Part 2 Drugs

abciximab

ab-SIX-ah-mab

ReoPro

Pharmacologic class: antiplatelet aggregator

Pregnancy risk category C

AVAILABLE FORMS

Injection: 2 mg/ml

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Adjunct to percutaneous coronary intervention (PCI) to prevent acute cardiac ischemic complications

Adults: 0.25 mg/kg as an I.V. bolus given 10 to 60 minutes before start of PCI; then, a continuous I.V. infusion of 0.125 mcg/kg/minute to maximum 10 mcg/minute for 12 hours.

[black right-pointing arrowhead] Unstable angina not responding to conventional medical therapy in patients scheduled for PCI within 24 hours

Adults: 0.25 mg/kg as an I.V. bolus; then an 18- to 24-hour infusion of 10 mcg/minute concluding 1 hour after PCI.

ADMINISTRATION

I.V.

•Give drug in a separate I.V. line. Don’t add other drugs to infusion solution.

•Inspect solution for particulate matter before administration. If opaque particles are visible, discard solution and obtain new vial.

•For bolus, withdraw needed amount of drug through a low-protein-binding 0.2- or 5-micron syringe filter.

•Give bolus 10 to 60 minutes before procedure.

•For continuous infusion, filter drug either by withdrawing needed amount of drug through a low-protein-binding 0.2- or 5-micron syringe filter into a syringe or by infusing with a continuous infusion set equipped with a low-protein-binding 0.2-or 0.22-micron in-line filter. Use normal saline solution or D₅W.

•Infuse at 0.125 mcg/kg/minute (maximum, 10 mcg/minute) for 12 hours via a continuous infusion pump.

•Discard unused portion after 12-hour infusion.

•Incompatibilities: None reported.

ACTION

Binds to the glycoprotein IIb/IIIa (GPIIb/IIIa) receptor of human platelets and inhibits platelet aggregation.

Route	Onset	Peak	Duration
I.V.	Immediate	Immediate	48 hr

Half-life: 10 to 30 minutes.

ADVERSE REACTIONS

CNS: confusion, headache, hyperesthesia, hypoesthesia, pain.

CV: hypotension, bradycardia, peripheral edema.

EENT: abnormal vision.

GI: nausea, abdominal pain, vomiting.

Hematologic: bleeding, thrombocytopenia, anemia, leukocytosis.

Respiratory: pleural effusion, pleurisy, pneumonia.

INTERACTIONS

Drug-drug. Antiplatelet drugs, dipyridamole, heparin, NSAIDs, other anticoagulants, thrombolytics, ticlopidine: May increase risk of bleeding. Monitor patient closely.

EFFECTS ON LAB TEST RESULTS

• May decrease hemoglobin level.

• May increaseWBC count. May decrease platelet count.

CONTRAINDICATIONS & CAUTIONS

•Contraindicated in patients hypersensitive to drug, its ingredients, or murine proteins.

•Contraindicated in those with active internal bleeding, significant GI or GU bleeding within 6 weeks, stroke within past 2 years, or significant residual neurologic deficit, bleeding diathesis, thrombocytopenia (platelet count lower than 100,000/mm³), major surgery or trauma within 6 weeks, intracranial neoplasm, intracranial arteriovenous malformation, intracranial aneurysm, severe uncontrolled hypertension, or history of vasculitis.

•Contraindicated when oral anticoagulants have been given within past 7 days unless PT is 1.2 times control or less, or when I.V. dextran is used before or during PCI.

•Use with caution in patients at increased risk for bleeding, including those who weigh less than 75 kg (165 lb) orwho are older than age 65, those who have a history of GI disease, and those who are receiving thrombolytics. Conditions that increase patient’s risk of bleeding include PCI within 12 hours of onset of symptoms for acute MI, prolonged PCI (lasting longer than 70 minutes), or failed PCI. Heparin use may also increase the risk of bleeding.

NURSING CONSIDERATIONS

•The risk of bleeding is reduced by using low-dose, weight-adjusted heparin, early sheath removal, and careful maintenance of access site immobility.

•Drug is intended for use with aspirin and heparin; review and monitor other drugs patient is taking.

•Alert: Keep epinephrine, dopamine, theophylline, antihistamines, and corticosteroids readily available in case of anaphylaxis.

•Monitor patient closely for bleeding at the arterial access site used for cardiac catheterization and internal bleeding involving the GI or GU tract or retroperitoneal sites.

•Institute bleeding precautions. Keep patient on bed rest for 6 to 8 hours after sheath removal or end of drug infusion, whichever is later. Minimize arterial and venous punctures, I.M. injections, urinary catheters, nasogastric tubes, automatic blood pressure cuffs, and nasotracheal intubation; avoid, if possible.

•During infusion, remove sheath only after heparin has been stopped and its effects largely reversed.

•Before treatment, obtain platelet count, PT, ACT, and activated PTT.

•Monitor platelet count closely. Obtain levels 2 to 4 hours after bolus dose, and 24 hours after bolus dose or before discharge, whichever is first.

•Anticipate stopping drug and giving platelets for severe bleeding or thrombocytopenia.

•Look alike-sound alike: Don’t confuse abciximab with infliximab.

PATIENT TEACHING

•Explain use and administration of drug to patient and family.

•Instruct patient to report adverse reactions immediately.

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 extendedrelease) 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 IOP.

Route	Onset	Peak	Duration
P.O.	60-90 min	1-4 hr	8-12 hr
P.O. (extendedrelease)	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 decreaseWBC 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.

adenosine

a-DEN-oh-seen

Adenocard

Pharmacologic class: nucleoside

Pregnancy risk category C

AVAILABLE FORMS

Injection: 3 mg/ml in 2-ml, 4-ml, and 5-ml vials and syringes

INDICATIONS & DOSAGES

[black right-pointing arrowhead] To convert paroxysmal supraventricular tachycardia (PSVT) to sinus rhythm

Adults and children who weigh 50 kg (110 lb) or more: 6 mg I.V. by rapid bolus injection over 1 to 2 seconds. If PSVT isn’t
eliminated in 1 to 2 minutes, give 12 mg by rapid I.V. push and repeat, if needed.

Children who weigh less than 50 kg: Initially, 0.05 to 0.1 mg/kg I.V. by rapid bolus injection followed by a saline flush. If PSVT isn’t eliminated in 1 to 2 minutes, give additional bolus injections, increasing the amount given by 0.05- to 0.1-mg/kg increments, followed by a saline flush. Continue, as needed, until conversion or a maximum single dose of 0.3 mg/kg is given.

ADMINISTRATION

I.V.

•Don’t give single doses exceeding 12 mg.

•In adults, avoid giving drug through a central line because more prolonged asystole may occur.

•Give by rapid I.V. injection to ensure drug action.

•Give directly into a vein, if possible. When giving through an I.V. line, use the port closest to the patient.

•Flush immediately and rapidly with normal saline solution to ensure that drug quickly reaches the systemic circulation.

•Incompatibilities: Other I.V. drugs.

ACTION

Naturally occurring nucleoside that acts on the AV node to slow conduction and inhibit reentry pathways. Drug is also useful in treating PSVTs, including those with accessory bypass tracts (Wolff-Parkinson-White syndrome).

Route	Onset	Peak	Duration
I.V.	Immediate	Immediate	Unknown

Half-life: Less than 10 seconds.

ADVERSE REACTIONS

CNS: dizziness, light-headedness, numbness, tingling in arms, headache.

CV: chest pressure, facial flushing.

GI: nausea.

Respiratory: dyspnea, shortness of breath.

INTERACTIONS

Drug-drug. Carbamazepine: May cause high-level heart block. Use together cautiously.

Digoxin, verapamil: May cause ventricular fibrillation. Monitor ECG closely.

Dipyridamole: May increase adenosine’s effects. Adenosine dose may need to be reduced. Use together cautiously.

Methylxanthines (caffeine, theophylline): May decrease adenosine’s effects. Adenosine dose may need to be increased or patients may not respond to adenosine therapy.

Drug-herb. Guarana: May decrease patient’s response to drug. Monitor patient.

EFFECTS ON LAB TEST RESULTS

None reported.

CONTRAINDICATIONS & CAUTIONS

•Contraindicated in patients hypersensitive to drug.

•Contraindicated in those with secondor third-degree heart block or sinus node disease (such as sick sinus syndrome and symptomatic bradycardia), except those with a pacemaker.

•Use cautiously in patients with asthma, emphysema, or bronchitis because bronchoconstriction may occur.

NURSING CONSIDERATIONS

•Alert: By decreasing conduction through the AV node, drug may produce first-, second-, or third-degree heart block. Patients who develop high-level heart block after a single dose shouldn’t receive additional doses.

•Alert: New arrhythmias, including heart block and transient asystole, may develop; monitor cardiac rhythm and treat as indicated.

•If solution is cold, crystals may form; gently warm solution to room temperature. Don’t use solutions that aren’t clear.

•Drug lacks preservatives. Discard unused portion.

•Alert: Don’t confuse adenosine with adenosine phosphate.

PATIENT TEACHING

•Instruct patient to report adverse reactions promptly.

•Tell patient to report discomfort at I.V. site.

•Inform patient that he may experience flushing or chest pain lasting 1 to 2 minutes.

NEW DRUG aliskiren

a-LIS-ke-ren

Tecturna

Pharmacologic class: renin inhibitor

Pregnancy risk category C for 1st trimester; D for 2nd and 3rd trimesters

AVAILABLE FORMS

Tablets: 150 mg, 300 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Hypertension, alone or with other antihypertensives

Adults: 150 mg P.O. daily; may increase to 300 mg P.O. daily.

ADMINISTRATION

P.O.

•Don’t give drug with high-fat meal because this may decrease the drug’s effectiveness.

ACTION

Inhibits conversion of angiotensin I to angiotensin II, decreasing vasoconstriction and lowering blood pressure.

Route	Onset	Peak	Duration
P.O.	Unknown	1-3 hr	Unknown

Half-life: Unknown.

ADVERSE REACTIONS

CNS: headache, dizziness, fatigue, seizures.

CV: hypotension.

EENT: nasopharyngitis.

GI: abdominal pain, diarrhea, dyspepsia, gastroesophageal reflux.

Metabolic: hyperuricemia, hyperkalemia.

Musculoskeletal: back pain.

Respiratory: cough, upper respiratory tract infection.

Skin: rash.

Other: angioedema.

INTERACTIONS

Drug-drug. Atorvastatin: May increase aliskiren levels. Use cautiously together.

Ketoconazole: May significantly increase aliskiren levels. Use cautiously together.

Irbesartan: May decrease aliskiren levels. Monitor patient for effectiveness.

Furosemide: May reduce furosemide peak levels. Monitor patient for effectiveness.

Drug-food. High fat meals: May substantially decrease plasma levels of drug.

Monitor patient for effectiveness.

EFFECTS ON LAB TEST RESULTS

• May increase potassium, creatine kinase, BUN, and serum creatinine levels.

CONTRAINDICATIONS & CAUTIONS

•Contraindicated in patients hypersensitive to drug or its components.

•Alert: Contraindicated in pregnant women. Because of risk of fetal toxicity, stop drug as soon as possible if patient becomes pregnant.

•Contraindicated in breast-feeding patients.

•Use cautiously in patients with history of angioedema, severe renal dysfunction (creatinine of 1.7 mg/dl in women and 2 mg/dl inmen, or GFR < 30 ml/minute), history of dialysis, nephrotic syndrome, or renovascular hypertension.

NURSING CONSIDERATIONS

•Monitor blood pressure for hypotension, especially if used in combination with other antihypertensives.

•Monitor potassium levels, especially in patients also taking ACE inhibitors.

•Alert: Rarely, angioedema occurs. Supportive measures may include antihistamines, steroids, and epinephrine.

•Monitor renal function. It’s unknown how patients with significant renal disorders will respond to the use of this drug.

•Effect of any dose is usually seen within 2 weeks.

PATIENT TEACHING

•Instruct patient not to take drug with a high fat meal because this may decrease the drug’s effectiveness.

•Instruct patient to monitor blood pressure daily, if possible, and to report low readings, dizziness, and headaches to prescriber.

•Tell patient to immediately report swelling of the face or neck or difficulty breathing.

•Advise patient of need for regular laboratory tests to monitor for adverse effects.

SAFETY ALERT! alprostadil

al-PROSS-ta-dil

Prostin VR Pediatric

Pharmacologic class: prostaglandin

Pregnancy risk category NR

AVAILABLE FORMS

Injection: 500 mcg/ml

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Palliative therapy for temporary maintenance of patency of ductus arteriosus until surgery can be performed

Neonates: 0.05 to 0.1 mcg/kg/minute by I.V. infusion. When therapeutic response is achieved, reduce infusion rate to lowest dose that will maintain response. Maximum dose is 0.4 mcg/kg/minute. Or, give drug through umbilical artery catheter placed at ductal opening.

ADMINISTRATION

I.V.

•Dilute drug before giving. Prepare fresh solution daily; discard solution after 24 hours.

•For infusion, dilute 1 ml of concentrate labeled as containing 500 mcg in normal saline solution or D₅W injection to yield a solution containing 2 to 20 mcg/ml.

•When using a device with a volumetric infusion chamber, add appropriate volume of diluent to the chamber; then add 1 ml of alprostadil concentrate.

•During dilution, avoid direct contact between concentrate and wall of plastic volumetric infusion chamber because solution may become hazy. If this occurs, discard solution.

•Don’t use diluents that contain benzyl alcohol. Fatal toxic syndrome may occur.

•Drug isn’t recommended for direct injection or intermittent infusion. Give by continuous infusion using an infusion pump. Infuse through a large peripheral or central vein or through an umbilical artery catheter placed at the level of the ductus arteriosus. If flushing from peripheral vasodilation occurs, reposition catheter.

•Reduce infusion rate if patient develops fever or significant hypotension.

•Incompatibilities: None reported.

ACTION

Relaxes smooth muscle of ductus arteriosus.

Route	Onset	Peak	Duration
I.V.	20 min	1-2 hr	Length of infusion

Half-life: About 5 to 10 minutes.

ADVERSE REACTIONS

CNS: fever, seizures.

CV: flushing, bradycardia, cardiac arrest, edema, hypotension, tachycardia.

GI: diarrhea.

Hematologic: DIC.

Metabolic: hypokalemia.

Respiratory: APNEA.

Other: sepsis.

INTERACTIONS

None significant.

EFFECTS ON LAB TEST RESULTS

• May decrease potassium level.

CONTRAINDICATIONS & CAUTIONS

•Contraindicated in neonates before making differential diagnosis between respiratory distress syndrome and cyanotic heart disease and in those with respiratory distress syndrome.

•Use cautiously in neonates with bleeding tendencies because drug inhibits platelet aggregation.

NURSING CONSIDERATIONS

•Keep respiratory support available.

•In infants with restricted pulmonary blood flow, measure drug’s effectiveness by monitoring blood oxygenation. In
infants with restricted systemic blood flow, measure drug’s effectiveness by monitoring systemic blood pressure and blood pH.

•Monitor arterial pressure by umbilical artery catheter, auscultation, or Doppler transducer. If arterial pressure falls significantly, slow infusion rate.

•Carefully monitor neonates receiving drug at recommended doses for longer than 120 hours for gastric outlet obstruction and antral hyperplasia.

•Alert: Apnea is most often seen in neonates weighing less than 2 kg (4.5 lb) at birth and usually appears during the 1st hour of drug infusion. CV and CNS adverse reactions occur more often in infants weighing less than 2 kg and in those receiving infusions for longer than 48 hours.

•Alert: Apnea and bradycardia may reflect drug overdose; if either occurs, stop infusion immediately.

•Look alike-sound alike: Don’t confuse alprostadil with alprazolam.

PATIENT TEACHING

•Tell parents why this drug is needed, and explain its use.

•Encourage parents to ask questions and express concerns.

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 0.75mg/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 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.

SAFETY ALERT! NEW DRUG ambrisentan

am-bree-SEN-tan

Pharmacologic class: endothelinreceptor antagonist

Pregnancy risk category X

AVAILABLE FORMS

Tablets: 5 mg, 10mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Pulmonary arterial hypertension (PAH) in patients withWorld 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 the ULN. If ALT and AST are between five and eight times the ULN, stop therapy and monitor until levels are less than three times the 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 infection ♦

Adults: 15 mg/kg/day I.V. in divided doses every 8 to 12 hours as part of a multipledrug 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.

SAFETY ALERT! amiodarone hydrochloride

am-ee-OH-dah-rohn

Cordarone, Pacerone

Pharmacologic class: benzofuran derivative

Pregnancy risk category D

AVAILABLE FORMS

Injection: 50 mg/ml in 3-ml ampules, vials

Tablets: 100 mg, 200 mg, 400 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Life-threatening recurrent ventricular fibrillation or recurrent hemodynamically unstable ventricular tachycardia unresponsive to adequate doses of other antiarrhythmics or when alternative drugs can’t be tolerated

Adults: Give loading dose of 800 to 1,600 mg P.O. daily divided b.i.d. for 1 to 3 weeks until first therapeutic response occurs; then 600 to 800 mg P.O. daily for 1 month, followed by maintenance dose 200 to 600 mg P.O. daily.

Or, give loading dose of 150 mg I.V. over 10 minutes (15 mg/minute); then 360 mg I.V. over next 6 hours (1 mg/minute), followed by 540 mg I.V. over next 18 hours (0.5 mg/minute). After first 24 hours, continue with maintenance I.V. infusion of 720 mg/24 hours (0.5 mg/minute).

ADMINISTRATION

P.O.

•Divide oral loading dose into two or three equal doses and give with meals to decrease GI intolerance. Give maintenance
dose once daily or divide into two doses, with meals to decrease GI intolerance.

I.V.

•Give drug I.V. only if continuous ECG and electrophysiologic monitoring are available.

•Mix first dose of 150mg in 100 ml of D₅W solution.

•If infusion will last 2 hours or longer, mix solution in glass or polyolefin bottles.

•If concentration is 2 mg/ml or more, give drug through a central line. If possible, use a dedicated line.

•Use an in-line filter.

•Continuously monitor patient’s cardiac status. If hypotension occurs, reduce infusion rate.

•Cordarone I.V. leaches out plasticizers from I.V. tubing and adsorbs to polyvinyl chloride (PVC) tubing, which can adversely affect male reproductive tract development in fetuses, infants, and toddlers when used at concentrations or flow rates outside of recommendations.

•Incompatibilities: Aminophylline, ampicillin sodium and sulbactam sodium, bivalirudin, cefazolin sodium, ceftazidime, digoxin, furosemide, heparin sodium, imipenem and cilastatin sodium, magnesium sulfate, normal saline solution, piperacillin sodium, piperacillin and tazobactam sodium, quinidine gluconate, sodium bicarbonate, sodium nitroprusside, sodium phosphates.

ACTION

Effects result from blockade of potassium chloride leading to a prolongation of action potential duration.

Route	Onset	Peak	Duration
P.O.	Variable	3-7 hr	Variable
I.V.	Unknown	Unknown	Variable

Half-life: 25 to 110 days (usually 40 to 50 days).

ADVERSE REACTIONS

CNS: fatigue, malaise, tremor, peripheral neuropathy, ataxia, paresthesia, insomnia, sleep disturbances, headache.

CV: hypotension, bradycardia, arrhythmias, heart failure, heart block, sinus arrest, edema.

EENT: asymptomatic corneal microdeposits, visual disturbances, optic neuropathy or neuritis resulting in visual impairment, abnormal smell.

GI: nausea, vomiting, abnormal taste, anorexia, constipation, abdominal pain.

Hematologic: coagulation abnormalities.

Hepatic: hepatic failure, hepatic dysfunction.

Metabolic: hypothyroidism, hyperthyroidism.

Respiratory: acute respiratory distress syndrome, SEVERE PULMONARY TOXICITY.

Skin: photosensitivity, solar dermatitis, blue-gray skin.

INTERACTIONS

Drug-drug. Antiarrhythmics: May reduce hepatic or renal clearance of certain antiarrhythmics, especially flecainide, procainamide, and quinidine. Use of amiodarone with other antiarrhythmics, especially mexiletine, propafenone, disopyramide, and procainamide, may induce torsades de pointes. Avoid using together.

Azole antifungals, disopyramide, pimozide: May increase the risk of arrhythmias, including torsades de pointes. Avoid using together.

Beta blockers, calcium channel blockers: May potentiate bradycardia, sinus arrest, and AV block; may increase hypotensive effect. Use together cautiously.

Cimetidine: May increase amiodarone level. Use together cautiously.

Cyclosporine: May increase cyclosporine level, resulting in an increase in the serum creatinine level and renal toxicity. Monitor cyclosporine levels and renal function tests.

Digoxin: May increase digoxin level 70% to 100%. Monitor digoxin level closely and reduce digoxin dosage by half or stop drug completely when starting amiodarone therapy.

Fentanyl: May cause hypotension, bradycardia, and decreased cardiac output. Monitor patient closely.

Fluoroquinolones: May increase risk of arrhythmias, including torsades de pointes. Avoid using together.

Macrolide antibiotics (azithromycin, clarithromycin, erythromycin, telithromycin): May cause additive or prolongation of the QT interval. Use with caution. Avoid use with telithromycin.

Methotrexate: May impair methotrexate metabolism, causing toxicity. Use together cautiously.

Phenytoin: May decrease phenytoin metabolism and amiodarone level. Monitor phenytoin level and adjust dosages of drugs if needed.

Protease inhibitors (amprenavir, atazanavir, indinavir, lopinavir and ritonavir, nelfinavir, ritonavir, and saquinavir): May increase the risk of amiodarone toxicity. Use of ritonavir or nelfinavir with amiodarone is contraindicated. Use other protease inhibitors cautiously.

Quinidine: May increase quinidine level, causing life-threatening cardiac arrhythmias. Avoid using together, or monitor quinidine level closely if use together can’t be avoided. Adjust quinidine dosage as needed.

Rifamycins: May decrease amiodarone level. Monitor patient closely.

Theophylline: May increase theophylline level and cause toxicity. Monitor theophylline level.

Warfarin: May increase anticoagulant response with the potential for serious or fatal bleeding. Decrease warfarin dosage 33% to 50% when starting amiodarone. Monitor patient closely.

Drug-herb. Pennyroyal: May change rate of formation of toxic metabolites of pennyroyal. Discourage use together.

St. John’s wort: May decrease amiodarone levels. Discourage use together.

Drug-food. Grapefruit juice: May inhibit CYP3A4 metabolism of drug in the intestinal mucosa, causing increased levels and risk of toxicity. Discourage use together.

Drug-lifestyle. Sun exposure: May cause photosensitivity reaction. Advise patient to avoid excessive sunlight exposure and to take precautions while in the sun.

EFFECTS ON LAB TEST RESULTS

• May increase alkaline phosphatase, ALT, AST, GGT, reverse T₃, and T₄ levels. May decrease T₃ level.

• May increase PT and INR.

CONTRAINDICATIONS & CAUTIONS

•Contraindicated in patients hypersensitive to drug or to iodine.

•Contraindicated in those with cardiogenic shock, second- or third-degree AV block, severe SA node disease resulting in bradycardia unless an artificial pacemaker is present, and in those for whom bradycardia has caused syncope.

•Use cautiously in patients receiving other antiarrhythmics.

•Use cautiously in patients with pulmonary, hepatic, or thyroid disease.

NURSING CONSIDERATIONS

•Be aware of the high risk of adverse reactions.

•Obtain baseline pulmonary, liver, and thyroid function test results and baseline chest X-ray.

•Give loading doses in a hospital setting and with continuous ECG monitoring because of the slow onset of antiarrhythmic effect and the risk of life-threatening arrhythmias.

•Alert: Drug may pose life-threatening management problems in patients at risk for sudden death. Use only in patients with life-threatening, recurrent ventricular arrhythmias unresponsive to or intolerant of other antiarrhythmics or alternative drugs. Amiodarone can cause fatal toxicities, including hepatic and pulmonary toxicity.

•Alert: Drug is highly toxic.Watch carefully for pulmonary toxicity. Risk increases in patients receiving doses over 400 mg/day.

•Watch for evidence of pneumonitis, exertional dyspnea, nonproductive cough, and pleuritic chest pain. Monitor pulmonary function tests and chest X-ray.

•Monitor liver and thyroid function test results and electrolyte, particularly potassium and magnesium, levels.

•Monitor PT and INR if patient takes warfarin and digoxin level if he takes digoxin.

•Instill methylcellulose ophthalmic solution during amiodarone therapy to minimize corneal microdeposits. About 1 to 4 months after starting amiodarone, most patients develop corneal microdeposits, although 10% or less have vision
disturbances. Regular ophthalmic examinations are advised.

•Monitor blood pressure and heart rate and rhythm frequently. Perform continuous ECG monitoring when starting or changing dosage. Notify prescriber of significant change in assessment results.

•Life-threatening gasping syndrome may occur in neonates given I.V. solutions containing benzyl alcohol.

•During or after treatment with I.V. form, patient may be transferred to oral therapy.

•Look alike-sound alike: Don’t confuse amiodarone with amiloride.

PATIENT TEACHING

•Advise patient to wear sunscreen or protective clothing to prevent sensitivity reaction to the sun. Monitor patient for skin burning or tingling, followed by redness and blistering. Exposed skin may turn blue-gray.

•Tell patient to take oral drug with food if GI reactions occur.

•Inform patient that adverse effects of drug are more common at high doses and become more frequent with treatment lasting longer than 6 months, but are generally reversible when drug is stopped. Resolution of adverse reactions may take up to 4 months.

•Tell patient not to stop taking this medication without consulting with his prescriber.

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.

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 200mg/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.

SAFETY ALERT! argatroban

ahr-GAH-troh-ban

Pharmacologic class: direct thrombin inhibitor

Pregnancy risk category B

AVAILABLE FORMS

Injection: 100 mg/ml

INDICATIONS & DOSAGES

[black right-pointing arrowhead] To prevent or treat thrombosis in patients with heparin-induced thrombocytopenia

Adults without hepatic impairment: 2 mcg/kg/minute, given as a continuous I.V. infusion; adjust dose until the steady-state activated PTT is 1½ to 3 times the initial baseline value, not to exceed 100 seconds; maximum dose 10 mcg/kg/minute. See current manufacturer’s label for recommended doses and infusion rates.

Adjust-a-dose: For patients with moderate hepatic impairment, reduce first dose to 0.5 mcg/kg/minute, given as a continuous infusion. Monitor PTT closely and adjust dosage as needed.

[black right-pointing arrowhead] Anticoagulation in patients with or at risk for heparin-induced thrombocytopenia during percutaneous coronary intervention (PCI)

Adults: 350 mcg/kg I.V. bolus over 3 to 5 minutes. Start a continuous I.V. infusion at 25 mcg/kg/minute. Check activated clotting time (ACT) 5 to 10 minutes after the bolus dose is completed.

Adjust-a-dose: Use the following table to adjust the dosage.

Activated clotting time	Additional I.V. bolus	Continuous I.V. infusion
< 300 sec	150 mcg/kg	30 mcg/kg/min^*
300-450 sec	None needed	25 mcg/kg/min
> 450 sec	None needed	15 mcg/kg/min^*
^*Check ACT again after 5 to 10 minutes.

In case of dissection, impending abrupt closure, thrombus formation during the procedure, or inability to achieve or maintain an ACT exceeding 300 seconds, give an additional bolus of 150 mcg/kg and increase infusion rate to 40 mcg/kg/minute. Check ACT again after 5 to 10 minutes.

ADMINISTRATION

I.V.

•Before starting therapy, obtain a complete list of patient’s prescription and OTC drugs and supplements, including herbs.

•Stop all parenteral anticoagulants before giving drug. Giving with antiplatelets, thrombolytics, and other anticoagulants may increase risk of bleeding.

•Before starting drug, get results of baseline coagulation tests, platelet count, hemoglobin level, and hematocrit, and report any abnormalities to prescriber.

•Dilute in normal saline solution, D₅W, or lactated Ringer’s injection to a final concentration of 1 mg/ml.

•Dilute each 2.5-ml vial 100-fold by mixing it with 250 ml of diluent.

•Mix the solution by repeated inversion of the diluent bag for 10 minutes.

•Don’t expose solution to direct sunlight.

•Prepared solutions are stable for up to 24 hours at 77° F (25° C).

•Incompatibilities: Other I.V. drugs.

ACTION

Reversibly binds to the thrombin-active site and inhibits thrombin-catalyzed or -induced reactions: fibrin formation; coagulation factor V, VIII, and XIII activation; protein C activation; and platelet aggregation. May inhibit the action of free and clot-associated thrombin.

Route	Onset	Peak	Duration
I.V.	Rapid	1-3 hr	Duration of infusion

Half-life: 39 to 51 minutes.

ADVERSE REACTIONS

CNS: cerebrovascular disorder, hemorrhage, fever, pain.

CV: atrial fibrillation, cardiac arrest, hypotension, ventricular tachycardia.

GI: abdominal pain, diarrhea, GI bleeding, nausea, vomiting.

GU: abnormal renal function, groin bleeding, hematuria, UTI.

Respiratory: cough, dyspnea, pneumonia, hemoptysis.

Other: allergic reactions, brachial bleeding, infection, sepsis.

INTERACTIONS

Drug-drug. Antiplatelet drugs, heparin, thrombolytics:May increase risk of intracranial bleeding. Avoid using together.

Oral anticoagulants: May prolong PT and INR and may increase risk of bleeding. Monitor patient closely.

Drug-herb. Angelica (dong quai), boldo, bromelains, capsicum, chamomile, dandelion, danshen, devil’s claw, fenugreek, feverfew, garlic, ginger, ginkgo, ginseng, horse chestnut, licorice, meadowsweet, onion, passion flower, red clover, willow: May increase risk of bleeding. Discourage use together.

EFFECTS ON LAB TEST RESULTS

• May decrease hemoglobin level and hematocrit.

CONTRAINDICATIONS & CAUTIONS

•Contraindicated in patients who have overt major bleeding who are hypersensitive to drug or any of its components.

•Use cautiously in patients with hepatic disease or conditions that increase the risk of hemorrhage, such as severe hypertension.

•Use cautiously in patients who have just had lumbar puncture, spinal anesthesia, or major surgery, especially of the brain, spinal cord, or eye; patients with hematologic conditions causing increased bleeding tendencies, such as congenital or acquired bleeding disorders; and patients with GI ulcers or other lesions.

NURSING CONSIDERATIONS

•Check activated PTT 2 hours after giving drug; dose adjustments may be required to get a targeted activated PTT of 1.5 to 3 times the baseline, no longer than
100 seconds. Steady state is achieved 1 to 3 hours after starting drug.

•Draw blood for additional ACT about every 20 to 30 minutes during prolonged PCI.

•Patients can hemorrhage from any site in the body. Any unexplained decrease in hematocrit or blood pressure or any other unexplained symptoms may signify a hemorrhagic event.

•To convert to oral anticoagulant therapy, give warfarin P.O. with argatroban at up to 2 mcg/kg/minute until the INR exceeds 4 on combined therapy. After argatroban is stopped, repeat the INR in 4 to 6 hours. If the repeat INR is less than the desired therapeutic range, resume the I.V. argatroban infusion. Repeat the procedure daily until the desired therapeutic range on warfarin alone is reached.

•Use cautiously in breast-feeding women; it’s unknown if drug appears in breast milk.

•Look alike-sound alike: Don’t confuse argatroban with Aggrastat.

PATIENT TEACHING

•Tell patient that this drug can cause bleeding, and ask him to report any unusual bruising or bleeding (nosebleeds, bleeding gums) or tarry stools to the prescriber immediately.

•Advise patient to avoid activities that carry a risk of injury, and to use a soft toothbrush and an electric razor during therapy.

•Advise patient to consult with prescriber before initiating any herbal therapy; many herbs have anticoagulant, antiplatelet, and fibrinolytic properties.

•Instruct patient to notify prescriber if he has wheezing, trouble breathing, or skin rash.

•Instruct woman who is pregnant, has recently delivered, or is breast-feeding to notify her prescriber.

•Tell patient to notify prescriber if he has GI ulcers or liver disease, or has had recent surgery, radiation treatment, falling episodes, or injury.

aspirin (acetylsalicylic acid, ASA)

ASS-pir-in

Aspergum ◊, Bayer ◊, Ecotrin, Empirin ◊, Halfprin, Heartline ◊, Norwich ◊, Novasen† ◊, St Joseph’s ◊, ZORprin ◊

Pharmacologic class: salicylate

Pregnancy risk category D

AVAILABLE FORMS

Chewing gum: 227.5 mg ◊

Suppositories: 120 mg ◊, 200mg ◊, 300 mg ◊, 600mg ◊

Tablets: 325 mg ◊, 500mg ◊

Tablets (chewable): 81 mg ◊

Tablets (controlled-release): 800 mg

Tablets (enteric-coated): 81 mg ◊, 165 mg ◊, 325mg ◊, 500mg ◊, 650 mg ◊, 975mg

Tablets (extended-release): 650 mg ◊

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Rheumatoid arthritis, osteoarthritis, or other polyarthritic or inflammatory conditions

Adults: Initially, 2.4 to 3.6 g P.O. daily in divided doses. Maintenance dosage is 3.2 to 6 g P.O. daily in divided doses.

[black right-pointing arrowhead] Juvenile rheumatoid arthritis

Children who weigh more than 25 kg (55 lb): 2.4 to 3.6 g P.O. daily in divided doses.

Children who weigh 25 kg or less: 60 to 130 mg/kg daily P.O. in divided doses. Increase by 10 mg/kg daily at no more than weekly intervals. Maintenance dosages usually range from 80 to 100 mg/kg daily; up to 130 mg/kg daily.

[black right-pointing arrowhead] Mild pain or fever

Adults and children older than age 11: 325 to 650 mg P.O. or P.R. every 4 hours p.r.n.

Children ages 2 to 11: 10 to 15 mg/kg/dose P.O. or P.R. every 4 hours up to 80 mg/kg daily.

[black right-pointing arrowhead] To prevent thrombosis

Adults: 1.3 g P.O. daily, divided b.i.d. to q.i.d.

[black right-pointing arrowhead] To reduce risk of MI in patients with previous MI or unstable angina

Adults: 75 to 325 mg P.O. daily.

[black right-pointing arrowhead] Kawasaki syndrome (mucocutaneous lymph node syndrome)

Children: 80 to 100 mg/kg P.O. daily, divided q.i.d. with immune globulin I.V. After the fever subsides, reduce dosage to 3 to 5 mg/kg once daily. Aspirin therapy usually continues for 6 to 8 weeks.

[black right-pointing arrowhead] Acute rheumatic fever

Adults: 5 to 8 g P.O. daily.

Children: 100 mg/kg daily P.O. for 2 weeks; then 75 mg/kg daily P.O. for 4 to 6 weeks.

[black right-pointing arrowhead] To reduce risk of recurrent transient ischemic attacks and stroke or death in patients at risk

Adults: 50 to 325 mg P.O. daily.

[black right-pointing arrowhead] Acute ischemic stroke

Adults: 160 to 325 mg P.O. daily, started within 48 hours of stroke onset and continued for up to 2 to 4 weeks.

[black right-pointing arrowhead] Acute pericarditis after MI

Adults: 160 to 325 mg P.O. daily. Higher doses (650 mg P.O. every 4 to 6 hours) may be needed.

ADMINISTRATION

P.O.

•For patient with swallowing difficulties, crush non-enteric-coated aspirin and dissolve in soft food or liquid. Give liquid immediately after mixing because drug will break down rapidly.

•Give drug with food, milk, antacid, or large glass of water to reduce GI effects.

•Give sustained-release or enteric-coated forms whole; don’t crush or break these tablets.

Rectal

•Refrigerate suppositories.

ACTION

Thought to produce analgesia and exert its anti-inflammatory effect by inhibiting prostaglandin and other substances that sensitize pain receptors. Drug may relieve fever through central action in the hypothalamic heat-regulating center. In low doses, drug also appears to interfere with clotting by keeping a platelet-aggregating substance from forming.

Route	Onset	Peak	Duration
P.O. (buffered)	5-30 min	1-2 hr	1-4 hr
P.O. (entericcoated)	5-30 min	Variable	1-4 hr
P.O. (extendedrelease)	5-30 min	1-4 hr	1-4 hr
P.O. (solution)	5-30 min	15-40 min	1-4 hr
P.O. (tablet)	5-30 min	25-40 min	1-4 hr
P.R.	Unknown	3-4 hr	Unknown

Half-life: 15 to 20 minutes.

ADVERSE REACTIONS

EENT: tinnitus, hearing loss.

GI: nausea, GI bleeding, dyspepsia, GI distress, occult bleeding.

Hematologic: prolonged bleeding time, leukopenia, thrombocytopenia.

Hepatic: hepatitis.

Skin: rash, bruising, urticaria.

Other: angioedema, Reye syndrome, hypersensitivity reactions.

INTERACTIONS

Drug-drug. ACE inhibitors: May decrease antihypertensive effects. Monitor blood pressure closely.

Ammonium chloride and other urine acidifiers: May increase levels of aspirin products.Watch for aspirin toxicity.

Antacids in high doses and other urine alkalinizers: May decrease levels of aspirin products.Watch for decreased aspirin effect.

Anticoagulants: May increase risk of bleeding. Use with extreme caution if must be used together.

Beta blockers: May decrease antihypertensive effect. Avoid long-term aspirin use if patient is taking antihypertensives.

Corticosteroids: May enhance salicylate elimination and decrease drug level.Watch for decreased aspirin effect.

Heparin: May increase risk of bleeding. Monitor coagulation studies and patient closely if used together.

Ibuprofen, other NSAIDs: May negate the antiplatelet effect of low-dose aspirin therapy. Patients using immediate-release aspirin (not enteric-coated) should take
ibuprofen at least 30 minutes after or more than 8 hours before aspirin. Occasional use of ibuprofen is unlikely to have a negative effect.

Methotrexate: May increase risk of methotrexate toxicity. Avoid using together.

Nizatidine: May increase risk of salicylate toxicity in patients receiving high doses of aspirin. Monitor patient closely.

Oral antidiabetics: May increase hypoglycemic effect. Monitor patient closely.

Probenecid, sulfinpyrazone: May decrease uricosuric effect. Avoid using together.

Valproic acid: May increase valproic acid level. Avoid using together.

Drug-herb. Dong quai, feverfew, ginkgo, horse chestnut, kelpware, red clover: May increase risk of bleeding. Monitor patient closely for increased effects. Discourage use together.

White willow: May increase risk of adverse effects. Discourage use together.

Drug-food. Caffeine: May increase drug absorption.Watch for increased effects.

Drug-lifestyle. Alcohol use: May increase risk of GI bleeding. Discourage use together.

EFFECTS ON LAB TEST RESULTS

• May increase liver function test values. May decrease platelet andWBC counts.

• May falsely increase protein-bound iodine level. May interfere with urine glucose analysis with Diastix, Chemstrip uG, Clinitest, and Benedict solution; with urinary 5-hydroxyindoleacetic acid and vanillylmandelic acid tests; and with Gerhardt test for urine acetoacetic acid.

CONTRAINDICATIONS & CAUTIONS

•Contraindicated in patients hypersensitive to drug and in those with NSAIDinduced sensitivity reactions, G6PD deficiency, or bleeding disorders, such as hemophilia, vonWillebrand disease, or telangiectasia.

•Use cautiously in patients with GI lesions, impaired renal function, hypoprothrombinemia, vitamin K deficiency, thrombocytopenia, thrombotic thrombocytopenic purpura, or severe hepatic impairment.

•Alert: Oral and rectal OTC products containing aspirin and nonaspirin salicylates shouldn’t be given to children or teenagers who have or are recovering from chickenpox or flulike symptoms because of the risk of Reye syndrome.

NURSING CONSIDERATIONS

•For inflammatory conditions, rheumatic fever, and thrombosis, give aspirin on a schedule rather than as needed.

•Because enteric-coated and sustained-release tablets are slowly absorbed, they aren’t suitable for rapid relief of acute pain, fever, or inflammation. They cause less GI bleeding and may be better suited for long-term therapy, such as for arthritis.

•For patients who can’t tolerate oral drugs, ask prescriber about using aspirin rectal suppositories.Watch for rectal mucosal irritation or bleeding.

•Febrile, dehydrated children can develop toxicity rapidly.

•Monitor elderly patients closely because they may be more susceptible to aspirin’s toxic effects.

•Monitor salicylate level. Therapeutic salicylate level for arthritis is 150 to 300 mcg/ml. Tinnitus may occur at levels above 200mcg/ml, but this isn’t a reliable indicator of toxicity, especially in very young patients and those older than age 60.With long-term therapy, severe toxic effects may occur with levels exceeding 400 mcg/ml.

•During prolonged therapy, assess hematocrit, hemoglobin level, PT, INR, and renal function periodically.

•Drug irreversibly inhibits platelet aggregation. Stop drug 5 to 7 days before elective surgery to allow time for production and release of new platelets.

•Monitor patient for hypersensitivity reactions, such as anaphylaxis and asthma.

•Look alike-sound alike: Don’t confuse aspirin with Asendin or Afrin.

PATIENT TEACHING

•Tell patient who’s allergic to tartrazine to avoid aspirin.

•Advise patient on a low-salt diet that 1 tablet of buffered aspirin contains 553 mg of sodium.

•Advise patient to take drug with food, milk, antacid, or large glass of water to reduce GI reactions.

•Tell patient not to crush or chew sustained-release or enteric-coated forms but to swallow them whole.

•Instruct patient to discard aspirin tablets that have a strong vinegar-like odor.

•Tell patient to consult prescriber if giving drug to children for longer than 5 days or adults for longer than 10 days.

•Advise patient receiving prolonged treatment with large doses of aspirin to watch for small, round, red pinprick spots, bleeding gums, and signs of GI bleeding, and to drink plenty of fluids. Encourage use of a soft-bristled toothbrush.

•Because of the many drug interactions with aspirin, warn patient taking prescription drugs to check with prescriber or pharmacist before taking aspirin or OTC products containing aspirin.

•Ibuprofen can interfere with the antiplatelet effect of low-dose aspirin therapy, negating its effect. Tell patient how to safely use ibuprofen in relation to aspirin therapy.

•Urge pregnant woman to avoid aspirin during last trimester of pregnancy unless specifically directed by prescriber.

•Drug is a leading cause of poisoning in children. Caution parents to keep drug out of reach of children. Encourage use of child-resistant containers.

SAFETY ALERT! atenolol

a-TEN-o-loll

Tenormin

Pharmacologic class: beta blocker

Pregnancy risk category D

AVAILABLE FORMS

Injection: 5 mg/10 ml

Tablets: 25 mg, 50 mg, 100 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Hypertension

Adults: Initially, 50 mg P.O. daily alone or in combination with a diuretic as a single dose, increased to 100 mg once daily after 7 to 14 days. Dosages of more than 100 mg daily are unlikely to produce further benefit.

[black right-pointing arrowhead] Angina pectoris

Adults: 50 mg P.O. once daily, increased as needed to 100 mg daily after 7 days for optimal effect. Maximum, 200 mg daily.

[black right-pointing arrowhead] Acute MI

Adults: 5 mg I.V. over 5 minutes; then another 5 mg after 10 minutes. After another 10 minutes, if patient tolerates the full 10-mg I.V. dose, give 50 mg P.O.; then give another 50 mg P.O. in 12 hours. Subsequently, give 100 mg P.O. daily (as a single dose or 50 mg b.i.d.) for 6 to 9 days or until discharged.

[black right-pointing arrowhead] Migraine prophylaxis ♦

Adults: 100 mg P.O. daily.

[black right-pointing arrowhead] Unstable angina ♦, non-STsegment elevationMI in patients at high risk for ischemic events ♦

Adults: Initially, 5 mg I.V. over 2 to 5 minutes, repeat every 5 minutes to maximum of 10 mg. Start oral therapy 1 to 2 hours after last I.V. dose at 50 to 100 mg P.O. daily. Maintenance dose, 50 to 200 mg daily.

Adjust-a-dose: If creatinine clearance is 15 to 35 ml/minute, maximum dose is 50 mg daily; if clearance is below 15 ml/minute, maximum dose is 25 mg daily. Hemodialysis patients need 25 to 50 mg after each dialysis session.

ADMINISTRATION

P.O.

•Check apical pulse before giving drug; if slower than 60 beats/minute, withhold drug and call prescriber.

•Give drug exactly as prescribed, at the same time each day.

I.V.

•Check apical pulse before giving drug; if slower than 60 beats/minute, withhold drug and call prescriber.

•Drug may be mixed with D₅W, normal saline solution, or dextrose and saline solution.

•Give by slow I.V. injection, not exceeding 1 mg/minute.

•Solution is stable for 48 hours after mixing.

•Incompatibilities: Other I.V. drugs.

ACTION

Selectively blocks beta₁ beta-adrenergic receptors, decreases cardiac output and cardiac oxygen consumption, and depresses renin secretion.

Route	Onset	Peak	Duration
P.O.	1 hr	2-4 hr	24 hr
I.V.	5 min	5 min	12 hr

Half-life: 6 to 7 hours.

ADVERSE REACTIONS

CNS: dizziness, fatigue, lethargy, vertigo, drowsiness, fever.

CV: hypotension, bradycardia, heart failure, intermittent claudication.

GI: nausea, diarrhea.

Musculoskeletal: leg pain.

Respiratory: bronchospasm, dyspnea.

Skin: rash.

INTERACTIONS

Drug-drug. Amiodarone: May increase risk of bradycardia, AV block, and myocardial depression. Monitor ECG and vital signs.

Antihypertensives: May increase hypotensive effect. Use together cautiously.

Calcium channel blockers, hydralazine, methyldopa: May cause additive hypotension and bradycardia. Adjust dosage as needed.

Cardiac glycosides, diltiazem, verapamil: May cause excessive bradycardia and increased depressant effect on myocardium. Use together cautiously.

Clonidine: May exacerbate rebound hypertension if clonidine is withdrawn. Atenolol should be withdrawn before clonidine by several days or added several days after clonidine is stopped.

Dolasetron: May decrease clearance of dolasetron and increase risk of toxicity. Monitor patient for toxicity.

Insulin, oral antidiabetics: May alter dosage requirements in previously stabilized diabetic patient. Observe patient carefully.

I.V. lidocaine: May reduce hepatic metabolism of lidocaine, increasing risk of toxicity. Give bolus doses of lidocaine at a slower rate and monitor lidocaine level closely.

NSAIDs: May decrease antihypertensive effects. Monitor blood pressure.

Prazosin: May increase the risk of orthostatic hypotension in the early phases of use together. Help patient stand slowly until effects are known.

Reserpine: May cause hypotension or marked bradycardia. Use together cautiously.

EFFECTS ON LAB TEST RESULTS

• May increase alkaline phosphatase, BUN, creatinine, glucose, LDH, potassium, transaminase, and uric acid levels. May decrease glucose level.

• May increase platelet count.

CONTRAINDICATIONS & CAUTIONS

•Contraindicated in patients with sinus bradycardia, heart block greater than first degree, overt cardiac failure, untreated pheochromocytoma, or cardiogenic shock.

•Use cautiously in patients at risk for heart failure and in those with bronchospastic disease, diabetes, hyperthyroidism, and impaired renal or hepatic function.

NURSING CONSIDERATIONS

•Monitor patient’s blood pressure.

•Monitor hemodialysis patients closely because of hypotension risk.

•Beta blockers may mask tachycardia caused by hyperthyroidism. In patients with suspected thyrotoxicosis, withdraw beta blocker gradually to avoid thyroid storm.

•Drug may mask signs and symptoms of hypoglycemia in diabetic patients.

•Drug may cause changes in exercise tolerance and ECG.

•Alert: Withdraw drug gradually over 2 weeks to avoid serious adverse reactions.

•Look alike-sound alike: Don’t confuse atenolol with timolol or albuterol.

PATIENT TEACHING

•Instruct patient to take drug exactly as prescribed, at the same time every day.

•Caution patient not to stop drug suddenly, but to notify prescriber if unpleasant adverse reactions occur.

•Teach patient how to take his pulse. Tell him to withhold drug and call prescriber if pulse rate is below 60 beats/minute.

•Tell woman of childbearing age to notify prescriber about planned, suspected, or known pregnancy. Drug will need to be stopped.

•Advise breast-feeding mother to contact prescriber; drug isn’t recommended for breast-feeding women.

atorvastatin calcium

ah-TOR-va-stah-tin

Lipitor

Pharmacologic class: HMG-CoA reductase inhibitor

Pregnancy risk category X

AVAILABLE FORMS

Tablets: 10mg, 20 mg, 40mg, 80 mg

INDICATIONS & DOSAGES

NEW INDICATION: In patients with clinically evident coronary heart disease, to reduce the risk of nonfatalMI, fatal and nonfatal strokes, angina, heart failure, and revascularization procedures

Adults: Initially, 10 to 20 mg P.O. daily. May increase based on patient response and tolerance; usual dosage, 10 to 80 mg P.O. daily.

[black right-pointing arrowhead] To reduce the risk of MI, stroke, angina, or revascularization procedures in patients with multiple risk factors for CAD but who don’t yet have the disease

Adults: 10 mg P.O. daily.

[black right-pointing arrowhead] Adjunct to diet to reduce LDL, total cholesterol, apolipoprotein B, and triglyceride levels and to increase HDL levels in patients with primary hypercholesterolemia (heterozygous familial and nonfamilial) and mixed dyslipidemia (Fredrickson types IIa and IIb); adjunct to diet to reduce triglyceride level (Fredrickson type IV); primary dysbetalipoproteinemia (Fredrickson type III) in patients who don’t respond adequately to diet

Adults: Initially, 10 or 20 mg P.O. once daily. Patient who requires a reduction of more than 45% in LDL level may be started at 40 mg once daily. Increase dose, as needed, to maximum of 80 mg daily as single dose. Dosage based on lipid levels drawn within 2 to 4 weeks of starting therapy and after dosage adjustment.

[black right-pointing arrowhead] Alone or as an adjunct to lipidlowering treatments, such as LDL apheresis, to reduce total and LDL cholesterol in patients with homozygous familial hypercholesterolemia

Adults: 10 to 80 mg P.O. once daily.

[black right-pointing arrowhead] Heterozygous familial hypercholesterolemia

Children ages 10 to 17 (girls should be 1 year postmenarche): Initially, 10 mg P.O. once daily. Adjustment intervals should be at least 4 weeks. Maximum daily dose is 20 mg.

ADMINISTRATION

P.O.

•Give drug without regard for meals.

ACTION

Inhibits HMG-CoA reductase, an early (and rate-limiting) step in cholesterol biosynthesis.

Route	Onset	Peak	Duration
P.O.	Unknown	1-2 hr	Unknown

Half-life: 14 hours.

ADVERSE REACTIONS

CNS: headache, asthenia, insomnia.

CV: peripheral edema.

EENT: pharyngitis, rhinitis, sinusitis.

GI: abdominal pain, constipation, diarrhea, dyspepsia, flatulence, nausea.

GU: UTI.

Musculoskeletal: rhabdomyolysis, arthritis, arthralgia, myalgia.

Respiratory: bronchitis.

Skin: rash.

Other: allergic reactions, flulike syndrome, infection.

INTERACTIONS

Drug-drug. Antacids, cholestyramine, colestipol: May decrease atorvastatin level. Separate administration times.

Cyclosporine, diltiazem, fibric acid derivatives, macrolides (azithromycin, clarithromycin, erythromycin, telithromycin), nefazodone, niacin, protease inhibitors, verapamil: May decrease metabolism of HMG-CoA reductase inhibitors, increasing toxicity. Monitor patient for adverse effects and report unexplained muscle pain.

Digoxin: May increase digoxin level. Monitor digoxin level and patient for evidence of toxicity.

Fluconazole, itraconazole, ketoconazole, voriconazole: May increase atorvastatin level and adverse effects. Avoid using together; or if unavoidable, reduce dose of atorvastatin.

Hormonal contraceptives: May increase norethindrone and ethinyl estradiol levels. Consider increased drug levels when selecting an oral contraceptive.

Drug-herb. Eucalyptus, jin bu huan, kava: May increase risk of hepatotoxicity. Discourage use together.

Red yeast rice: May increase risk of adverse reactions because herb contains compounds similar to those in drug. Discourage use together.

Drug-food. Grapefruit juice: May increase drug levels, increasing risk of adverse reactions. Discourage use together.

EFFECTS ON LAB TEST RESULTS

• May increase ALT, AST, and CK levels.

CONTRAINDICATIONS & CAUTIONS

•Contraindicated in patients hypersensitive to drug and in those with active liver disease or unexplained persistent elevations of transaminase levels.

•Contraindicated in pregnant and breast-feeding women and in women of childbearing age.

•Use cautiously in patients with history of liver disease or heavy alcohol use.

•Withhold or stop drug in patients at risk for renal failure caused by rhabdomyolysis resulting from trauma; in serious, acute conditions that suggest myopathy; and in major surgery, severe acute infection, hypotension, uncontrolled seizures, or severe metabolic, endocrine, or electrolyte disorders.

•Limit use in children to those older than age 9 with homozygous familial hypercholesterolemia.

NURSING CONSIDERATIONS

•Patient should follow a standard cholesterol-lowering diet before and during therapy.

•Before treatment, assess patient for underlying causes for hypercholesterolemia and obtain a baseline lipid profile. Obtain periodic liver function test results and lipid levels before starting treatment and at 6 and 12 weeks after initiation, or after an increase in dosage and periodically thereafter.

•Watch for signs of myositis.

•Look alike-sound alike: Don’t confuse Lipitor with Levatol.

PATIENT TEACHING

•Teach patient about proper dietary management, weight control, and exercise. Explain their importance in controlling high fat levels.

•Warn patient to avoid alcohol.

•Tell patient to inform prescriber of adverse reactions, such as muscle pain, malaise, and fever.

•Advise patient that drug can be taken at any time of day, without regard for meals.

•Alert: Tell woman to stop drug and notify prescriber immediately if she is or may be pregnant or if she’s breast-feeding.

SAFETY ALERT! atropine sulfate

AT-troe-peen

AtroPen, Sal-Tropine

Pharmacologic class: anticholinergic, belladonna alkaloid

Pregnancy risk category C

AVAILABLE FORMS

Injection: 0.05 mg/ml, 0.1 mg/ml, 0.3 mg/ml, 0.4 mg/ml, 0.5 mg/ml, 0.8 mg/ml, 1 mg/ml

Prefilled auto-injectors: 0.5 mg, 1 mg, 2 mg

Tablets: 0.4 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Symptomatic bradycardia, bradyarrhythmia (junctional or escape rhythm)

Adults: Usually 0.5 to 1 mg I.V. push, repeated every 3 to 5 minutes to maximum of 2 mg p.r.n.

Children and adolescents: 0.02 mg/kg I.V., with minimum dose of 0.1 mg and maximum single dose of 0.5 mg in children or 1 mg in adolescents. May repeat dose at 5-minute intervals to a maximum total dose of 1 mg in children or 2 mg in adolescents.

[black right-pointing arrowhead] Antidote for anticholinesterase-insecticide poisoning

Adults: Initially, 1 to 2 mg I.V.; may repeat with 2 mg I.M. or I.V. every 5 to 60 minutes until muscarinic signs and symptoms disappear or signs of atropine toxicity appear. Severe poisoning may require up to 6 mg hourly.

Children: 0.05 mg/kg I.V. or I.M. repeated every 10 to 30 minutes until muscarinic signs and symptoms disappear (may be repeated if they reappear) or until atropine toxicity occurs.

[black right-pointing arrowhead] Preoperatively to diminish secretions and block cardiac vagal reflexes

Adults and children who weigh 20 kg (44 lb) or more: 0.4 to 0.6 mg I.V., I.M., or subcutaneously 30 to 60 minutes before anesthesia.

Children who weigh less than 20 kg: 0.01 mg/kg I.V., I.M., or subcutaneously up to maximum dose of 0.4 mg 30 to 60 minutes before anesthesia. May repeat every 4 to 6 hours p.r.n.

Infants who weigh more than 5 kg (11 lb): 0.03 mg/kg every 4 to 6 hours p.r.n.

Infants who weigh 5 kg or less: 0.04 mg/kg every 4 to 6 hours p.r.n.

[black right-pointing arrowhead] Adjunct treatment of peptic ulcer disease; functional GI disorders such as irritable bowel syndrome

Adults: 0.4 to 0.6 mg P.O. every 4 to 6 hours.

ADMINISTRATION

P.O.

•Give drug without regard for food.

I.V.

•Give into a large vein or into I.V. tubing over at least 1 minute.

•Slow delivery may cause slowing of the heart rate.

•Incompatibilities: Alkalies, bromides, iodides, isoproterenol, methohexital, norepinephrine, pentobarbital sodium, sodium bicarbonate.

I.M.

•Document administration site.

Subcutaneous

•Auto-injection may be given through clothing.

•Firmly jab tip into outer thigh at 90-degree angle.

•Hold auto-injector in place for at least 10 seconds to allow time for complete administration.

•Make sure needle is visible after removing auto-injector. If needle didn’t engage, repeat injection, jabbing more firmly.

•Massage injection site for several seconds after removing auto-injector.

•In very thin or young patients, pinch the skin on the thigh together before injection.

ACTION

Inhibits acetylcholine at parasympathetic neuroeffector junction, blocking vagal effects on SA and AV nodes, enhancing conduction through AV node and increasing heart rate.

Route	Onset	Peak	Duration
P.O.	30-120 min	1-2 hr	4 hr
I.V.	Immediate	2-4 min	4 hr
I.M.	5-40 min	20-60 min	4 hr
Subcut.	Unknown	Unknown	Unknown

Half-life: Initial, 2 hours; second phase, 12½ hours.

ADVERSE REACTIONS

CNS: headache, restlessness, insomnia, dizziness, ataxia, disorientation, hallucinations, delirium, excitement, agitation, confusion.

CV: bradycardia, palpitations, tachycardia.

EENT: blurred vision, mydriasis, photophobia, cycloplegia, increased intraocular pressure.

GI: dry mouth, constipation, thirst, nausea, vomiting.

GU: urine retention, impotence.

Other: anaphylaxis.

INTERACTIONS

Drug-drug. Antacids: May decrease absorption of oral anticholinergics. Separate doses by at least 1 hour.

Anticholinergics, drugs with anticholinergic effects (amantadine, antiarrhythmics, antiparkinsonians, glutethimide, meperidine, phenothiazines, tricyclic antidepressants): May increase anticholinergic effects. Use together cautiously.

Ketoconazole, levodopa: May decrease absorption of these drugs. Separate doses by at least 2 hours, and monitor patient for clinical effect.

Potassium chloride wax-matrix tablets: May increase risk of mucosal lesions. Use together cautiously.

Drug-herb. Jaborandi tree, pill-bearing spurge: May decrease effectiveness of drug. Discourage use together.

Jimsonweed: May adversely affect CV function. Discourage use together.

Squaw vine: Tannic acid may decrease metabolic breakdown of drug. Monitor patient.

EFFECTS ON LAB TEST RESULTS

None reported.

CONTRAINDICATIONS & CAUTIONS

•Contraindicated in patients hypersensitive to drug.

•Contraindicated in those with acute angle-closure glaucoma, obstructive uropathy, obstructive disease of GI tract, paralytic ileus, toxic megacolon, intestinal atony, unstable CV status in acute hemorrhage, tachycardia, myocardial ischemia, asthma, or myasthenia gravis.

•Use cautiously in patients with Down syndrome because they may be more sensitive to drug.

NURSING CONSIDERATIONS

•In adults, avoid doses less than 0.5 mg because of risk of paradoxical bradycardia.

•Alert: Watch for tachycardia in cardiac patients because it may lead to ventricular fibrillation.

•Many adverse reactions (such as dry mouth and constipation) vary with dose.

•Monitor fluid intake and urine output. Drug causes urine retention and urinary hesitancy.

PATIENT TEACHING

•Teach patient receiving oral form of drug how to handle distressing anticholinergic effects such as dry mouth.

•Instruct patient to report serious or persistent adverse reactions promptly.

•Tell patient about potential for sensitivity of the eyes to the sun and suggest use of sunglasses.

benazepril hydrochloride

ben-A-za-pril

Lotensin

Pharmacologic class: ACE inhibitor

Pregnancy risk category C; D in 2nd and 3rd trimesters

AVAILABLE FORMS

Tablets: 5 mg, 10 mg, 20 mg, 40 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Hypertension

Adults: For patients not receiving a diuretic, 10 mg P.O. daily initially. Adjust dosage as needed and tolerated; usually 20 to 40 mg daily in one or two divided doses. For patients receiving a diuretic, 5 mg P.O. daily initially.

Children age 6 and older: 0.2 mg/kg (up to 10mg) P.O. daily. Adjust as needed up to 0.6 mg/kg (maximum 40 mg) P.O. daily.

Adjust-a-dose: If creatinine clearance is below 30 ml/minute, give 5 mg P.O. daily. Daily dose may be adjusted up to 40 mg.

ADMINISTRATION

P.O.

•Request oral suspension for patients who can’t swallow tablets.

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. Drug also acts as antihypertensive in patients with low-renin hypertension.

Route	Onset	Peak	Duration
P.O.	1 hr	2-4 hr	24 hr

Half-life: benazepril, 0.6 hour.

ADVERSE REACTIONS

CNS: headache, dizziness, drowsiness, fatigue, somnolence.

CV: symptomatic hypotension.

GI: nausea.

GU: impotence.

Metabolic: hyperkalemia.

Musculoskeletal: arthralgia, arthritis, myalgia.

Respiratory: dry, persistent, nonproductive cough.

Skin: increased diaphoresis.

Other: hypersensitivity reactions.

INTERACTIONS

Drug-drug. Azathioprine: May increase risk of anemia or leukopenia. Monitor hematologic study results if used together.

Diuretics, other antihypertensives: May cause excessive hypotension. Stop diuretic or lower dosage of benazepril, as needed.

Lithium: May increase lithium level and toxicity. Use together cautiously; monitor lithium level.

Nesiritide: May increase risk of hypotension. Monitor blood pressure.

NSAIDs: May decrease antihypertensive effects. Monitor blood pressure.

Potassium-sparing diuretics, potassium supplements: May cause hyperkalemia. Monitor potassium level and renal function.

Drug-herb. Capsaicin: May cause cough. Discourage use together.

Ma huang: May decrease antihypertensive effects. Discourage use together.

Drug-food. Salt substitutes containing potassium: May cause hyperkalemia. Monitor potassium level and renal function.

EFFECTS ON LAB TEST RESULTS

• May increase BUN, creatinine, and potassium levels.

CONTRAINDICATIONS & CAUTIONS

•Contraindicated in patients hypersensitive to ACE inhibitors.

•Use cautiously in patients with impaired hepatic or renal function.

NURSING CONSIDERATIONS

•Monitor patient for hypotension. Excessive hypotension can occur when drug is given with diuretics. If possible, diuretic therapy should be stopped 2 to 3 days before starting benazepril to decrease potential for excessive hypotensive response. If drug doesn’t adequately control blood pressure, diuretic may be cautiously reinstituted.

•Although ACE inhibitors reduce blood pressure in all races, they reduce it less in blacks taking the ACE inhibitor alone. Black patients should take drug with a thiazide diuretic for a more favorable response.

•Drug may increase risk of angioedema in black patients.

•Measure blood pressure when drug level is at peak (2 to 6 hours after administration) and at trough (just before a dose) to verify adequate blood pressure control.

•Assess renal and hepatic function before and periodically during therapy. Monitor potassium level.

•Look alike-sound alike: Don’t confuse benazepril with Benadryl or Lotensin with Loniten or lovastatin.

PATIENT TEACHING

•Instruct patient to avoid salt substitutes because they may contain potassium, which can cause high potassium level in patients taking drug.

•Inform patient that light-headedness can occur, especially during first few days of therapy. Tell him to rise slowly to minimize this effect and to report dizziness to prescriber. If fainting occurs, he should stop drug and call prescriber immediately.

•Warn patient to use caution in hot weather and during exercise. Inadequate fluid intake, vomiting, diarrhea, and excessive perspiration can lead to light-headedness and fainting.

•Advise patient to report signs of infection, such as fever and sore throat. Tell him to call prescriber if he develops easy
bruising or bleeding; swelling of tongue, lips, face, eyes, mucous membranes, or extremities; difficulty swallowing or breathing; or hoarseness.

•Tell woman of childbearing age to notify prescriber if she becomes pregnant. Drug will need to be stopped.

SAFETY ALERT! bivalirudin

bye-VAL-ih-roo-din

Angiomax

Pharmacologic class: direct thrombin inhibitor

Pregnancy risk category B

AVAILABLE FORMS

Injection: 250-mg vial

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Anticoagulation in patients with unstable angina undergoing percutaneous transluminal coronary angioplasty (PTCA); anticoagulation in patients with unstable angina undergoing percutaneous coronary intervention (PCI), with provisional use of a platelet glycoprotein IIb/IIIa inhibitor (GPI)

Adults: Give 0.75 mg/kg I.V. bolus followed by a continuous infusion of 1.75 mg/kg/hour during the procedure. Check activated clotting time 5 minutes after bolus dose is given. May give additional 0.3 mg/kg bolus dose if needed. Infusion may continue for up to 4 hours after procedure. After 4-hour infusion, may give an additional infusion of 0.2 mg/kg/hour for up to 20 hours, if needed. Use with 300 to 325 mg aspirin.

[black right-pointing arrowhead] Patients undergoing PCI who have or are at risk for heparin-induced thrombocytopenia (HIT) or heparin-induced thrombocytopenia and thrombosis syndrome (HITTS)

Adults: 0.75 mg/kg I.V. bolus, followed by a continuous infusion of 1.75 mg/kg/hour throughout the procedure. Consult prescriber about continuing the infusion after PCI.

Adjust-a-dose: For patients with creatinine clearance of 30 ml/minute or less, decrease infusion rate to 1 mg/kg/hour. For patients on hemodialysis, reduce infusion rate to 0.25 mg/kg/hour. No reduction of bolus dose is needed.

ADMINISTRATION

I.V.

•Reconstitute each 250-mg vial with 5 ml of sterile water for injection.

•Dilute each reconstituted vial in 50 ml D₅W or normal saline solution to yield a final concentration of 5 mg/ml.

•To prepare low-rate infusion, further dilute each reconstituted vial in 500 ml D₅W or normal saline solution to yield a final concentration of 0.5 mg/ml.

•Solutions with concentrations of 0.5 to 5 mg/ml are stable at room temperature for 24 hours.

•Incompatibilities: Alteplase, amiodarone, amphotericin B, chlorpromazine, diazepam, prochlorperazine, reteplase, streptokinase, vancomycin.

ACTION

Binds specifically and rapidly to thrombin to produce an anticoagulant effect.

Route	Onset	Peak	Duration
I.V.	Rapid	Immediate	1-2 hr

Half-life: 25 minutes in patients with normal renal function.

ADVERSE REACTIONS

CNS: anxiety, headache, insomnia, nervousness, fever, pain.

CV: bradycardia, hypertension, hypotension.

GI: abdominal pain, dyspepsia, nausea, vomiting.

GU: urine retention.

Hematologic: severe, spontaneous bleeding (cerebral, retroperitoneal, GU, GI).

Musculoskeletal: back pain, pelvic pain.

Skin: pain at injection site.

INTERACTIONS

Drug-drug. Heparin, warfarin, other oral anticoagulants: May increase risk of hemorrhage. Use together cautiously.

EFFECTS ON LAB TEST RESULTS

None reported.

CONTRAINDICATIONS & CAUTIONS

•Contraindicated in patients hypersensitive to drug or its components and in those with active major bleeding. Avoid using in patients with unstable angina who aren’t undergoing PTCA or PCI or in patients with other acute coronary syndromes.

•Use cautiously in patients with HIT or HITTS and in those with diseases linked to increased risk of bleeding.

•Use cautiously in breast-feeding women; it’s unknown if drug appears in breast milk.

NURSING CONSIDERATIONS

•Monitor coagulation test results, hemoglobin level, and hematocrit before starting therapy and periodically thereafter.

•Circumstances for provisional use of a GPI during PCI include decreased thrombolysis-in-MI, flow; slow reflow; dissection with decreased flow; new or suspected thrombus; persistent residual stenosis; distal embolization; unplanned stent; suboptimal stenting; side-branch closure; abrupt closure; instability; and prolonged ischemia.

•Obtain a complete list of patient’s prescription and OTC drugs and supplements, including herbs.

•Hemorrhage can occur at any site in the body. If patient has unexplained decrease in hematocrit, decrease in blood pressure, or other unexplained symptoms, suspect hemorrhage.

•Monitor venipuncture sites for bleeding, hematoma, or inflammation.

•Puncture-site hemorrhage and catheterization-site hematoma may occur in patients age 65 and older more often than in younger patients.

•Don’t give drug I.M.

PATIENT TEACHING

•Advise patient that drug can cause bleeding and tell him to report unusual bruising or bleeding (nosebleeds, bleeding gums) or tarry stools immediately.

•Counsel patient that drug is given with aspirin and caution him to avoid other aspirin-containing drugs or NSAIDs while receiving this drug.

•Advise patient to consult with prescriber before initiating any herbal therapy; many herbs have anticoagulant, antiplatelet, and fibrinolytic properties.

•Advise patient to avoid activities that carry a risk of injury, and instruct him to use a soft toothbrush and electric razor while on 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 withWorld 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 table at right. 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.

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.

ADMINISTRATION

P.O.

•Give drug in morning and evening without regard for meals.

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.

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.

candesartan cliexetil

kan-dah-SAR-tan

Atacand

Pharmacologic class: angiotensin II receptor antagonist

Pregnancy risk category C; D in 2nd and 3rd trimesters

AVAILABLE FORMS

Tablets: 4 mg, 8 mg, 16 mg, 32 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Hypertension (used alone or with other antihypertensives)

Adults: Initially, 16 mg P.O. once daily when used alone; usual range is 8 to 32 mg P.O. daily as a single dose or divided b.i.d.

[black right-pointing arrowhead] Heart failure

Adults: Initially, 4 mg P.O. once daily. Double the dose about every 2 weeks as tolerated to a target dose of 32 mg once daily.

Adjust-a-dose: If patient takes a diuretic, consider a lower starting dose.

ADMINISTRATION

P.O.

• Give drug without regard for food.

ACTION

Inhibits vasoconstrictive action of angiotensin II by blocking angiotensin II receptor on the surface of vascular smooth muscle and other tissue cells.

Route	Onset	Peak	Duration
P.O.	Unknown	3-4 hr	24 hr

Half-life: 9 hours.

ADVERSE REACTIONS

CNS: dizziness, fatigue, headache.

CV: chest pain, peripheral edema.

EENT: pharyngitis, rhinitis, sinusitis.

GI: abdominal pain, diarrhea, nausea, vomiting.

GU: albuminuria.

Musculoskeletal: arthralgia, back pain.

Respiratory: coughing, bronchitis, upper respiratory tract infection.

INTERACTIONS

Drug-drug. Lithium: May increase lithium concentration. Monitor lithium levels closely.

Potassium-sparing diuretics, potassium supplements: May cause hyperkalemia. Monitor patient closely.

Drug-herb. Ma huang: May decrease antihypertensive effects. Discourage use together.

Drug-food. Salt substitutes containing potassium: May cause hyperkalemia. Monitor patient closely.

EFFECTS ON LAB TEST RESULTS

• May increase potassium, BUN, and serum creatinine levels.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug or its components.

• Use cautiously in patients whose renal function depends on the renin-angiotensinaldosterone system (such as patients with heart failure) because of risk of oliguria and progressive azotemia with acute renal failure or death.

• Contraindicated in pregnant patients, especially in the second and third trimesters.

• Use cautiously in patients who are volume or salt depleted because they could develop symptoms of hypotension. Start therapy with a lower dosage range, and monitor blood pressure carefully.

NURSING CONSIDERATIONS

• Alert: Drugs such as candesartan that act directly on the renin-angiotensin system can cause fetal and neonatal illness and death when given to pregnant women. If pregnancy is suspected, notify prescriber immediately.

• If hypotension occurs after a dose of candesartan, place patient in the supine position and, if needed, give an I.V. infusion of normal saline solution.

• Most of drug’s antihypertensive effect occurs within 2 weeks. Maximal effect may take 4 to 6 weeks.Diureticmay be added if blood pressure isn’t controlled by drug alone.

• Carefully monitor elderly patients and those with renal disease for therapeutic response and adverse reactions.

PATIENT TEACHING

• Inform woman of childbearing age of the consequences of second and third trimester exposure to drug. Prescriber should be notified immediately if pregnancy is suspected.

• Advise breast-feeding woman of the risk of adverse effects on the infant and the need to stop either breast-feeding or drug.

• Instruct patient to store drug at room temperature and to keep container tightly sealed.

• Inform patient to report adverse reactions without delay.

• Tell patient that drug may be taken without regard to meals.

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.

[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.

carvedilol

kar-VAH-da-lol

Coreg

carvedilol phosphate

Coreg CR

Pharmacologic class: alpha-nonselective beta blocker

Pregnancy risk category C

AVAILABLE FORMS

Capsules (extended-release): 10 mg, 20 mg, 40 mg, 80 mg

Tablets: 3.125 mg, 6.25 mg, 12.5 mg, 25 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Hypertension

Adults: Dosage highly individualized. Initially, 6.25 mg P.O. b.i.d. Measure standing blood pressure 1 hour after first dose. If tolerated, continue dosage for 7 to 14 days. May increase to 12.5 mg P.O. b.i.d. for 7 to 14 days, following same blood pressure monitoring protocol as before. Maximum dose is 25 mg P.O. b.i.d. as tolerated. May be switched to extended-release capsule after controlled on immediate-release tablets.

[black right-pointing arrowhead] Left ventricular dysfunction after MI

Adults: Dosage individualized. Start therapy after patient is hemodynamically stable and fluid retention has been minimized. Initially, 6.25 mg P.O. b.i.d. Increase after 3 to 10 days to 12.5 mg b.i.d., then again to a target dose of 25 mg b.i.d. Or start with 3.25 mg b.i.d., or adjust dosage slower if indicated. May be switched to extended-release capsule after controlled on immediate-release tablets.

[black right-pointing arrowhead] Mild to severe heart failure

Adults: Dosage highly individualized. Initially, 3.125 mg P.O. b.i.d. for 2 weeks; if tolerated, may increase to 6.25 mg P.O. b.i.d. Dosage may be doubled every 2 weeks, as tolerated. Maximum dose for patients who weigh less than 85 kg (187 lb) is 25 mg P.O. b.i.d.; for those weighing more than 85 kg, dose is 50 mg P.O. b.i.d. May be switched to extended-release capsule after controlled on immediate-release tablets.

Adjust-a-dose: In patient with pulse rate below 55 beats/minute, reduce dosage.

[black right-pointing arrowhead] Angina pectoris ♦

Adults: 25 to 50 mg P.O. b.i.d. May be switched to extended-release capsule after controlled on immediate-release tablets.

[black right-pointing arrowhead] Idiopathic cardiomyopathy ♦

Adults: 6.25 to 25 mg P.O. b.i.d. May be switched to extended-release capsule after controlled on immediate-release tablets.

ADMINISTRATION

P.O.

• Give drug with food.

• Capsules may be opened, mixed in cool applesauce, and taken immediately; don’t store.

• Give capsules in the morning.

• Extended-release equivalent of 3.125 mg immediate-release b.i.d. is 10 mg; 6.25 mg immediate-release b.i.d. is 20 mg; 12.5 mg immediate-release b.i.d. is 40 mg; and 25 mg immediate-release b.i.d. is 80 mg. Dosage may be further titrated based on clinical response.

ACTION

Nonselective beta blocker with alphablocking activity.

Route	Onset	Peak	Duration
P.O.	Rapid	1-2 hr	7-10 hr
P.O. (extended-release)	30 min	5 hr	Unknown

Half-life: Immediate release: 7 to 10 hours; extended-release: unknown.

ADVERSE REACTIONS

CNS: asthenia, dizziness, fatigue, stroke, pain, headache, malaise, fever, hypesthesia, paresthesia, vertigo, somnolence, depression, insomnia.

CV: hypotension, postural hypertension, AV block, bradycardia, edema, syncope, angina pectoris, peripheral edema, hypovolemia, fluid overload, hypertension, palpitations, peripheral vascular disorder, chest pain.

EENT: sinusitis, abnormal vision, blurred vision, pharyngitis, rhinitis.

GI: diarrhea, vomiting, nausea, melena, periodontitis, abdominal pain, dyspepsia.

GU: impotence, abnormal renal function, albuminuria, hematuria, UTI.

Hematologic: thrombocytopenia, purpura, anemia.

Metabolic: hyperglycemia, weight gain, hyperkalemia, hypoglycemia, weight loss, hypercholesterolemia, hyperuricemia, hyponatremia, glycosuria, hypervolemia, diabetes mellitus, gout, hypertriglyceridemia.

Musculoskeletal: arthralgia, back pain, muscle cramps, hypotonia, arthritis.

Respiratory: upper respiratory tract infection, lung edema, bronchitis, cough, rales, dyspnea.

Other: hypersensitivity reactions, infection, flulike syndrome, viral infection, injury.

INTERACTIONS

Drug-drug. Amiodarone: May increase risk of bradycardia, AV block, and myocardial depression. Monitor patient’s ECG and vital signs.

Catecholamine-depleting drugs such as MAO inhibitors, reserpine: May cause bradycardia or severe hypotension. Monitor patient closely.

Cimetidine: May increase bioavailability of carvedilol. Monitor vital signs closely.

Clonidine: May increase blood pressureand heart rate-lowering effects. Monitor vital signs closely.

Cyclosporine: May increase cyclosporine level. Monitor cyclosporine level.

Digoxin: May increase digoxin level by about 15% when given together. Monitor digoxin level.

Diltiazem, verapamil: May cause isolated conduction disturbances. Monitor patient’s heart rhythm and blood pressure.

Fluoxetine, paroxetine, propafenone, quinidine: May increase level of carvedilol. Monitor patient for hypotension and dizziness.

Insulin, oral antidiabetics: May enhance hypoglycemic properties. Monitor glucose level.

NSAIDs: May decrease antihypertensive effects. Monitor blood pressure.

Rifampin: May reduce carvedilol level by 70%. Monitor vital signs closely.

Drug-herb. Ma huang: May decrease antihypertensive effects. Discourage use together.

Drug-food. Any food: May delay rate of absorption of carvedilol with no change in bioavailability. Advise patient to take drug with food to minimize orthostatic effects.

EFFECTS ON LAB TEST RESULTS

• May increase alkaline phosphatase, ALT, AST, BUN, cholesterol, creatinine, GGT, nonprotein nitrogen, potassium, triglyceride, sodium, and uric acid levels. May increase or decrease glucose level.

• May decrease PT and platelet count.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug and in those with New York Heart Association class IV decompensated cardiac failure requiring I.V. inotropic therapy.

• Contraindicated in those with bronchial asthma or related bronchospastic conditions, second- or third-degree AV block, sick sinus syndrome (unless a permanent pacemaker is in place), cardiogenic shock, severe bradycardia, or symptomatic hepatic impairment.

• Use cautiously in hypertensive patients with left-sided heart failure, perioperative patients who receive anesthetics that depress myocardial function (such as cyclopropane and trichloroethylene), and diabetic patients receiving insulin or oral antidiabetics, and in those subject to spontaneous hypoglycemia.

• Use cautiously in patients with thyroid disease (may mask hyperthyroidism; withdrawal may precipitate thyroid storm or exacerbation of hyperthyroidism), pheochromocytoma, Prinzmetal’s or variant angina, bronchospastic disease (in those who can’t tolerate other antihypertensives), or peripheral vascular disease (may precipitate or aggravate symptoms of arterial insufficiency).

• Use cautiously in breast-feeding women.

• Safety and effectiveness in children younger than age 18 haven’t been established.

NURSING CONSIDERATIONS

• Alert: Patients who have a history of severe anaphylactic reaction to several allergens may be more reactive to repeated challenge (accidental, diagnostic, or therapeutic). They may be unresponsive to dosages of epinephrine typically used to treat allergic reactions.

• Mild hepatocellular injury may occur during therapy. At first sign of hepatic dysfunction, perform tests for hepatic injury or jaundice; if present, stop drug.

• If drug must be stopped, do so gradually over 1 to 2 weeks, if possible.

• Patient should be stable on maximum immediate-release dose before switching to extended-release form.

• Monitor patient with heart failure for worsened condition, renal dysfunction, or fluid retention; diuretics may need to be increased.

• Monitor diabetic patient closely; drug may mask signs of hypoglycemia, or hyperglycemia may be worsened.

• Observe patient for dizziness or light-headedness for 1 hour after giving each new dose.

• Monitor elderly patients carefully; drug levels are about 50% higher in elderly patients than in younger patients.

PATIENT TEACHING

• Tell patient not to interrupt or stop drug without medical approval.

• Inform patient that improvement of heart failure symptoms might take several weeks of drug therapy.

• Advise patient with heart failure to call prescriber if weight gain or shortness of breath occurs.

• Inform patient that he may experience low blood pressure when standing. If dizziness or fainting occurs (rare), advise him to sit or lie down and to notify prescriber if symptoms persist.

• Caution patient against performing hazardous tasks during start of therapy.

• Advise diabetic patient to promptly report changes in glucose level.

• Inform patient who wears contact lenses that his eyes may feel dry.

• Tell patient to take drug with food. Extended-release capsule may be opened and contents mixed with cool applesauce and taken immediately; don’t store.

• Advise patient that capsules shouldn’t be crushed, chewed, or contents divided.

chloramphenicol sodium succinate

klor-am-FEN-i-kole

Chloromycetin Sodium Succinate, Pentamycetin†

Pharmacologic class: dichloroacetic acid derivative

Pregnancy risk category C

AVAILABLE FORMS

Injection: 1-g vial

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Haemophilus influenzae meningitis, acute Salmonella typhi infection, and meningitis, bacteremia, or other severe infections caused by sensitive Salmonella species, rickettsia, lymphogranuloma, psittacosis, or various sensitive gram-negative organisms

Adults: 50 to 100 mg/kg I.V. daily, divided every 6 hours. Maximum dose is 100 mg/kg daily.

Full-term infants older than age 2 weeks with normal metabolic processes: Up to 50 mg/kg I.V. daily, divided every 6 hours. May use up to 100 mg/kg/day in four divided doses for meningitis.

Premature infants, neonates age 2 weeks and younger, and children and infants with immature metabolic processes: 25 mg/kg I.V. once daily.

ADMINISTRATION

I.V.

• Reconstitute 1-g vial of powder for injection with 10 ml of sterile water to yield 100 mg/ml.

• Give slowly over at least 1 minute.

• Check injection site daily for phlebitis and irritation.

• Solution is stable for 30 days at room temperature, but you should refrigerate it.

• Don’t use cloudy solution.

• Obtain specimen for culture and sensitivity tests before giving first dose. Begin therapy while awaiting results.

• Incompatibilities: Chlorpromazine, fluconazole, glycopyrrolate, hydroxyzine, metoclopramide, polymyxin B sulfate, prochlorperazine, promethazine, vancomycin.

ACTION

Inhibits bacterial protein synthesis by binding to the 50S subunit of the ribosome; bacteriostatic.

Route	Onset	Peak	Duration
I.V.	Unknown	1-3 hr	Unknown

Half-life: 1½ to 4½ hours.

ADVERSE REACTIONS

CNS: confusion, delirium, headache, mild depression, peripheral neuropathy with prolonged therapy.

EENT: decreased visual acuity, optic neuritis in patients with cystic fibrosis.

GI: diarrhea, enterocolitis, glossitis, nausea, vomiting, stomatitis.

Hematologic: aplastic anemia, granulocytopenia, hypoplastic anemia, thrombocytopenia.

Hepatic: jaundice.

Other: anaphylaxis, gray syndrome in neonates, hypersensitivity reactions.

INTERACTIONS

Drug-drug. Anticoagulants, barbiturates, hydantoins, iron salts, sulfonylureas: May increase levels of these drugs. Monitor patient for toxicity.

Penicillins: May have synergistic or antagonistic effects. Monitor patient for change in effectiveness.

Rifampin: May reduce chloramphenicol level. Monitor patient for changes in effectiveness.

Vitamin B₁₂: May decrease response of vitamin B₁₂ in patients with pernicious anemia. Monitor patient closely.

EFFECTS ON LAB TEST RESULTS

• May decrease hemoglobin level.

• May decrease granulocyte and platelet counts.

• May falsely elevate urine PABA levels if given during a bentiromide test for pancreatic function. May cause false-positive results in urine glucose tests that use cupric sulfate (Clinitest).

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug.

• Use cautiously in patients with impaired hepatic or renal function, acute intermittent porphyria, and G6PD deficiency.

• Use cautiously in those taking other drugs that cause bone marrow suppression or blood disorders.

• Alert: Use cautiously in premature infants and neonates because potentially fatal gray syndrome may occur. Symptoms include abdominal distention, gray cyanosis, vasomotor collapse, respiratory distress, and death within a few hours of symptom onset.

NURSING CONSIDERATIONS

• Obtain drug level measurement; maintain peak level of 10 to 20 mcg/ml and trough level of 5 to 10 mcg/ml.

• Alert: Drug has been reported to cause aplastic anemia and other serious blood dyscrasias; use for serious infections only.

• Monitor CBC, iron level, and platelet and reticulocyte counts before and every 2 days during therapy. Stop drug and notify prescriber immediately if anemia, reticulocytopenia, leukopenia, or thrombocytopenia develops.

• Monitor patient for signs and symptoms of superinfection.

PATIENT TEACHING

• Instruct patient to notify prescriber if adverse reactions occur, especially nausea, vomiting, diarrhea, fever, confusion, sore throat, or mouth sores.

• Tell patient receiving drug I.V. to report discomfort at I.V. insertion site.

• Instruct patient to report signs and symptoms of superinfection.

cholestyramine

koe-LESS-tir-a-meen

Prevalite, Questran, Questran Light

Pharmacologic class: bile acid sequestrant

Pregnancy risk category C

AVAILABLE FORMS

Powder: 378-g cans, 9-g single-dose packets; each scoop of powder or single-dose packet contains 4 g of cholestyramine resin

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Primary hyperlipidemia or pruritus caused by partial bile obstruction, adjunct for reduction of increased cholesterol level in patients with primary hypercholesterolemia

Adults: 4 g once or twice daily. Maintenance dose is 8 to 16 g daily divided into two doses. Maximum daily dose is 24 g.

Children: 240 mg/kg daily in two to three divided doses, not to exceed 8 g/day.

ADMINISTRATION

P.O.

• Mix thoroughly with 60 to 180 ml of water or other noncarbonated beverage.

• Give drug with a meal.

• Give other drugs 1 hour before or at least 4 hours after cholestyramine to avoid impeding absorption.

ACTION

Binds bile acids in the intestinal tract, impeding their absorption and causing their elimination in feces. In response to this bile acid depletion, LDL cholesterol levels decrease as the liver uses LDL cholesterol to replenish reduced bile acid stores.

Route	Onset	Peak	Duration
P.O.	Unknown	Unknown	2-4 wk

Half-life: Unknown.

ADVERSE REACTIONS

CNS: dizziness, headache, vertigo, anxiety, fatigue, insomnia, syncope, tinnitus.

GI: abdominal discomfort, constipation, fecal impaction, nausea, anorexia, diarrhea, flatulence, GI bleeding, hemorrhoids, steatorrhea, vomiting.

GU: dysuria, hematuria.

Hematologic: anemia, bleeding tendencies, ecchymoses.

Metabolic: hyperchloremic acidosis.

Musculoskeletal: backache, muscle and joint pains, osteoporosis.

Skin: rash, irritation of skin, tongue, and perianal area.

Other: vitamin A, D, E, and K deficiencies from decreased absorption.

INTERACTIONS

Drug-drug. Acetaminophen, beta blockers, cardiac glycosides, corticosteroids, estrogens, fat-soluble vitamins (A, D, E, and K), iron preparations, niacin, penicillin G, phenobarbital, progestins, tetracycline, thiazide diuretics, thyroid hormones, warfarin and other coumarin derivatives: May decrease absorption of these drugs. Give other drugs 1 hour before or 4 to 6 hours after cholestyramine.

EFFECTS ON LAB TEST RESULTS

• May increase alkaline phosphatase level. May decrease hemoglobin level and hematocrit.

• May increase PT.

• May cause abnormal results in cholecystography that uses iopanoic acid because iopanoic acid is also bound by cholestyramine.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to bile-acid sequestering resins and in those with complete biliary obstruction.

• Use cautiously in patients predisposed to constipation and in those with conditions aggravated by constipation, such as severe, symptomatic coronary artery disease.

NURSING CONSIDERATIONS

• Monitor cholesterol and triglyceride levels regularly during therapy.

• Monitor levels of cardiac glycosides in patients receiving cardiac glycosides and cholestyramine together. If cholestyramine therapy is stopped, adjust dosage of cardiac glycosides, if necessary, to avoid toxicity.

• Monitor bowel habits. Encourage a diet high in fiber and fluids. If severe constipation develops, decrease dosage, add a stool softener, or stop drug.

• Watch for hyperchloremic acidosis with long-term use or very high doses.

• Long-term use may lead to deficiencies of vitamins A, D, E, and K and folic acid.

• For patients with phenylketonuria, light form contains 28.1 mg of phenylalanine per 6.4-g dose.

• Look alike-sound alike: Don’t confuse Questran with Quarzan.

PATIENT TEACHING

• Alert: Tell patient never to take drug in its dry form because it may irritate the esophagus or cause severe constipation.

• Tell patient to prepare drug in a large glass containing water, milk, or juice (especially pulpy fruit juice). Tell him to sprinkle powder on the surface of the
beverage, let the mixture stand for a few minutes, and then stir thoroughly. Discourage mixing with carbonated beverages because of excessive foaming. After drinking preparation, patient should swirl a small additional amount of liquid in the same glass and then drink again to make sure he has taken the entire dose.

• Tell patient to avoid sipping or holding the suspension in the mouth because drug may damage tooth surfaces. Advise patient to maintain good oral hygiene.

• Advise patient to take at mealtime, if possible.

• Advise patient to take all other drugs at least 1 hour before or 4 to 6 hours after cholestyramine to avoid blocking their absorption.

• Teach patient about proper dietary management of fats. When appropriate, recommend weight control, exercise, and smoking cessation programs.

• Tell patient that drug may deplete body stores of vitamins A, D, E, and K and folic acid. Patient should discuss need for supplements with prescriber.

cilostazol

sill-AHS-tah-zoll

Pletal

Pharmacologic class: quinolone phosphodiesterase inhibitor

Pregnancy risk category C

AVAILABLE FORMS

Tablets: 50 mg, 100 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] To reduce symptoms of intermittent claudication

Adults: 100 mg P.O. b.i.d., at least 30 minutes before or 2 hours after breakfast and dinner.

Adjust-a-dose: Decrease dose to 50 mg P.O. b.i.d. when giving with drugs that may interact to cause an increase in cilostazol level.

ADMINISTRATION

P.O.

• Give drug at least 30 minutes before or 2 hours after breakfast and dinner.

• Don’t give drug with grapefruit juice.

ACTION

Thought to inhibit the enzyme phosphodiesterase III, thus inhibiting platelet aggregation and causing vasodilation.

Route	Onset	Peak	Duration
P.O.	Unknown	2-4 hr	Unknown

Half-life: 11 to 13 hours.

ADVERSE REACTIONS

CNS: dizziness, headache, vertigo.

CV: palpitations, peripheral edema, tachycardia.

EENT: pharyngitis, rhinitis.

GI: abnormal stools, diarrhea, abdominal pain, dyspepsia, flatulence, nausea.

Musculoskeletal: back pain, myalgia.

Respiratory: increased cough.

Other: infection, bleeding.

INTERACTIONS

Drug-drug. Diltiazem: May increase cilostazol level. Reduce cilostazol dosage to 50 mg b.i.d.

Erythromycin, other macrolides: May increase level of cilostazol and its metabolites. Reduce cilostazol dosage to 50 mg b.i.d.

Omeprazole: May increase level of cilostazol metabolite. Reduce cilostazol dosage to 50 mg b.i.d.

Strong inhibitors of CYP3A4 (such as fluconazole, fluoxetine, fluvoxamine, itraconazole, ketoconazole, miconazole, nefazodone, sertraline): May increase level of cilostazol and its metabolites. Reduce cilostazol dosage to 50 mg b.i.d.

Drug-food. Grapefruit juice: May increase drug level. Discourage use together.

Drug-lifestyle. Smoking: May decrease drug exposure. Discourage smoking.

EFFECTS ON LAB TEST RESULTS

• May reduce triglyceride levels. May increase HDL level.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug or its components and in those with heart failure of any severity.

• Contraindicated in patients with hemostatic disorders or active bleeding, such as bleeding peptic ulcer and intracranial bleeding.

• Use cautiously in patients with severe underlying heart disease; also use cautiously with other drugs having antiplatelet activity.

NURSING CONSIDERATIONS

• Beneficial effects may not be seen for up to 12 weeks after therapy starts.

• Alert: Cilostazol and similar drugs that inhibit the enzyme phosphodiesterase decrease the likelihood of survival in patients with class III and IV heart failure.

• Alert: CV risk is unknown in patients who use drug on long-term basis and in those with severe underlying heart disease.

• Dosage can be reduced or stopped without such rebound effects as platelet hyperaggregation.

PATIENT TEACHING

• Instruct patient to take drug on an empty stomach, at least 30 minutes before or 2 hours after breakfast and dinner.

• Tell patient that beneficial effect of drug on cramping pain isn’t likely to be noticed for 2 to 4 weeks and that it may take as long as 12 weeks.

• Advise patient to avoid drinking grapefruit juice during drug therapy.

• Inform patient that CV risk is unknown in patients who use drug on a long-term basis and in those with severe underlying heart disease.

• Tell patient that drug may cause dizziness. Caution patient not to drive or perform other activities that require alertness until response to drug is known.

clindamycin hydrochloride

klin-da-MYE-sin

Cleocin, Dalacin C†

clindamycin palmitate hydrochloride

Cleocin Pediatric, Dalacin C Flavored Granules†

clindamycin phosphate

Cleocin Phosphate, Dalacin C Phosphate Sterile Solution†

Pharmacologic class: lincomycin derivative

Pregnancy risk category B

AVAILABLE FORMS

clindamycin hydrochloride

Capsules: 75 mg, 150 mg, 300 mg

clindamycin palmitate hydrochloride

Granules for oral solution: 75 mg/5 ml

clindamycin phosphate

Injectable infusion (in D₅W): 300 mg (50 ml), 600 mg (50 ml), 900 mg (50 ml)

Injection: 150-mg base/ml, 300-mg base/2 ml, 600-mg base/4 ml, 900-mg base/6 ml

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Infections caused by sensitive staphylococci, streptococci, pneumococci, Bacteroides, Fusobacterium,Clostridium perfringens, and other sensitive aerobic and anaerobic organisms

Adults: 150 to 450 mg P.O. every 6 hours; or 300 to 600 mg I.M. or I.V. every 6, 8, or 12 hours.

Children older than age 1 month: 8 to 20 mg/kg P.O. daily, in divided doses every 6 or 8 hours; or 15 to 40 mg/kg I.M. or I.V. daily, in divided doses every 6 or 8 hours.

[black right-pointing arrowhead] Pelvic inflammatory disease

Adults and adolescents: 900 mg I.V. every 8 hours, with gentamicin. Continue at least 48 hours after symptoms improve; then switch to oral clindamycin 450 mg q.i.d. for total of 10 to 14 days or doxycycline 100 mg P.O. every 12 hours for total of 10 to 14 days.

[black right-pointing arrowhead] Pneumocystis jiroveci (carinii) pneumonia ♦

Adults: 600 mg I.V. every 6 hours or 900 mg I.V. every 8 hours, with primaquine.

[black right-pointing arrowhead] CNS toxoplasmosis in AIDS patients, as alternative to sulfonamides with pyrimethamine ♦

Adults: 1,200 to 2,400 mg/day in divided doses.

ADMINISTRATION

P.O.

• Obtain specimen for culture and sensitivity tests before giving first dose. Begin therapy while awaiting results.

• Give capsule form with a full glass of water to prevent esophageal irritation.

• Don’t refrigerate reconstituted oral solution because it will thicken. Drug is stable for 2 weeks at room temperature.

I.V.

• Obtain specimen for culture and sensitivity tests before giving first dose. Begin therapy while awaiting results.

• Never give undiluted as a bolus.

• For infusion, dilute each 300 mg in 50 ml solution and give over 10 to 60 minutes at no more than 30 mg/minute.

• Check site daily for phlebitis and irritation.

• Incompatibilities: Allopurinol, aminophylline, ampicillin, azithromycin, barbiturates, calcium gluconate, ceftriaxone, ciprofloxacin hydrochloride, doxapram, filgrastim, fluconazole, gentamicin sulfate with cefazolin sodium, idarubicin, magnesium sulfate, phenytoin sodium, ranitidine, rubber closures such as those on I.V. tubing, tobramycin sulfate.

I.M.

• Obtain specimen for culture and sensitivity tests before giving first dose. Begin therapy while awaiting results.

• Inject deep into muscle. Rotate sites. Don’t exceed 600 mg per injection.

ACTION

Inhibits bacterial protein synthesis by binding to the 50S subunit of the ribosome.

Route	Onset	Peak	Duration
P.O.	Unknown	45-60 min	Unknown
I.V.	Immediate	Immediate	Unknown
I.M.	Unknown	3 hr	Unknown

Half-life: 2½ to 3 hours.

ADVERSE REACTIONS

CV: thrombophlebitis.

GI: nausea, pseudomembranous colitis, abdominal pain, diarrhea, vomiting.

Hematologic: thrombocytopenia, transientleukopenia, eosinophilia.

Hepatic: jaundice.

Skin: maculopapular rash, urticaria.

Other: anaphylaxis.

INTERACTIONS

Drug-drug. Erythromycin: May block access of clindamycin to its site of action. Avoid using together.

Kaolin: May decrease absorption of oral clindamycin. Separate dosage times.

Neuromuscular blockers: May increase neuromuscular blockade. Monitor patient closely.

Drug-food. Diet foods with sodium cyclamate: May decrease drug level. Discourage patient from eating these foods.

EFFECTS ON LAB TEST RESULTS

• May increase alkaline phosphatase, AST, and bilirubin levels.

• May increase eosinophil count. May decrease platelet and WBC counts.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug or lincomycin.

• Use cautiously in neonates and patients with renal or hepatic disease, asthma, history of GI disease, or significant allergies.

NURSING CONSIDERATIONS

• I.M. injection may raise CK level in response to muscle irritation.

• Monitor renal, hepatic, and hematopoietic functions during prolonged therapy.

• Observe patient for signs and symptoms of superinfection.

• Alert: Don’t give opioid antidiarrheals to treat drug-induced diarrhea; they may prolong and worsen this condition.

• Drug doesn’t penetrate blood-brain barrier.

PATIENT TEACHING

• Advise patient to take capsule form with a full glass of water to prevent esophageal irritation.

• Warn patient that I.M. injection may be painful.

• Tell patient to report discomfort at I.V. insertion site.

• Instruct patient to notify prescriber of adverse reactions (especially diarrhea). Warn him not to treat diarrhea himself because drug may cause life-threatening colitis.

clonidine hydrochloride

KLOE-ni-deen

Catapres, Catapres-TTS, Dixarit†, Duraclon

Pharmacologic class: centrally acting alpha agonist

Pregnancy risk category C

AVAILABLE FORMS

Transdermal: TTS-1 (releases 0.1 mg/24 hours), TTS-2 (releases 0.2 mg/24 hours), TTS-3 (releases 0.3 mg/24 hours)

Injection for epidural use: 100 mcg/ml

Injection for epidural use, concentrate: 500 mcg/ml

Tablets: 0.025 mg†, 0.1 mg, 0.2 mg, 0.3 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Essential and renal hypertension

Adults and children age 12 and older: Initially, 0.1 mg P.O. b.i.d.; then increased by 0.1 to 0.2mg daily on a weekly basis. Usual range is 0.2 to 0.6 mg daily in divided doses; infrequently, dosages as high as 2.4 mg daily are used.

Or, apply transdermal patch once every 7 days, starting with 0.1-mg system and adjusted with another 0.1-mg or larger system.

[black right-pointing arrowhead] Severe cancer pain unresponsive to epidural or spinal opiate analgesia or other more conventional methods of analgesia

Adults: Initially, 30 mcg/hour by continuous epidural infusion. Experience with rates greater than 40 mcg/hour is limited.

Children: Initially, 0.5 mcg/kg/hour by epidural infusion. Dosage should be cautiously adjusted, based on response.

[black right-pointing arrowhead] Pheochromocytoma diagnosis ♦

Adults: 0.3 mg P.O. for a single dose.

[black right-pointing arrowhead] Migraine prophylaxis ♦

Adults: 0.025 mg P.O. two to four times daily or up to 0.15 mg P.O. daily in divided doses.

[black right-pointing arrowhead] Dysmenorrhea ♦

Adults: 0.025 mg P.O. b.i.d. for 14 days before and during menses.

[black right-pointing arrowhead] Vasomotor symptoms of menopause ♦

Adults: 0.025 to 0.2 mg P.O. b.i.d. or 0.1-mg/24-hour patch applied once every 7 days.

[black right-pointing arrowhead] Opiate dependence ♦

Adults: Initially, 0.005 or 0.006 mg/kg test dose, followed by 0.017 mg/kg P.O. daily in three or four divided doses for 10 days. Or, initially, 0.1 mg P.O. three or four times daily, with dosage adjusted by 0.1 to 0.2 mg daily. Dosage range is 0.3 to 1.2 mg P.O. daily. Stop drug gradually. Follow protocols.

[black right-pointing arrowhead] Alcohol withdrawal ♦

Adults: 300 to 600 mcg every 6 hours.

[black right-pointing arrowhead] Smoking cessation ♦

Adults: Initially, 0.1 mg P.O. b.i.d., beginning on or shortly before the day of smoking cessation. Increase dosage every 7 days by 0.1 mg daily, if needed. Or, 0.1-mg/24-hour transdermal patch applied every 7 days. Therapy should begin on or shortly before the day of smoking cessation. Increase dosage by 0.1 mg/24 hours at weekly intervals, if needed.

[black right-pointing arrowhead] Attention deficit hyperactivity disorder ♦

Children: Initially, 0.05 mg P.O. at bedtime. May increase dosage cautiously over 2 to 4 weeks. Maintenance dosage is 0.05 to 0.4 mg P.O. daily.

ADMINISTRATION

P.O.

• Give last dose immediately before bedtime.

Transdermal

• Apply patch to nonhairy area of intact skin on upper arm or torso.

ACTION

Unknown. Thought to stimulate alpha₂ receptors and inhibit the central vasomotor centers, decreasing sympathetic outflow to the heart, kidneys, and peripheral vasculature, and lowering peripheral vascular resistance, blood pressure, and heart rate.

Route	Onset	Peak	Duration
P.O.	30-60 min	2-4 hr	12-24 hr
Transdermal	2-3 days	2-3 days	7-8 days
Epidural	Unknown	30-60 min	Unknown

Half-life: 6 to 20 hours.

ADVERSE REACTIONS

CNS: drowsiness, dizziness, sedation, weakness, fatigue, malaise, agitation, depression.

CV: bradycardia, severe rebound hypertension, orthostatic hypotension.

GI: constipation, dry mouth, nausea, vomiting, anorexia.

GU: urine retention, impotence.

Metabolic: weight gain.

Skin: pruritus, dermatitis with transdermal patch, rash.

Other: loss of libido.

INTERACTIONS

Drug-drug. Amitriptyline, amoxapine, clomipramine, desipramine, doxepin, imipramine, nortriptyline, protriptyline, trimipramine: May cause loss of blood pressure control with life-threatening elevations in blood pressure. Avoid using together.

CNS depressants: May increase CNS depression. Use together cautiously.

Digoxin, verapamil: May cause AV block and severe hypotension. Monitor blood pressure and ECG.

Diuretics, other antihypertensives: May increase hypotensive effect. Monitor patient closely.

Beta blockers: May cause life-threatening hypertension. Closely monitor blood pressure.

Levodopa: May reduce effectiveness of levodopa. Monitor patient.

MAO inhibitors, prazosin: May decrease antihypertensive effect. Use together cautiously.

Propranolol, other beta blockers: May cause paradoxical hypertensive response. Monitor patient carefully.

Drug-herb. Capsicum: May reduce antihypertensive effectiveness. Discourage use together.

Ma huang: May decrease antihypertensive effects. Discourage use together.

EFFECTS ON LAB TEST RESULTS

• May decrease urinary excretion of vanillylmandelic acid and catecholamines. May cause a weakly positive Coombs’ test result.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug.

• Transdermal form is contraindicated in patients hypersensitive to any component of the adhesive layer of transdermal system.

• Epidural form is contraindicated in patients receiving anticoagulant therapy, in those with bleeding diathesis, in those with an injection site infection, and in those who are hemodynamically unstable or have severe CV disease.

• Use cautiously in patients with severe coronary insufficiency, conduction disturbances, recent MI, cerebrovascular disease, chronic renal failure, or impaired liver function.

NURSING CONSIDERATIONS

• Drug may be given to lower blood pressure rapidly in some hypertensive emergencies.

• Monitor blood pressure and pulse rate frequently. Dosage is usually adjusted to patient’s blood pressure and tolerance.

• Elderly patients may be more sensitive than younger ones to drug’s hypotensive effects.

• Observe patient for tolerance to drug’s therapeutic effects, which may require increased dosage.

• Noticeable antihypertensive effects of transdermal clonidine may take 2 to
3 days. Oral antihypertensive therapy may have to be continued in the interim.

• Alert: Remove transdermal patch before defibrillation to prevent arcing.

• Stop drug gradually by reducing dosage over 2 to 4 days to avoid rapid rise in blood pressure, agitation, headache, and tremor. When stopping therapy in patients receiving both clonidine and a beta blocker, gradually withdraw the beta blocker several days before gradually stopping clonidine to minimize adverse reactions.

• Don’t stop drug before surgery.

• Look alike-sound alike: Don’t confuse clonidine with quinidine or clomiphene; or Catapres with Cetapred or Combipres.

• Alert: The injection form is for epidural use only.

• The injection form concentrate containing 500 mcg/ml must be diluted before use in normal saline injection to yield 100 mcg/ml.

• When drug is given epidurally, carefully monitor infusion pump, and inspect catheter tubing for obstruction or dislodgment.

PATIENT TEACHING

• Instruct patient to take drug exactly as prescribed.

• Advise patient that stopping drug abruptly may cause severe rebound high blood pressure. Tell him dosage must be reduced gradually over 2 to 4 days, as instructed by prescriber.

• Tell patient to take the last dose immediately before bedtime.

• Reassure patient that the transdermal patch usually remains attached despite showering and other routine daily activities. Instruct him on the use of the adhesive overlay to provide additional skin adherence, if needed. Also tell him to place patch at a different site each week.

• Caution patient that drug may cause drowsiness but that this adverse effect usually diminishes over 4 to 6 weeks.

• Inform patient that dizziness upon standing can be minimized by rising slowly from a sitting or lying position and avoiding sudden position changes.

clopidogrel bisulfate

cloe-PID-oh-grel

Plavix

Pharmacologic class: inhibitor of adenosine diphosphate-induced platelet aggregation

Pregnancy risk category B

AVAILABLE FORMS

Tablets: 75 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] To reduce thrombotic events in patients with atherosclerosis documented by recent stroke,MI, or peripheral arterial disease

Adults: 75 mg P.O. daily.

[black right-pointing arrowhead] To reduce thrombotic events in patients with acute coronary syndrome (unstable angina and non—Q-wave MI), including those receiving drugs and those having percutaneous coronary intervention (with or without stent) or coronary artery bypass graft

Adults: Initially, a single 300-mg P.O. loading dose; then 75 mg P.O. once daily. Start and continue aspirin (75 to 325 mg once daily) with clopidogrel.

[black right-pointing arrowhead] ST-segment elevation acute MI

Adults: 75 mg P.O. once daily, with aspirin, with or without thrombolytics. A 300-mg loading dose is optional.

ADMINISTRATION

P.O.

• Give drug without regard to meals.

ACTION

Inhibits the binding of adenosine diphosphate (ADP) to its platelet receptor, impeding ADP-mediated activation and subsequent platelet aggregation, and irreversibly modifies the platelet ADP receptor.

Route	Onset	Peak	Duration
P.O.	2 hr	Unknown	5 days

Half-life: 8 hours.

ADVERSE REACTIONS

CNS: depression, dizziness, fatigue, headache, pain.

CV: edema, hypertension.

EENT: epistaxis, rhinitis.

GI: hemorrhage, abdominal pain, constipation, diarrhea, dyspepsia, gastritis, ulcers.

GU: UTI.

Hematologic: purpura.

Musculoskeletal: arthralgia.

Respiratory: bronchitis, coughing, dyspnea, upper respiratory tract infection.

Skin: rash, pruritus.

Other: flulike syndrome.

INTERACTIONS

Drug-drug. Aspirin, NSAIDs: May increase risk of GI bleeding. Monitor patient.

Heparin, warfarin: Safety hasn’t been established. Use together cautiously.

Salicylates: May increase the risk of serious bleeding in patients with TIA or ischemic stroke. Avoid use together.

Drug-herb. Red clover: May increase risk of bleeding. Discourage use together.

EFFECTS ON LAB TEST RESULTS

• May decrease platelet count.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug or its components and in those with pathologic bleeding (such as peptic ulcer or intracranial hemorrhage).

• Use cautiously in patients at risk for increased bleeding from trauma, surgery, or other pathologic conditions and in those with renal or hepatic impairment.

NURSING CONSIDERATIONS

• Platelet aggregation won’t return to normal for at least 5 days after drug has been stopped.

• Alert: Drug may cause fatal thrombotic thrombocytopenic purpura (thrombocytopenia, hemolytic anemia, neurologic findings, renal dysfunction, and fever) that requires urgent treatment, including plasmapheresis.

• Look alike-sound alike: Don’t confuse Plavix with Paxil.

PATIENT TEACHING

• Advise patient it may take longer than usual to stop bleeding. Tell him to refrain from activities in which trauma and bleeding may occur, and encourage him to wear a seat belt when in a car.

• Instruct patient to notify prescriber if unusual bleeding or bruising occurs.

• Tell patient to inform all health care providers, including dentists, before undergoing procedures or starting new drug therapy, that he is taking drug.

• Inform patient that drug may be taken without regard to meals.

colesevelam hydrochloride

koe-leh-SEVE-eh-lam

WelChol

Pharmacologic class: bile acid sequestrant

Pregnancy risk category B

AVAILABLE FORMS

Tablets: 625 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Adjunct to diet and exercise, either alone or with an HMG-CoA reductase inhibitor, to reduce elevated LDL cholesterol in patients with primary hypercholesterolemia (Fredrickson type IIa)

Adults: 3 tablets (1,875 mg) P.O. b.i.d. with meals and liquid, or 6 tablets (3,750 mg) once daily with a meal and liquid. Maximum dosage is 7 tablets (4,375 mg) daily.

ADMINISTRATION

P.O.

• Give drug with a meal and plenty of fluids.

• Store tablets at room temperature and protect them from moisture.

ACTION

Binds bile acids in the intestinal tract, impeding their absorption and causing their elimination in feces. In response to this bile acid depletion, LDL cholesterol levels decrease as the liver uses LDL
cholesterol to replenish reduced bile acid stores.

Route	Onset	Peak	Duration
P.O.	Unknown	2 wk	Unknown

Half-life: Unknown.

ADVERSE REACTIONS

CNS: headache, asthenia, pain.

EENT: pharyngitis, rhinitis, sinusitis.

GI: constipation, flatulence, abdominal pain, diarrhea, dyspepsia, nausea.

Musculoskeletal: back pain, myalgia.

Respiratory: increased cough.

Other: infection, accidental injury, flulike syndrome.

INTERACTIONS

None reported.

EFFECTS ON LAB TEST RESULTS

None reported.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug or any of its components and in patients with bowel obstruction.

• Use cautiously in patients susceptible to vitamin K or fat-soluble vitamin deficiencies and in patients with swallowing disorders, severe GI motility disorders, or major GI tract surgery.

• Use cautiously in patients with triglyceride levels greater than 300 mg/dl.

NURSING CONSIDERATIONS

• Before starting drug, assess patient for underlying causes of hypercholesterolemia, such as poorly controlled diabetes, hypothyroidism, nephrotic syndrome, dysproteinemias, obstructive liver disease, other drug therapy, and alcoholism.

• Monitor patient’s bowel habits. If severe constipation develops, decrease dosage, add a stool softener, or stop drug.

• Monitor the effects of patient’s other drugs to identify drug interactions.

• Monitor total and LDL cholesterol and triglyceride levels periodically during therapy.

• Use only when clearly needed in breast-feeding women because it isn’t known if drug appears in breast milk.

PATIENT TEACHING

• Instruct patient to take drug with a meal and plenty of fluids.

• Teach patient to monitor bowel habits. Encourage a diet high in fiber and fluids. Instruct patient to notify prescriber promptly if severe constipation develops.

• Encourage patient to follow prescribed diet, exercise, and monitoring of cholesterol and triglyceride levels.

• Tell patient to notify prescriber if she’s pregnant or breast-feeding.

SAFETY ALERT! dalteparin sodium

DAHL-tep-ah-rin

Fragmin

Pharmacologic class: low-molecular-weight heparin

Pregnancy risk category B

AVAILABLE FORMS

Injection: 2,500 antifactor Xa international units/0.2 ml syringe, 5,000 antifactor Xa international units/0.2 ml syringe, 7,500 antifactor Xa international units/0.3 ml syringe, 10,000 antifactor Xa international units/ml syringe, 10,000 antifactor Xa international units/ml in 9.5-ml multidose vial, 25,000 antifactor Xa international units/ml in 3.8-ml multidose vial. Each multidose vial contains 14 mg/ml of benzyl alcohol.

INDICATIONS & DOSAGES

[black right-pointing arrowhead] To prevent deep vein thrombosis (DVT) in patients undergoing abdominal surgery who are at moderate to high risk for thromboembolic complications

Adults: 2,500 international units subcutaneously daily, starting 1 to 2 hours before surgery and repeated once daily for 5 to 10 days postoperatively. Or, for patients at high risk, give 5,000 international units subcutaneously the evening before surgery,
then once daily postoperatively for 5 to 10 days.

[black right-pointing arrowhead] To prevent DVT in patients undergoing hip replacement surgery

Adults: 2,500 international units subcutaneously within 2 hours before surgery and second dose 2,500 international units subcutaneously in the evening after surgery (at least 6 hours after first dose). If surgery is performed in the evening, omit second dose on day of surgery. Starting on first postoperative day, give 5,000 international units subcutaneously once daily for 5 to 10 days. Or, give 5,000 international units subcutaneously on the evening before surgery; then 5,000 international units subcutaneously once daily starting in the evening of surgery for 5 to 10 days postoperatively.

[black right-pointing arrowhead] Unstable angina non—Q-wave MI

Adults: 120 international units/kg subcutaneously every 12 hours with aspirin (75 to 165 mg daily) P.O., unless contraindicated. Maximum dose, 10,000 international units. Treatment usually lasts 5 to 8 days.

[black right-pointing arrowhead] To prevent DVT in patients at risk for thromboembolic complications because of severely restricted mobility during acute illness

Adults: 5,000 international units subcutaneously once daily for 12 to 14 days.

NEW INDICATION: Symptomatic venous thromboembolism in cancer patients

Adults: Initially, 200 international units/kg (maximum, 18,000 international units) subcutaneously daily for 30 days; then 150 international units/kg (maximum, 18,000 international units) subcutaneously daily months 2 through 6.

Adjust-a-dose: In patients with platelet count 50,000 to 100,000/mm³, reduce dose by 2,500 international units until platelet count exceeds 100,000/mm³. In patients with platelet count less than 50,000/mm³, stop drug until platelet count exceeds 50,000/mm³. For patients with creatinine clearance of 30 ml/minute or less, monitor anti-Xa levels to determine appropriate dose. Target anti-Xa range is 0.5 to 1.5 international units/ml. Draw anti-Xa 4 to 6 hours after dose and only after the patient has received three to four doses.

ADMINISTRATION

Subcutaneous

• Before giving injection, obtain complete list of all prescribed and OTC medications, and supplements, including herbs.

• Have patient sit or lie supine when giving drug.

• Injection sites include a U-shaped area around the navel, upper outer side of thigh, and upper outer quadrangle of buttock. Rotate sites daily.

• When area around the navel or thigh is used, use thumb and forefinger to lift up a fold of skin while giving injection.

• Give subcutaneous injection deeply, inserting the entire length of needle at a 45- to 90-degree angle.

ACTION

Enhances inhibition of factor Xa and thrombin by antithrombin.

Route	Onset	Peak	Duration
Subcut.	Unknown	4 hr	Unknown

Half-life: 3 to 5 hours.

ADVERSE REACTIONS

CNS: fever.

GU: hematuria.

Hematologic: thrombocytopenia, hemorrhage, ecchymoses, bleeding complications.

Skin: pruritus, rash, hematoma at injection site, injection site pain.

Other: anaphylaxis.

INTERACTIONS

Drug-drug. Antiplatelet drugs (aspirin, NSAIDs, clopidogrel, dipyridamole, ticlodipine), oral anticoagulants, thrombolytics: May increase risk of bleeding. Use together cautiously.

EFFECTS ON LAB TEST RESULTS

• May increase ALT and AST levels.

• May decrease platelet count.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug, heparin, or pork products; in those with active major bleeding; and in those with thrombocytopenia and antiplatelet antibodies in presence of drug.

• Contraindicated in patients with unstable angina or non-Q-wave MI who are undergoing regional anesthesia because of an increased risk of bleeding associated with the dose of dalteparin recommended for these indications.

• Use with caution in patients with history of heparin-induced thrombocytopenia and in patients at increased risk for hemorrhage, such as those with severe uncontrolled hypertension, bacterial endocarditis, congenital or acquired bleeding disorders, active ulceration, angiodysplastic GI disease, or hemorrhagic stroke; also use with caution shortly after brain, spinal, or ophthalmic surgery. Monitor vital signs.

• Use with caution in patients with bleeding diathesis, thrombocytopenia, platelet defects, severe hepatic or renal insufficiency, hypertensive or diabetic retinopathy, or recent GI bleeding.

NURSING CONSIDERATIONS

• Alert: Patients who have received epidural or spinal anesthesia are at increased risk for developing an epidural or spinal hematoma, which may result in long-term or permanent paralysis. Monitor these patients closely for neurologic impairment.

• DVT is a risk factor in patients who are candidates for therapy, including those older than age 40, those who are obese, those undergoing surgery under general anesthesia lasting longer than 30 minutes, and those who have additional risk factors (such as malignancy or history of DVT or pulmonary embolism).

• Never give drug I.M.

• Don’t mix with other injections or infusions unless specific compatibility data support such mixing.

• Multidose vial shouldn’t be used in pregnant women because of benzyl alcohol content. Benzyl alcohol has been associated with fatal “gasping syndrome” in premature neonates.

• Alert: Drug isn’t interchangeable (unit for unit) with unfractionated heparin or other low-molecular-weight heparin.

• Periodic, routine CBC and fecal occult blood tests are recommended during therapy. Patients don’t need regular monitoring of PT or activated PTT.

• Monitor patient closely for thrombocytopenia.

• Stop drug if a thromboembolic event occurs despite dalteparin prophylaxis. May use alternative therapy, or may have been inadequate dose.

• Obtain a complete list of patient’s prescription and OTC drugs and supplements, including herbs.

PATIENT TEACHING

• Instruct patient and family to watch for and report signs of bleeding (bruising and blood in stools).

• Tell patient to avoid OTC drugs containing aspirin or other salicylates unless ordered by prescriber.

• Advise patient to consult with prescriber prior to initiating any herbal therapy; many herbs have anticoagulant, antiplatelet, and fibrinolytic properties.

• Tell patient to use a soft toothbrush and electric razor during treatment.

SAFETY ALERT! digoxin

di-JOX-in

Digitek, Digoxin, Lanoxicaps, Lanoxin*

Pharmacologic class: cardiac glycoside

Pregnancy risk category C

AVAILABLE FORMS

Capsules: 0.05 mg, 0.1 mg, 0.2 mg

Elixir: 0.05 mg/ml (pediatric)

Injection: 0.05 mg/ml†, 0.1 mg/ml (pediatric), 0.25 mg/ml

Tablets: 0.125 mg, 0.25 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Heart failure, paroxysmal supraventricular tachycardia, atrial fibrillation and flutter

Capsules

Adults: For rapid digitalization, give 0.4 to 0.6 mg P.O. initially, followed by 0.1 to 0.3 mg every 6 to 8 hours, as needed and tolerated, for 24 hours. For slow digitalization, give 0.05 to 0.35 mg daily in two divided doses. Therapeutic levels are reached in 7 to 22 days. Maintenance dose is 0.05 to 0.35 mg daily in one or two divided doses.

Children: Digitalizing dose is based on child’s age and is given in three or more divided doses over the first 24 hours. First dose is 50% of the total dose; subsequent doses are given as 25% of total dose for two doses every 6 to 8 hours as needed and tolerated.

Children age 10 and older: For rapid digitalization, give 8 to 12 mcg/kg P.O. over 24 hours, divided as described previously. Maintenance dose is 25% to 35% of total digitalizing dose, given daily as a single dose.

Children ages 5 to 10: For rapid digitalization, give 15 to 30 mcg/kg P.O. over 24 hours, divided as described previously. Maintenance dose is 25% to 35% of total digitalizing dose, divided and given in two or three equal portions daily.

Children ages 2 to 5: For rapid digitalization, give 25 to 35 mcg/kg P.O. over 24 hours, divided as described previously. Maintenance dose is 25% to 35% of total digitalizing dose, divided and given in two or three equal portions daily.

Elixir, tablets

Adults: For rapid digitalization, give 0.75 to 1.25 mg P.O. over 24 hours in two or more divided doses every 6 to 8 hours. For slow digitalization, give 0.0625 to 0.5 mg daily. Titrate every 2 weeks as needed. Maintenance dose is 0.0625 to 0.5 mg daily.

Children age 10 and older: 10 to 15 mcg/kg P.O. over 24 hours in two or more divided doses every 6 to 8 hours. Maintenance dose is 25% to 35% of total digitalizing dose.

Children ages 5 to 10: 20 to 35 mcg/kg P.O. over 24 hours in two or more divided doses every 6 to 8 hours. Maintenance dose is 25% to 35% of total digitalizing dose.

Children ages 2 to 5: 30 to 40 mcg/kg P.O. over 24 hours in two or more divided doses every 6 to 8 hours. Maintenance dose is 25% to 35% of total digitalizing dose.

Infants ages 1 month to 2 years: 35 to 60mcg/kg P.O. over 24 hours in two or more divided doses every 6 to 8 hours. Maintenance dose is 25% to 35% of total digitalizing dose.

Neonates: 25 to 35 mcg/kg P.O. over 24 hours in two or more divided doses every 6 to 8 hours. Maintenance dose is 25% to 35% of total digitalizing dose.

Premature infants: 20 to 30 mcg/kg P.O. over 24 hours in two or more divided doses every 6 to 8 hours. Maintenance dose is 20% to 30% of total digitalizing dose.

Injection

Adults: For rapid digitalization, give 0.4 to 0.6 mg I.V. initially, followed by 0.1 to 0.3 mg I.V. every 6 to 8 hours, as needed and tolerated, for 24 hours. For slow digitalization, give appropriate daily maintenance dose for 7 to 22 days until therapeutic levels are reached. Maintenance dose is 0.075 to 0.35 mg I.V. daily in one or two divided doses.

Children: Digitalizing dose is based on child’s age; give in three or more divided doses over the first 24 hours. First dose is 50% of total dose; subsequent doses are given every 6 to 8 hours as needed and tolerated.

Children age 10 and older: For rapid digitalization, give 8 to 12 mcg/kg I.V. over 24 hours, divided as described previously. Maintenance dose is 25% to 35% of total digitalizing dose, given daily as a single dose.

Children ages 5 to 10: For rapid digitalization, give 15 to 30 mcg/kg I.V. over 24 hours, divided as described previously. Maintenance dose is 25% to 35% of total digitalizing dose, divided and given in two or three equal portions daily.

Children ages 2 to 5: For rapid digitalization, give 25 to 35 mcg/kg I.V. over 24 hours, divided as described previously. Maintenance dose is 25% to 35% of total digitalizing dose, divided and given in two or three equal portions daily.

Infants ages 1 month to 2 years: For rapid digitalization, give 30 to 50 mcg/kg I.V. over 24 hours, divided as described previously. Maintenance dose is 25% to 35% of total digitalizing dose, divided and given in two or three equal portions daily.

Neonates: For rapid digitalization, give 20 to 30 mcg/kg I.V. over 24 hours, divided as described previously. Maintenance dose is 25% to 35% of the total digitalizing dose, divided and given in two or three equal portions daily.

Premature infants: For rapid digitalization, give 15 to 25 mcg/kg I.V. over 24 hours, divided as described previously. Maintenance dose is 20% to 30% of the total digitalizing dose, divided and given in two or three equal portions daily.

Adjust-a-dose: For patients with impaired renal function, give smaller loading and maintenance doses; extended dosing intervals may be needed.

ADMINISTRATION

P.O.

• Before giving loading dose, obtain baseline data (heart rate and rhythm, blood pressure, and electrolytes) and ask patient about use of cardiac glycosides within the previous 2 to 3 weeks.

• Before giving drug, take apical-radial pulse for 1 minute. Record and notify prescriber of significant changes (sudden increase or decrease in pulse rate, pulse deficit, irregular beats and, particularly, regularization of a previously irregular rhythm). If these occur, check blood pressure and obtain a 12-lead ECG.

I.V.

• Before giving loading dose, obtain baseline data (heart rate and rhythm, blood pressure, and electrolytes) and ask patient about use of cardiac glycosides within the previous 2 to 3 weeks.

• Dilute fourfold with D₅W, normal saline solution, or sterile water for injection to reduce the chance of precipitation.

• Infuse drug slowly over at least 5 minutes.

• Protect solution from light.

• Incompatibilities: Amiodarone, amphotericin B cholesteryl sulfate complex, dobutamine, doxapram, fluconazole, foscarnet, propofol, remifentanil. Mixing with other drugs isn’t recommended.

ACTION

Inhibits sodium-potassium-activated adenosine triphosphatase, promoting movement of calcium from extracellular to intracellular cytoplasm and strengthening myocardial contraction. Also acts on CNS to enhance vagal tone, slowing conduction through the SA and AV nodes.

Route	Onset	Peak	Duration
P.O.	30-120 min	2-6 hr	3-4 days
I.V.	5-30 min	1-4 hr	3-4 days

Half-life: 30 to 40 hours.

ADVERSE REACTIONS

CNS: agitation, fatigue, generalized muscle weakness, hallucinations, dizziness, headache, malaise, paresthesia, stupor, vertigo.

CV: arrhythmias, heart block.

EENT: blurred vision, diplopia, light flashes, photophobia, yellow-green halos around visual images.

GI: anorexia, nausea, diarrhea, vomiting.

INTERACTIONS

Drug-drug. Amiloride: May decrease digoxin effect and increase renal clearance of digoxin. Monitor patient for altered digoxin effect.

Amiodarone, diltiazem, indomethacin, nifedipine, quinidine, verapamil: May increase digoxin level. Monitor patient for toxicity.

Amphotericin B, carbenicillin, corticosteroids, diuretics (such as chlorthalidone,loop diuretics, metolazone, thiazides), ticarcillin: May cause hypokalemia, predisposing patient to digitalis toxicity. Monitor potassium level.

Antacids, kaolin-pectin: May decrease absorption of oral digoxin. Separate doses as much as possible.

Antibiotics (azole antifungals, macrolides,telithromycin, tetracyclines), propafenone,ritonavir: May increase risk of toxicity. Monitor patient for toxicity.

Anticholinergics: May increase digoxin absorption of oral digoxin tablets. Monitor drug level and observe for toxicity.

Beta blockers, calcium channel blockers: May have additive effects on AV node conduction causing advanced or complete heart block. Use cautiously.

Cholestyramine, colestipol, metoclopramide: May decrease absorption of oral digoxin. Monitor patient for decreased digoxin level and effect. Give digoxin 1½ hours before or 2 hours after other drugs.

Parenteral calcium, thiazides: May cause hypercalcemia and hypomagnesemia, predisposing patient to digitalis toxicity. Monitor calcium and magnesium levels.

Drug-herb. Betel palm, Foxglove, fumitory, goldenseal, hawthorn, lily of the valley, motherwort, rue, shepherd’s purse: May increase cardiac effects. Discourage use together.

Gossypol, horsetail, licorice, oleander, Siberian ginseng, squill: May increase toxicity. Monitor patient closely.

Plantain, St. John’s wort: May decrease effectiveness of drug. Discourage use together.

EFFECTS ON LAB TEST RESULTS

• May prolong PR interval or depress ST segment.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug and in those with digitalisinduced toxicity, ventricular fibrillation, or ventricular tachycardia unless caused by heart failure.

• Don’t use in patients with Wolff-Parkinson-White syndrome unless the conduction accessory pathway has been pharmacologically or surgically disabled.

• Use with extreme caution in elderly patients and in those with acute MI, incomplete AV block, sinus bradycardia, PVCs, chronic constrictive pericarditis, hypertrophic cardiomyopathy, renal insufficiency, severe pulmonary disease, or hypothyroidism.

NURSING CONSIDERATIONS

• Drug-induced arrhythmias may increase the severity of heart failure and hypotension.

• In children, cardiac arrhythmias, including sinus bradycardia, are usually early signs of toxicity.

• Patients with hypothyroidism are extremely sensitive to cardiac glycosides and may need lower doses.

• Loading dose is usually divided over the first 24 hours with about half the loading dose given in the first dose.

• Toxic effects on the heart may be life-threatening and require immediate attention.

• Absorption of digoxin from liquid-filled capsules is superior to absorption from tablets or elixir. Expect dosage reduction of 20% to 25% when changing from tablets or elixir to liquid-filled capsules or parenteral therapy.

• Monitor digoxin level. Therapeutic level ranges from 0.8 to 2 ng/ml. Obtain blood for digoxin level at least 6 to 8 hours after last oral dose, preferably just before next scheduled dose.

• Alert: Excessively slow pulse rate (60 beats/minute or less) may be a sign of digoxin toxicity.Withhold drug and notify prescriber.

• Monitor potassium level carefully. Take corrective action before hypokalemia occurs. Hyperkalemia may result from digoxin toxicity.

• Reduce drug dose for 1 or 2 days before elective cardioversion. Adjust dosage after cardioversion.

• Look alike-sound alike: Don’t confuse digoxin with doxepin.

PATIENT TEACHING

• Teach patient and a responsible family member about drug action, dosage regimen, how to take pulse, reportable signs, and follow-up care.

• Tell patient to report pulse less than 60 beats/minute or more than 110 beats/minute, or skipped beats or other rhythm changes.

• Instruct patient to report adverse reactions promptly. Nausea, vomiting, diarrhea, appetite loss, and visual disturbances may be indicators of toxicity.

• Encourage patient to eat a consistent amount of potassium-rich foods.

• Tell patient not to substitute one brand for another.

• Advise patient to avoid the use of herbal drugs or to consult his prescriber before taking one.

diltiazem hydrochloride

dil-TYE-a-zem

Apo-Diltiaz†, Cardizem, Cardizem CD, Cardizem LA, Cartia XT, Dilacor XR, Diltia XT, Dilt-XR, Nu-Diltiaz†, Nu-Diltiaz CD†, Taztia XT, Tiazac, Tiazac XC†

Pharmacologic class: calcium channel blocker

Pregnancy risk category C

AVAILABLE FORMS

Capsules (extended-release): 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

Injection: 5 mg/ml in 5-, 10-, 25-ml vials

Powder for injection: 25 mg

Tablets: 30 mg, 60 mg, 90 mg, 120 mg

Tablets (extended-release): 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] To manage Prinzmetal’s or variant angina or chronic stable angina pectoris

Adults: 30 mg P.O. q.i.d. before meals and at bedtime. Increase dose gradually to maximum of 360 mg/day divided into three or four doses, as indicated. Or, give 120- or 180-mg extended-release capsule or 180-mg extended-release tablet P.O. once daily. Adjust over a 7- to 14-day period as needed and tolerated up to a maximum dose of 360 mg/day (Cardizem LA), 480 mg/day (Cardizem CD, Cartia XT, Dilacor XR, Dilacor XT), or 540 mg/day (Tiazac)

[black right-pointing arrowhead] Hypertension

Adults: 180- to 240-mg extended-release capsule P.O. once daily. Adjust dosage based on patient response to a maximum dose of 480 mg/day. Or, 120 to 240 mg P.O. (Cardizem LA) once daily. Dosage can be adjusted about every 2 weeks to a maximum of 540 mg daily.

[black right-pointing arrowhead] Atrial fibrillation or flutter; paroxysmal supraventricular tachycardia

Adults: 0.25 mg/kg I.V. as a bolus injection over 2 minutes. Repeat after 15 minutes if response isn’t adequate with a dose of 0.35 mg/kg I.V. over 2 minutes. Follow bolus with continuous I.V. infusion at 5 to 15 mg/hour (for up to 24 hours).

ADMINISTRATION

P.O.

• Don’t crush or allow patient to chew extended-release tablets; they should be swallowed whole.

• Tiazac extended-release capsules can be opened and the contents sprinkled onto a spoonful of applesauce. The applesauce must be eaten immediately and without chewing, followed by a glass of cool water.

I.V.

• For 100-mg Cardizem Monovials, reconstitute according to manufacturer’s directions.

• For direct injection, you need not dilute the 5 mg/ml injection.

• For continuous infusion, add 25 ml of drug to 100 ml solution, 50 ml of drug to 250 ml solution, or 50 ml of drug to 500 ml solution of 5 mg/ml injection to yield 1 mg/ml, 0.83 mg/ml, or 0.45 mg/ml, respectively. Compatible solutions include normal saline solution, D₅W, or 5% dextrose and half-normal saline solution.

• For direct injection or continuous infusion; give slowly while monitoring ECG and blood pressure continuously.

• Don’t infuse for longer than 24 hours.

• Incompatibilities: Acetazolamide, acyclovir, aminophylline, ampicillin, ampicillin sodium and sulbactam sodium, cefoperazone, diazepam, furosemide, heparin, hydrocortisone, insulin, methylprednisolone, nafcillin, phenytoin, rifampin, sodium bicarbonate, thiopental.

ACTION

A calcium channel blocker that inhibits calcium ion influx across cardiac and smooth-muscle cells, decreasing myocardial contractility and oxygen demand. Drug also dilates coronary arteries and arterioles.

Route	Onset	Peak	Duration
P.O.	30-60 min	2-3 hr	6-8 hr
P.O. (extended-release capsule)	2-3 hr	10-14 hr	12-24 hr
P.O. (Cardizem LA)	3-4 hr	11-18 hr	6-9 hr
I.V.	< 3 min	2-7 min	1-10 hr

Half-life: 3 to 9 hours.

ADVERSE REACTIONS

CNS: headache, dizziness, asthenia, somnolence.

CV: edema, arrhythmias, AV block,bradycardia, heart failure, flushing, hypotension, conduction abnormalities, abnormal ECG.

GI: nausea, constipation, abdominal discomfort.

Hepatic: acute hepatic injury.

Skin: rash.

INTERACTIONS

Drug-drug. Anesthetics: May increase effects of anesthetics. Monitor patient.

Carbamazepine: May increase level of carbamazepine. Monitor carbamazepine level, and watch for signs and symptoms of toxicity.

Cimetidine: May inhibit diltiazem metabolism, increasing additive AV node conduction slowing. Monitor patient for toxicity.

Cyclosporine: May increase cyclosporine level, possibly by decreasing its metabolism, leading to increased risk of cyclosporine toxicity. Monitor cyclosporine level with each dosage change.

Diazepam, midazolam, triazolam: May increase CNS depression and prolonged effects of these drugs. Use lower dose of these benzodiazepines.

Digoxin: May increase digoxin level. Monitor patient for digoxin toxicity.

Furosemide: May form a precipitate when mixed with diltiazem injection. Give through separate I.V. lines.

Lithium: May reduce lithium levels, causing loss of mania control, and neurotoxic and psychotic symptoms. Monitor patient for signs of neurotoxicity.

Propranolol, other beta blockers: May precipitate heart failure or prolong conduction time. Use together cautiously.

Sirolimus, tacrolimus: May increase level of these drugs. Monitor drug level and patient for toxicity.

Theophylline: May enhance action of theophylline, causing intoxication. Monitor theophylline levels.

EFFECTS ON LAB TEST RESULTS

None reported.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug and in those with sick sinus syndrome or second- or third-degree AV block in the absence of an artificial pacemaker, cardiogenic shock, ventricular tachycardia, systolic blood pressure below 90 mm Hg, acute MI, or pulmonary congestion (documented by X-ray).

• Contraindicated in I.V. form for patients who have atrial fibrillation or flutter with an accessory bypass tract, as in Wolff-Parkinson-White syndrome or short PR interval syndrome.

• Use cautiously in elderly patients and in those with heart failure or impaired hepatic or renal function.

NURSING CONSIDERATIONS

• Patients controlled on drug alone or with other drugs may be switched to Cardizem LA tablets once a day at the nearest equivalent total daily dose.

• Monitor blood pressure and heart rate when starting therapy and during dosage adjustments.

• Maximal antihypertensive effect may not be seen for 14 days.

• If systolic blood pressure is below 90 mmHg or heart rate is below 60 beats/minute, withhold dose and notify prescriber.

PATIENT TEACHING

• Instruct patient to take drug as prescribed, even when he feels better.

• Advise patient to avoid hazardous activities during start of therapy.

• If nitrate therapy is prescribed during dosage adjustment, stress patient compliance. Tell patient that S.L. nitroglycerin may be taken with drug, as needed, when angina symptoms are acute.

• Alert: Tell patient to swallow extended-release tablets whole, and not to crush or chew them.

• If patient is taking Tiazac extended-release capsules, inform him that these capsules can be opened and the contents sprinkled onto a spoonful of applesauce. He must eat the applesauce immediately and without chewing, and then drink a glass of cool water.

dipyridamole

dye-peer-IH-duh-mohl

Persantine

Pharmacologic class: pyrimidine analogue

Pregnancy risk category B

AVAILABLE FORMS

Injection: 5 mg/ml in 2- and 10-ml vials

Tablets: 25 mg, 50 mg, 75 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] To inhibit platelet adhesion in prosthetic heart valves (given together with warfarin)

Adults: 75 to 100 mg P.O. q.i.d.

[black right-pointing arrowhead] Alternative to exercise in evaluation of coronary artery disease (CAD) during thallium myocardial perfusion scintigraphy

Adults: 0.57 mg/kg as an I.V. infusion at a constant rate over 4 minutes (0.142 mg/kg/minute).

ADMINISTRATION

P.O.

• If GI distress develops, give drug 1 hour before meals or with meals.

I.V.

• For use as a diagnostic drug, dilute in half-normal or normal saline solution or D₅Win at least a 1:2 ratio for a total volume of 20 to 50 ml.

• Inject thallium-201 within 5 minutes after completing the 4-minute dipyridamole infusion.

• Don’t mix in same syringe or infusion container with other drugs.

• Incompatibilities: Other drugs.

ACTION

May involve drug’s ability to increase adenosine, which is a coronary vasodilator and platelet aggregation inhibitor.

Route	Onset	Peak	Duration
P.O.	Unknown	75 min	Unknown
I.V.	Unknown	2 min	Unknown
Half-life: 1 to 12 hours.

ADVERSE REACTIONS

CNS: dizziness, headache, syncope.

CV: angina pectoris, chest pain, ECGabnormalities, blood pressure lability, flushing, hypertension, hypotension.

GI: nausea, abdominal distress, diarrhea, vomiting.

INTERACTIONS

Drug-drug. Adenosine: May increase levels and cardiac effects of adenosine. Adjust adenosine dose as needed.

Cholinesterase inhibitors: May counteract anticholinesterase effects and aggravate myasthenia gravis. Monitor patient.

Heparin: May increase risk of bleeding. Monitor patient closely.

Theophylline: May prevent coronary vasodilation by I.V. dipyridamole, causing a false-negative thallium-imaging result. Avoid using together.

EFFECTS ON LAB TEST RESULTS

• May increase liver enzyme levels.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug.

• Use cautiously in patients with hypotension and those with severe CAD.

NURSING CONSIDERATIONS

• Observe for adverse reactions, especially with large doses. Monitor blood pressure.

• Observe for signs and symptoms of bleeding; note prolonged bleeding time (especially with large doses or long-term therapy).

• The value of drug as part of an antithrombotic regimen is controversial; its use may not provide significantly better results than aspirin alone.

• Look alike-sound alike: Don’t confuse dipyridamole with disopyramide. Don’t confuse Persantine with Periactin or Bosentan.

• Persantine may contain tartrazine.

PATIENT TEACHING

• Instruct patient to take drug exactly as prescribed.

• Tell patient to report adverse reactions promptly.

• Tell patient receiving drug I.V. to report discomfort at insertion site.

disopyramide

dye-soe-PEER-a-mide

Rythmodan†

disopyramide phosphate

Norpace, Norpace CR, Rythmodan-LA†

Pharmacologic class: pyridine derivative

Pregnancy risk category C

AVAILABLE FORMS

disopyramide

Capsules: 100 mg†, 150mg†

disopyramide phosphate

Capsules: 100 mg, 150 mg

Capsules (controlled-release): 100 mg, 150 mg

Tablets (sustained-release): 250 mg†

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Ventricular tachycardia and life-threatening ventricular arrhythmias

Adults who weigh more than 50 kg (110 lb): 150 mg P.O. every 6 hourswith regular-release formulation or 300 mg every 12 hours with extended-release preparations.

Adults who weigh 50 kg or less: 100 mg P.O. every 6 hours with regular-release formulation or 200 mg P.O. every 12 hours with extended-release preparations.

Children ages 12 to 18 years: 6 to 15 mg/kg P.O. daily, divided into four doses (every 6 hours).

Children ages 4 to 12 years: 10 to 15 mg/kg P.O. daily, divided into four doses (every 6 hours).

Children ages 1 to 4 years: 10 to 20 mg/kg P.O. daily, divided into four doses (every 6 hours).

Children younger than age 1 year: 10 to 30 mg/kg P.O. daily, divided into four doses (every 6 hours).

Adjust-a-dose: If creatinine clearance is 30 to 40 ml/minute, give 100 mg every 8 hours; if clearance is 15 to 30 ml/minute, give 100 mg every 12 hours; if clearance is less than 15 ml/minute, give 100 mg every 24 hours. All dosages are for immediate-release form.

Don’t use extended-release capsules in patients with a creatinine clearance less than or equal to 40 ml/minute. For patients with creatinine clearance greater than 40 ml/minute or patients with hepatic insufficiency, give 400 mg/day in divided doses (100 mg every 6 hours with immediate-release form or 200 mg every 12 hours with controlled-release form).

ADMINISTRATION

P.O.

• Correct electrolyte abnormalities before starting therapy.

• Check apical pulse before giving drug. Notify prescriber if pulse rate is slower than 60 beats/minute or faster than 120 beats/minute.

• Don’t use sustained- or controlled-release preparations to control ventricular arrhythmias when therapeutic drug level must be rapidly attained, in patients with cardiomyopathy or possible cardiac decompensation, or in those with severe renal impairment.

• Alert: Don’t open the extended-release capsules.

• For use in young children, pharmacist may prepare disopyramide suspension
using 100-mg capsules and cherry syrup. Pharmacist should dispense suspension in amber glass bottles. Protect suspension from light.

ACTION

A class IA antiarrhythmic that depresses phase 0, prolongs the action potential, and has membrane-stabilizing effects.

Route	Onset	Peak	Duration
P.O.	½-3½ hr	2-2½ hr	1½-8½ hr
Half-life: 7 hours.

ADVERSE REACTIONS

CNS: agitation, dizziness, depression, fatigue, headache, nervousness, acute psychosis, syncope.

CV: hypotension, heart failure, heartblock, arrhythmias, edema, shortness of breath, chest pain.

EENT: blurred vision, dry eyes or nose.

GI: dry mouth, constipation, nausea, vomiting, anorexia, bloating, gas, weight gain, abdominal pain, diarrhea.

GU: urinary hesitancy, urine retention, urinary frequency, urinary urgency, impotence.

Hepatic: cholestatic jaundice.

Musculoskeletal: muscle weakness, aches, pain.

Skin: rash, pruritus, dermatosis.

INTERACTIONS

Drug-drug. Antiarrhythmics: May increase QRS complex or QT interval, which may lead to other arrhythmias. Monitor ECG closely.

Macrolides and related antibiotics(azithromycin, clarithromycin, erythromycin,telithromycin): May prolong the QT interval. Use with caution. Avoid use with telithromycin.

Phenytoin: May increase metabolism of disopyramide.Watch for decreased antiarrhythmic effect.

Quinidine: May increase disopyramide levels and decrease quinidine levels. Monitor patient closely.

Quinolones: May cause life-threatening arrhythmias, including torsades de pointes. Avoid using together.

Rifampin: May decrease disopyramide level. Monitor patient for lack of effect.

Thioridazine: May cause life-threatening arrhythmias, including torsades de pointes. Avoid using together.

Verapamil: May cause additive effects and impairment of left ventricular function. Don’t give disopyramide 48 hours before starting verapamil or 24 hours after verapamil is stopped.

Drug-herb. Jimsonweed: May adversely affect CV function. Discourage use together.

EFFECTS ON LAB TEST RESULTS

None reported.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug.

• Contraindicated with sparfloxacin, thioridazine, or ziprasidone because of increased risk of life-threatening arrhythmias.

• Contraindicated in those with sick sinus syndrome, cardiogenic shock, congenital QT interval prolongation, or second- or third-degree heart block in the absence of an artificial pacemaker.

• Use cautiously, or avoid if possible, in patients with heart failure.

• Use cautiously in patients with underlying conduction abnormalities, urinary tract diseases (especially prostatic hyperplasia), hepatic or renal impairment, myasthenia gravis, or acute angle-closure glaucoma.

NURSING CONSIDERATIONS

• Digitalize patients with atrial fibrillation or flutter before starting disopyramide because of the risk of enhancing AV conduction.

• Watch for recurrence of arrhythmias and check for adverse reactions; notify prescriber if any occur.

• Stop drug if heart block develops, if QRS complex widens by more than 25%, or if QT interval lengthens by more than 25% above baseline.

• Look alike-sound alike: Don’t confuse disopyramide with desipramine or dipyridamole.

PATIENT TEACHING

• Teach patient importance of taking drug on time and exactly as prescribed.

• If transferring patient from immediate-release to sustained-release capsules, advise him to take the first sustained-release capsule 6 hours after taking the last immediate-release capsule.

• Tell patient not to crush or chew sustained-release capsules or tablets.

• If not contraindicated, advise patient to chew gum or hard candy to relieve dry mouth and to increase fiber and fluid intake to relieve constipation.

SAFETY ALERT! dobutamine hydrochloride

DOE-byoo-ta-meen

Pharmacologic class: adrenergic, beta₁ agonist

Pregnancy risk category B

AVAILABLE FORMS

Injection: 12.5 mg/ml in 20-ml vials (parenteral)

Dobutamine in 5% dextrose: 0.5 mg/ml (125 or 250 mg); 1 mg/ml (250 or 500 mg); 2 mg/ml (500 mg); 4 mg/ml (1,000 mg)

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Increased cardiac output in short-term treatment of cardiac decompensation caused by depressed contractility, such as during refractory heart failure; adjunctive therapy in cardiac surgery

Adults: 0.5 to 1 mcg/kg/minute I.V. infusion, titrating to optimum dosage of 2 to 20 mcg/kg/minute. Usual effective range to increase cardiac output is 2.5 to 10 mcg/kg/minute. Rarely, rates up to 40 mcg/kg/minute may be needed.

ADMINISTRATION

I.V.

• Before starting therapy, give a plasma volume expander to correct hypovolemia and a cardiac glycoside.

• Dilute concentrate before injecting. Compatible solutions include D₅W, D₁₀W, half-normal or normal saline solution for injection, lactated Ringer’s injection, Isolyte-M with D₅W, Normosol-M in D₅W, and 20% Osmitrol.

• Diluting one vial (250 mg) with 1,000 ml of solution yields 250 mcg/ml. Diluting with 500 ml yields 500 mcg/ml. Diluting with 250 ml yields 1,000 mcg/ml.

• Oxidation may slightly discolor admixture. This doesn’t indicate a significant loss of potency, provided drug is used within 24 hours of reconstitution.

• Give through a central venous catheter or large peripheral vein using an infusion pump.

• Titrate rate according to patient’s condition. Don’t exceed 5 mg/ml.

• Infusions lasting up to 72 hours produce no more adverse effects than shorter infusions.

• Watch for irritation and infiltration; extravasation can cause tissue damage and necrosis. Change I.V. sites regularly to avoid phlebitis.

• Solution remains stable for 24 hours. Don’t freeze.

• Incompatibilities: Acyclovir, alkaline solutions, alteplase, aminophylline, bretylium, bumetanide, calcium chloride, calcium gluconate, cefamandole, cefazolin, cefepime, diazepam, digoxin, ethacrynate, furosemide, heparin, hydrocortisone sodium succinate, indomethacin, insulin, magnesium sulfate, midazolam, penicillin, phenytoin, phytonadione, piperacillin with tazobactam, potassium chloride, sodium bicarbonate, thiopental, verapamil, warfarin. Don’t give through same line with other drugs.

ACTION

Stimulates heart’s beta₁ receptors to increase myocardial contractility and stroke volume. At therapeutic dosages, drug increases cardiac output by decreasing peripheral vascular resistance, reducing ventricular filling pressure, and facilitating AV node conduction.

Route	Onset	Peak	Duration
I.V.	1-2 min	10 min	< 5 min after infusion

Half-life: 2 minutes.

ADVERSE REACTIONS

CNS: headache.

CV: hypertension, increased heart rate, angina, PVCs, phlebitis, nonspecific chest pain, palpitations, ventricular ectopy, hypotension.

GI: nausea, vomiting.

Respiratory: asthma attack, shortness of breath.

Other: anaphylaxis, hypersensitivity reactions.

INTERACTIONS

Drug-drug. Beta blockers: May antagonize dobutamine effects. Avoid using together.

Bretylium: May increase risk of arrhythmias. Monitor ECG.

General anesthetics: May have greater risk of ventricular arrhythmias. Monitor ECG closely.

Guanethidine, oxytocic drugs: May increase pressor response, causing severe hypertension. Monitor blood pressure closely.

Tricyclic antidepressants: May potentiate pressor response and cause arrhythmias. Use together cautiously.

Drug-herb. Rue: May increase inotropic potential. Discourage use together.

EFFECTS ON LAB TEST RESULTS

• May decrease potassium level.

• May decrease platelet count.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug or its components and in those with idiopathic hypertrophic subaortic stenosis.

• Use cautiously in patients with history of hypertension because drug may increase pressor response.

• Use cautiously after acute MI.

• Use cautiously in patients with history of sulfite sensitivity.

NURSING CONSIDERATIONS

• Because drug increases AV node conduction, patients with atrial fibrillation may develop a rapid ventricular rate.

• Continuously monitor ECG, blood pressure, pulmonary artery wedge pressure, cardiac output, and urine output.

• Monitor electrolyte levels. Drug may lower potassium level.

• Look alike-sound alike: Don’t confuse dobutamine with dopamine.

PATIENT TEACHING

• Tell patient to report adverse reactions promptly, especially labored breathing and drug-induced headache.

• Instruct patient to report discomfort at I.V. insertion site.

dofetilide

doe-FE-ti-lyed

Tikosyn

Pharmacologic class: antiarrhythmic

Pregnancy risk category C

AVAILABLE FORMS

Capsules: 125 mcg, 250 mcg, 500 mcg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] To maintain normal sinus rhythm in patients with symptomatic atrial fibrillation or atrial flutter lasting longer than 1 week who have been converted to normal sinus rhythm; to convert atrial fibrillation and atrial flutter to normal sinus rhythm

Adults: Individualized dosage based on creatinine clearance and baseline QTc interval (or QT interval if heart rate is below 60 beats/minute), determined before first dose; usually 500 mcg P.O. b.i.d. for patients with creatinine clearance greater than 60 ml/minute.

Adjust-a-dose: If creatinine clearance is 40 to 60 ml/minute, starting dose is 250 mcg P.O. b.i.d.; if clearance is 20 to 39 ml/minute, starting dose is 125 mcg P.O. b.i.d. Don’t use drug at all if clearance is less than 20 ml/minute.

Determine QTc interval 2 to 3 hours after first dose. If QTc interval has increased by more than 15% above baseline or if it’s more than 500 msec (550 msec in patients with ventricular conduction abnormalities), adjust dosage as follows: If starting dose based on creatinine clearance was 500 mcg P.O. b.i.d., give 250 mcg P.O. b.i.d. If starting dose
based on clearance was 250 mcg b.i.d., give 125 mcg b.i.d. If starting dose based on clearance was 125 mcg b.i.d., give 125 mcg once a day.

Determine QTc interval 2 to 3 hours after each subsequent dose while patient is in hospital. If at any time after second dose the QTc interval exceeds 500 msec (550 msec in patients with ventricular conduction abnormalities), stop drug.

ADMINISTRATION

P.O.

• Give drug without regard for food or antacid administration.

• Don’t give drug with grapefruit juice.

ACTION

Prolongs repolarization without affecting conduction velocity. Drug doesn’t affect sodium channels, alpha-adrenergic receptors, or beta-adrenergic receptors.

Route	Onset	Peak	Duration
P.O.	Unknown	2-3 hr	Unknown

Half-life: 10 hours.

ADVERSE REACTIONS

CNS: headache, stroke, dizziness, insomnia, anxiety, migraine, cerebral ischemia, asthenia, paresthesia, syncope.

CV: chest pain, ventricular fibrillation,ventricular tachycardia, torsades depointes, AV block, heart block, bradycardia,cardiac arrest, MI, bundle-branch block, angina, atrial fibrillation, hypertension, palpitations, edema.

GI: nausea, diarrhea, abdominal pain.

GU: UTI.

Hepatic: liver damage.

Musculoskeletal: back pain, arthralgia, facial paralysis.

Respiratory: respiratory tract infection, dyspnea, increased cough.

Skin: rash, sweating.

Other: angioedema, flu syndrome, peripheral edema.

INTERACTIONS

Drug-drug. Antiarrhythmics (classes I and III): May increase dofetilide level. Withhold other antiarrhythmics for at least three plasma half-lives before giving dofetilide.

Drugs secreted by renal tubular cationic transport (amiloride, metformin, triamterene): May increase dofetilide level. Use together cautiously; monitor patient for adverse effects.

Drugs that prolong QT interval: May increase risk of QT interval prolongation. Avoid using together.

Inhibitors of CYP3A4 (amiodarone), azoleantifungals, cannabinoids, diltiazem, macrolides, nefazodone, norfloxacin, protease inhibitors, quinine, SSRIs, zafirlukast: May decrease metabolism and increase dofetilide level. Use together cautiously.

Inhibitors of renal cationic secretion (cimetidine,ketoconazole, megestrol,prochlorperazine, trimethoprim with orwithout sulfamethoxazole), verapamil: May increase dofetilide level. Use together is contraindicated.

Potassium-depleting diuretics: May increase risk of hypokalemia or hypomagnesemia. Monitor potassium and magnesium levels.

Thiazide diuretics: May cause hypokalemia and arrhythmias. Use together is contraindicated.

Drug-food. Grapefruit juice: May decrease hepatic metabolism and increase drug level. Discourage use together.

EFFECTS ON LAB TEST RESULTS

None reported.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug, in those with congenital or acquired long QT interval syndromes or with baseline QTc interval greater than 440 msec (500 msec in patients with ventricular conduction abnormalities), and in those with creatinine clearance less than 20 ml/minute.

• Contraindicated for use with verapamil and with cation transport system inhibitors (cimetidine, ketoconazole, megestrol, prochlorperazine, trimethoprim with or without sulfamethoxazole).

• Use cautiously in patients with severe hepatic impairment.

NURSING CONSIDERATIONS

• Provide continuous ECG monitoring for at least 3 days.

• Don’t discharge patient within 12 hours of conversion to normal sinus rhythm.

• Monitor patient for prolonged diarrhea, sweating, and vomiting. Report these signs to prescriber because electrolyte imbalance may increase potential for arrhythmia development.

• Monitor renal function and QTc interval every 3 months.

• Use of potassium-depleting diuretics may cause hypokalemia and hypomagnesemia, increasing the risk of torsades de pointes. Give dofetilide after potassium level reaches and stays in normal range.

• If patient doesn’t convert to normal sinus rhythm within 24 hours of starting dofetilide, consider electrical conversion.

• Before starting dofetilide, stop previous antiarrhythmics while carefully monitoring patient for a minimum of three plasma half-lives. Don’t give drug after amiodarone therapy until amiodarone level falls below 0.3 mcg/ml or until amiodarone has been stopped for at least 3 months.

• If dofetilide must be stopped to allow dosing with interacting drugs, allow at least 2 days before starting other drug therapy.

PATIENT TEACHING

• Tell patient to report any change in OTC or prescription drug use, or supplement or herb use.

• Inform patient that drug can be taken without regard to meals or antacid administration.

• Tell patient to immediately report excessive or prolonged diarrhea, sweating, vomiting, or loss of appetite or thirst.

• Advise patient not to take drug with grapefruit juice.

• Advise patient to use antacids, such as Zantac 75 mg, Pepcid, Prilosec, Axid, or Prevacid, instead of Tagamet HB if needed for ulcers or heartburn.

• Instruct patient to tell prescriber if she becomes pregnant.

• Advise patient not to breast-feed while taking dofetilide because drug appears in breast milk.

• If a dose is missed, tell patient not to double a dose but to skip that dose and take the next regularly scheduled dose.

SAFETY ALERT! dopamine hydrochloride

DOE-pa-meen

Pharmacologic class: adrenergic

Pregnancy risk category C

AVAILABLE FORMS

Injection: 40 mg/ml, 80 mg/ml, 160 mg/ml parenteral concentrate for injection for I.V. infusion; 0.8 mg/ml (200 or 400 mg) in D₅W; 1.6 mg/ml (400 or 800 mg) in D₅W; 3.2 mg/ml (800 mg) in D₅W parenteral injection for I.V. infusion

INDICATIONS & DOSAGES

[black right-pointing arrowhead] To treat shock and correct hemodynamic imbalances; to improve perfusion to vital organs; to increase cardiac output; to correct hypotension

Adults: Initially, 2 to 5 mcg/kg/minute by I.V. infusion. Titrate dosage to desired hemodynamic or renal response. Increase by 1 to 4 mcg/kg/minute at 10-to 30-minute intervals. In seriously ill patients, start with 5 mcg/kg/minute and increase gradually in increments of 5 to 10 mcg/kg/minute to a rate of 20 to 50 mcg/kg/minute, as needed.

Adjust-a-dose: In patients with occlusive vascular disease, initial dose is 1 mcg/kg/minute or less.

ADMINISTRATION

I.V.

• Dilute with D₅W, normal saline solution, D₅W in normal saline or 0.45%saline, lactated Ringer’s, or D₅W in lactated Ringer’s. Mix just before use.

• Use a central line or large vein, as in the antecubital fossa, to minimize risk of extravasation.

• Use a continuous infusion pump to regulate flow rate.

• Watch infusion site carefully for extravasation; if it occurs, stop infusion immediately and call prescriber. You may
need to infiltrate area with 5 to 10 mg phentolamine in 10 to 15 ml normal saline solution.

• Because solution will deteriorate rapidly, discard after 24 hours or earlier if it’s discolored.

• Incompatibilities: Acyclovir sodium, additives with a dopamine and dextrose solution, alteplase, amphotericin B, cefepime, furosemide, gentamicin, indomethacin sodium trihydrate, iron salts, insulin, oxidizing agents, penicillin G potassium, sodium bicarbonate or other alkaline solutions, thiopental. Don’t mix other drugs in I.V. container with dopamine.

ACTION

Stimulates dopaminergic and alpha and beta receptors of the sympathetic nervous system resulting in a positive inotropic effect and increased cardiac output. Action is dose-related; large doses cause mainly alpha stimulation.

Route	Onset	Peak	Duration
I.V.	5 min	Unknown	< 10 min after infusion

Half-life: 2 minutes.

ADVERSE REACTIONS

CNS: headache, anxiety.

CV: hypotension, ventricular arrhythmias(high doses), ectopic beats, tachycardia, angina, palpitations, vasoconstriction.

GI: nausea, vomiting.

Metabolic: azotemia, hyperglycemia.

Respiratory: asthmatic episodes, dyspnea.

Skin: necrosis and tissue sloughing with extravasation, piloerection.

Other: anaphylactic reactions.

INTERACTIONS

Drug-drug. Alpha and beta blockers: May antagonize dopamine effects. Monitor patient closely.

Ergot alkaloids: May cause extremely high blood pressure. Avoid using together.

Inhaled anesthetics: May increase risk of arrhythmias or hypertension. Monitor patient closely.

MAO inhibitors (phenelzine, tranylcypromine): May cause fever, hypertensive crisis, or severe headache. Avoid using together; if patient received an MAO inhibitor in the past 2 to 3 weeks, initial dopamine dose is less than or equal to 10% of the usual dose.

Oxytocics: May cause severe, persistent hypertension. Use together cautiously.

Phenytoin: May cause severe hypotension, bradycardia, and cardiac arrest. Monitor patient carefully.

Tricyclic antidepressants: May decrease pressor response. Monitor patient closely.

EFFECTS ON LAB TEST RESULTS

• May increase catecholamine, glucose, and urine urea levels.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients with uncorrected tachyarrhythmias, pheochromocytoma, or ventricular fibrillation.

• Use cautiously in patients with occlusive vascular disease, cold injuries, diabetic endarteritis, and arterial embolism; in pregnant or breast-feeding women; in those with a history of sulfite sensitivity; and in those taking MAO inhibitors.

NURSING CONSIDERATIONS

• Most patients receive less than 20 mcg/kg/minute. Doses of 0.5 to 2 mcg/kg/minute mainly stimulate dopamine receptors and dilate the renal vasculature. Doses of 2 to 10 mcg/kg/minute stimulate beta receptors for a positive inotropic effect. Higher doses also stimulate alpha receptors, constricting blood vessels and increasing blood pressure.

• Drug isn’t a substitute for blood or fluid volume deficit. If deficit exists, replace fluid before giving vasopressors.

• During infusion, frequently monitor ECG, blood pressure, cardiac output, central venous pressure, pulmonary artery wedge pressure, pulse rate, urine output, and color and temperature of limbs.

• If diastolic pressure rises disproportionately with a significant decrease in pulse pressure, decrease infusion rate, and watch carefully for further evidence of predominant vasoconstrictor activity, unless such an effect is desired.

• Observe patient closely for adverse reactions; dosage may need to be adjusted or drug stopped.

• Check urine output often. If urine flow decreases without hypotension, notify prescriber because dosage may need to be reduced.

• Alert: After drug is stopped, watch closely for sudden drop in blood pressure. Taper dosage slowly to evaluate stability of blood pressure.

• Acidosis decreases effectiveness of drug.

• Look alike-sound alike: Don’t confuse dopamine with dobutamine.

PATIENT TEACHING

• Tell patient to report adverse reactions promptly.

• Instruct patient to report discomfort at I.V. insertion site.

doxazosin mesylate

dox-AY-zo-sin

Cardura, Cardura XL

Pharmacologic class: alpha blocker

Pregnancy risk category C

AVAILABLE FORMS

Tablets: 1 mg, 2 mg, 4 mg, 8 mg

Tablets (extended-release): 4 mg, 8 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Essential hypertension

Adults: Initially, 1 mg P.O. daily; determine effect on standing and supine blood pressure at 2 to 6 hours and 24 hours after dose. May increase at 2-week intervals to 2 mg and, thereafter, 4 mg and 8 mg once daily, if needed. Maximum daily dose is 16 mg, but doses over 4 mg daily increase the risk of adverse reactions.

[black right-pointing arrowhead] BPH

Adults: Initially, 1 mg P.O. once daily in the morning or evening; may increase at 1- or 2-week intervals to 2 mg and, thereafter, 4 mg and 8 mg once daily, if needed.

ADMINISTRATION

P.O.

• Swallow extended-release tablets whole; don’t chew, divide, cut, or crush.

• Give extended-release tablet with breakfast.

• Don’t give evening dose the night before switching to extended-release from immediate-release formula.

ACTION

An alpha blocker that acts on the peripheral vasculature to reduce peripheral vascular resistance and produce vasodilation. Drug also decreases smooth muscle tone in the prostate and bladder neck.

Route	Onset	Peak	Duration
P.O.	1-2 hr	2-3 hr	24 hr

Half-life: 19 to 22 hours.

ADVERSE REACTIONS

CNS: dizziness, asthenia, headache, vertigo, somnolence, drowsiness, pain.

CV: orthostatic hypotension, arrhythmias, hypotension, edema, palpitations, tachycardia.

EENT: rhinitis, pharyngitis, abnormal vision.

GI: nausea, vomiting, diarrhea, constipation.

Hematologic: leukopenia, neutropenia.

Musculoskeletal: arthralgia, myalgia.

Respiratory: dyspnea.

Skin: rash, pruritus.

INTERACTIONS

Drug-drug. Midodrine: May decrease the effectiveness of midodrine. Monitor patient for therapeutic effect.

Drug-herb. Butcher’s broom: May decrease effect of doxazosin. Discourage use together.

Ma huang: May decrease antihypertensive effects. Discourage use together.

EFFECTS ON LAB TEST RESULTS

• May decreaseWBC and neutrophil counts.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug and quinazoline derivatives (including prazosin and terazosin).

• Use cautiously in patients with impaired hepatic function.

NURSING CONSIDERATIONS

• Monitor blood pressure closely.

• If syncope occurs, place patient in a recumbent position and treat supportively. A transient hypotensive response isn’t considered a contraindication to continued therapy.

• Initial extended-release dose is 4 mg. If patient stops medication briefly, he should resume at 4-mg dose and titrate back to 8 mg if appropriate.

• Wait 3 to 4 weeks before increasing extended-release dose.

• Look alike-sound alike: Don’t confuse doxazosin with doxapram, doxorubicin, or doxepin. Don’t confuse Cardura with Coumadin, K-Dur, Cardene, or Cordarone.

PATIENT TEACHING

• Instruct patient to take drug exactly as prescribed.

• Alert: Advise patient that he is susceptible to a first-dose effect (marked low blood pressure on standing up with dizziness or fainting). This is most common after first dose but also can occur during dosage adjustment or interruption of therapy.

• Advise patient to consult prescriber if dizziness or palpitations are bothersome.

• Advise patient to rise slowly from sitting or lying position.

• Advise patient to avoid driving and other hazardous activities until drug’s effects are known.

enalaprilat

eh-NAH-leh-prel-at

enalaprilmaleate

Vasotec

Pharmacologic class: ACE inhibitor

Pregnancy risk category C; D in 2nd and 3rd trimesters

AVAILABLE FORMS

enalaprilat

Injection: 1.25 mg/ml

enalapril maleate

Tablets: 2.5 mg, 5 mg, 10 mg, 20 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Hypertension

Adults: In patients not taking diuretics, initially, 5 mg P.O. once daily; then adjusted based on response. Usual dosage range is 10 to 40 mg daily as a single dose or two divided doses. Or, 1.25 mg I.V. infusion over 5 minutes every 6 hours.

Children ages 1 month to 16 years: 0.08 mg/kg (up to 5 mg) P.O. once daily; dosage should be adjusted as needed up to 0.58 mg/kg (maximum 40 mg). Don’t use if creatinine clearance is less than 30 ml/minute.

Adjust-a-dose: If patient is taking diuretics or creatinine clearance is 30 ml/minute or less, initially, 2.5 mg P.O. once daily. Or, 0.625 mg I.V. over 5 minutes, and repeat in 1 hour, if needed; then 1.25 mg I.V. every 6 hours.

[black right-pointing arrowhead] To convert from I.V. therapy to oral therapy

Adults: Initially, 2.5 mg P.O. once daily; if patient was receiving 0.625 mg I.V. every 6 hours, then 2.5 mg P.O. once daily. Adjust dosage based on response.

[black right-pointing arrowhead] To convert from oral therapy to I.V. therapy

Adults: 1.25 mg I.V. over 5 minutes every 6 hours. Higher dosages aren’t more effective.

Adjust-a-dose: If creatinine level is more than 1.6 mg/dl or sodium level below 130 mEq/L, initially, 2.5 mg P.O. daily and adjust slowly.

[black right-pointing arrowhead] To manage symptomatic heart failure

Adults: Initially, 2.5 mg P.O. daily or b.i.d., increased gradually over several weeks. Maintenance is 5 to 20 mg daily in two divided doses. Maximum daily dose is 40 mg in two divided doses.

[black right-pointing arrowhead] Asymptomatic left ventricular dysfunction

Adults: Initially, 2.5 mg P.O. b.i.d. Increase as tolerated to target daily dose of 20 mg P.O. in divided doses.

ADMINISTRATION

P.O.

• Give drug without regard for food.

• Request oral suspension for patient who has difficulty swallowing.

I.V.

• Compatible solutions include D₅W, normal saline solution for injection, dextrose 5% in lactated Ringer injection, dextrose 5% in normal saline solution for injection, and Isolyte E.

• Inject drug slowly over at least 5 minutes, or dilute in 50 ml of a compatible solution and infuse over 15 minutes.

• Incompatibilities: Amphotericin B, cefepime hydrochloride, phenytoin sodium.

ACTION

May inhibit ACE, preventing conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. Less angiotensin II decreases peripheral arterial resistance, decreasing aldosterone secretion, reducing sodium and water retention, and lowering blood pressure.

Route	Onset	Peak	Duration
P.O.	1 hr	4-6 hr	24 hr
I.V.	15 min	1-4 hr	6 hr
Half-life: 12 hours.

ADVERSE REACTIONS

CNS: asthenia, headache, dizziness, fatigue, vertigo, syncope.

CV: hypotension, chest pain, angina pectoris.

GI: diarrhea, nausea, abdominal pain, vomiting.

GU: decreased renal function (in patients with bilateral renal artery stenosis or heart failure).

Hematologic: bone marrow depression.

Respiratory: dry, persistent, tickling, nonproductive cough, dyspnea.

Skin: rash.

Other: angioedema.

INTERACTIONS

Drug-drug. Azathioprine: May increase risk of anemia or leukopenia. Monitor hematologic study results if used together.

Diuretics: May excessively reduce blood pressure. Use together cautiously.

Insulin, oral antidiabetics: May cause hypoglycemia, especially at start of enalapril therapy. Monitor patient closely.

Lithium: May cause lithium toxicity. Monitor lithium level.

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. Capsaicin: May cause cough. Discourage use together.

Ma huang: May decrease antihypertensive effects. Discourage use together.

Drug-food. Salt substitutes containing potassium: May cause hyperkalemia. Monitor patient closely.

EFFECTS ON LAB TEST RESULTS

• May increase bilirubin, BUN, creatinine, and potassium levels. May decrease sodium and hemoglobin levels and hematocrit.

• May increase liver function test values.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to drug and in those with a history of angioedema related to previous treatment with an ACE inhibitor.

• Use cautiously in renally impaired patients or those with aortic stenosis or hypertrophic cardiomyopathy.

NURSING CONSIDERATIONS

• Closely monitor blood pressure response to drug.

• Look alike-sound alike: Similar packaging and labeling of enalaprilat injection and pancuronium, a neuromuscularblocking drug, could result in a fatal medication error. Check all labels carefully.

• Monitor CBC with differential counts before and during therapy.

• Diabetic patients, those with impaired renal function or heart failure, and those receiving drugs that can increase potassium level may develop hyperkalemia. Monitor potassium intake and potassium level.

• Look alike-sound alike: Don’t confuse enalapril with Anafranil or Eldepryl.

PATIENT TEACHING

• Instruct patient to report breathing difficulty or swelling of face, eyes, lips, or tongue. Swelling of the face and throat
(including swelling of the larynx) may occur, especially after first dose.

• Advise patient to report signs of infection, such as fever and sore throat.

• Inform patient that light-headedness can occur, especially during first few days of therapy. Tell him to rise slowly to minimize this effect and to notify prescriber if symptoms develop. If he faints, he should stop taking drug and call prescriber immediately.

• Tell patient to use caution in hot weather and during exercise. Inadequate fluid intake, vomiting, diarrhea, and excessive perspiration can lead to light-headedness and fainting.

• Advise patient to avoid salt substitutes; these products may contain potassium, which can cause high potassium levels in patients taking this drug.

• Tell woman of childbearing age to notify prescriber if pregnancy occurs. Drug will need to be stopped.

SAFETY ALERT! enoxaparin sodium

en-OCKS-a-par-in

Lovenox

Pharmacologic class: low-molecular-weight heparin

Pregnancy risk category B

AVAILABLE FORMS

Syringes (graduated prefilled): 60 mg/0.6 ml, 80 mg/0.8 ml, 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml

Syringes (prefilled): 30 mg/0.3 ml, 40 mg/0.4 ml

Vial (multidose): 300 mg/3 ml (contains 15 mg/ml of benzyl alcohol)

INDICATIONS & DOSAGES

[black right-pointing arrowhead] To prevent pulmonary embolism and deep vein thrombosis (DVT) after hip or knee replacement surgery

Adults: 30 mg subcutaneously every 12 hours for 7 to 10 days. Give initial dose between 12 and 24 hours postoperatively, as long as hemostasis has been established. Continue treatment during postoperative period until risk of DVT has diminished. Hip replacement patients may receive 40 mg subcutaneously 12 hours preoperatively. After initial phase of therapy, hip replacement patients should continue with 40 mg subcutaneously daily for 3 weeks.

[black right-pointing arrowhead] To prevent pulmonary embolism and DVT after abdominal surgery

Adults: 40 mg subcutaneously daily with initial dose 2 hours before surgery. Give subsequent dose, as long as hemostasis has been established, 24 hours after initial preoperative dose and continue once daily for 7 to 10 days. Continue treatment during postoperative period until risk of DVT has diminished.

[black right-pointing arrowhead] To prevent pulmonary embolism and DVT in patients with acute illness who are at increased risk because of decreased mobility

Adults: 40 mg once daily subcutaneously for 6 to 11 days. Treatment for up to 14 days has been well tolerated.

Adjust-a-dose: In patients with creatinine clearance less than 30 ml/minute receiving drug as prophylaxis after abdominal surgery or hip or knee replacement surgery, and in medical patients for prophylaxis during acute illness, give 30 mg subcutaneously once daily.

[black right-pointing arrowhead] To prevent ischemic complications of unstable angina and non—Q-wave MI with oral aspirin therapy

Adults: 1 mg/kg subcutaneously every 12 hours until clinical stabilization (minimum 2 days) with aspirin 100 to 325 mg P.O. once daily.

NEW INDICATION: Acute ST-segment elevation MI

Adults younger than age 75: 30 mg single I.V. bolus plus 1 mg/kg subcutaneously followed by 1 mg/kg subcutaneously every 12 hours (maximum of 100 mg for the first two doses only) with aspirin.When given with a thrombolytic, give enoxaparin from 15 minutes before to 30 minutes after the start of fibrinolytic therapy. For patients with percutaneous coronary intervention (PCI), if the last subcutaneous dose was given less than 8 hours before balloon inflation, no additional dose is needed. If the last dose was given more than 8 hours
before balloon inflation, give 0.3 mg/kg I.V. bolus.

Adults age 75 and older: 0.75 mg/kg subcutaneously every 12 hours (maximum 75 mg for the first two doses only).

Adjust-a-dose: In adults younger than age 75 with severe renal impairment, 30 mg single I.V. bolus plus 1 mg/kg subcutaneously followed by 1 mg/kg subcutaneously once daily. In adults age 75 and older with severe renal impairment, 1 mg/kg subcutaneously once daily with no initial bolus.

[black right-pointing arrowhead] Inpatient treatment of acute DVT with and without pulmonary embolism when given with warfarin sodium

Adults: 1 mg/kg subcutaneously every 12 hours. Or, 1.5 mg/kg subcutaneously once daily (at same time daily) for 5 to 7 days until therapeutic oral anticoagulant effect (INR 2 to 3) is achieved.Warfarin sodium therapy is usually started within 72 hours of enoxaparin injection.

[black right-pointing arrowhead] Outpatient treatment of acute DVT without pulmonary embolism when given with warfarin sodium

Adults: 1 mg/kg subcutaneously every 12 hours for 5 to 7 days until therapeutic oral anticoagulant effect (INR 2 to 3) is achieved.Warfarin sodium therapy usually is started within 72 hours of enoxaparin injection.

Adjust-a-dose: In patients with creatinine clearance less than 30 ml/minute receiving drug for acute DVT or prophylaxis of ischemic complications of unstable angina and non—Q-wave MI, give 1 mg/kg subcutaneously once daily.

ADMINISTRATION

Subcutaneous

• With patient lying down, give by deep subcutaneous injection, alternating doses between left and right anterolateral and posterolateral abdominal walls.

• Don’t massage after subcutaneous injection. Watch for signs of bleeding at site. Rotate sites and keep record.

ACTION

Accelerates formation of antithrombin III-thrombin complex and deactivates thrombin, preventing conversion of fibrinogen to fibrin. Drug has a higher antifactor-Xa-to-antifactor-IIa activity ratio than heparin.

Route	Onset	Peak	Duration
Subcut.	Unknown	4 hr	Unknown
Half-life: 4½ hours.

ADVERSE REACTIONS

CNS: confusion, fever, pain.

CV: edema, peripheral edema.

GI: nausea, diarrhea.

Hematologic: thrombocytopenia, hemorrhage, ecchymoses, bleeding complications, hypochromic anemia.

Skin: irritation, pain, hematoma, and erythema at injection site, rash, urticaria.

Other: angioedema, anaphylaxis.

INTERACTIONS

Drug-drug. Anticoagulants, antiplatelet drugs, NSAIDs: May increase risk of bleeding. Use together cautiously. Monitor PT and INR.

EFFECTS ON LAB TEST RESULTS

• May increase ALT and AST levels. May decrease hemoglobin level.

• May decrease platelet count.

CONTRAINDICATIONS & CAUTIONS

• Use cautiously in patients with history of heparin-induced thrombocytopenia, aneurysms, cerebrovascular hemorrhage, spinal or epidural punctures (as with anesthesia), uncontrolled hypertension, or threatened abortion.

• Use cautiously in elderly patients and in those with conditions that place them at increased risk for hemorrhage, such
as bacterial endocarditis, congenital or acquired bleeding disorders, ulcer disease, angiodysplastic GI disease, hemorrhagic stroke, or recent spinal, eye, or brain surgery.

• Use cautiously in patients with prosthetic heart valves, with regional or lumbar block anesthesia, blood dyscrasias, recent childbirth, pericarditis or pericardial effusion, renal insufficiency, or severe CNS trauma.

NURSING CONSIDERATIONS

• It’s important to achieve hemostasis at the puncture site after PCI. The vascular access sheath for instrumentation should remain in place for 6 hours after a dose if manual compression method is used; give next dose no sooner than 6 to 8 hours after sheath removal. Monitor vital signs and site for hematoma and bleeding.

• Monitor pregnant women closely. Warn pregnant women and women of childbearing age about the potential risk of therapy to her and the fetus.

• Multidose vial shouldn’t be used in pregnant women because of benzyl alcohol content.

• Monitor anti-Xa levels in pregnant women with mechanical heart valves.

• Alert: Patients who receive epidural or spinal anesthesia during therapy are at increased risk for developing an epidural or spinal hematoma, which may result in long-term or permanent paralysis. Monitor these patients closely for neurologic impairment.

• Draw blood to establish baseline coagulation parameters before therapy.

• Never give drug I.M.

• Alert: Don’t try to expel the air bubble from the 30- or 40-mg prefilled syringes. This may lead to loss of drug and an incorrect dose.

• Avoid I.M. injections of other drugs to prevent or minimize hematoma.

• Monitor platelet counts regularly. Patients with normal coagulation won’t need close monitoring of PT or PTT.

• Regularly inspect patient for bleeding gums, bruises on arms or legs, petechiae, nosebleeds, melena, tarry stools, hematuria, hematemesis.

• To treat severe overdose, give protamine sulfate (a heparin antagonist) by slow I.V. infusion at concentration of 1% to equal dose of drug injected.

• Alert: Drug isn’t interchangeable with heparin or other low-molecular-weight heparins.

PATIENT TEACHING

• Instruct patient and family to watch for signs of bleeding or abnormal bruising and to notify prescriber immediately if any occur.

• Tell patient to avoid OTC drugs containing aspirin or other salicylates unless ordered by prescriber.

• Advise patient to consult with prescriber before initiating any herbal therapy; many herbs have anticoagulant, antiplatelet, or fibrinolytic properties.

SAFETY ALERT! ephedrine sulfate

e-FED-rin

Pharmacologic class: adrenergic

Pregnancy risk category C

AVAILABLE FORMS

Capsules: 25mg, 50 mg

Injection: 25 mg/ml, 50 mg/ml

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Hypotension

Adults: 25 mg P.O. once daily to q.i.d. Or, 5 to 25 mg I.V., p.r.n., to maximum of 150 mg/24 hours. Or, 25 to 50 mg I.M. or subcutaneously.

Children: 3 mg/kg P.O. or 0.5 mg/kg or 16.7 mg/m² subcutaneously or I.M. every 4 to 6 hours.

[black right-pointing arrowhead] Bronchodilation

Adults and children older than age 12: 12.5 to 25 mg P.O. every 4 hours, as needed, not to exceed 150 mg in 24 hours.

Children age 2 to 12: 2 to 3 mg/kg or 100 mg/m² P.O. daily in four to six divided doses. Or, for children ages 6 to 12, 6.25 to 12.5 mg P.O. every 4 hours, not to exceed 75 mg in 24 hours.

ADMINISTRATION

P.O.

• Give last dose of the day at least 2 hours before bedtime, to prevent insomnia.

I.V.

• Drug is compatible with most common solutions.

• Give slowly by direct injection.

• If needed, repeat in 5 to 10 minutes.

• Incompatibilities: Fructose 10% in normal saline solution; hydrocortisone sodium succinate; Ionosol B, D-CM, and D solutions; pentobarbital sodium; phenobarbital sodium; thiopental.

I.M.

• Don’t use solution with particulate matter or discoloration.

• Document injection site.

Subcutaneous

• Don’t use solution with particulate matter or discoloration.

• Document injection site.

ACTION

Relaxes bronchial smooth muscle by stimulating beta₂ receptors; also stimulates alpha and beta receptors and is a directand indirect-acting sympathomimetic.

Route	Onset	Peak	Duration
P.O.	15-60 min	Unknown	3-5 hr
I.V.	5 min	Unknown	60 min
I.M., Subcut.	10-20 min	Unknown	30-60 min
Half-life: 3 to 6 hours.

ADVERSE REACTIONS

CNS: insomnia, nervousness, cerebralhemorrhage, dizziness, headache, muscle weakness, euphoria, confusion, delirium, tremor.

CV: palpitations, arrhythmias, tachycardia, hypertension, precordial pain.

EENT: dry nose and throat.

GI: nausea, vomiting, anorexia.

GU: urine retention, painful urination from visceral sphincter spasm.

Skin: diaphoresis.

INTERACTIONS

Drug-drug. Acetazolamide: May increase ephedrine level. Monitor patient for toxicity.

Alpha blockers: May reduce vasopressor response. Monitor patient closely.

Antihypertensives: May decrease effects. Monitor blood pressure.

Beta blockers: May block the effects of ephedrine. Monitor patient closely.

Cardiac glycosides, general anesthetics (halogenated hydrocarbons): May increase risk of ventricular arrhythmias. Monitor ECG closely.

Guanethidine: May decrease pressor effects of ephedrine. Monitor patient closely.

MAO inhibitors (phenelzine, tranylcypromine): May cause severe headache, hypertension, fever, and hypertensive crisis. Avoid using together.

Methyldopa, reserpine: May inhibit ephedrine effects. Use together cautiously.

Oxytocics: May cause severe hypertension. Avoid using together.

Tricyclic antidepressants: May decrease pressor response. Monitor patient closely.

EFFECTS ON LAB TEST RESULTS

None reported.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients hypersensitive to ephedrine and other sympathomimetics and in those with porphyria, severe coronary artery disease, arrhythmias, angle-closure glaucoma, psychoneurosis, angina pectoris, substantial organic heart disease, or CV disease.

• Contraindicated in those receiving MAO inhibitors or general anesthesia with cyclopropane or halothane.

• Use with caution in elderly patients and in those with hypertension, hyperthyroidism, nervous or excitable states, diabetes, or prostatic hyperplasia.

NURSING CONSIDERATIONS

• Alert: Hypoxia, hypercapnia, and acidosis must be identified and corrected before or during therapy because they may reduce effectiveness or increase adverse reactions.

• Drug isn’t a substitute for blood or fluid volume replenishment. Volume deficit must be corrected before giving vasopressors.

• Effectiveness decreases after 2 to 3 weeks as tolerance develops. Prescriber may increase dosage. Drug isn’t addictive.

• Look alike-sound alike: Don’t confuse ephedrine with epinephrine.

PATIENT TEACHING

• Tell patient taking oral form of drug at home to take last dose of day at least 2 hours before bedtime to prevent insomnia.

• Warn patient not to take OTC drugs or herbs that contain ephedrine without consulting prescriber.

SAFETY ALERT! epinephrine (adrenaline)

ep-i-NEF-rin

Primatene Mist ◊

epinephrine hydrochloride

Adrenalin Chloride, EpiPen, EpiPen Jr, microNefrin ◊, Nephron ◊

Pharmacologic class: adrenergic

Pregnancy risk category C

AVAILABLE FORMS

Aerosol inhaler: 220 mcg

Injection: 0.1 mg/ml (1:10,000), 0.5 mg/ml (1:2,000), 1 mg/ml (1:1,000) parenteral

Nebulizer inhaler: 1% (1:100), 1.125%

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Bronchospasm, hypersensitivity reactions, anaphylaxis

Adults: 0.1 to 0.5 ml of 1:1,000 solution I.M. or subcutaneously. Repeat every 10 to 15 minutes as needed. Or, 0.1 to 0.25 ml of 1:1,000 solution I.V. slowly over 5 to 10 minutes (1 to 2.5 ml of a commercially available 1:10,000 injection or of a 1:10,000 dilution prepared by diluting 1 ml of a commercially available 1:1,000 injection with 10 ml of water for injection or normal saline solution for injection). May repeat every 5 to 15 minutes as needed, or follow with a continuous I.V. infusion, starting at 1 mcg/minute and increasing to 4 mcg/minute, as needed.

Children: 0.01 ml/kg (10 mcg) of 1:1,000 solution subcutaneously; repeat every 20 minutes to 4 hours, as needed. Maximum single dose shouldn’t exceed 0.5 mg.

[black right-pointing arrowhead] Hemostasis

Adults: 1:50,000 to 1:1,000, sprayed or applied topically.

[black right-pointing arrowhead] Acute asthma attacks

Adults and children age 4 and older: One inhalation, repeated once if needed after at least 1 minute; don’t give subsequent doses for at least 3 hours. Or, 1 to 3 deep inhalations using a hand-bulb nebulizer containing 1% (1:100) solution of epinephrine repeated every 3 hours, as needed.

[black right-pointing arrowhead] To prolong local anesthetic effect

Adults and children: With local anesthetics, may be used in concentrations of 1:500,000 to 1:50,000; most commonly, 1:200,000.

[black right-pointing arrowhead] To restore cardiac rhythm in cardiac arrest

Adults: 0.5 to 1 mg I.V., repeated every 3 to 5 minutes, if needed. A higher dose may be used if 1 mg fails: 3 to 5 mg (about 0.1 mg/kg); repeat every 3 to 5 minutes.

Children: 0.01 mg/kg (0.1 ml/kg of 1:10,000 injection) I.V. First endotracheal dose is 0.1 mg/kg (0.1 ml/kg of a 1:1,000 injection) diluted in 1 to 2 ml of half-normal or normal saline solution. Give subsequent I.V. or intratracheal doses from 0.1 to 0.2 mg/kg (0.1 to 0.2 ml/kg of a 1:1,000 injection), repeated every 3 to 5 minutes, if needed.

ADMINISTRATION

I.V.

• Keep solution in light-resistant container, and don’t remove before use.

• Just before use, mix with D₅W, normal saline solution for injection, lactated Ringer’s injection, or combinations of dextrose in saline solution.

• Monitor blood pressure, heart rate, and ECG when therapy starts and frequently thereafter.

• Discard solution if it’s discolored or contains precipitate or after 24 hours.

• Incompatibilities: Aminophylline; ampicillin sodium; furosemide; hyaluronidase; Ionosol D-CM, PSL, and T solutions with D₅W; mephentermine; thiopental sodium. Compatible with most other I.V. solutions. Rapidly destroyed by alkalies or oxidizing drugs, including halogens, nitrates, nitrites, permanganates, sodium bicarbonate, and salts of easily reducible metals, such as iron, copper, and zinc. Don’t mix with alkaline solutions.

I.M.

• Avoid I.M. use of parenteral suspension into buttocks. Gas gangrene may occur because drug reduces oxygen tension of the tissues, encouraging growth of contaminating organisms.

• Massage site after I.M. injection to counteract vasoconstriction. Repeated local injection can cause necrosis at injection site.

Subcutaneous

• Don’t refrigerate and protect from light.

• Preferred route. Don’t inject too deeply and enter muscle.

Inhalational

• Teach patient to perform oral inhalation correctly. See “Patient teaching” for complete instructions.

• Epinephrine 1:100 will turn from pink to brown if exposed to air, light, heat, alkalies, and some metals. Don’t use solution that’s discolored or has a precipitate.

ACTION

Relaxes bronchial smooth muscle by stimulating beta₂ receptors and alpha and beta receptors in the sympathetic nervous system.

Route	Onset	Peak	Duration
I.V.	Immediate	5 min	Short
I.M.	Variable	Unknown	1-4 hr
Subcut.	5-15 min	30 min	1-4 hr
Inhalation	1-5 min	Unknown	1-3 hr
Half-life: Unknown.

ADVERSE REACTIONS

CNS: drowsiness, headache, nervousness, tremor, cerebral hemorrhage, stroke, vertigo, pain, disorientation, agitation, fear, dizziness, weakness.

CV: palpitations, ventricular fibrillation,shock, widened pulse pressure, hypertension, tachycardia, anginal pain, altered ECG (including a decreased T-wave amplitude).

GI: nausea, vomiting.

Respiratory: dyspnea.

Skin: urticaria, hemorrhage at injection site, pallor.

Other: tissue necrosis.

INTERACTIONS

Drug-drug. Alpha blockers: May cause hypotension from unopposed beta-adrenergic effects. Avoid using together.

Antihistamines, thyroid hormones: When given with sympathomimetics, may cause severe adverse cardiac effects. Avoid using together.

Cardiac glycosides, general anesthetics (halogenated hydrocarbons): May increase risk of ventricular arrhythmias. Monitor ECG closely.

Carteolol, nadolol, penbutolol, pindolol, propranolol, timolol: May cause hypertension followed by bradycardia. Stop beta blocker 3 days before starting epinephrine.

Doxapram, methylphenidate: May enhance CNS stimulation or pressor effects. Monitor patient closely.

Ergot alkaloids: May decrease vasoconstrictor activity. Monitor patient closely.

Guanadrel, guanethidine: May enhance pressor effects of epinephrine. Monitor patient closely.

Levodopa: May enhance risk of arrhythmias. Monitor ECG closely.

MAO inhibitors: May increase risk of hypertensive crisis. Monitor blood pressure closely.

Tricyclic antidepressants: May potentiate the pressor response and cause arrhythmias. Use together cautiously.

EFFECTS ON LAB TEST RESULTS

• May increase BUN, glucose, and lactic acid levels.

CONTRAINDICATIONS & CAUTIONS

• Contraindicated in patients with angle-closure glaucoma, shock (other than anaphylactic shock), organic brain damage, cardiac dilation, arrhythmias, coronary insufficiency, or cerebral arteriosclerosis.

• Contraindicated in patients receiving general anesthesia with halogenated hydrocarbons or cyclopropane and in patients in labor (may delay second stage).

• Commercial products containing sulfites contraindicated in patients with sulfite allergies, except when epinephrine is being used to treat serious allergic reactions or other emergency situations.

• Contraindicated for use in fingers, toes, ears, nose, or genitalia when used with local anesthetic.

• Use cautiously in patients with longstanding bronchial asthma or emphysema who have developed degenerative heart disease.

• Use cautiously in elderly patients and in those with hyperthyroidism, CV disease, hypertension, psychoneurosis, and diabetes.

NURSING CONSIDERATIONS

• In patients with Parkinson disease, drug increases rigidity and tremor.

• Drug interferes with tests for urinary catecholamines.

• One mg equals 1 ml of 1:1,000 solution or 10 ml of 1:10,000 solution.

• Epinephrine is drug of choice in emergency treatment of acute anaphylactic reactions.

• Observe patient closely for adverse reactions. Notify prescriber if adverse reactions develop; adjusting dosage or stopping drug may be necessary.

• If blood pressure increases sharply, give rapid-acting vasodilators, such as nitrates and alpha blockers, to counteract the marked pressor effect of large doses.

• Drug is rapidly destroyed by oxidizing products, such as iodine, chromates, nitrites, oxygen, and salts of easily reducible metals (such as iron).

• When treating patient with reactions caused by other drugs given I.M. or subcutaneously, inject this drug into the site where the other drug was given to minimize further absorption.

• Look alike-sound alike: Don’t confuse epinephrine with ephedrine or norepinephrine.

PATIENT TEACHING

• Teach patient to perform oral inhalation correctly. Give the following instructions for using a metered-dose inhaler:

– Shake canister.

– Clear nasal passages and throat.

– Breathe out, expelling as much air from lungs as possible.

– Place mouthpiece well into mouth, and inhale deeply as you release dose from inhaler.Or, hold inhaler about 1 inch (two fingerwidths) from open mouth, and inhale while releasing dose.

– Hold breath for several seconds, remove mouthpiece, and exhale slowly.

• If more than one inhalation is prescribed, advise 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.

• Instruct patient to remove canister and wash inhaler with warm, soapy water at least once weekly.

• If patient has acute hypersensitivity reactions (such as to bee stings), you may need to teach him to self-inject drug.

eplerenone

ep-LER-eh-nown

Inspra

Pharmacologic class: selective aldosterone receptor antagonist

Pregnancy risk category B

AVAILABLE FORMS

Tablets: 25 mg, 50 mg

INDICATIONS & DOSAGES

[black right-pointing arrowhead] Hypertension

Adults: 50 mg P.O. once daily. If response is inadequate after 4 weeks, increase dosage to 50 mg P.O. b.i.d. Maximum daily dose, 100 mg.

Adjust-a-dose: In patients taking weak CYP3A4 inhibitors (erythromycin,
fluconazole, saquinavir, verapamil), reduce eplerenone starting dose to 25 mg P.O. once daily.

[black right-pointing arrowhead] Heart failure after an MI

Adults: Initially, 25 mg P.O. once daily. Increase within 4 weeks, as tolerated and according to potassium level, to 50 mg P.O. once daily.

Adjust-a-dose: If potassium level is less than 5 mEq/L, increase dosage from 25 mg every other day to 25 mg daily; or increase dosage from 25 mg daily to 50 mg daily. If potassium level is 5 to 5.4 mEq/L, don’t adjust dosage. If potassium level is 5.5 to 5.9 mEq/L, decrease dosage from 50 mg daily to 25 mg daily; or decrease dosage from 25 mg daily to 25 mg every other day; or if dosage was 25 mg every other day, withhold drug. If potassium level is greater than 6 mEq/L,withhold drug. May restart drug at 25 mg every other day when potassium level is less than 5.5 mEq/L. In patients taking weak CYP3A4 inhibitors (erythromycin, fluconazole, saquinavir, verapamil), reduce eplerenone starting dose to 25 mg P.O. once daily.

ADMINISTRATION

P.O.

• Give drug without regard for meals.

ACTION

Binds to mineralocorticoid receptors and blocks aldosterone, which increases blood pressure through induction of sodium reabsorption and possibly other mechanisms.

Route	Onset	Peak	Duration
P.O.	Unknown	90 min	Unknown

Half-life: 4 to 6 hours.

ADVERSE REACTIONS

CNS: dizziness, fatigue.

GI: diarrhea, abdominal pain.

GU: albuminuria, abnormal vaginal bleeding.

Metabolic: hyperkalemia.

Respiratory: cough.

Other: flulike syndrome, gynecomastia.

INTERACTIONS

Drug-drug. ACE inhibitors, angiotensin II receptor antagonists: May increase risk of hyperkalemia. Use together cautiously.

Azole antifungals (itraconazole, ketoconazole),macrolides (clarithromycin), nefazodone,protease inhibitors (nelfinavir, ritonavir): Inhibits the CYP3A4 metabolism of eplerenone. Use together is contraindicated.

Lithium: May increase risk of lithium toxicity. Monitor lithium level.

NSAIDs: May reduce the antihypertensive effect and cause severe hyperkalemia in patients with impaired renal function. Monitor blood pressure and potassium level.

Potassium supplements, potassium-sparingdiuretics (amiloride, spironolactone, triamterene): May increase risk of hyperkalemia and sometimes-fatal arrhythmias. Use together is contraindicated.

Weak CYP3A4 inhibitors (erythromycin, fluconazole, saquinavir, verapamil): May increase eplerenone level. Reduce eplerenone starting dose to 25 mg P.O. once daily.

Drug-herb. St. John’s wort: May decrease eplerenone level over time. Discourage use together.

EFFECTS ON LAB TEST RESULTS

• May increase ALT, BUN, cholesterol, creatinine, GGT, potassium, triglyceride, and uric acid levels. May decrease sodium level.

CONTRAINDICATIONS & CAUTIONS

• When used for hypertension, contraindicated in patients with type 2 diabetes with microalbuminuria, creatinine level greater than 2 mg/dl in men or greater than 1.8 mg/dl in women, or creatinine clearance less than 50 ml/minute and in patients taking potassium supplements or potassium-sparing diuretics (amiloride, spironolactone, or triamterene).

• Contraindicated in patients with potassium level greater than 5.5 mEq/ml or creatinine clearance 30 ml/minute or less and in patients taking strong CYP3A4 inhibitors, such as ketoconazole, clarithromycin, ritonavir, nelfinavir, nefazodone, or itraconazole.

• Use cautiously in patient with mild to moderate hepatic impairment.

• Use in pregnant woman only if the potential benefits justify the potential risk to the fetus. Use cautiously in breast-feeding women; it’s unknown if drug appears in breast milk.

NURSING CONSIDERATIONS

• Drug may be used alone or with other antihypertensives.

• Full therapeutic effect of the drug occurs in 4 weeks.

• In patients with heart failure, measure potassium level at baseline, within the first week, at 1 month after starting therapy, and periodically thereafter.

• Monitor patient for signs and symptoms of hyperkalemia.

• Look alike-sound alike: Don’t confuse Inspra with Spiriva.

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Tags: Disease & Drug Consult: Cardiovascular Disorders

Jul 9, 2016 | Posted by drzezo in CARDIOLOGY | Comments Off

Thoracic Key

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Part 2 Drugs

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Part 2 Drugs

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