, induration, sterile abscesses, temperature elevation, tissue sloughing at I.M. injection site.
Other: anaphylaxis, hypersensitivity reactions, serum sickness.
INTERACTIONS
Drug-drug. Aminoglycosides: May increase risk of nephrotoxicity. Monitor patient’s renal function tests.
Probenecid: May inhibit excretion and increase cefotaxime. Use together cautiously.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, ALT, AST, bilirubin, GGT, and LDH levels. May decrease hemoglobin level.
• May increase eosinophil count. May decrease granulocyte, neutrophil, and platelet counts.
• May cause positive Coombs’ test results.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other cephalosporins.
• Use cautiously in patients hypersensitive to penicillin because of possibility of cross-sensitivity with other beta-lactam antibiotics.
• Use cautiously in breast-feeding women and in patients with history of colitis or renal insufficiency.
NURSING CONSIDERATIONS
• If large doses are given, therapy is prolonged, or patient is at high risk, monitor patient for superinfection.
• Look alike-sound alike: Don’t confuse drug with other cephalosporins that sound alike.
PATIENT TEACHING
• Tell patient to report adverse reactions and signs and symptoms of superinfection promptly.
• Instruct patient to report discomfort at I.V. insertion site.
cefoxitin sodium
se-FOX-i-tin
Mefoxin
Pharmacologic class: second-generation cephalosporin
Pregnancy risk category B
AVAILABLE FORMS
Infusion: 1 g, 2 g in 50-ml or 100-ml container
Injection: 1 g, 2 g
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Serious infection of the respiratory and GU tracts; skin, soft-tissue, bone, or joint infection; bloodstream or intra-abdominal infection caused by susceptible organisms (such as Escherichia coli and other coliform bacteria, penicillinaseand non-penicillinase-producing
Staphylococcus aureus, S. epidermidis, streptococci, Klebsiella, Haemophilus influenzae, and Bacteroides, including B. fragilis)
Adults: 1 to 2 g I.V. or I.M. every 6 to 8 hours for uncomplicated infections. Up to 12 g daily may be used in life-threatening infections.
Children older than age 3 months: 80 to 160 mg/kg daily I.V. or I.M., given in four to six equally divided doses. Maximum daily dose is 12 g.
[black right-pointing arrowhead] Uncomplicated gonorrhea
Adults: 2 g I.M. with 1 g probenecid P.O. as a single dose. Give probenecid within 30 minutes before cefoxitin dose.
[black right-pointing arrowhead] Perioperative prevention
Adults: 2 g I.M. or I.V. 30 to 60 minutes before surgery; then 2 g I.M. or I.V. every 6 hours for up to 24 hours. For transurethral prostatectomy, 1 g I.M. or I.V. before surgery; then continue giving 1 g every 8 hours for up to 5 days.
Children age 3 months and older: 30 to 40 mg/kg I.M. or I.V. 30 to 60 minutes before surgery; then 30 to 40 mg/kg every 6 hours for up to 24 hours.
Adjust-a-dose: For patients with creatinine clearance of 30 to 50 ml/minute, 1 to 2 g every 8 to 12 hours; if clearance is 10 to 29 ml/minute, 1 to 2 g every 12 to 24 hours; if clearance is 5 to 9 ml/minute, 0.5 to 1 g every 12 to 24 hours; and if clearance is less than 5 ml/minute, 0.5 to 1 g every 24 to 48 hours. For patients receiving hemodialysis, give a loading dose of 1 to 2 g after each hemodialysis session; then give the maintenance dose based on creatinine level.
ADMINISTRATION
I.V.
• Before giving drug, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• Reconstitute 1 g with at least 10 ml of sterile water for injection and 2 g with 10 to 20 ml of sterile water for injection.
Solutions of D5W and normal saline solution for injection also may be used.
Solutions of D5W and normal saline solution for injection also may be used.
• For direct injection, give drug over 3 to 5 minutes into a large vein or into the tubing of a free-flowing I.V. solution.
• For intermittent infusion, add reconstituted drug to 50 or 100 ml of D5W or normal saline solution for injection.
• Interrupt flow of primary solution during infusion.
• Assess site often to detect evidence of thrombophlebitis.
• Incompatibilities: Aminoglycosides, filgrastim, hetastarch, pentamidine isethionate, ranitidine.
I.M.
• Before giving drug, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• Reconstitute each 1 g of drug with 2 ml of sterile water for injection or 0.5% or 1% lidocaine hydrochloride (without epinephrine) to minimize pain. Inject deep into a large muscle, such as the gluteus maximus or the lateral aspect of the thigh.
• After reconstitution, drug may be stored for 24 hours at room temperature or 1 week under refrigeration.
ACTION
Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
Route | Onset | Peak | Duration |
|---|---|---|---|
I.V. | Immediate | Immediate | Unknown |
I.M. | Unknown | 20-30 min | Unknown |
Half-life: About ½ to 1 hours. | |||
ADVERSE REACTIONS
CNS: fever.
CV: phlebitis, thrombophlebitis, hypotension.
GI: diarrhea, pseudomembranous colitis, nausea, vomiting.
GU: acute renal failure.
Hematologic: thrombocytopenia, transient neutropenia, eosinophilia, hemolytic anemia, anemia.
Respiratory: dyspnea.
Skin: maculopapular and erythematous rashes, urticaria, pain, induration, sterile abscesses, tissue sloughing at injection site, exfoliative dermatitis.
Other: anaphylaxis, hypersensitivity reactions, serum sickness.
INTERACTIONS
Drug-drug. Aminoglycosides: May increase risk of nephrotoxicity. Monitor patient’s renal function tests.
Probenecid: May inhibit excretion and increase cefoxitin level. Probenecid may be used for this effect.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, ALT, AST, bilirubin, and LDH levels. May decrease hemoglobin level.
• May increase eosinophil count. May decrease neutrophil and platelet counts.
• May falsely increase serum or urine creatinine level in tests using Jaffe reaction. May cause false-positive results of Coombs’ test and urine glucose tests that use cupric sulfate, such as Benedict’s reagent and Clinitest.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other cephalosporins.
• Use cautiously in patients hypersensitive to penicillin because of possibility of cross-sensitivity with other beta-lactam antibiotics.
• Use cautiously in breast-feeding women and in patients with history of colitis or renal insufficiency.
NURSING CONSIDERATIONS
• Alert: The premixed frozen product is for I.V. use only.
• If large doses are given, therapy is prolonged, or patient is at high risk, monitor patient for signs and symptoms of superinfection.
• Look alike-sound alike: Don’t confuse drug with other cephalosporins that sound alike.
cefpodoxime proxetil
SEF-pod-OX-eem
Vantin
Pharmacologic class: thirdgeneration cephalosporin
Pregnancy risk category B
AVAILABLE FORMS
Oral suspension: 50 mg/5 ml or 100 mg/5 ml in 50-, 75-, or 100-ml bottles
Tablets (film-coated): 100 mg, 200 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Acute, community-acquired pneumonia caused by strains of Haemophilus influenzae or Streptococcus pneumoniae
Adults and children age 12 and older: 200 mg P.O. every 12 hours for 14 days.
[black right-pointing arrowhead] Acute bacterial worsening of chronic bronchitis caused by S. pneumoniae or H. influenzae (strains that don’t produce beta-lactamase only), or Moraxella catarrhalis
Adults and children age 12 and older: 200 mg P.O. every 12 hours for 10 days.
[black right-pointing arrowhead] Uncomplicated gonorrhea in men and women; rectal gonococcal infections in women
Adults and children age 12 and older: 200 mg P.O. as a single dose. Follow with doxycycline 100 mg P.O. b.i.d. for 7 days.
[black right-pointing arrowhead] Uncomplicated skin and skin-structure infections caused by Staphylococcus aureus or S. pyogenes
Adults and children age 12 and older: 400 mg P.O. every 12 hours for 7 to 14 days.
[black right-pointing arrowhead] Acute otitis media caused by S. pneumoniae (penicillin-susceptible strains only), S. pyogenes, H. influenzae, or M. catarrhalis
Children age 2 months to 12 years: 5 mg/kg P.O. every 12 hours for 5 days. Don’t exceed 200 mg per dose.
[black right-pointing arrowhead] Pharyngitis or tonsillitis caused by S. pyogenes
Adults: 100 mg P.O. every 12 hours for 5 to 10 days.
Children ages 2 months to 12 years: 5 mg/kg P.O. every 12 hours for 5 to 10 days. Don’t exceed 100 mg per dose.
[black right-pointing arrowhead] Uncomplicated UTIs caused by Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, or Staphylococcus saprophyticus
Adults: 100 mg P.O. every 12 hours for 7 days.
[black right-pointing arrowhead] Mild to moderate acute maxillary sinusitis caused by H. influenzae, S. pneumoniae, or M. catarrhalis
Adults and adolescents age 12 and older: 200 mg P.O. every 12 hours for 10 days. Children ages 2 months to 12 years: 5 mg/kg P.O. every 12 hours for 10 days; maximum is 200 mg/dose.
Adjust-a-dose: For patients with creatinine clearance less than 30 ml/minute, increase dosage interval to every 24 hours. Give to dialysis patients three times weekly after dialysis.
ADMINISTRATION
P.O.
• Before administration, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• Give drug with food to enhance absorption. Shake suspension well before using.
• Store suspension in the refrigerator (36° to 46° F [2° to 8° C]). Discard unused portion after 14 days.
ACTION
Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 2-3 hr | Unknown |
Half-life: 2 to 3 hours. | |||
ADVERSE REACTIONS
CNS: headache.
GI: diarrhea, pseudomembranous colitis, nausea, vomiting, abdominal pain.
GU: vaginal fungal infections.
Skin: rash.
Other: anaphylaxis, hypersensitivity reactions.
INTERACTIONS
Drug-drug. Aminoglycosides: May increase risk of nephrotoxicity. Monitor renal function tests closely.
Antacids, H2-receptor antagonists: May decrease absorption of cefpodoxime. Avoid using together.
Probenecid: May decrease excretion of cefpodoxime. Monitor patient for toxicity.
Drug-food. Any food: May increase absorption. Give tablets with food to enhance absorption. Oral suspension may be given without regard to food.
EFFECTS ON LAB TEST RESULTS
• May falsely increase serum or urine creatinine level in tests using Jaffe reaction. May cause false-positive results of Coombs’ test and urine glucose tests that use cupric sulfate, such as Benedict’s reagent and Clinitest.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other cephalosporins.
• Use cautiously in patients with a history of penicillin hypersensitivity because of risk of cross-sensitivity.
• Use cautiously in patients receiving nephrotoxic drugs because other cephalosporins have been shown to have nephrotoxic potential.
• Use cautiously in breast-feeding women because drug appears in breast milk.
NURSING CONSIDERATIONS
• Monitor renal function and compare with baseline.
• Monitor patient for superinfection. Drug may cause overgrowth of nonsusceptible bacteria or fungi.
• Look alike-sound alike: Don’t confuse drug with other cephalosporins that sound alike.
PATIENT TEACHING
• Tell patient to take drug as prescribed, even after he feels better.
• Instruct patient to take drug with food. If patient is using suspension, tell him to shake container before measuring dose and to keep container refrigerated.
• Tell patient to call prescriber if rash or signs and symptoms of superinfection occur.
• Instruct patient to notify prescriber about loose stools or diarrhea.
cefprozil
sef-PRO-zil
Cefzil
Pharmacologic class: second-generation cephalosporin
Pregnancy risk category B
AVAILABLE FORMS
Oral suspension: 125 mg/5 ml, 250 mg/5 ml
Tablets: 250 mg, 500 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Pharyngitis or tonsillitis caused by Streptococcus pyogenes
Adults and children age 13 and older: 500 mg P.O. daily for at least 10 days.
[black right-pointing arrowhead] Otitis media caused by Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis
Infants and children ages 6 months to 12 years: 15 mg/kg P.O. every 12 hours for 10 days.
[black right-pointing arrowhead] Secondary bacterial infections of acute bronchitis and acute bacterial worsening of chronic bronchitis caused by S. pneumoniae, H. influenzae, and M. catarrhalis
Adults and children age 13 and older: 500 mg P.O. every 12 hours for 10 days.
[black right-pointing arrowhead] Uncomplicated skin and skin-structure infections caused by Staphylococcus aureus and S. pyogenes
Adults and children age 13 and older: 250 or 500 mg P.O. every 12 hours or 500 mg daily for 10 days.
[black right-pointing arrowhead] Acute sinusitis caused by S. pneumoniae, H. influenzae (beta-lactamase-positive and -negative strains), and M. catarrhalis (including strains that produce beta-lactamase)
Adults and children age 13 and older: 250 mg P.O. every 12 hours for 10 days; for moderate to severe infection, 500 mg P.O. every 12 hours for 10 days.
Children ages 6 months to 12 years: 7.5 mg/kg P.O. every 12 hours for 10 days; for moderate to severe infections, 15 mg/kg P.O. every 12 hours for 10 days.
Adjust-a-dose: If creatinine clearance is less than 30 ml/minute, give 50% of standard dose at standard intervals. If patient is receiving dialysis, give dose after hemodialysis is completed; drug is removed by hemodialysis.
ADMINISTRATION
P.O.
• Obtain specimen for culture and sensitivity tests before giving first dose. Start therapy while awaiting results.
• Before giving, ask patient if he’s allergic to penicillins or cephalosporins.
• Shake suspension well before using.
ACTION
Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 1½ hr | Unknown |
Half-life: 1¼ hours in patients with normal renal function; 2 hours in patients with impaired hepatic function; and 5¼ to 6 hours in patients with end-stage renal disease. | |||
ADVERSE REACTIONS
CNS: dizziness, hyperactivity, headache, nervousness, insomnia, confusion, somnolence.
GI: diarrhea, nausea, vomiting, abdominal pain.
GU: genital pruritus, vaginitis.
Hematologic: eosinophilia.
Skin: rash, urticaria, diaper rash.
Other: anaphylaxis, superinfection, hypersensitivity reactions, serum sickness.
INTERACTIONS
Drug-drug. Aminoglycosides: May increase risk of nephrotoxicity. Monitor renal function tests closely.
Probenecid: May inhibit excretion and increase cefprozil level. Use together cautiously.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, ALT, AST, bilirubin, BUN, creatinine, and LDH levels.
• May increase eosinophil count. May decrease leukocyte, platelet, and WBC counts.
• May falsely increase serum or urine creatinine level in tests using Jaffe reaction. May cause false-positive results of Coombs’ test and urine glucose tests that use cupric sulfate, such as Benedict’s reagent and Clinitest.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other cephalosporins.
• Use cautiously in patients hypersensitive to penicillin because of possibility of cross-sensitivity with other beta-lactam antibiotics.
• Use cautiously in breast-feeding women and in patients with history of colitis and renal insufficiency.
NURSING CONSIDERATIONS
• Monitor renal function and liver function test results.
• Monitor patient for superinfection. May cause overgrowth of nonsusceptible bacteria or fungi.
• Look alike-sound alike: Don’t confuse drug with other cephalosporins that sound alike.
PATIENT TEACHING
• Advise patient to take drug as prescribed, even after he feels better.
• Tell patient to shake suspension well before measuring dose.
• Inform patient or parent that oral suspension is bubble gum-flavored to improve palatability and promote compliance in children. Tell him to refrigerate reconstituted suspension and to discard unused drug after 14 days.
• Instruct patient to notify prescriber if rash or signs and symptoms of superinfection occur.
ceftazidime
sef-TAZ-i-deem
Ceptaz, Fortaz, Tazicef
Pharmacologic class: thirdgeneration cephalosporin
Pregnancy risk category B
AVAILABLE FORMS
Infusion: 1 g, 2 g in 50-ml and 100-ml vials (premixed)
Injection (with arginine): 500 mg, 1 g, 2 g Injection (with sodium carbonate): 500 mg, 1 g, 2 g
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Serious UTI and lower respiratory tract infection; skin, gynecologic, intra-abdominal, and CNS infection; bacteremia; and septicemia caused by susceptible microorganisms, such as streptococci (including Streptococcus pneumoniae and S. pyogenes), penicillinaseand non-penicillinase-producing Staphylococcus aureus, Escherichia coli, Klebsiella, Proteus, Enterobacter, Haemophilus influenzae, Pseudomonas, and some strains of Bacteroides
Adults and children age 12 and older: 1 to 2 g I.V. or I.M. every 8 to 12 hours; up to 6 g daily in life-threatening infections.
Children ages 1 month to 12 years: 30 to 50 mg/kg I.V. every 8 hours. Maximum dose is 6 g/day. Use sodium carbonate formulation.
Neonates up to age 4 weeks: 30 mg/kg I.V. every 12 hours. Use sodium carbonate formulation.
[black right-pointing arrowhead] Uncomplicated UTI
Adults: 250 mg I.V. or I.M. every 12 hours.
[black right-pointing arrowhead] Complicated UTI
Adults and children age 12 and older: 500 mg to 1 g I.V. or I.M. every 8 to 12 hours.
Adjust-a-dose: If creatinine clearance is 31 to 50 ml/minute, give 1 g every 12 hours; if clearance is 16 to 30 ml/minute, give 1 g every 24 hours; if clearance is 6 to 15 ml/minute, give 500 mg every 24 hours; if clearance is less than 5 ml/minute, give 500 mg every 48 hours. Ceftazidime is removed by hemodialysis; give a loading dose of 1 g, followed by 1 g after each hemodialysis period.
ADMINISTRATION
I.V.
• Before administration, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• Each brand of drug includes specific instructions for reconstitution. Read and follow them carefully.
• To reconstitute solution that contains sodium carbonate, add 5 ml sterile water for injection to a 500-mg vial, or add 10 ml to a 1-g or 2-g vial. Shake well to dissolve drug. Because carbon dioxide is released during dissolution, positive pressure will develop in vial.
• To reconstitute solution that contains arginine, use 10 ml of sterile water for injection. This product won’t release gas bubbles.
• Infuse drug over 15 to 30 minutes.
• Incompatibilities: Aminoglycosides, aminophylline, amiodarone, amphotericin B cholesteryl sulfate complex, azithromycin, clarithromycin, fluconazole, idarubicin, midazolam, pentamidine isethionate, ranitidine hydrochloride, sargramostim, sodium bicarbonate solutions, vancomycin.
I.M.
• Before administration, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• Inject deep into a large muscle, such as the gluteus maximus or the side of the thigh.
ACTION
Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
Route | Onset | Peak | Duration |
|---|---|---|---|
I.V. | Immediate | Immediate | Unknown |
I.M. | Unknown | 1 hr | Unknown |
Half-life: 1½ to 2 hours. | |||
ADVERSE REACTIONS
CNS: seizures, headache, dizziness, paresthesia.
CV: phlebitis, thrombophlebitis.
GI: pseudomembranous colitis, nausea, vomiting, diarrhea, abdominal cramps.
GU: vaginitis, candidiasis.
Hematologic: agranulocytosis, leukopenia, thrombocytopenia, eosinophilia, thrombocytosis, hemolytic anemia.
Skin: maculopapular and erythematous rashes, urticaria, pain, induration, sterile abscesses, tissue sloughing at injection site.
Other: anaphylaxis, hypersensitivity reactions, serum sickness.
INTERACTIONS
Drug-drug. Aminoglycosides: May cause additive or synergistic effect against some strains of Pseudomonas aeruginosa and Enterobacteriaceae; may increase risk of nephrotoxicity. Monitor patient for effects and monitor renal function.
Chloramphenicol: May cause antagonistic effect. Avoid using together.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, ALT, AST, bilirubin, and LDH levels. May decrease hemoglobin level.
• May increase eosinophil count. May decrease granulocyte and WBC counts. May increase or decrease platelet count.
• May falsely increase serum or urine creatinine level in tests using Jaffe reaction. May cause false-positive results of Coombs’ test and urine glucose tests that use cupric sulfate, such as Benedict’s reagent and Clinitest.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other cephalosporins.
• Use cautiously in patients hypersensitive to penicillin because of possibility of cross-sensitivity with other beta-lactam antibiotics.
• Use cautiously in breast-feeding women and in patients with history of colitis or renal insufficiency.
NURSING CONSIDERATIONS
• If large doses are given, therapy is prolonged, or patient is at high risk, monitor patient for signs and symptoms of superinfection.
• Alert: Drug contains either sodium carbonate (Fortaz or Tazicef) or arginine (Ceptaz) to facilitate dissolution of drug. Safety and effectiveness of solutions containing arginine in children younger than age 12 haven’t been established.
• Look alike-sound alike: Don’t confuse drug with other cephalosporins that sound alike.
PATIENT TEACHING
• Tell patient to report adverse reactions or signs and symptoms of superinfection promptly.
• Instruct patient to report discomfort at I.V. insertion site.
• Advise patient to notify prescriber about loose stools or diarrhea.
ceftizoxime sodium
sef-ti-ZOX-eem
Cefizox
Pharmacologic class: thirdgeneration cephalosporin
Pregnancy risk category B
AVAILABLE FORMS
Infusion: 1 g, 2 g in 100-ml vials or in 50-ml containers
Injection: 500 mg, 1 g, 2 g
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Serious UTI, lower respiratory tract infection, gynecologic infection, bacteremia, septicemia, meningitis, intra-abdominal infection, bone or joint infection, and skin infection caused by susceptible microorganisms, such as streptococci (including Streptococcus pneumoniae and S. pyogenes), Staphylococcus aureus, S. epidermidis, Escherichia coli, Haemophilus influenzae, and Klebsiella, Enterobacter, Proteus, Peptostreptococcus, and some Pseudomonas species
Adults: 1 to 2 g I.V. or I.M. every 8 to 12 hours. For life-threatening infections, give up to 2 g I.V. every 4 hours, or 3 to 4 g I.V. every 8 hours.
Children older than age 6 months: 50 mg/kg I.V. every 6 to 8 hours. For serious infections, up to 200 mg/kg/day in divided doses may be used. Don’t exceed 12 g/day.
[black right-pointing arrowhead] Uncomplicated gonorrhea Adults: 1 g I.M. as a single dose.
Adjust-a-dose: If creatinine clearance is 50 to 79 ml/minute, give 500 mg to 1.5 g every 8 hours; if clearance is 5 to 49 ml/minute, give 250 mg to 1 g every 12 hours; if clearance is less than 5 ml/minute or patient undergoes hemodialysis, give 500 mg to 1 g every 48 hours, or 250 to 500 mg every 24 hours.
ADMINISTRATION
I.V.
• Before giving drug, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• To reconstitute powder, add 5 ml of sterile water to a 500-mg vial, 10 ml to a 1-g vial, or 20 ml to a 2-g vial.
• Reconstitute drug in piggyback vials with 50 to 100 ml of normal saline solution or D5W. Shake well.
• For direct injection, give drug over 3 to 5 minutes or slowly into I.V. tubing of free-flowing compatible solution.
• For infusion, give drug over 15 to 30 minutes.
• Incompatibilities: Aminoglycosides, cisatracurium besylate, filgrastim; possibly promethazine hydrochloride and vancomycin hydrochloride.
I.M.
• Before giving drug, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• Mix 1.5 ml of diluent per 500 mg of drug. Inject deep into a large muscle, such as the gluteus maximus or the side of the thigh. Divide doses of more than 2 g and give at two separate sites.
ACTION
Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
Route | Onset | Peak | Duration |
|---|---|---|---|
I.V. | Immediate | Immediate | Unknown |
I.M. | Unknown | 30-90 min | Unknown |
Half-life: 1½ to 2 hours. | |||
ADVERSE REACTIONS
CNS: fever.
CV: phlebitis, thrombophlebitis.
GI: diarrhea, pseudomembranous colitis, nausea, anorexia, vomiting.
GU: vaginitis.
Hematologic: thrombocytopenia, thrombocytosis, transient neutropenia, eosinophilia, hemolytic anemia, anemia.
Respiratory: dyspnea.
Skin: maculopapular and erythematous rashes, urticaria, pain, induration, sterile abscesses, tissue sloughing at injection site.
Other: anaphylaxis, hypersensitivity reactions, serum sickness.
INTERACTIONS
Drug-drug. Aminoglycosides: May increase nephrotoxicity. Monitor renal function.
Probenecid: May inhibit excretion and increase ceftizoxime level. Use probenecid for this effect.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, ALT, AST, bilirubin, BUN, creatinine, GGT, and LDH levels. May decrease albumin, hemoglobin, and protein levels.
• May decrease PT and granulocyte, neutrophil, platelet, RBC, and WBC counts.
• May falsely increase serum or urine creatinine level in tests using Jaffe reaction. May cause false-positive results of Coombs’ test and urine glucose tests that use cupric sulfate, such as Benedict’s reagent and Clinitest.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other cephalosporins.
• Use cautiously in patients hypersensitive to penicillin because of possible cross-sensitivity with other beta-lactam antibiotics.
• Use cautiously in breast-feeding women and in patients with history of colitis or renal insufficiency.
NURSING CONSIDERATIONS
• If large doses are given, therapy is prolonged, or patient is at high risk, monitor patient for signs or symptoms of superinfection.
• Look alike-sound alike: Don’t confuse drug with other cephalosporins that sound alike.
PATIENT TEACHING
• Tell patient to report adverse reactions and signs and symptoms of superinfection promptly.
• Instruct patient to report discomfort at I.V. site.
• Tell patient to notify prescriber about loose stools or diarrhea.
ceftriaxone sodium
sef-try-AX-ohn
Rocephin
Pharmacologic class: thirdgeneration cephalosporin
Pregnancy risk category B
AVAILABLE FORMS
Infusion: 1 g, 2-g piggyback; 1 g, 2 g/50 ml premixed
Injection: 250 mg, 500 mg, 1 g, 2 g
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Uncomplicated gonococcal vulvovaginitis
Adults: 125 mg I.M. as a single dose, plus azithromycin 1 g P.O. as a single dose or doxycycline 100 mg P.O. b.i.d. for 7 days.
[black right-pointing arrowhead] UTI; lower respiratory tract, gynecologic, bone or joint, intraabdominal, skin, or skin structure infection; septicemia
Adults and children older than age 12 years: 1 to 2 g I.M. or I.V. daily or in equally divided doses every 12 hours. Total daily dose shouldn’t exceed 4 g.
Children age 12 and younger: 50 to 75 mg/kg I.M. or I.V., not to exceed 2 g/day, given in divided doses every 12 hours.
[black right-pointing arrowhead] Meningitis
Adults and children: Initially, 100 mg/kg I.M. or I.V. Don’t exceed 4 g; then 100 mg/kg I.M. or I.V., given once daily or in divided doses every 12 hours, not to exceed 4 g, for 7 to 14 days.
[black right-pointing arrowhead] Perioperative prevention
Adults: 1 g I.V. as a single dose 30 minutes to 2 hours before surgery.
[black right-pointing arrowhead] Acute bacterial otitis media
Children: 50 mg/kg I.M. as a single dose. Don’t exceed 1 g.
[black right-pointing arrowhead] Neurologic complications, carditis, and arthritis from penicillin G-refractory Lyme disease ♦
Adults: 2 g I.V. daily for 14 to 28 days.
ADMINISTRATION
I.V.
• Before giving drug, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving first dose. Begin therapy while awaiting results.
• Reconstitute drug with sterile water for injection, normal saline solution for injection, D5W, or a combination of normal saline solution and dextrose injection and other compatible solutions.
• Add 2.4 ml of diluent to the 250-mg vial, 4.8 ml to the 500-mg vial, 9.6 ml to the 1-g vial, and 19.2 ml to the 2-g vial. All reconstituted solutions average 100 mg/ml.
• For intermittent infusion, dilute further to achieve desired concentration.
• Diluted I.V. preparation is stable 24 hours at room temperature or 10 days if refrigerated.
• Alert: Don’t mix or coadminister ceftriaxone with calcium-containung I.V. solutions, including parenteral nutrition. This includes the use of different infusion lines at different sites. Don’t administer within 48 hours of each other in any patient.
• Incompatibilities: Aminoglycosides, aminophylline, amphotericin B cholesteryl sulfate complex, azithromycin, calcium, clindamycin phosphate, filgrastim, fluconazole, gentamicin, labetalol, lidocaine hydrochloride, linezolid, metronidazole, pentamidine isethionate, theophylline, vancomycin, vinorelbine tartrate.
I.M.
• Before giving drug, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving first dose. Begin therapy while awaiting results.
• Inject deep into a large muscle, such as the gluteus maximus or the lateral aspect of the thigh.
ACTION
Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
Route | Onset | Peak | Duration |
|---|---|---|---|
I.V. | Immediate | Immediate | Unknown |
I.M. | Unknown | 1½-4 hr | Unknown |
Half-life: 5½ to 11 hours. | |||
ADVERSE REACTIONS
CNS: fever, headache, dizziness.
CV: phlebitis.
GI: pseudomembranous colitis, diarrhea.
GU: genital pruritus, candidiasis.
Hematologic: eosinophilia, thrombocytosis, leukopenia.
Skin: pain, induration, tenderness at injection site, rash, pruritus.
Other: hypersensitivity reactions, serum sickness, anaphylaxis, chills.
INTERACTIONS
Drug-drug. Aminoglycosides: May cause synergistic effect against some strains of P. aeruginosa and Enterobacteriaceae species. Monitor patient.
Probenecid: High doses (1 g or 2 g daily) may enhance hepatic clearance of ceftriaxone and shorten its half-life. Avoid using together.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, ALT, AST, bilirubin, BUN, and LDH levels.
• May increase eosinophil and platelet counts. May decrease WBC count.
• May falsely increase serum or urine creatinine level in tests using Jaffe reaction. May cause false-positive results of Coombs’ test and urine glucose tests that use cupric sulfate, such as Benedict’s reagent and Clinitest.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other cephalosporins.
• Use cautiously in patients hypersensitive to penicillin because of possibility of cross-sensitivity with other beta-lactam antibiotics.
• Use cautiously in breast-feeding women and in patients with history of colitis and renal insufficiency.
NURSING CONSIDERATIONS
• If large doses are given, therapy is prolonged, or patient is at high risk, monitor patient for signs and symptoms of superinfection.
• Monitor PT and INR in patients with impaired vitamin K synthesis or low vitamin K stores. Vitamin K therapy may be needed.
• Drug is commonly used in home antibiotic programs for outpatient treatment of serious infections, such as osteomyelitis and community-acquired pneumonia.
• Look alike-sound alike: Don’t confuse drug with other cephalosporins that sound alike.
PATIENT TEACHING
• Tell patient to report adverse reactions promptly.
• Instruct patient to report discomfort at I.V. insertion site.
• Teach patient and family receiving home care how to prepare and give drug.
• If home care patient is diabetic and is testing his urine for glucose, tell him drug may affect results of cupric sulfate tests; he should use an enzymatic test instead.
• Tell patient to notify prescriber about loose stools or diarrhea.
cefuroxime axetil
se-fyoor-OX-eem
Ceftin
cefuroxime sodium
Zinacef
Pharmacologic class: second-generation cephalosporin
Pregnancy risk category B
AVAILABLE FORMS
cefuroxime axetil
Suspension: 125 mg/5 ml, 250 mg/5 ml
Tablets: 125 mg, 250 mg, 500 mg
cefuroxime sodium
Infusion: 750-mg, 1.5-g vials, infusion packs, and ADD-Vantage vials
Injection: 750 mg, 1.5 g
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Serious lower respiratory tract infection, UTI, skin or skin-structure infections, bone or joint infection, septicemia, meningitis, and gonorrhea
Adults and children age 13 and older: 750 mg to 1.5 g cefuroxime sodium I.V. or I.M. every 8 hours for 5 to 10 days. For life-threatening infections and infections caused by less susceptible organisms, 1.5 g I.V. or I.M. every 6 hours; for bacterial meningitis, up to 3 g I.V. every 8 hours.
Children age 3 months to 12 years: 50 to 100 mg/kg/day cefuroxime sodium I.V. or I.M. in equally divided doses every 6 to 8 hours. Use higher dosage of 100 mg/kg/day, not to exceed maximum adult dosage, for more severe or serious infections. For bacterial meningitis, 200 to 240 mg/kg/day cefuroxime sodium I.V. in divided doses every 6 to 8 hours.
[black right-pointing arrowhead] Perioperative prevention
Adults: 1.5 g I.V. 30 to 60 minutes before surgery; in lengthy operations, 750 mg I.V. or I.M. every 8 hours. For open-heart surgery, 1.5 g I.V. at induction of anesthesia and then every 12 hours for a total dose of 6 g.
[black right-pointing arrowhead] Bacterial exacerbations of chronic bronchitis or secondary bacterial infection of acute bronchitis
Adults and children age 13 and older: 250 or 500 mg P.O. b.i.d. for 10 days (chronic bronchitis) or 5 to 10 days (acute bronchitis).
[black right-pointing arrowhead] Acute bacterial maxillary sinusitis
Adults and children age 13 and older: 250 mg P.O. b.i.d. for 10 days.
Children ages 3 months to 12 years: 250 mg b.i.d. for 10 days. For children who can’t swallow tablets whole, 30 mg/kg/day oral suspension divided b.i.d. for 10 days.
[black right-pointing arrowhead] Pharyngitis and tonsillitis
Adults and children age 13 and older: 250 mg P.O. b.i.d. for 10 days.
Children ages 3 months to 12 years: 125 mg P.O. b.i.d. for 10 days. For children who can’t swallow tablets whole, give 20 mg/kg daily of oral suspension divided b.i.d. for 10 days. Maximum daily dose for suspension is 500 mg.
[black right-pointing arrowhead] Otitis media
Children ages 3 months to 12 years: 250 mg P.O. b.i.d. for 10 days. For children who can’t swallow tablets whole, give 30 mg/kg/day of oral suspension divided b.i.d. for 10 days. Maximum daily dose for suspension is 1,000 mg.
[black right-pointing arrowhead] Uncomplicated skin and skin structure infection
Adults and children age 13 and older: 250 or 500 mg P.O. b.i.d. for 10 days.
[black right-pointing arrowhead] Uncomplicated UTI
Adults: 125 or 250 mg P.O. b.i.d. for 7 to 10 days.
[black right-pointing arrowhead] Uncomplicated gonorrhea
Adults: 1.5 g I.M. with 1 g probenecid P.O. for one dose. Or, 1 g P.O. as a single dose.
[black right-pointing arrowhead] Early Lyme disease
Adults and children age 13 and older: 500 mg P.O. b.i.d. for 20 days.
[black right-pointing arrowhead] Impetigo
Children ages 3 months to 12 years: 30 mg/kg/day of oral suspension divided b.i.d. for 10 days. Maximum daily dose, 1,000 mg.
Adjust-a-dose: In adults with creatinine clearance of 10 to 20 ml/minute, give 750 mg I.V. or I.M. every 12 hours; if clearance is less than 10 ml/min, give 750 mg I.V. or I.M. every 24 hours.
ADMINISTRATION
P.O.
• Before giving drug, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving first dose. Therapy may begin while awaiting results.
• Give tablets without regard for meals; give oral suspension with food.
• Crush tablets, if absolutely necessary, for patients who can’t swallow tablets. Tablets may be dissolved in small amounts of apple, orange, or grape juice or chocolate milk. However, the drug has a bitter taste that is difficult to mask, even with food.
I.V.
• Before giving drug, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving first dose. Therapy may begin while awaiting results.
• Reconstitute each 750-mg vial with 8 ml and each 1.5-g vial with 16 ml of sterile water for injection.
• Withdraw entire contents of vial for a dose.
• For direct injection, inject over 3 to 5 minutes into a large vein or into the tubing of a free-flowing I.V. solution.
• For intermittent infusion, add reconstituted drug to 100 ml D5W, normal saline solution for injection, or other compatible I.V. solution.
• Infuse over 15 to 60 minutes.
• Incompatibilities: Aminoglycosides, azithromycin, ciprofloxacin, cisatracurium, clarithromycin, cyclophosphamide, doxapram, filgrastim, fluconazole, gentamicin, midazolam, ranitidine, sodium bicarbonate injection, vancomycin, vinorelbine tartrate.
I.M.
• Before giving drug, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving first dose. Therapy may begin while awaiting results.
• Inject deep into a large muscle, such as the gluteus maximus or the side of the thigh.
ACTION
Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 15-60 min | Unknown |
I.V. | Immediate | Immediate | Unknown |
I.M. | Unknown | 2 hr | Unknown |
Half-life: 1 to 2 hours. | |||
ADVERSE REACTIONS
CV: phlebitis, thrombophlebitis.
GI: diarrhea, pseudomembranous colitis, nausea, anorexia, vomiting.
Hematologic: hemolytic anemia, thrombocytopenia, transient neutropenia, eosinophilia.
Skin: maculopapular and erythematous rashes, urticaria, pain, induration, sterile abscesses, temperature elevation, tissue sloughing at I.M. injection site.
Other: anaphylaxis, hypersensitivity reactions, serum sickness.
INTERACTIONS
Drug-drug. Aminoglycosides: May cause synergistic activity against some organisms; may increase nephrotoxicity. Monitor patient’s renal function closely.
Loop diuretics: May increase risk of adverse renal reactions. Monitor renal function test results closely.
Probenecid: May inhibit excretion and increase cefuroxime level. Probenecid may be used for this effect.
Drug-food. Any food: May increase absorption. Give drug with food.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, ALT, AST, bilirubin, and LDH levels. May decrease hemoglobin level and hematocrit.
• May increase PT and INR and eosinophil count. May decrease neutrophil and platelet counts.
• May falsely increase serum or urine creatinine level in tests using Jaffe reaction. May cause false-positive results of Coombs’ test and urine glucose tests that use cupric sulfate, such as Benedict’s reagent and Clinitest.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other cephalosporins.
• Use cautiously in patients hypersensitive to penicillin because of possibility of
cross-sensitivity with other beta-lactam antibiotics.
cross-sensitivity with other beta-lactam antibiotics.
• Use cautiously in breast-feeding women and in patients with history of colitis or renal insufficiency.
NURSING CONSIDERATIONS
• Alert: Tablets and suspension aren’t bioequivalent and can’t be substituted milligram-for-milligram.
• Monitor patient for signs and symptoms of superinfection.
• Look alike-sound alike: Don’t confuse drug with other cephalosporins that sound alike.
PATIENT TEACHING
• Tell patient to take drug as prescribed, even after he feels better.
• If patient has difficulty swallowing tablets, show him how to dissolve or crush tablets, but warn him that the bitter taste is hard to mask, even with food.
• Tell parent to shake suspension well before measuring dose. Suspension may be stored at room temperature or refrigerated, but must be discarded after 10 days.
• Instruct caregiver to give oral suspension with food.
• Instruct patient to notify prescriber about rash, loose stools, diarrhea, or evidence of superinfection.
• Advise patient receiving drug I.V. to report discomfort at I.V. insertion site.
cephalexin
sef-a-LEX-in
Apo-Cephalex†, Keflex, Novo-Lexin†, Nu-Cephalex†
Pharmacologic class: firstgeneration cephalosporin
Pregnancy risk category B
AVAILABLE FORMS
Capsules: 250 mg, 333 mg, 500 mg, 750 mg
Oral suspension: 125 mg/5 ml, 250 mg/5 ml
Tablets: 250 mg, 500 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Respiratory tract, GI tract, skin, soft-tissue, bone, and joint infections and otitis media caused by Escherichia coli and other coliform bacteria, group A beta-hemolytic streptococci, Klebsiella species, Proteus mirabilis, Streptococcus pneumoniae, and staphylococci
Adults: 250 mg to 1 g P.O. every 6 hours or 500 mg every 12 hours. Maximum 4 g daily.
Children: 25 to 50 mg/kg/day P.O. in two to four equally divided doses. In severe infections, dose can be doubled.
Adjust-a-dose: For adults with impaired renal function, initial dose is the same. Then, for those with creatinine clearance of 11 to 40 ml/minute, give 500 mg P.O. every 8 to 12 hours; for clearance of 5 to 10 ml/minute, give 250 mg P.O. every 12 hours; and for clearance of less than 5 ml/minute, give 250 mg P.O. every 12 to 24 hours.
ADMINISTRATION
P.O.
• Before giving, ask patient if he’s allergic to penicillins or cephalosporins.
• Obtain specimen for culture and sensitivity tests before giving. Begin therapy while awaiting results.
• To prepare oral suspension, add required amount of water to powder in two portions. Shake well after each addition. After mixing, store in refrigerator. Mixture will remain stable for 14 days. Keep tightly closed and shake well before using.
• Give drug with food or milk to lessen GI discomfort.
ACTION
Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 1 hr | Unknown |
Half-life: 30 minutes to 1 hour. | |||
ADVERSE REACTIONS
CNS: dizziness, headache, fatigue, agitation, confusion, hallucinations.
GI: anorexia, diarrhea, nausea, pseudomembranous colitis, vomiting, gastritis,
glossitis, dyspepsia, abdominal pain, anal pruritus, tenesmus, oral candidiasis.
glossitis, dyspepsia, abdominal pain, anal pruritus, tenesmus, oral candidiasis.
GU: genital pruritus, candidiasis, vaginitis, interstitial nephritis.
Hematologic: neutropenia, thrombocytopenia, eosinophilia, anemia.
Musculoskeletal: arthritis, arthralgia, joint pain.
Skin: maculopapular and erythematous rashes, urticaria.
Other: anaphylaxis, hypersensitivity reactions, serum sickness.
INTERACTIONS
Drug-drug. Aminoglycosides: May increase risk of nephrotoxicity. Avoid using together.
Probenecid: May increase cephalosporin level. Use probenecid for this effect.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, ALT, AST, bilirubin, and LDH levels. May decrease hemoglobin level.
• May increase eosinophil count. May decrease neutrophil and platelet counts.
• May falsely increase serum or urine creatinine level in tests using Jaffe reaction. May cause false-positive results of Coombs’ test and urine glucose tests that use cupric sulfate, such as Benedict’s reagent and Clinitest.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to cephalosporins.
• Use cautiously in patients hypersensitive to penicillin because of possibility of cross-sensitivity with other beta-lactam antibiotics.
• Use cautiously in breast-feeding women and in patients with history of colitis or renal insufficiency.
NURSING CONSIDERATIONS
• If large doses are given or if therapy is prolonged, monitor patient for superinfection, especially if patient is high risk.
• Treat group A beta-hemolytic streptococcal infections for a minimum of 10 days.
• Look alike-sound alike: Don’t confuse drug with other cephalosporins that sound alike.
PATIENT TEACHING
• Tell patient to take drug exactly as prescribed, even after he feels better.
• Instruct patient to take drug with food or milk to lessen GI discomfort. If patient is taking suspension form, instruct him to shake container well before measuring dose and to store in refrigerator.
• Tell patient to notify prescriber if rash or signs and symptoms of superinfection develop.
cetirizine hydrochloride
se-TEER-i-zeen
Zyrtec ◊
Pharmacologic class: piperazine derivative
Pregnancy risk category B
AVAILABLE FORMS
Oral solution: 5 mg/5 ml ◊
Tablets: 5 mg, 10 mg ◊
Tablets (chewable): 5 mg ◊, 10 mg ◊
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Seasonal allergic rhinitis
Adults and children age 6 and older: 5 to 10 mg P.O. once daily.
Children ages 2 to 5: 2.5 mg P.O. once daily. Maximum daily dose is 5 mg.
[black right-pointing arrowhead] Perennial allergic rhinitis, chronic urticaria
Adults and children age 6 and older: 5 to 10 mg P.O. once daily.
Children ages 6 months to 5 years: 2.5 mg P.O. once daily; in children ages 1 to 5, increase to maximum of 5 mg daily. Children ages 12 to 23 months should receive the 5-mg dose as two divided doses.
Adjust-a-dose: In adults and children age 6 and older receiving hemodialysis, those with hepatic impairment, and those with creatinine clearance less than 31 ml/minute, give 5 mg P.O. daily. Don’t use in children younger than age 6 with renal or hepatic impairment.
ADMINISTRATION
P.O.
• Give drug without regard for food.
ACTION
A long-acting, nonsedating antihistamine that selectively inhibits peripheral H1 receptors.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Rapid | 60 min | 24 hr |
Half-life: About 8 hours. | |||
ADVERSE REACTIONS
CNS: somnolence, fatigue, dizziness, headache.
EENT: pharyngitis.
GI: dry mouth, nausea, vomiting, abdominal distress.
INTERACTIONS
Drug-drug. CNS depressants: May cause additive effect. Monitor patient closely for excessive sedation or other adverse effects.
Theophylline: May decrease cetirizine clearance. Monitor patient closely.
Drug-lifestyle. Alcohol use: May cause additive effects. Discourage use together.
EFFECTS ON LAB TEST RESULTS
• May prevent, reduce, or mask positive result in diagnostic skin test.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or to hydroxyzine and in breast-feeding women.
• Use cautiously in patients with renal or hepatic impairment.
NURSING CONSIDERATIONS
• Stop drug 4 days before diagnostic skin testing because antihistamines can prevent, reduce, or mask positive skin test response.
• Look alike-sound alike: Don’t confuse Zyrtec with Zyprexa or Zantac.
PATIENT TEACHING
• Warn patient not to perform hazardous activities until CNS effects of drug are known. Somnolence is a common adverse reaction.
• Advise patient not to use alcohol or other CNS depressants while taking drug.
• Inform patient that sugarless gum, hard candy, or ice chips may relieve dry mouth.
SAFETY ALERT!
chlorambucil
klor-AM-byoo-sill
Leukeran
Pharmacologic class: nitrogen mustard
Pregnancy risk category D
AVAILABLE FORMS
Tablets: 2 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Chronic lymphocytic leukemia; malignant lymphomas, including lymphosarcoma, giant follicular lymphoma, and Hodgkin lymphoma
Adults: 0.1 to 0.2 mg/kg P.O. daily for 3 to 6 weeks; then adjust for maintenance (usually 4 to 10 mg daily); or, 3 to 6 mg/m2 P.O. daily.
Children: 0.1 to 0.2 mg/kg P.O. or 4.5 mg/m2 P.O. daily for 3 to 6 weeks.
Adjust-a-dose: Reduce first dose if given within 4 weeks after a full course of radiation therapy or myelosuppressive drugs, or if pretreatment leukocyte or platelet counts are depressed from bone marrow disease.
[black right-pointing arrowhead] Macroglobulinemia ♦
Adults: 2 to 10 mg P.O. daily for up to 9 years. Or, 8 mg/m2 P.O. daily with prednisone for 10 days; repeat every 6 to 8 weeks as needed.
[black right-pointing arrowhead] Nephrotic syndrome ♦
Children: 0.1 to 0.2 mg/kg P.O. daily with prednisone for 8 to 12 weeks.
[black right-pointing arrowhead] Intractable idiopathic uveitis, Behçet syndrome ♦
Adults: 6 to 12 mg or 0.1 to 0.2 mg/kg P.O. daily for at least 1 year.
ADMINISTRATION
P.O.
• For initial therapy and short courses of therapy, give entire daily dose at one time.
ACTION
Cross-links strands of cellular DNA and interferes with RNA transcription, causing an imbalance of growth that leads to cell death. Not specific to cell cycle.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 1 hr | Unknown |
Half-life: 2 hours for parent compound; 2½ hours for phenylacetic acid metabolite. | |||
ADVERSE REACTIONS
CNS: seizures, peripheral neuropathy, tremor, muscle twitching, confusion, agitation, ataxia, flaccid paresis.
GI: nausea, vomiting, stomatitis, diarrhea.
GU: azoospermia, infertility, sterile cystitis.
Hematologic: neutropenia, bone marrow suppression, thrombocytopenia, anemia, myelosuppression.
Hepatic: hepatotoxicity.
Respiratory: interstitial pneumonitis, pulmonary fibrosis.
Skin: rash, erythema multiforme, epidermal necrolysis, Stevens-Johnson syndrome.
Other: drug fever, hypersensitivity reactions, secondary malignancies.
INTERACTIONS
Drug-drug. Anticoagulants, aspirin: May increase risk of bleeding. Avoid using together.
Myelosuppressives: May increase myelosuppression. Monitor patient.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, AST, and blood and urine uric acid levels. May decrease hemoglobin level.
• May decrease granulocyte, neutrophil, platelet, RBC, and WBC counts.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients with hypersensitivity or resistance to previous therapy. Patients hypersensitive to other alkylating drugs may also be hypersensitive to this drug.
• Use cautiously in patients with history of head trauma or seizures and in patients receiving other drugs that lower the seizure threshold.
• Use cautiously within 4 weeks of a full course of radiation or chemotherapy.
NURSING CONSIDERATIONS
• Monitor CBC with differential.
• Monitor patient for neutropenia, which may not appear until after the 3rd week of treatment. The absolute neutrophil count (ANC) may continue to decrease for up to 10 days after treatment ends.
• Use the ANC to calculate the patient’s immunosuppression.
• Monitor uric acid level. To prevent hyperuricemia with resulting uric acid nephropathy, allopurinol may be used with adequate hydration.
• If WBC count falls below 2,000/mm3 or granulocyte count falls below 1,000/mm3, follow institutional policy for infection control in immunocompromised patients. Patients may receive injections of WBC colony-stimulating factor to increase WBC count recovery. Severe neutropenia is reversible up to cumulative dose of 6.5 mg/kg in a single course.
• Therapeutic effects are frequently accompanied by toxicity.
• To prevent bleeding, avoid all I.M. injections when platelet count is below 50,000/mm3.
• Anticipate blood transfusions during treatment because of cumulative anemia. Patient may receive injections of RBC colony-stimulating factor to promote RBC production and decrease need for blood transfusions.
PATIENT TEACHING
• Advise patient to watch for signs of infection (fever, sore throat, fatigue) and bleeding (easy bruising, nosebleeds, bleeding gums, tarry stools). Tell patient to take temperature daily.
• Instruct patient to avoid OTC products containing aspirin and NSAIDs.
• Advise women to stop breast-feeding during therapy because of risk of toxicity to infant.
• Advise women of childbearing age to avoid becoming pregnant during therapy and to notify prescriber immediately if pregnancy is suspected.
chlorpheniramine maleate
klor-fen-IR-a-meen
Aller-Chlor ◊*, Allergy ◊,
Chlo-Amine ◊,
Chlor-Trimeton Allergy
4 Hour ◊, Chlor-Trimeton Allergy
8 Hour ◊, Chlor-Trimeton Allergy
12 Hour ◊, Efidac
Pharmacologic class: alkylamine
Pregnancy risk category B
AVAILABLE FORMS
Capsules (sustained-release) ◊: 8 mg, 12 mg
Syrup ◊: 2 mg/5 ml* Tablets ◊: 4 mg
Tablets (chewable) ◊: 2 mg
Tablets (extended-release) ◊: 8 mg, 12 mg, 16 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Allergic rhinitis
Adults and children age 12 and older: 4 mg P.O. every 4 to 6 hours, not to exceed 24 mg daily. Or, 8 to 12 mg timed-release P.O. every 8 to 12 hours, not to exceed 24 mg daily. Or, 16 mg timed-release P.O. once daily.
Children ages 6 to 12 years: Give 2 mg P.O. every 4 to 6 hours, not to exceed 12 mg daily. Or, 8 mg timed-release P.O. at bedtime.
Children ages 2 to 5 years: Give 1 mg P.O. every 4 to 6 hours, not to exceed 6 mg daily.
ADMINISTRATION
P.O.
• Give extended-release tablets whole and not crushed or divided.
ACTION
Competes with histamine for H1-receptor sites on effector cells. Drug prevents, but doesn’t reverse, histamine-mediated responses.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | 15-60 min | 2-6 hr | 24 hr |
Half-life: Adults with normal renal and hepatic function, 12 to 43 hours; children with normal renal and hepatic function, 9½ to 13 hours; chronic renal failure on hemodialysis, 11½ to 13¾ days. | |||
ADVERSE REACTIONS
CNS: drowsiness, stimulation, sedation, excitability in children.
CV: hypotension, palpitations, weak pulse.
GI: dry mouth, epigastric distress.
GU: urine retention.
Respiratory: thick bronchial secretions.
Skin: rash, urticaria, pallor.
INTERACTIONS
Drug-drug. CNS depressants: May increase sedation. Use together cautiously.
MAO inhibitors: May increase anticholinergic effects. Avoid using together.
Drug-lifestyle. Alcohol use: May increase CNS depression. Discourage use together.
EFFECTS ON LAB TEST RESULTS
• May prevent, reduce, or mask positive result in diagnostic skin test.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients having acute asthmatic attacks and in those with angle-closure glaucoma, symptomatic prostatic hyperplasia, pyloroduodenal obstruction, or bladder neck obstruction.
• Contraindicated in breast-feeding women and in patients taking MAO inhibitors.
• Use cautiously in elderly patients and in those with increased intraocular pressure, hyperthyroidism, CV or renal disease, hypertension, bronchial asthma, urine retention, prostatic hyperplasia, and stenosing peptic ulcerations.
NURSING CONSIDERATIONS
• Stop drug 4 days before diagnostic skin testing because antihistamines can prevent, reduce, or mask positive skin test response.
PATIENT TEACHING
• Warn patient to avoid alcohol and hazardous activities that require alertness until CNS effects of drug are known.
• Inform patient that sugarless gum, hard candy, or ice chips may relieve dry mouth.
• Instruct patient to notify prescriber if tolerance develops because a different antihistamine may need to be prescribed.
• Advise patient that extended-release tablets should be swallowed whole and not crushed, chewed, or divided.
NEW DRUGciclesonide
si-CLEH-son-ide
Alvesco†, Omnaris
Pharmacologic class: nonhalogenated glucocorticoid
Pregnancy risk category C
AVAILABLE FORMS
Nasal spray: 50 mcg/metered spray
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Symptoms of seasonal or perennial allergic rhinitis
Adults and children age 12 and older: 2 sprays in each nostril once daily (200 mcg/day).
ADMINISTRATION
Intranasal
• Before first use, gently shake container, then prime by spraying eight times. If not used for 4 consecutive days, gently shake and reprime with 1 spray or until a fine mist appears.
ACTION
Hydrolyzed by the nasal mucosa to a biologically active metabolite with anti-inflammatory properties.
Route | Onset | Peak | Duration |
|---|---|---|---|
Nasal | 1-2 days | 1-5 wk | Unknown |
Half-life: Unknown. | |||
ADVERSE REACTIONS
CNS: headache.
EENT: epistaxis, nasopharyngitis, ear pain, nasal discomfort.
Metabolic: growth retardation.
INTERACTIONS
None significant.
EFFECTS ON LAB TEST RESULTS
None reported.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to the drug or its components.
• Contraindicated in patients who have had recent nasal septal ulcers, nasal surgery, or nasal trauma until healing has occurred.
• Use cautiously in patients who have changed from systemic to inhaled corticosteroids; renal insufficiency, steroid withdrawal (pain, lassitude, depression) or acute worsening of symptoms may occur.
• Use cautiously in immunosuppressed patients or in those with wounds; corticosteroids suppress the immune system.
• Use cautiously in children; may cause a decline in growth rate.
• Use cautiously in breast-feeding women.
NURSING CONSIDERATIONS
• Monitor infants born to mothers using drug during pregnancy for hypoadrenalism.
• Monitor patients who are switched from systemic to inhaled corticosteroids for worsening of symptoms and other side effects of withdrawal.
• Monitor children for decline in growth rate; potential to regain growth after drug is stopped hasn’t been studied.
• Monitor patient for nasal side effects.
PATIENT TEACHING
• Teach patient how to use the spray properly. Refer patient to package insert.
• Instruct patient to contact his prescriber if he has no relief from symptoms after 1 week.
• Advise patient to use drug every day, as directed.
• Warn patient to avoid exposure to people with infections, such as chickenpox or measles; corticosteroids have immunosuppressant effects.
cidofovir
sye-DOE-fo-veer
Vistide
Pharmacologic class: nucleotide analogue
Pregnancy risk category C
AVAILABLE FORMS
Injection: 75 mg/ml in 5-ml vial
INDICATIONS & DOSAGES
[black right-pointing arrowhead] CMV retinitis in patients with AIDS
Adults: Initially, 5 mg/kg I.V. infused over 1 hour once weekly for 2 consecutive
weeks; then maintenance dose of 5 mg/kg I.V. infused over 1 hour once every 2 weeks. Give probenecid and prehydration with normal saline solution I.V. simultaneously to reduce risk of nephrotoxicity.
weeks; then maintenance dose of 5 mg/kg I.V. infused over 1 hour once every 2 weeks. Give probenecid and prehydration with normal saline solution I.V. simultaneously to reduce risk of nephrotoxicity.
Adjust-a-dose: For patients with creatinine level of 0.3 to 0.4 mg/dl above baseline, reduce dosage to 3 mg/kg at same rate and frequency. If creatinine level reaches 0.5 mg/dl or more above baseline, or patient develops 3+ or higher proteinuria, stop drug.
ADMINISTRATION
I.V.
• Drug has mutagenic effects; prepare it in a class II laminar flow biological safety cabinet and wear surgical gloves and a closed-front surgical gown with knit cuffs.
• If drug contacts skin, wash and flush thoroughly with water.
• Place excess drug and all materials used to prepare and give it in a leak-proof, puncture-proof container.
• Let drug reach room temperature before use.
• Using a syringe, withdraw prescribed dose and add to an I.V. bag containing 100 ml of normal saline solution.
• Infuse over 1 hour using an infusion pump.
• Because of the risk of nephrotoxicity, don’t exceed recommended dosages or frequency or rate of infusion.
• Discard any partially used vials.
• Give within 24 hours of preparing. Admixture may be refrigerated at 36° to 46° F (2° to 8° C) for up to 24 hours.
• Alert: Give 1 L normal saline solution I.V. over 1- to 2-hour period, immediately before giving drug.
• Alert: Give probenecid with cidofovir.
• Compatibility of admixture with Ringer’s, lactated Ringer’s, and bacteriostatic solutions hasn’t been evaluated.
• Incompatibilities: Other drugs or supplements.
ACTION
Suppresses CMV replication by selective inhibition of viral DNA synthesis.
Route | Onset | Peak | Duration |
|---|---|---|---|
I.V. | Unknown | Unknown | Unknown |
Half-life: Unknown. | |||
ADVERSE REACTIONS
CNS: asthenia, fever, headache, seizures, abnormal gait, amnesia, anxiety, confusion, depression, dizziness, hallucinations, insomnia, neuropathy, paresthesia, somnolence, malaise.
CV: hypotension, orthostatic hypotension, pallor, syncope, tachycardia, vasodilation.
EENT: ocular hypotony, abnormal vision, amblyopia, conjunctivitis, eye disorders, iritis, pharyngitis, retinal detachment, rhinitis, sinusitis, uveitis.
GI: abdominal pain, anorexia, diarrhea, nausea, vomiting, aphthous stomatitis, colitis, constipation, dry mouth, dyspepsia, dysphagia, flatulence, gastritis, melena, mouth ulcers, oral candidiasis, rectal disorders, stomatitis, taste perversion, tongue discoloration.
GU: proteinuria, nephrotoxicity, glycosuria, hematuria, urinary incontinence, UTI.
Hematologic: anemia, neutropenia, thrombocytopenia.
Hepatic: hepatomegaly.
Metabolic: fluid imbalance, hyperglycemia, hyperlipemia, hypocalcemia, hypokalemia, weight loss.
Musculoskeletal: arthralgia, myalgia, myasthenia, pain in back, chest, or neck.
Respiratory: dyspnea, asthma, bronchitis, coughing, hiccups, increased sputum, lung disorders, pneumonia.
Skin: alopecia, rash, acne, dry skin, pruritus, skin discoloration, sweating, urticaria.
Other: chills, infections, sarcoma, sepsis, allergic reactions, facial edema, herpes simplex.
INTERACTIONS
Drug-drug. Nephrotoxic drugs (such as aminoglycosides, amphotericin B, foscarnet, I.V. pentamidine): May increase nephrotoxicity. Avoid using together.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, ALT, AST, BUN, creatinine, LDH, and urine
protein levels. May decrease bicarbonate and hemoglobin levels.
protein levels. May decrease bicarbonate and hemoglobin levels.
• May decrease neutrophil and platelet counts.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug, probenecid, and other sulfa drugs.
• Contraindicated in patients receiving other drugs with nephrotoxic potential (stop such drugs at least 7 days before starting cidofovir therapy) and in those with creatinine level exceeding 1.5 mg/dl, creatinine clearance of 55 ml/minute or less, or urine protein level of 100 mg/dl or more (equivalent to 2+ proteinuria or more).
• Use within 1 month of placement of a ganciclovir ocular implant may cause profound hypotony.
• Safety and effectiveness in children haven’t been established.
• Use cautiously in patients with renal impairment. Monitor renal function tests and patient’s fluid balance.
NURSING CONSIDERATIONS
• Safety and effectiveness of drug haven’t been established for treating other CMV infections, congenital or neonatal CMV disease, or CMV disease in patients not infected with HIV.
• Monitor creatinine and urine protein levels and WBC counts with differential before each dose.
• Drug may cause Fanconi syndrome and decreased bicarbonate level with renal tubular damage. Monitor patient closely.
• Drug may cause granulocytopenia.
• Stop zidovudine therapy or reduce dosage by 50% on the days when cidofovir is given; probenecid reduces metabolic clearance of zidovudine.
PATIENT TEACHING
• Inform patient that drug doesn’t cure CMV retinitis and that regular ophthalmologic examinations are needed.
• Alert patient taking zidovudine that he’ll need to obtain dosage guidelines on days cidofovir is given.
• Tell patient that close monitoring of kidney function will be needed and that abnormalities may require a change in therapy.
• Stress importance of completing a full course of probenecid with each cidofovir dose. Tell patient to take probenecid after a meal to decrease nausea.
• Patients with AIDS should use effective contraception, especially during and for 1 month after treatment.
• Advise men to practice barrier contraception during and for 3 months after treatment.
ciprofloxacin
si-proe-FLOX-a-sin
Cipro, Cipro I.V., Cipro XR, Proquin XR
Pharmacologic class: fluoroquinolone
Pregnancy risk category C
AVAILABLE FORMS
Infusion (premixed): 200 mg in 100 ml D5W, 400 mg in 200 ml D5W
Injection: 200 mg, 400 mg
Suspension (oral): 5 g/100 ml (5%), 10 g/100 ml (10%)
Tablets (extended-release, film-coated): 500 mg, 1,000 mg
Tablets (film-coated): 100 mg, 250 mg, 500 mg, 750 mg
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Complicated intra-abdominal infection
Adults: 500 mg P.O. or 400 mg I.V. every 12 hours for 7 to 14 days. Give with metronidazole.
[black right-pointing arrowhead] Severe or complicated bone or joint infection, severe respiratory tract infection, severe skin or skin-structure infection
Adults: 750 mg P.O. every 12 hours or 400 mg I.V. every 8 hours.
[black right-pointing arrowhead] Severe or complicated UTI; mild to moderate bone or joint infection; mild to moderate respiratory infection; mild to moderate skin or skin-structure infection; infectious diarrhea; typhoid fever
Adults: 500 mg P.O. or 400 mg I.V. every 12 hours. Or, 1,000 mg extended-release tablets P.O. every 24 hours.
[black right-pointing arrowhead] Complicated UTI or pyelonephritis
Children age 1 to 17: 6 to 10 mg/kg I.V. every 8 hours for 10 to 21 days. Maximum I.V. dose, 400 mg. Or, 10 to 20 mg/kg P.O. every 12 hours. Maximum P.O. dose, 750 mg. Don’t exceed maximum dose, even in patients who weigh more than 51 kg (112 lb).
[black right-pointing arrowhead] Nosocomial pneumonia
Adults: 400 mg I.V. every 8 hours for 10 to 14 days.
[black right-pointing arrowhead] Mild to moderate UTI
Adults: 250 mg P.O. or 200 mg I.V. every 12 hours for 7 to 14 days.
[black right-pointing arrowhead] Uncomplicated UTI
Adults: 500 mg extended-release tablet P.O. once daily for 3 days.
[black right-pointing arrowhead] Chronic bacterial prostatitis
Adults: 500 mg P.O. every 12 hours or 400 mg I.V. every 12 hours for 28 days.
[black right-pointing arrowhead] Acute uncomplicated cystitis
Adults: 100 mg or 250 mg P.O. every 12 hours for 3 days.
[black right-pointing arrowhead] Mild to moderate acute sinusitis
Adults: 500 mg P.O. or 400 mg I.V. every 12 hours for 10 days.
[black right-pointing arrowhead] Empirical therapy in febrile neutropenic patients
Adults: 400 mg I.V. every 8 hours used with piperacillin 50 mg/kg I.V. every 4 hours (not to exceed 24 g/day).
[black right-pointing arrowhead] Inhalation anthrax (postexposure)
Adults: 400 mg I.V. every 12 hours initially until susceptibility test results are known; then 500 mg P.O. b.i.d. Give drug with one or two additional antimicrobials. Switch to oral therapy when appropriate. Treat for 60 days (I.V. and P.O. combined).
Children: 10 mg/kg I.V. every 12 hours; then 15 mg/kg P.O. every 12 hours. Don’t exceed 800 mg/day I.V. or 1,000 mg/day P.O. Give drug with one or two additional antimicrobials. Switch to oral therapy when appropriate. Treat for 60 days (I.V. and P.O. combined).
[black right-pointing arrowhead] Cutaneous anthrax ♦
Adults: 500 mg P.O. b.i.d. for 60 days.
Children: 10 to 15 mg/kg every 12 hours. Don’t exceed 1,000 mg/day. Treat for 60 days.
Adjust-a-dose: For patients with a creatinine clearance of 30 to 50 ml/minute, give 250 to 500 mg P.O. every 12 hours or the usual I.V. dose; if clearance is 5 to 29 ml/minute, give 250 to 500 mg P.O. every 18 hours or 200 to 400 mg I.V. every 18 to 24 hours. If patient is receiving hemodialysis, give 250 to 500 mg P.O. every 24 hours after dialysis.
ADMINISTRATION
P.O.
• Obtain specimen for culture and sensitivity tests before giving first dose. Begin therapy while awaiting results.
• To avoid decreasing the effects of ciprofloxacin, separate dosage of certain drugs by up to 6 hours. Food doesn’t affect absorption but may delay peak levels.
• Caffeine should be avoided during therapy with this drug because of potential for increased caffeine effects.
• Give drug with plenty of fluids to reduce risk of urine crystals.
• Don’t crush or split the extended-release tablets.
I.V.
• Obtain specimen for culture and sensitivity tests before giving first dose. Begin therapy while awaiting results.
• Dilute drug to 1 to 2 mg/ml using D5W or normal saline solution for injection.
• If giving drug through a Y-type set, stop the other I.V. solution while infusing.
• Infuse over 1 hour into a large vein to minimize discomfort and vein irritation.
• Incompatibilities: Aminophylline, ampicillin-sulbactam, azithromycin, cefepime, clindamycin phosphate, dexamethasone sodium phosphate, furosemide, heparin sodium, methylprednisolone sodium succinate, phenytoin sodium.
ACTION
Inhibits bacterial DNA synthesis, mainly by blocking DNA gyrase; bactericidal.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | Unknown | 30-120 min | Unknown |
P.O. (extended-release) | Unknown | 1-4 hr | Unknown |
I.V. | Unknown | Immediate | Unknown |
Half-life: 4 hours; Cipro XR, 6 hours in adults with normal renal function. | |||
ADVERSE REACTIONS
CNS: seizures, confusion, depression, dizziness, drowsiness, fatigue, hallucinations, headache, insomnia, lightheadedness, paresthesia, restlessness, tremor.
CV: chest pain, edema, thrombophlebitis.
GI: pseudomembranous colitis, diarrhea, nausea, abdominal pain or discomfort, constipation, dyspepsia, flatulence, oral candidiasis, vomiting.
GU: crystalluria, interstitial nephritis.
Hematologic: leukopenia, neutropenia, thrombocytopenia, eosinophilia.
Musculoskeletal: aching, arthralgia, arthropathy, joint inflammation, joint or back pain, joint stiffness, neck pain, tendon rupture.
Skin: rash, Stevens-Johnson syndrome, toxic epidermal necrolysis, burning, erythema, exfoliative dermatitis, photosensitivity, pruritus.
Other: hypersensitivity reactions.
INTERACTIONS
Drug-drug. Aluminum hydroxide, aluminum-magnesium hydroxide, calcium carbonate, didanosine (chewable tablets, buffered tablets, or pediatric powder for oral solution), magnesium hydroxide, products containing zinc: May decrease ciprofloxacin absorption and effects. Give ciprofloxacin 2 hours before or 6 hours after these drugs.
Cyclosporine: May increase risk for cyclosporine toxicity. Monitor cyclosporine level.
Iron salts: May decrease absorption of ciprofloxacin, reducing anti-infective response. Give at least 2 hours apart.
NSAIDs: May increase risk of CNS stimulation. Monitor patient closely.
Probenecid: May elevate level of ciprofloxacin. Monitor patient for toxicity.
Sucralfate: May decrease ciprofloxacin absorption, reducing anti-infective response. If use together can’t be avoided, give at least 6 hours apart.
Theophylline: May increase theophylline level and prolong theophylline half-life. Monitor level of theophylline and watch for adverse effects.
Tizanidine: Increases tizanidine levels, causing low blood pressure, somnolence, dizziness, and slowed psychomotor skills. Avoid using together.
Warfarin: May increase anticoagulant effects. Monitor PT and INR closely.
Drug-herb. Dong quai, St. John’s wort: May cause photosensitivity. Advise patient to avoid excessive sunlight exposure.
Yerba maté: May decrease clearance of herb’s methylxanthines and cause toxicity. Discourage use together.
Drug-food. Caffeine: May increase effect of caffeine. Monitor patient closely.
Dairy products, other foods: May delay peak drug levels. Advise patient to take drug on an empty stomach.
Orange juice fortified with calcium: May decrease GI absorption of drug, reducing its effects. Discourage use together.
Drug-lifestyle. Sun exposure: May cause photosensitivity reactions. Advise patient to avoid excessive sunlight exposure.
EFFECTS ON LAB TEST RESULTS
• May increase alkaline phosphatase, ALT, AST, bilirubin, BUN, creatinine, LDH, and GGT levels.
• May increase eosinophil count. May decrease WBC, neutrophil, and platelet counts.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients sensitive to fluoroquinolones.
• Use cautiously in patients with CNS disorders, such as severe cerebral arteriosclerosis or seizure disorders, and in those at risk for seizures. Drug may cause CNS stimulation.
• Drug is associated with increased risk of adverse reactions involving joints, tendons, and surrounding tissues in children younger than age 18.
NURSING CONSIDERATIONS
• Monitor patient’s intake and output and observe patient for signs of crystalluria.
• Tendon rupture may occur in patients receiving quinolones. If pain or inflammation occurs or if patient ruptures a tendon, stop drug.
• Long-term therapy may result in overgrowth of organisms resistant to drug.
• Cutaneous anthrax patients with signs of systemic involvement, extensive edema, or lesions on the head or neck need I.V. therapy and a multidrug approach.
• Additional antimicrobials for anthrax multidrug regimens can include rifampin, vancomycin, penicillin, ampicillin, chloramphenicol, imipenem, clindamycin, and clarithromycin.
• Steroids may be used as adjunctive therapy for anthrax patients with severe edema and for meningitis.
• Follow current Centers for Disease Control and Prevention (CDC) recommendations for anthrax.
• Pregnant women and immunocompromised patients should receive the usual doses and regimens for anthrax.
PATIENT TEACHING
• Tell patient to take drug as prescribed, even after he feels better.
• Advise patient to drink plenty of fluids to reduce risk of urine crystals.
• Advise patient not to crush, split, or chew the extended-release tablets.
• Warn patient to avoid hazardous tasks that require alertness, such as driving, until effects of drug are known.
• Instruct patient to avoid caffeine while taking drug because of potential for increased caffeine effects.
• Advise patient that hypersensitivity reactions may occur even after first dose. If a rash or other allergic reaction occurs, tell him to stop drug immediately and notify prescriber.
• Tell patient that tendon rupture can occur with drug and to notify prescriber if he experiences pain or inflammation.
• Tell patient to avoid excessive sunlight or artificial ultraviolet light during therapy.
• Because drug appears in breast milk, advise woman to stop breast-feeding during treatment or to consider treatment with another drug.
SAFETY ALERT!
cisplatin (CDDP)
SIS-pla-tin
Platinol, Platinol AQ
Pharmacologic class: platinum coordination complex
Pregnancy risk category D
AVAILABLE FORMS
Injection: 0.5 mg/ml†, 1 mg/ml
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Adjunctive therapy in metastatic testicular cancer
Adults: 20 mg/m2 I.V. daily for 5 days. Repeat every 3 weeks for three or four cycles.
[black right-pointing arrowhead] Adjunctive therapy in metastatic ovarian cancer
Adults: 100 mg/m2 I.V.; repeat every 4 weeks. Or, 75 to 100 mg/m2 I.V. once every 4 weeks with cyclophosphamide.
[black right-pointing arrowhead] Advanced bladder cancer ♦
Adults: 50 to 70 mg/m2 I.V. every 3 to 4 weeks. Give 50 mg/m2 every 4 weeks in patients who have received other antineoplastics or radiation therapy.
[black right-pointing arrowhead] Cervical cancer ♦
Adults: 40 to 75 mg/m2 I.V. weekly or daily as monotherapy, in combination therapy, or with radiation therapy.
[black right-pointing arrowhead] Non small-cell lung cancer ♦
Adults: 75 to 100 mg/m2 I.V. every 3 to 4 weeks in combination therapy.
[black right-pointing arrowhead] Osteogenic sarcoma or neuroblastoma ♦
Children ♦: 90 mg/m2 I.V. every 3 weeks, or 30 mg/m2 I.V. once weekly.
[black right-pointing arrowhead] Recurrent brain tumor ♦
Children: 60 mg/m2 I.V. daily for 2 consecutive days every 3 to 4 weeks.
[black right-pointing arrowhead] Head and neck cancer ♦
Adults: 80 to 120 mg/m2 I.V. every 3 weeks or 50 mg/m2 I.V. on days 1 and 8 every 4 weeks. Doses of 50 to 120 mg/m2 I.V. may be used in combination therapy.
ADMINISTRATION
I.V.
• Preparing and giving parenteral form of drug may be mutagenic, teratogenic,
or carcinogenic. Follow facility policy to reduce risks.
or carcinogenic. Follow facility policy to reduce risks.
• Hydrate patient with normal saline solution before giving drug. Maintain urine output of at least 100 ml/hour for 4 consecutive hours before therapy and for 24 hours after therapy.
• Reconstitute powder using sterile water for injection. Add 10 ml to 10-mg vial or 50 ml to 50-mg vial to make a solution containing 1 mg/ml.
• Infusions are most stable in solutions containing chloride (such as normal or half-normal saline solution and 0.22% sodium chloride). Don’t use D5W alone.
• Further dilute with dextrose 5% in 0.3% sodium chloride injection or dextrose 5% in half-normal saline solution for injection.
• Give mannitol or furosemide boluses or infusions before and during cisplatin infusion to maintain diuresis of 100 to 400 ml/hour during and for 24 hours after therapy.
• Add potassium chloride (10 to 20 mEq/L) to I.V. fluids before and after cisplatin therapy to prevent hypokalemia. Add magnesium sulfate to I.V. fluids before and after therapy to prevent hypomagnesemia.
• Give drug as an I.V. infusion in 2 L of dextrose 5% in half-normal saline solution or dextrose 5% in 0.33% sodium chloride solution with 37.5 g of mannitol over 6 to 8 hours.
• Solutions are stable for 20 hours at room temperature. Don’t refrigerate.
• Incompatibilities: Aluminum administration sets, amifostine, amphotericin B cholesteryl sulfate complex, cefepime, D5W, etoposide with mannitol and potassium chloride, fluorouracil, mesna, 0.1% sodium chloride solution, paclitaxel, piperacillin sodium with tazobactam sodium, sodium bicarbonate, sodium bisulfate, sodium thiosulfate, solutions with a chloride content less than 2%, thiotepa.
ACTION
May cross-link strands of cellular DNA and interfere with RNA transcription, causing an imbalance of growth that leads to cell death. Not specific to cell cycle.
Route | Onset | Peak | Duration |
|---|---|---|---|
I.V. | Unknown | Unknown | Several days |
Half-life: Initial phase, 25 to 79 minutes; terminal phase, 58 to 78 hours. | |||
ADVERSE REACTIONS
CNS: peripheral neuritis, seizures.
EENT: tinnitus, hearing loss, ototoxicity, vestibular toxicity, optic neuritis, papilledema, cerebral blindness, blurred vision.
GI: loss of taste, nausea, vomiting.
GU: PROLONGED RENAL TOXICITY WITH REPEATED COURSES OF THERAPY.
Hematologic: MYELOSUPPRESSION, leukopenia, thrombocytopenia, anemia.
Metabolic: hypomagnesemia, hypokalemia, hypocalcemia, hyponatremia, hypophosphatemia, hyperuricemia.
Other: anaphylactoid reaction.
INTERACTIONS
Drug-drug. Aminoglycosides: May increase nephrotoxicity. Carefully monitor renal function study results.
Aminoglycosides, bumetanide, ethacrynic acid, furosemide, torsemide: May increase ototoxicity. Avoid using together, if possible.
Aspirin, NSAIDs: May increase risk of bleeding. Avoid using together.
Fosphenytoin, phenytoin: May decrease phenytoin and fosphenytoin levels. Monitor levels.
Myelosuppressives: May increase myelosuppression. Monitor patient.
EFFECTS ON LAB TEST RESULTS
• May increase uric acid level. May decrease calcium, hemoglobin, magnesium, phosphate, potassium, and sodium levels.
• May decrease platelet and WBC counts.
CONTRAINDICATIONS & CAUTIONS
• Contraindicated in patients hypersensitive to drug or other platinum-containing compounds and in those with severe renal disease, hearing impairment, or myelosuppression.
NURSING CONSIDERATIONS
• Monitor CBC, electrolyte levels (especially potassium and magnesium), platelet count, and renal function studies before initial and subsequent doses.
• To detect hearing loss, obtain audiometry tests before initial and subsequent doses.
• Prehydration and mannitol diuresis may significantly reduce renal toxicity and ototoxicity.
• Therapeutic effects are frequently accompanied by toxicity.
• Some prescribers use I.V. sodium thiosulfate or amifostine to minimize toxicity. Check current protocol.
• Patients may experience vomiting 3 to 5 days after treatment, requiring prolonged antiemetic treatment. Some prescribers combine metoclopramide with dexamethasone and antihistamines, or ondansetron or granisetron with dexamethasone to control vomiting. Monitor intake and output. Continue I.V. hydration until patient can tolerate adequate oral intake.
• Renal toxicity is cumulative; don’t give next dose until renal function returns to normal.
• Don’t repeat dose unless platelet count exceeds 100,000/mm3, WBC count exceeds 4,000/mm3, creatinine level is below 1.5 mg/dl, creatinine clearance is 50 ml/minute or more, and BUN level is below 25 mg/dl.
• To prevent bleeding, avoid all I.M. injections when platelet count is less than 50,000/mm3.
• Anticipate need for blood transfusions during treatment because of cumulative anemia.
• Alert: Immediately give epinephrine, corticosteroids, or antihistamines for anaphylactoid reactions.
• Safety of drug in children hasn’t been established.
• Look alike-sound alike: Don’t confuse cisplatin with carboplatin; they aren’t interchangeable.
PATIENT TEACHING
• Advise patient to watch for signs and symptoms of infection (fever, sore throat, fatigue) and bleeding (easy bruising, nosebleeds, bleeding gums, tarry stools). Tell patient to take temperature daily.
• Tell patient to immediately report ringing in the ears or numbness in hands or feet.
• Instruct patient to avoid OTC products containing aspirin.
• Advise women to stop breast-feeding during therapy because of risk of toxicity to infant.
• Advise women of childbearing age to consult prescriber before becoming pregnant.
clemastine fumarate
KLEM-as-teen
Dayhist-1 ◊, Tavist Allergy ◊
Pharmacologic class: ethanolamine
Pregnancy risk category B
AVAILABLE FORMS
Syrup: 0.67 mg (equivalent to 0.5 mg clemastine)/5 ml*
Tablets: 1.34 mg (equivalent to 1 mg clemastine) ◊, 2.68 mg (equivalent to 2 mg clemastine)
INDICATIONS & DOSAGES
[black right-pointing arrowhead] Rhinitis, allergy symptoms
Adults and children age 12 and older: 1.34 mg P.O. b.i.d.; not to exceed 8.04 mg/day for syrup and 2.68 mg/day for tablets.
Children ages 6 to 11: Give 0.67 mg syrup P.O. b.i.d.; not to exceed 4.02 mg/day.
[black right-pointing arrowhead] Allergic skin manifestation of urticaria and angioedema
Adults and children age 12 and older: 2.68 mg P.O. b.i.d.; not to exceed 8.04 mg daily.
Children ages 6 to 11: Give 1.34 mg syrup P.O. b.i.d.; not to exceed 4.02 mg/day.
ADMINISTRATION
P.O.
• Give drug without regard for food.
ACTION
Competes with histamine for H1-receptor sites effector cells. Drug prevents, but doesn’t reverse, histamine-mediated responses.
Route | Onset | Peak | Duration |
|---|---|---|---|
P.O. | 15-60 min | 5-7 hr | 12 hr |
Half-life: Unknown. | |||
ADVERSE REACTIONS
CNS: incoordination, dizziness, sleepiness, sedation, drowsiness, seizures, nervousness, tremor, confusion, restlessness, vertigo, headache, fatigue.
CV: hypotension, palpitations, tachycardia.
GI: dry mouth, epigastric distress, anorexia, diarrhea, nausea, vomiting, constipation.
GU: urine retention, urinary frequency.
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