rabeprazole sodium
rah-bep-rah-zole
(Aciphex, Pariet J)
Do not confuse Aciphex with Accupril or Aricept.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Proton pump inhibitor. CLINICAL: Gastric acid inhibitor.
ACTION
A proton pump inhibitor that converts to active metabolites that irreversibly bind to and inhibit hydrogen-potassium adenosine triphosphate, an enzyme on the surface of gastric parietal cells. Actively secretes hydrogen ions for potassium ions, resulting in an accumulation of hydrogen ions in gastric lumen. Therapeutic Effect: Increases gastric pH, reducing gastric acid production.
PHARMACOKINETICS
Rapidly absorbed from the GI tract after passing through the stomach relatively intact. Protein binding: 96%. Metabolized extensively in the liver. Primarily excreted in urine. Unknown if removed by hemodialysis. Half-life: 1U2 hr (increased with hepatic impairment).
USES
Short-term treatment (4U8 wk) in healing and maintenance of erosive or ulcerative gastroesophageal reflux disease (GERD). Treatment of daytime and nighttime heartburn, other symptoms of GERD. Short-term treatment (4 wk or less) in healing, symptomatic relief of duodenal ulcers. Long-term treatment of pathologic hypersecretory conditions, including Zollinger-Ellison syndrome. Treatment of NSAID-induced ulcers. Treatment of H. pylori (in combination with other medication).
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category B. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Digoxin: May increase the plasma concentration of digoxin. Ketoconazole: May decrease the blood concentration of ketoconazole. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum alkaline phosphatase, AST, and ALT levels.
AVAILABILITY (Rx)
TABLETS (DELAYED-RELEASE): 20 mg.
ADMINISTRATION/HANDLING
N Give before meals. N Do not crush, chew, split tablet; swallow whole.
INDICATIONS/ROUTES/DOSAGE
GASTROESOPHAGEAL REFLUX DISEASE
DUODENAL ULCER
NSAID-INDUCED ULCER
PATHOLOGIC HYPERSECRETORY CONDITIONS
H. PYLORI INFECTION
SIDE EFFECTS
RARE (less than 2%): Headache, nausea, dizziness, rash, diarrhea, malaise.
ADVERSE REACTIONS/TOXIC EFFECTS
Hyperglycemia, hypokalemia, hyponatremia, and hyperlipemia occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Obtain baseline lab values, especially serum chemistries.
INTERVENTION/EVALUATION
Monitor ongoing laboratory results. Evaluate for therapeutic response (i.e., relief of GI symptoms). Question if GI discomfort, nausea, diarrhea, headache occurs. Assess skin for evidence of rash. Observe for evidence of dizziness; utilize appropriate safety precautions.
PATIENT/FAMILY TEACHING
N Swallow tablets whole; do not chew, split, crush tablets. N Report headache.
raloxifene
ra-lox-i-feen
(Evista)
Do not confuse raloxifene with propoxyphene.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Selective estrogen receptor modulator. CLINICAL: Osteoporosis preventive.
ACTION
A selective estrogen receptor modulator that affects some receptors like estrogen. Therapeutic Effect: Like estrogen, prevents bone loss and improves lipid profiles.
PHARMACOKINETICS
Rapidly absorbed after PO administration. Highly bound to plasma proteins (greater than 95%) and albumin. Undergoes extensive first-pass metabolism in liver. Excreted mainly in feces and, to a lesser extent, in urine. Unknown if removed by hemodialysis. Half-life: 27.7 hr.
USES
Prevention and treatment of osteoporosis in postmenopausal women. OFF-LABEL: Prevention of fractures, treatment of breast cancer in postmenopausal women.
PRECAUTIONS
CONTRAINDICATIONS: Active or history of venous thromboembolic events, such as deep vein thrombosis (DVT), pulmonary embolism, and retinal vein thrombosis; women who are or may become pregnant. CAUTIONS: Cardiovascular disease, history of cervical or uterine cancer, renal or hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if distributed in breast milk. Not recommended for breast-feeding mothers. Pregnancy Category X. Children: Not used in this population. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Ampicillin, cholestyramine: Reduce raloxifene absorption. Hormone replacement therapy, systemic estrogen: Don't use raloxifene concurrently with these drugs. Warfarin: May decrease PT and the effects of warfarin. HERBAL: None known. FOOD: None known. LAB VALUES: Lowers serum total cholesterol and LDL levels, but does not affect HDL or triglyceride levels. Slightly decreases platelet count and serum inorganic phosphate, albumin, calcium, and protein levels.
AVAILABILITY (Rx)
TABLETS: 60 mg.
ADMINISTRATION/HANDLING
N Give at any time of day without regard to meals.
INDICATIONS/ROUTES/DOSAGE
PREVENTION OR TREATMENT OF OSTEOPOROSIS
SIDE EFFECTS
FREQUENT (25%U10%): Hot flashes, flu-like symptoms, arthralgia, sinusitis. OCCASIONAL (9%U5%): Weight gain, nausea, myalgia, pharyngitis, cough, dyspepsia, leg cramps, rash, depression. RARE (4%U3%): Vaginitis, UTI, peripheral edema, flatulence, vomiting, fever, migraine, diaphoresis.
ADVERSE REACTIONS/TOXIC EFFECTS
Pneumonia, gastroenteritis, chest pain, vaginal bleeding, and breast pain occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Question for possibility of pregnancy (Pregnancy Category X). Drug should be discontinued 72 hr before and during prolonged immobilization (postop recovery, prolonged bed rest). Therapy may be resumed only after patient is fully ambulatory. Determine serum total and LDL cholesterol levels before therapy and routinely thereafter.
INTERVENTION/EVALUATION
Monitor serum total and LDL cholesterol, total calcium, inorganic phosphate, total protein, albumin, bone mineral density, platelet count.
PATIENT/FAMILY TEACHING
N Avoid prolonged restriction of movement during travel (increased risk of venous thromboembolic events). N Take supplemental calcium, vitamin D if daily dietary intake is inadequate. N Encourage regular exercise. N Recommend modification and discontinuation of cigarette smoking, alcohol consumption.
ramelteon
rah-mel-tea-on
(Rozerem)
Do not confuse Rozerem with Razadyne.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Melatonin receptor agonist. CLINICAL: Hypnotic.
ACTION
A nonscheduled sleep medication; no evidence of abuse or dependence. Selectively targets melatonin receptors, thought to be involved in the maintenance of the circadian rhythm underlying the normal sleep-wake cycle. Therapeutic Effect: Prevents insomnia characterized by difficulty with sleep onset.
PHARMACOKINETICS
Rapidly absorbed following PO administration. Protein binding: 82%. Substantial tissue distribution. Metabolized in the liver. Excreted mainly in urine with a small amount eliminated in the feces. Half-life: 2U5 hr.
USES
Long-term treatment of insomnia in patients who experience difficulty with sleep onset.
PRECAUTIONS
CONTRAINDICATIONS: Severe hepatic impairment, concurrent fluvoxamine therapy. CAUTIONS: Clinical depression, alcohol consumption, moderate hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if distributed in breast milk; breast-feeding not recommended. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: Age-related hepatic impairment may require dosage adjustment.
INTERACTIONS
DRUG: Alcohol: Concurrent use with ramelteon produces additive effect. Fluconazole, ketoconazole: May increase the serum levels, effects of ramelteon. Fluvoxamine: May cause severe increase in ramelteon serum level, toxicity. Rifampin: May decrease the levels and effects of ramelteon. HERBAL: None known. FOOD: Heavy meals: The onset of action may be reduced if taken with or immediately after a heavy meal. LAB VALUES: May decrease testosterone levels. May increase prolactin levels.
AVAILABILITY (Rx)
TABLETS, FILM-COATED: 8 mg (Rozerem).
ADMINISTRATION/HANDLING
N Should be administered within 30 min before bedtime. N Do not give with, or immediately following, a high-fat meal. N Do not crush or break tablet.
INDICATIONS/ROUTES/DOSAGE
INSOMNIA
SIDE EFFECTS
FREQUENT (7%U5%): Headache, dizziness, somnolence. OCCASIONAL (4%U3%): Fatigue, nausea, exacerbated insomnia. RARE (2%): Diarrhea, myalgia, depression, altered taste sensation, arthralgia.
ADVERSE REACTIONS/TOXIC EFFECTS
There is an association with an effect on reproductive hormones in adults, e.g. decreased testosterone levels and increased prolactin levels resulting in unexplained amenorrhea, galactorrhea, decreased libido, or problems with fertility.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Assess BP, pulse, respirations. Raise bed rails, provide call light. Provide environment conducive to sleep (quiet environment, low or no lighting, TV off).
INTERVENTION/EVALUATION
Assess sleep pattern of patient. Evaluate for therapeutic response: rapid induction of sleep onset, decrease in number of nocturnal awakenings.
PATIENT/FAMILY TEACHING
N Take within 30 min before going to bed and confine activities to those necessary to prepare for bed. N Avoid engaging in any hazardous activities after taking medication. N Do not take medication with or immediately after a high fat meal.
ramipril
ram-i-pril
(Altace)
Do not confuse Altace with Alteplase or Artane.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Renin-angiotensin system antagonist. CLINICAL: Antihypertensive.
ACTION
An angiotensin-converting enzyme (ACE) inhibitor that suppresses the renin-angiotensin-aldosterone system. Decreases plasma angiotensin II, increases plasma renin activity, and decreases aldosterone secretion. Therapeutic Effect: Reduces peripheral arterial resistance and BP.
PHARMACOKINETICS
Route Onset Peak Duration
Well absorbed from the GI tract. Protein binding: 73%. Metabolized in the liver to active metabolite. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 5.1 hr.
USES
Treatment of hypertension. Used alone or in combination with other antihypertensives. Treatment of CHF. Prevention of heart attack, stroke. OFF-LABEL: Treatment of hypertension and renal crisis in scleroderma.
PRECAUTIONS
CONTRAINDICATIONS: Bilateral renal artery stenosis. CAUTIONS: Renal impairment, CHF, collagen vascular disease, hypovolemia, renal stenosis, hyperkalemia.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Distributed in breast milk. May cause fetal or neonatal mortality or morbidity. Pregnancy Category C (D if used in second or third trimester). Children: Safety and efficacy not established. Elderly: May be more sensitive to hypotensive effects.
INTERACTIONS
DRUG: Alcohol, antihypertensives, diuretics: May increase the effects of ramipril. Lithium: May increase lithium blood concentration and risk of lithium toxicity. NSAIDs: May decrease the effects of ramipril. Potassium-sparing diuretics, potassium supplements: May cause hyperkalemia. HERBAL: Garlic: May increase antihypertensive effect. Ginseng, yohimbe: May worsen hypertension. FOOD: None known. LAB VALUES: May increase BUN, serum alkaline phosphatase, serum bilirubin, serum creatinine, serum potassium, AST, and ALT levels. May decrease serum sodium levels. May cause positive antinuclear antibody titer.
AVAILABILITY (Rx)
CAPSULES: 1.25 mg, 2.5 mg, 5 mg, 10 mg.
ADMINISTRATION/HANDLING
N Give without regard to food. N Do not chew or break capsules. N May mix with water, apple juice or sauce.
INDICATIONS/ROUTES/DOSAGE
HYPERTENSION (MONOTHERAPY)
HYPERTENSION (IN COMBINATION WITH OTHER ANTIHYPERTENSIVES)
CHF
RISK REDUCTION FOR MI STROKE
DOSAGE IN RENAL IMPAIRMENT
CREATININE CLEARANCE EQUAL TO OR LESS THAN 40 ml/min: 25% of normal dose.
HYPERTENSION: Initially, 1.25 mg/day titrated upward.
CHF: Initially, 1.25 mg/day, titrated up to 2.5 mg twice a day.
SIDE EFFECTS
FREQUENT (12%U5%): Cough, headache. OCCASIONAL (4%U2%): Dizziness, fatigue, nausea, asthenia (loss of strength). RARE (less than 2%): Palpitations, insomnia, nervousness, malaise, abdominal pain, myalgia.
ADVERSE REACTIONS/TOXIC EFFECTS
Excessive hypotension ("first-dose syncope") may occur in patients with CHF and in those who are severely salt or volume depleted. Angioedema and hyperkalemia occur rarely. Agranulocytosis and neutropenia may be noted in those with collagen vascular disease, including scleroderma and systemic lupus erythematosus, and impaired renal function. Nephrotic syndrome may be noted in those with history of renal disease.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Obtain BP immediately before each dose, in addition to regular monitoring (be alert to fluctuations). If excessive reduction in BP occurs, place patient in supine position with legs elevated. Renal function tests should be performed before beginning therapy. In patients with prior renal disease, urine test for protein (by dipstick method) should be made with first urine of day before beginning therapy and periodically thereafter. In those with renal impairment, autoimmune disease, or taking drugs that affect leukocytes or immune response, CBC, differential count should be performed before beginning therapy and q2wk for 3 mo, then periodically thereafter.
INTERVENTION/EVALUATION
Monitor renal function, serum potassium, WBC. Assess for cough (frequent effect). Assist with ambulation if dizziness occurs. Assess lung sounds for rales, wheezing in patients with CHF. Monitor urinalysis for proteinuria. Monitor serum potassium levels in those on concurrent diuretic therapy.
PATIENT/FAMILY TEACHING
N Do not discontinue medication without physician approval. N Report palpitations, cough, chest pain. N Dizziness, lightheadedness may occur in the first few days. N Avoid tasks that require alertness, motor skills until response to drug is established.
ranitidine hydrochloride H
(Apo-Ranitidine J, Novo-Ranitidine J, Zantac, Zantac-75, Zantac-150, Zantac-300, Zantac EFFERdose, Zantac-25 EFFERdose, Zantac-150 EFFERdose, Zantac-150 Maximum Strength)
ranitidine bismuth citrate
ra-ni-ti-deen
(Tritec)
Do not confuse Zantac with Xanax, Ziac, or Zyrtec.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Histamine H2 receptor antagonist. CLINICAL: Antiulcer.
ACTION
An antiulcer agent that inhibits histamine action at histamine 2 receptors of gastric parietal cells. Therapeutic Effect: Inhibits gastric acid secretion when fasting, at night, or when stimulated by food, caffeine, or insulin. Reduces volume and hydrogen ion concentration of gastric juice.
PHARMACOKINETICS
Rapidly absorbed from the GI tract. Protein binding: 15%. Widely distributed. Metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: PO , 2.5 hr; IV, 2U2.5 hr (increased with impaired renal function).
USES
Short-term treatment of active duodenal ulcer. Prevention of duodenal ulcer recurrence. Treatment of active benign gastric ulcer, pathologic GI hypersecretory conditions, acute gastroesophageal reflux disease (GERD), including erosive esophagitis. Maintenance of healed erosive esophagitis. Part of regimen for H. pylori eradication to reduce risk of duodenal ulcer recurrence. OTC: Relieve heartburn, acid indigestion, sour stomach. OFF-LABEL: Prevention of aspiration pneumonia, treatment of recurrent postop ulcer, upper GI bleeding, prevention of acid aspiration pneumonitis during surgery, prevention of stress-induced ulcers.
PRECAUTIONS
CONTRAINDICATIONS: History of acute porphyria. CAUTIONS: Renal/hepatic impairment, elderly.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category B. Children: No age-related precautions noted. Elderly: Confusion more likely in patients with hepatic/renal impairment.
INTERACTIONS
DRUG: Antacids: May decrease the absorption of ranitidine. Ketoconazole: May decrease the absorption of ketoconazole. HERBAL: None known. FOOD: None known. LAB VALUES: Interferes with skin tests using allergen extracts. May increase hepatic function enzyme, gamma-glutamyl transpeptidase, and serum creatinine levels.
AVAILABILITY (Rx)
TABLETS (EFFERVESCENT): 25 mg (Zantac-25 EFFERdose), 150 mg (Zantac-150 EFFERdose). CAPSULES (ZANTAC): 150 mg, 300 mg. GRANULES (ZANTAC EFFERDOSE): 150 mg. SYRUP (ZANTAC): 15 mg/ml. TABLETS (HYDROCHLORIDE): 75 mg (Zantac-75 [OTC]), 150 mg (Zantac-150, Zantac-150 Maximum Strength), 300 mg (Zantac-300). TABLETS (BISUMUTH CITRATE [TRITEC]): 400 mg. INJECTION (ZANTAC): 25 mg/ml.
ADMINISTRATION/HANDLING
L IV
Reconstitution N For IV push, dilute each 50 mg with 20 ml 0.9% NaCl, D5W. N For intermittent IV infusion (piggyback), dilute each 50 mg with 50 ml 0.9% NaCl, D5W. N For IV infusion, dilute with 250U1,000 ml 0.9% NaCl, D5W.
Rate of administration N Administer IV push over minimum of 5 min (prevents arrhythmias, hypotension). N Infuse IV piggyback over 15U20 min. N Infuse IV infusion over 24 hr.
Storage N IV solutions appear clear, colorless to yellow (slight darkening does not affect potency). N IV infusion (piggyback) is stable for 48 hr at room temperature (discard if discolored or precipitate forms).
IM
N May be given undiluted. N Give deep IM into large muscle mass.
N Give without regard to meals. Best given after meals or at bedtime. N Do not administer within 1 hr of magnesium- or aluminum-containing antacids (decreases absorption by 33%).
IV INCOMPATIBILITIES
Amphotericin B complex (Abelcet, AmBisome, Amphotec).
IV COMPATIBILITIES
Diltiazem (Cardizem), dobutamine (Dobutrex), dopamine (Intropin), heparin, hydromorphone (Dilaudid), insulin, lidocaine, lorazepam (Ativan), morphine, norepinephrine (Levophed), potassium chloride, propofol (Diprivan).
INDICATIONS/ROUTES/DOSAGE
DUODENAL ULCERS, GASTRIC ULCERS, GERD
DUODENAL ULCERS ASSOCIATED WITH H. PYLORI INFECTION
EROSIVE ESOPHAGITIS
HYPERSECRETORY CONDITIONS
OTC USE
USUAL PARENTERAL DOSAGE
IV, IM: ADULTS, ELDERLY: 50 mg/dose q6U8h. Maximum: 400 mg/day. CHILDREN: 2U4 mg/kg/day in divided doses q6U8h. Maximum: 200 mg/day.
USUAL NEONATAL DOSAGE
IV: NEONATES: Initially, 1.5 mg/kg/dose; then 1.5U2 mg/kg/day in divided doses q12h.
DOSAGE IN RENAL IMPAIRMENT
For patients with creatinine clearance less than 50 ml/min, give 150 mg PO q24h or 50 mg IV or IM q18U24h.
SIDE EFFECTS
OCCASIONAL (2%): Diarrhea. RARE (1%): Constipation, headache (may be severe).
ADVERSE REACTIONS/TOXIC EFFECTS
Reversible hepatitis and blood dyscrasias occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Obtain baseline liver/renal function tests.
INTERVENTION/EVALUATION
Monitor serum AST, ALT levels. Assess mental status in elderly.
PATIENT/FAMILY TEACHING
N Smoking decreases effectiveness of medication. N Do not take medicine within 1 hr of magnesium- or aluminum-containing antacids. N Transient burning/itching may occur with IV administration. N Report headache. N Avoid alcohol, aspirin.
ribavirin
rye-ba-vye rin
(Copegus, Rebetol, Rebetron, Virazole)
Do not confuse ribavirin with riboflavin.
FIXED-COMBINATION(S)
With interferon, alfa 2b (Rebetron). Individually packaged.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Synthetic nucleoside. CLINICAL: Antiviral.
ACTION
A synthetic nucleoside that inhibits influenza virus RNA polymerase activity and interferes with expression of messenger RNA. Therapeutic Effect: Inhibits viral protein synthesis and replication of viral RNA and DNA.
USES
Inhalation: Treatment of respiratory syncytial virus (RSV) infections (especially in patients with underlying compromising conditions such as chronic lung disorders, congenital heart disease, recent transplant recipients). Capsule/Tablet/Oral Solution: Treatment of chronic hepatitis C in patients with compensated hepatic disease. OFF-LABEL: Treatment of influenza A or B and west Nile virus.
PRECAUTIONS
CONTRAINDICATIONS: Autoimmune hepatitis, creatinine clearance less than 50 ml/min, hemoglobinopathies, hepatic decompensation, hypersensitivity to ribavirin products, pregnancy, significant or unstable cardiac disease, women of childbearing age who won't use contraception reliably. CAUTIONS: Inhalation: Patients requiring assisted ventilation, chronic obstructive pulmonary disease (COPD), asthma. Oral: Cardiac, pulmonary disease, elderly, history of psychiatric disorders. Pregnancy Category X.
INTERACTIONS
DRUG: Didanosine: May increase the risk of pancreatitis and peripheral neuropathy and decrease the effects of didanosine. Nucleoside analogues (including adefovir, didanosine, lamivudine, stavudine, zalcitabine, zidovudine): May increase the risk of lactic acidosis. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
CAPSULES (REBETOL, REBETRON COMBINATION THERAPY WITH ALFA-2B INJECTION): 200 mg. TABLETS (CEPEGUS): 200 mg. POWDER FOR RECONSTITUTION (AEROSOL [VIRAZOLE]): 6 g. ORAL SOLUTION (REBETOL): 40 mg/ml.
ADMINISTRATION/HANDLING
N Store Rebetron combination package in the refrigerator. Store oral solution in the refrigerator or at room temperature. N Capsules may be taken without regard to food. N Tablets should be given with food.
INHALATION
O ALERT P May be given via nasal or oral inhalation.
N Solution appears clear and colorless, is stable for 24 hr at room temperature. N Discard solution for nebulization after 24 hr. N Discard solution if discolored or cloudy. N Add 50U100 ml sterile water for injection or inhalation to 6-g vial. N Transfer to a flask, serving as reservoir for aerosol generator. N Further dilute to final volume of 300 ml, giving a solution concentration of 20 mg/ml. N Use only aerosol generator available from manufacturer of drug. N Do not give concomitantly with other drug solutions for nebulization. N Discard reservoir solution when fluid levels are low and at least q24h. N Controversy over safety in ventilator-dependent patients; only experienced personnel should administer drug.
INDICATIONS/ROUTES/DOSAGE
CHRONIC HEPATITIS C
SEVERE LOWER RESPIRATORY TRACT INFECTION CAUSED BY RSV
INHALATION: CHILDREN, INFANTS: Use with Viratek small-particle aerosol generator at a concentration of 20 mg/ml (6 g reconstituted with 300 ml sterile water) over 12U18 hr/day for 3U7 days.
SIDE EFFECTS
FREQUENT (greater than 10%): Dizziness, headache, fatigue, fever, insomnia, irritability, depression, emotional lability, impaired concentration, alopecia, rash, pruritus, nausea, anorexia, dyspepsia, vomiting, decreased hemoglobin, hemolysis, arthralgia, musculoskeletal pain, dyspnea, sinusitis, flu-like symptoms. OCCASIONAL (1%U10%): Nervousness, altered taste, weakness.
ADVERSE REACTIONS/TOXIC EFFECTS.
Cardiac arrest, apnea and ventilator dependence, bacterial pneumonia, pneumonia, and pneumothorax occur rarely. Anemia may occur if ribavirin therapy exceeds 7 days.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Obtain sputum specimens before giving first dose or at least during first 24 hr of therapy. Assess respiratory status for baseline. Oral: CBC with differential, pretreatment and monthly pregnancy test for women of childbearing age.
INTERVENTION/EVALUATION
Monitor I&O, fluid balance carefully. Check hematology reports for anemia due to reticulocytosis when therapy exceeds 7 days. For ventilator-assisted patients, watch for ‘‘rainout’’ in tubing and empty frequently; be alert to impaired ventilation/gas exchange due to drug precipitate. Assess skin for rash. Monitor BP, respirations; assess lung sounds.
PATIENT/FAMILY TEACHING
N Report immediately any difficulty breathing, itching/swelling/redness of eyes. N Educate females about prevention of pregnancy and need for pregnancy testing. N Educate males about protection of female partners from pregnancy.
rifaximin
rye-fax-ih-min
(Xifaxan)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Anti-infective. CLINICAL: Site-specific antibiotic.
ACTION
An anti-infective that inhibits bacterial RNA synthesis by binding to a subunit of bacterial DNA-dependent RNA polymerase. Therapeutic Effect: Bactericidal.
PHARMACOKINETICS
Less than 0.4% absorbed after PO administration. Primarily eliminated in feces; minimal excretion in urine. Half-life: 5.85 hr.
USES
Treatment of traveler's diarrhea caused by noninvasive strains of E. Coli. OFF-LABEL: Treatment of hepatic encephalopathy.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to other rifamycin antibiotics. CAUTIONS: Pseudomembranous colitis.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug is excreted in breast milk. Pregnancy Category C. Children: Safety and efficacy not established in children younger than 12 yr. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
TABLETS: 200 mg.
ADMINISTRATION/HANDLING
N Give without regard to food. N Store at room temperature. N Do not break or crush film-coated tablets.
INDICATIONS/ROUTES/DOSAGE
TRAVELER'S DIARRHEA
HEPATIC ENCEPHALOPATHY
SIDE EFFECTS
OCCASIONAL (11%U5%): Flatulence, headache, abdominal discomfort, rectal tenesmus, defecation urgency, nausea. RARE (4%U2%): Constipation, fever, vomiting.
ADVERSE REACTIONS/TOXIC EFFECTS
Hypersensitivity reactions, including dermatitis, angioneurotic edema, pruritus, rash, and urticaria may occur. Superinfection occurs rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Check baseline hydration status: skin turgor, mucous membranes for dryness, urinary status.
INTERVENTION/EVALUATION
Encourage adequate fluid intake. Assess bowel sounds for peristalsis. Monitor pattern of bowel activity and stool consistency. Assess for GI disturbances.
PATIENT/FAMILY TEACHING
N Notify physician if diarrhea worsens or within 48 hr, blood occurs in the stool, or fever develops.
risedronate sodium
rize-droe-nate
(Actonel)
FIXED-COMBINATION(S)
Actonel with Calcium: Risedronate/Calcium: 35 mg/6 x 500 mg.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Bisphosphonate. CLINICAL: Calcium regulator.
ACTION
A bisphosphonate that binds to bone hydroxyapatite and inhibits osteoclasts. Therapeutic Effect: Reduces bone turnover (the number of sites at which bone is remodeled) and bone resorption.
PHARMACOKINETICS
Rapidly absorbed following PO administration. Bioavailability is decreased when administered with food. Protein binding: 24%. Not metabolized. Excreted unchanged in urine and feces. Not removed by hemodialysis. Half-life: 1.5 hr (initial); 480 hr (terminal).
USES
Treatment of Paget's disease of bone (osteitis deformans). Treatment/prophylaxis for postmenopausal, glucocorticoid-induced osteoporosis.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to other bisphosphonates, including etidronate, tiludronate, risedronate, and alendronate; hypocalcemia; inability to stand or sit upright for at least 20 minutes; renal impairment when serum creatinine clearance is greater than 5 mg/dl. CAUTIONS: GI diseases (duodenitis, dysphagia, esophagitis, gastritis, ulcers [drug may exacerbate these conditions]), severe renal impairment. Pregnancy Category C.
INTERACTIONS
DRUG: Antacids containing aluminum, calcium, magnesium; vitamin D: May decrease the absorption of risedronate. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
TABLETS: 5 mg, 30 mg, 35 mg.
ADMINISTRATION/HANDLING
N Administer 30U60 min before taking any food, drink, other medications orally to avoid interference with absorption. N Take on empty stomach with full glass of water (not mineral water). N Avoid lying down for 30 min after swallowing tablet (assists with delivery to stomach, reduces risk of esophageal irritation).
INDICATIONS/ROUTES/DOSAGE
PAGET'S DISEASE
PREVENTION AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS
GLUCOCORTICOID-INDUCED OSTEOPOROSIS
SIDE EFFECTS
FREQUENT (30%): Arthralgia. OCCASIONAL (12%U8%): Rash, flu-like symptoms, peripheral edema. RARE (5%U3%): Bone pain, sinusitis, asthenia, dry eye, tinnitus.
ADVERSE REACTIONS/TOXIC EFFECTS
Overdose causes hypocalcemia, hypophosphatemia, and significant GI disturbances.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Hypocalcemia, vitamin D deficiency must be corrected before therapy. Obtain lab baselines, especially serum electrolytes, renal function.
INTERVENTION/EVALUATION
Check serum electrolytes (especially calcium, alkaline phosphatase levels). Monitor I&O, BUN, creatinine in patients with renal impairment.
PATIENT/FAMILY TEACHING
N Instruct patient that expected benefits occur only when medication is taken with full glass (6U8 oz) of plain water, first thing in the morning and at least 30 min before first food, beverage, medication of the day. Any other beverage (mineral water, orange juice, coffee) significantly reduces absorption of medication. N Do not lie down for at least 30 min after taking medication (potentiates delivery to stomach, reduces risk of esophageal irritation). N Consider weight-bearing exercises, modify behavioral factors (e.g., cigarette smoking, alcohol consumption).
risperidone
ris-per-i-done
(Risperdal, Risperdal Consta, Risperdol M-Tabs)
Do not confuse risperidone with reserpine.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Benzisoxazole derivative. CLINICAL: Antipsychotic.
ACTION
A benzisoxazole derivative that may antagonize dopamine and serotonin receptors. Therapeutic Effect: Suppresses psychotic behavior.
PHARMACOKINETICS
Well absorbed from the GI tract; unaffected by food. Protein binding: 90%. Extensively metabolized in the liver to active metabolite. Primarily excreted in urine. Half-life: 3U20 hr; metabolite: 21U30 hr (increased in elderly).
USES
Management of manifestations of psychotic disorders (e.g., schizophrenia). Treatment of acute mania associated with bipolar disorder. OFF-LABEL: Autism in children, behavioral symptoms associated with dementia, Tourette's disorder.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Renal or hepatic impairment, seizure disorders, cardiac disease, recent MI, breast cancer, suicidal patients, those at risk for aspiration pneumonia. May increase risk of stroke in patients with dementia. May increase risk of hyperglycemia.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is excreted in breast milk. Recommend against breast-feeding. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: More susceptible to postural hypotension. Age-related renal or hepatic impairment may require dosage adjustment.
INTERACTIONS
DRUG: Alcohol, other CNS depressants: May increase CNS depression. Carbamazepine: May decrease the risperidone blood concentration. Clozapine: May increase the risperidone blood concentration. Dopamine agonists, levodopa: May decrease the effects of these drugs. Paroxetine: May increase the risperidone blood concentration and the risk of extrapyramidal symptoms. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum prolactin, creatinine, alkaline phosphatase, uric acid, AST, ALT, and triglyceride levels. May increase blood glucose, decrease serum potassium, protein, and sodium levels. May cause EKG changes.
AVAILABILITY (Rx)
ORAL SOLUTION (RISPERDAL) 1 mg/ml. TABLETS (RISPERDAL): 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg. TABLETS (ORALLY-DISINTEGRATING [RISPERDAL M-TABS]): 0.5 mg, 1 mg, 2 mg. INJECTION (RISPERDAL CONSTA): 25 mg, 37.5 mg, 50 mg.
ADMINISTRATION/HANDLING
O ALERT P Do not administer risperidone via IV route.
IM
Reconstitution N Use only the diluent and needle supplied in the dose pack. N All the components in the dose pack are required for administration. Don’t substitute any components. N Prepare the suspension according to the manufacturer's directions. N The drug may be given up to 6 hr after reconstitution, but immediate administration is recommended. N If 2 min pass before the injection, reconstitute the solution by shaking the upright vial vigorously back and forth for as long as it takes to resuspend the microspheres.
Rate of administration: N Inject the drug IM into the upper outer quadrant of the gluteus maximus.
Storage: N Store the drug below 77°F (25°C) once it is in suspension.
N Give without regard to food. N May mix oral solution with water, coffee, orange juice, low-fat milk. Do not mix with cola, tea.
INDICATIONS/ROUTES/DOSAGE
PSYCHOTIC DISORDER
IM: ADULTS, ELDERLY: 25 mg q2wk. Maximum: 50 mg q2wk.
MANIA
DOSAGE IN RENAL IMPAIRMENT
Initial dosage for adults and elderly patients is 0.25U0.5 mg twice a day. Dosage is titrated slowly to desired effect.
SIDE EFFECTS
FREQUENT (26%U13%): Agitation, anxiety, insomnia, headache, constipation. OCCASIONAL (10%U4%): Dyspepsia, rhinitis, somnolence, dizziness, nausea, vomiting, rash, abdominal pain, dry skin, tachycardia. RARE (3%U2%): Visual disturbances, fever, back pain, pharyngitis, cough, arthralgia, angina, aggressive behavior, orthostatic hypotension, breast swelling.
ADVERSE REACTIONS/TOXIC EFFECTS
Rare reactions include tardive dyskinesia (characterized by tongue protrusion, puffing of the cheeks, and chewing or puckering of the mouth) and neuroleptic malignant syndrome (marked by hyperpyrexia, muscle rigidity, change in mental status, irregular pulse or BP, tachycardia, diaphoresis, cardiac arrhythmias, rhabdomyolysis, and acute renal failure). Hyperglycemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Serum renal and liver function tests should be performed before therapy. Assess behavior, appearance, emotional status, response to environment, speech pattern, thought content. Obtain fasting blood glucose value.
INTERVENTION/EVALUATION
Monitor BP, heart rate, weight, liver function tests, EKG. Monitor for fine tongue movement (may be first sign of tardive dyskinesia, which may be irreversible). Supervise suicidal-risk patient closely during early therapy (as depression lessens, energy level improves, increasing suicide potential). Assess for therapeutic response (greater interest in surroundings, improved self-care, increased ability to concentrate, relaxed facial expression). Monitor for potential neuroleptic malignant syndrome: fever, muscle rigidity, irregular BP or pulse, altered mental status. Monitor fasting blood glucose periodically during therapy.
PATIENT/FAMILY TEACHING
N Avoid tasks that may require alertness, motor skills until response to drug is established (may cause dizziness/drowsiness). N Avoid alcohol. N Use caution when changing position from lying or sitting to standing. N Inform physician of trembling in fingers, altered gait, unusual muscle or skeletal movements, palpitations, severe dizziness/fainting, swelling or pain in breasts, visual changes, rash, difficulty in breathing.
risperidone
ris-per-i-done
(Risperdal, Risperdal Consta, Risperdol M-Tabs)
Do not confuse risperidone with reserpine.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Benzisoxazole derivative. CLINICAL: Antipsychotic.
ACTION
A benzisoxazole derivative that may antagonize dopamine and serotonin receptors. Therapeutic Effect: Suppresses psychotic behavior.
PHARMACOKINETICS
Well absorbed from the GI tract; unaffected by food. Protein binding: 90%. Extensively metabolized in the liver to active metabolite. Primarily excreted in urine. Half-life: 3U20 hr; metabolite: 21U30 hr (increased in elderly).
USES
Management of manifestations of psychotic disorders (e.g., schizophrenia). Treatment of acute mania associated with bipolar disorder. OFF-LABEL: Autism in children, behavioral symptoms associated with dementia, Tourette's disorder.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Renal or hepatic impairment, seizure disorders, cardiac disease, recent MI, breast cancer, suicidal patients, those at risk for aspiration pneumonia. May increase risk of stroke in patients with dementia. May increase risk of hyperglycemia.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is excreted in breast milk. Recommend against breast-feeding. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: More susceptible to postural hypotension. Age-related renal or hepatic impairment may require dosage adjustment.
INTERACTIONS
DRUG: Alcohol, other CNS depressants: May increase CNS depression. Carbamazepine: May decrease the risperidone blood concentration. Clozapine: May increase the risperidone blood concentration. Dopamine agonists, levodopa: May decrease the effects of these drugs. Paroxetine: May increase the risperidone blood concentration and the risk of extrapyramidal symptoms. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum prolactin, creatinine, alkaline phosphatase, uric acid, AST, ALT, and triglyceride levels. May increase blood glucose, decrease serum potassium, protein, and sodium levels. May cause EKG changes.
AVAILABILITY (Rx)
ORAL SOLUTION (RISPERDAL) 1 mg/ml. TABLETS (RISPERDAL): 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg. TABLETS (ORALLY-DISINTEGRATING [RISPERDAL M-TABS]): 0.5 mg, 1 mg, 2 mg. INJECTION (RISPERDAL CONSTA): 25 mg, 37.5 mg, 50 mg.
ADMINISTRATION/HANDLING
O ALERT P Do not administer risperidone via IV route.
IM
Reconstitution N Use only the diluent and needle supplied in the dose pack. N All the components in the dose pack are required for administration. Don’t substitute any components. N Prepare the suspension according to the manufacturer's directions. N The drug may be given up to 6 hr after reconstitution, but immediate administration is recommended. N If 2 min pass before the injection, reconstitute the solution by shaking the upright vial vigorously back and forth for as long as it takes to resuspend the microspheres.
Rate of administration: N Inject the drug IM into the upper outer quadrant of the gluteus maximus.
Storage: N Store the drug below 77°F (25°C) once it is in suspension.
N Give without regard to food. N May mix oral solution with water, coffee, orange juice, low-fat milk. Do not mix with cola, tea.
INDICATIONS/ROUTES/DOSAGE
PSYCHOTIC DISORDER
IM: ADULTS, ELDERLY: 25 mg q2wk. Maximum: 50 mg q2wk.
MANIA
DOSAGE IN RENAL IMPAIRMENT
Initial dosage for adults and elderly patients is 0.25U0.5 mg twice a day. Dosage is titrated slowly to desired effect.
SIDE EFFECTS
FREQUENT (26%U13%): Agitation, anxiety, insomnia, headache, constipation. OCCASIONAL (10%U4%): Dyspepsia, rhinitis, somnolence, dizziness, nausea, vomiting, rash, abdominal pain, dry skin, tachycardia. RARE (3%U2%): Visual disturbances, fever, back pain, pharyngitis, cough, arthralgia, angina, aggressive behavior, orthostatic hypotension, breast swelling.
ADVERSE REACTIONS/TOXIC EFFECTS
Rare reactions include tardive dyskinesia (characterized by tongue protrusion, puffing of the cheeks, and chewing or puckering of the mouth) and neuroleptic malignant syndrome (marked by hyperpyrexia, muscle rigidity, change in mental status, irregular pulse or BP, tachycardia, diaphoresis, cardiac arrhythmias, rhabdomyolysis, and acute renal failure). Hyperglycemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Serum renal and liver function tests should be performed before therapy. Assess behavior, appearance, emotional status, response to environment, speech pattern, thought content. Obtain fasting blood glucose value.
INTERVENTION/EVALUATION
Monitor BP, heart rate, weight, liver function tests, EKG. Monitor for fine tongue movement (may be first sign of tardive dyskinesia, which may be irreversible). Supervise suicidal-risk patient closely during early therapy (as depression lessens, energy level improves, increasing suicide potential). Assess for therapeutic response (greater interest in surroundings, improved self-care, increased ability to concentrate, relaxed facial expression). Monitor for potential neuroleptic malignant syndrome: fever, muscle rigidity, irregular BP or pulse, altered mental status. Monitor fasting blood glucose periodically during therapy.
PATIENT/FAMILY TEACHING
N Avoid tasks that may require alertness, motor skills until response to drug is established (may cause dizziness/drowsiness). N Avoid alcohol. N Use caution when changing position from lying or sitting to standing. N Inform physician of trembling in fingers, altered gait, unusual muscle or skeletal movements, palpitations, severe dizziness/fainting, swelling or pain in breasts, visual changes, rash, difficulty in breathing.
ritonavir
ri-tone-a-veer
(Norvir, Norvisec J)
Do not confuse ritonavir with Retrovir.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Protease inhibitor. CLINICAL: Antiviral.
ACTION
Inhibits HIV-1 and HIV-2 proteases, rendering these enzymes incapable of processing the polypeptide precursors; this results in the production of noninfectious, immature HIV particles. Therapeutic Effect: Impedes HIV replication, slowing the progression of HIV infection.
PHARMACOKINETICS
Well absorbed after PO administration (absorption increased with food). Protein binding: 98%U99%. Extensively metabolized in the liver to active metabolite. Primarily eliminated in feces. Unknown if removed by hemodialysis. Half-life: 2.7U5 hr.
USES
Treatment of HIV infection in combination with other antiretroviral agents.
PRECAUTIONS
CONTRAINDICATIONS: Concurrent use of amiodarone, astemizole, bepridil, bupropion, cisapride, clozapine, encainide, flecainide, meperidine, piroxicam, propafenone, propoxyphene, quinidine, rifabutin, or terfenadine (increased risk of serious or life-threatening drug interactions, such as arrhythmias, hematologic abnormalities, and seizures); concurrent use of alprazolam, clorazepate, diazepam, estazolam, flurazepam, midazolam, triazolam, or zolpidem (may produce extreme sedation and respiratory depression). CAUTIONS: Hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Breast-feeding not recommended (possibility of HIV transmission). Pregnancy Category B. Children: No age-related precautions noted in those older than 2 yr. Elderly: None known.
INTERACTIONS
DRUG: Desipramine, fluoxetine, other antidepressants: May increase the blood concentration of these drugs. Disulfiram, drugs causing disulfiram-like reaction (such as metronidazole): May produce a disulfiram-like reaction. Enzyme inducers (including carbamazepine, dexamethasone, nevirapine, phenobarbital, phenytoin, rifabutin, rifampin): May increase the metabolism and decrease the efficacy of ritonavir. Oral contraceptives, theophylline: May decrease the effectiveness of these drugs. HERBAL: St. John's
AVAILABILITY (Rx)
ORAL SOLUTION: 80 mg/ml. SOFT GELATIN CAPSULES: 100 mg.
ADMINISTRATION/HANDLING
N Store capsules, solution in refrigerator. N Protect from light. N Refrigeration of oral solution is recommended but not necessary if used within 30 days and stored below 77°F. N Give without regard to meals (preferably give with food). N May improve taste of oral solution by mixing with chocolate milk, Ensure, Advera, Boost within 1 hr of dosing.
INDICATIONS/ROUTES/DOSAGE
HIV INFECTION
DOSAGE ADJUSTMENTS IN COMBINATION THERAPY
Amprenavir: Amprenavir 1,200 mg and ritonavir 200 mg once a day or amprenavir 600 mg and ritonavir 100 mg twice a day.
Ampenavir and efavirenz: Amprenavir 1,200 mg twice a day and ritonavir 200 mg twice a day with standard dose of efavirenz.
Indinavir: Indinavir 800 mg twice a day and ritonavir 100U200 mg twice a day or indinavir 400 mg twice a day and ritonavir 400 mg twice a day.
Nelfinavir or saquinavir: Ritonavir 400 mg twice a day.
Rifabutin: Decrease rifabutin dosage to 150 mg every other day.
SIDE EFFECTS
FREQUENT: GI disturbances (abdominal pain, anorexia, diarrhea, nausea, vomiting), circumoral and peripheral paresthesias, altered taste, headache, dizziness, fatigue, asthenia. OCCASIONAL: Allergic reaction, flu-like symptoms, hypotension. RARE: Diabetes mellitus, hyperglycemia.
ADVERSE REACTIONS/TOXIC EFFECTS
Hepatitis and fatal cases of pancreatitis have been reported.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Patients beginning combination therapy with ritonavir and nucleosides may promote GI tolerance by beginning ritonavir alone and subsequently adding nucleosides before completing 2 wk of ritonavir monotherapy. Obtain baseline laboratory testing, especially serum liver function tests, triglycerides before beginning ritonavir therapy and at periodic intervals during therapy. Offer emotional support to patient and family.
INTERVENTION/EVALUATION
Closely monitor for evidence of GI disturbances, neurologic abnormalities (particularly paraesthesias). Monitor serum liver function tests, blood glucose, CD4 cell count, plasma levels of HIV RNA.
PATIENT/FAMILY TEACHING
N Continue therapy for full length of treatment. N Doses should be evenly spaced. N Ritonavir is not a cure for HIV infection, nor does it reduce risk of transmission to others. N Patients may continue to acquire illnesses associated with advanced HIV infection. N If possible, take ritonavir with food. N Taste of solution may be improved when mixed with chocolate milk, Ensure, Advera, Boost. N Inform physician of increased thirst, frequent urination, nausea, vomiting, abdominal pain.
rituximab A
rye-tucks-ih-mab
(Rituxan)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Monoclonal antibody. CLINICAL: Antineoplastic.
ACTION
Binds to CD20, the antigen found on the surface of B lymphocytes and B-cell non-Hodgkin's lymphomas.Therapeutic Effect: Produces cytotoxicity, reducing tumor size.
PHARMACOKINETICS
Rapidly depletes B cells. Half-life: 59.8 hr after first infusion and 174 hr after fourth infusion.
USES
Treatment of relapsed or refractory low-grade or follicular B-cell non-Hodgkin's lymphoma. First line treatment for diffuse large B cell, CB20, positive, non-Hodgkin's lymphoma. Treatment of moderate to severe rheumatoid arthritis.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to murine proteins. CAUTIONS: Those with history of cardiac disease.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Has potential to cause fetal B-cell depletion. Unknown if distributed in breast milk. Those with childbearing potential should use contraceptive methods during treatment and up to 12 mo following therapy. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
INJECTION: 10 mg/ml.
ADMINISTRATION/HANDLING
L IV
Reconstitution N Dilute with 0.9% NaCl or D5W to provide a final concentration of 1U4 mg/ml into infusion bag.
Rate of administration N Infuse at rate of 50 mg/hr. May increase infusion rate in 50 mg/hr increments q30min to maximum 400 mg/hr. N Subsequent infusion can be given at 100 mg/hr and increased by 100 mg/hr increments q30min to maximum 400 mg/hr.
Storage
O ALERT P Do not give by IV push or bolus.
N Refrigerate vials. N Diluted solution is stable for 24 hr if refrigerated and at room temperature for an additional 12 hr.
D IV INCOMPATIBILITIES
Don’t mix rituximab with any other medications.
INDICATIONS/ROUTES/DOSAGE
NON-HODGKIN'S LYMPHOMA
IV: ADULTS: 375 mg/m2 once weekly for 4U8 wk. May administer a second 4Uwk course.
RHEUMATOID ARTHRITIS
IV: ADULTS: 100 mg every 2 wk times 2 doses.
SIDE EFFECTS
FREQUENT: Fever (49%), chills (32%), asthenia (16%), headache (14%), angioedema (13%), hypotension (10%), nausea (18%), rash or pruritus (10%). OCCASIONAL (less than 10%): Myalgia, dizziness, abdominal pain, throat irritation, vomiting, neutropenia, rhinitis, bronchospasm, urticaria.
ADVERSE REACTIONS/TOXIC EFFECTS
A hypersensitivity reaction marked by hypotension, bronchospasm, and angioedema may occur. Arrhythmias may occur, particularly in those with a history of preexisting cardiac conditions.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Pretreatment with acetaminophen and diphenhydramine before each infusion may prevent infusion-related effects. CBC, platelet count should be obtained at regular interval during therapy.
INTERVENTION/EVALUATION
Monitor for an infusion-related symptoms complex consisting mainly of fever, chills, rigors that generally occurs within 30 minU2 hr of beginning first infusion. Slowing infusion resolves symptoms.
rivastigmine tartrate
rye-vah-stig-meen
(Exelon)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Cholinesterase inhibitor. CLINICAL: Anti-Alzheimer's dementia agent.
ACTION
A cholinesterase inhibitor that inhibits the enzyme acetylcholinesterase, thus increasing the concentration of acetylcholine at cholinergic synapses and enhancing cholinergic function in the CNS. Therapeutic Effect: Slows the progression of symptoms of Alzheimer's disease.
PHARMACOKINETICS
Rapidly and completely absorbed. Protein binding: 60%. Widely distributed throughout the body. Rapidly and extensively metabolized. Primarily excreted in urine. Half-life: 1.5 hr.
USES
Treatment of mild to moderate dementia of the Alzheimer's type.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to other carbamate derivatives. CAUTIONS: Peptic ulcer disease, concurrent use of NSAIDs, sick sinus syndrome, bradycardia, urinary obstruction, seizure disorders, asthma, chronic obstructive pulmonary disease (COPD).
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if distributed in breast milk. Pregnancy Category B. Children: Not indicated for use in children. Elderly: No age-related precautions.
INTERACTIONS
DRUG: Anticholinergics: May decrease the effects of rivastigmine or anticholinergics. Bethanecol: May increase the effects of rivastigmine or bethanecol. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
CAPSULES: 1.5 mg, 3 mg, 4.5 mg, 6 mg. ORAL SOLUTION: 2 mg/ml.
ADMINISTRATION/HANDLING
N Give with food in divided doses morning and evening.
ORAL SOLUTION
N Using oral syringe (provided by manufacturer), withdraw prescribed amount rivastigmine from container. N May be swallowed directly from syringe or mixed in small glass of water, cold fruit juice, soda (use within 4 hr of mixing).
INDICATIONS/ROUTES/DOSAGE
ALZHEIMER'S DISEASE
SIDE EFFECTS
FREQUENT (47%U17%): Nausea, vomiting, dizziness, diarrhea, headache, anorexia. OCCASIONAL (13%U6%): Abdominal pain, insomnia, dyspepsia (heartburn, indigestion, epigastric pain), confusion, UTI, depression. RARE (5%U3%): Anxiety, somnolence, constipation, malaise, hallucinations, tremor, flatulence, rhinitis, hypertension, flu-like symptoms, weight loss, syncope.
ADVERSE REACTIONS/TOXIC EFFECTS
Overdose may result in cholinergic crisis, characterized by severe nausea and vomiting, increased salivation, diaphoresis, bradycardia, hypotension, respiratory depression, and seizures.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Obtain baseline vital signs. Assess history for peptic ulcer, urinary obstruction, asthma, COPD. Assess cognitive, behavioral, functional deficits.
INTERVENTION/EVALUATION
Monitor for cholinergic reaction: GI discomfort or cramping, feeling of facial warmth, excessive salivation and diaphoresis, lacrimation, pallor, urinary urgency, dizziness. Monitor for nausea, diarrhea, headache, insomnia.
PATIENT/FAMILY TEACHING
N Take with meals (at breakfast, dinner). N Swallow capsule whole. Do not chew, break, crush capsules. N Report nausea, vomiting, diarrhea, diaphoresis, increased salivary secretions, severe abdominal pain, dizziness.
rizatriptan benzoate
rize-a-trip-tan
(Maxalt, Maxalt-MLT)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Serotonin receptor agonist. CLINICAL: Antimigraine.
ACTION
A serotonin receptor agonist that binds selectively to vascular receptors, producing a vasoconstrictive effect on cranial blood vessels. Therapeutic Effect: Relieves migraine headache.
PHARMACOKINETICS
Well absorbed after PO administration. Protein binding: 14%. Crosses the blood-brain barrier. Metabolized by the liver to inactive metabolite. Eliminated primarily in urine and, to a lesser extent, in feces. Half-life: 2U3 hr.
USES
Treatment of acute migraine attack with or without aura.
PRECAUTIONS
CONTRAINDICATIONS: Basilar or hemiplegic migraine, coronary artery disease, ischemic heart disease (including angina pectoris, history of MI, silent ischemia, and Prinzmetal's angina), uncontrolled hypertension, use within 24 hr of ergotamine-containing preparations or another serotonin receptor agonist, use within 14 days of MAOIs. CAUTIONS: Mild to moderate renal or hepatic impairment, patient profile suggesting cardiovascular risks.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug is distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Ergotamine-containing medications: May produce a vasospastic reaction. Fluoxetine, fluvoxamine, paroxetine, sertraline: May produce hyperreflexia, incoordination, and weakness. MAOIs, propranolol: May dramatically increase plasma concentration of rizatriptan. HERBAL: None known. FOOD: All foods: Delay peak drug concentration by 1 hr. LAB VALUES: None known.
AVAILABILITY (Rx)
TABLETS (MAXALT): 5 mg, 10 mg. TABLETS (ORALLY-DISINTEGRATING [MAXALT-MLT]): 5 mg, 10 mg.
ADMINISTRATION/HANDLING
N Oral disintegrating tablet is packaged in an individual aluminum pouch. N Open packet with dry hands. N Place tablet onto tongue; allow to dissolve and swallow dissolved and with saliva. Administration with water is not necessary.
INDICATIONS/ROUTES/DOSAGE
ACUTE MIGRAINE ATTACK
SIDE EFFECTS
FREQUENT (9%U7%): Dizziness, somnolence, paraesthesia, fatigue. OCCASIONAL (6%U3%): Nausea, chest pressure, dry mouth. RARE (2%): Headache; neck, throat, or jaw pressure; photosensitivity.
ADVERSE REACTIONS/TOXIC EFFECTS
Cardiac reactions (such as ischemia, coronary artery vasospasm, and MI) and noncardiac vasospasm-related reactions (including hemorrhage and cerebrovascular accident [CVA]), occur rarely, particularly in patients with hypertension, diabetes, or a strong family history of coronary artery disease; obese patients; smokers; males older than 40 yr; and postmenopausal women.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Question for history of peripheral vascular disease, renal or hepatic impairment. Question patient regarding onset, location, duration of migraine and possible precipitating symptoms.
INTERVENTION/EVALUATION
Monitor for evidence of dizziness. Assess for relief of migraine headache and potential for photophobia, phonophobia (sound sensitivity, nausea, vomiting).
PATIENT/FAMILY TEACHING
N Take a single dose as soon as symptoms of an actual migraine attack appear. N Medication is intended to relieve migraine, not to prevent or reduce number of attacks. N Avoid tasks that require alertness, motor skills until response to drug is established. N If palpitations, pain or tightness in chest/throat, pain or weakness of extremities occurs, contact physician immediately. N Do not remove the blister from the orally disintegrating tablet until just before dosing. N Use protective measures (sunscreen, protective clothing) against exposure to UV light and sunlight.
ropinirole hydrochloride
ro-pin-i-role
(Requip)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Dopamine agonist. CLINICAL: Antiparkinson agent.
ACTION
An antiparkinson agent that stimulates dopamine receptors in the striatum. Therapeutic Effect: Relieves signs and symptoms of Parkinson's disease.
PHARMACOKINETICS
Rapidly absorbed after PO administration. Protein binding: 40%. Extensively distributed throughout the body. Extensively metabolized. Steady-state concentrations achieved within 2 days. Eliminated in urine. Unknown if removed by hemodialysis. Half-life: 6 hr.
USES
Treatment of signs/symptoms of idiopathic Parkinson's disease.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: History of orthostatic hypotension, syncope, hallucinations, especially in elderly. Concurrent use of CNS depressants.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Distributed in breast milk. Drug activity possible in breast-feeding infant. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: No age-related precautions noted, but hallucinations appear to occur more frequently.
INTERACTIONS
DRUG: Butyrophenones, metoclopramide, phenothiazines, thioxanthenes: Decrease the effectiveness of ropinirole. Cimetidine, diltiazem, enoxacin, erythromycin, fluvoxamine, mexiletine, norfloxacin, tacrine: Alter ropinirole blood concentration. Ciprofloxacin: Increases ropinirole blood concentration. CNS depressants: May increase CNS depressant effects. Estrogens: Reduce the clearance of ropinirole. Levodopa: Increases the blood concentration of levodopa. HERBAL: Kava kava: May decrease the effectiveness of ropinirole. FOOD: All foods: Delay peak plasma levels by 1 hr but don't affect drug absorption. LAB VALUES: May increase serum alkaline phosphatase level.
AVAILABILITY (Rx)
TABLETS: 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg.
ADMINISTRATION/HANDLING
N Ascending-dose schedule should increase very gradually at weekly intervals:
Week 1: 0.25 mg 3 times a day to total daily dose 0.75 mg. Week 2: 0.5 mg 3 times a day to total daily dose 1.5 mg. Week 3: 0.75 mg 3 times a day to total daily dose 2.25 mg. Week 4: 1 mg 3 times a day to total daily dose 3 mg. N Discontinue medication gradually. Decrease frequency from 3 times a day to 2 times a day for 4 days. For the remaining 3 days, decrease frequency to once a day before complete withdrawal.
INDICATIONS/ROUTES/DOSAGE
PARKINSON'S DISEASE
RESTLESS LEG SYNDROME
PO: ADULTS, ELDERLY: 0.25 mg for days 1 and 2; 0.5 mg for days 3U7; 1 mg for week 2; 1.5 mg for week 3; 2 mg for week 4; 2.5 mg for week 5; 3 mg for week 6; 4 mg for week 7. All doses to be given 1U3 hours before bedtime.
SIDE EFFECTS
FREQUENT (60%U40%): Nausea, dizziness, somnolence. OCCASIONAL (12%U5%): Syncope, vomiting, fatigue, viral infection, dyspepsia, diaphoresis, asthenia, orthostatic hypotension, abdominal discomfort, pharyngitis, abnormal vision, dry mouth, hypertension, hallucinations, confusion. RARE (less than 4%): Anorexia, peripheral edema, memory loss, rhinitis, sinusitis, palpitations, impotence.
ADVERSE REACTIONS/TOXIC EFFECTS
Falling asleep without warning while engaged in activities of daily living, including driving motor vehicles, has been reported.
NURSING CONSIDERATION
INTERVENTION/EVALUATION
Assess for clinical improvement, clinical reversal of symptoms (improvement of tremors of head/hands at rest, mask-like facial expression, shuffling gait, muscular rigidity). Assist with ambulation if dizziness occurs.
PATIENT/FAMILY TEACHING
N Drowsiness, dizziness may be an initial response to drug. N Postural hypotension may occur more frequently during initial therapy. Instruct patient to rise from lying to sitting or sitting to standing position slowly to prevent risk of postural hypotension. N Avoid tasks that require alertness, motor skills until response to drug is established. N If nausea occurs, take medication with food. N Inform patient that hallucinations may occur, more so in the elderly than in younger patients with Parkinson's disease.
rosiglitazone maleate A
roz-ih-glit-a-zone
(Avandia)
Do not confuse Avandia with Avalide, Avinza, or Prandin, or Avandaryl with Benadryl.
FIXED-COMBINATION(S)
Avandamet: rosiglitazone/metformin: 1 mg/500 mg; 2 mg/500 mg; 4 mg/500 mg; 2 mg/1 g; 4 mg/1 g. Avandaryl: rosiglitazone/glimepiride (an antidiabetic): 4 mg/1 mg, 4 mg/2 mg, 4 mg/4 mg.
CLASSIFICATION
CLINICAL: Antidiatic
ACTION
An antidiabetic that improves target-cell response to insulin without increasing pancreatic insulin secretion. Decreases hepatic glucose output and increases insulin-dependent glucose utilization in skeletal muscle. Therapeutic Effect: Lowers blood glucose concentration.
PHARMACOKINETICS
Rapidly absorbed. Protein binding: 99%. Metabolized in the liver. Excreted primarily in urine, with a lesser amount in feces. Not removed by hemodialysis. Half-life: 3U4 hr.
USES
Adjunct to diet/exercise to lower blood glucose in those with type 2 nonUinsulin-dependent diabetes mellitus (NIDDM). Used as monotherapy or in combination with metformin, sulfonylurea, or insulin to improve glycemic control.
PRECAUTIONS
CONTRAINDICATIONS: Active hepatic disease, diabetic ketoacidosis, increased serum transaminase levels, including ALT greater than 2.5 times the normal serum level, type 1 diabetes mellitus. CAUTIONS: Hepatic impairment, CHF, edematous patients. May cause or worsen macular edema.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Not recommended in pregnant or breast-feeding women. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: No age-related precautions noted in the elderly.
INTERACTIONS
DRUG: Gemfibrozil: May increase plasma concentrations of rosiglitazone. HERBAL: Bitter melon, eucalyptus, fenugreek, ginseng, guar gum, St. John's
AVAILABILITY (Rx)
TABLETS: 2 mg, 4 mg, 8 mg.
ADMINISTRATION/HANDLING
N Give without regard to meals.
INDICATIONS/ROUTES/DOSAGE
DIABETES MELLITUS, COMBINATION THERAPY
DIABETES MELLITUS, MONOTHERAPY
ADULTS, ELDERLY: Initially, 4 mg as single daily dose or in divided doses twice a day. May increase to 8 mg/day after 12 wk of therapy.
SIDE EFFECTS
FREQUENT (9%): Upper respiratory tract infection. OCCASIONAL (4%U2%): Headache, edema, back pain, fatigue, sinusitis, diarrhea.
ADVERSE REACTIONS/TOXIC EFFECTS
Hepatotoxicity occurs rarely.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Obtain hepatic enzyme levels before initiation of therapy and periodically thereafter. Ensure follow-up instruction if patient or family does not thoroughly understand diabetes management or glucose-testing technique.
INTERVENTION/EVALUATION
Monitor blood glucose, Hgb, serum hepatic function tests, esp. AST, ALT. Assess for hypoglycemia (cool/wet skin, tremors, dizziness, anxiety, headache, tachycardia, numbness in mouth, hunger, diplopia), hyperglycemia (polyuria, polyphagia, polydipsia, nausea, vomiting, dim vision, fatigue, deep/rapid breathing). Be alert to conditions that alter glucose requirements: fever, increased activity/stress, surgical procedures.
PATIENT/FAMILY TEACHING
N Diabetes mellitus requires lifelong control. N Prescribed diet, exercise are principal parts of treatment; do not skip/delay meals. N Wear medical alert identification. N Continue to adhere to dietary instructions, a regular exercise program, regular testing of urine or blood glucose. N When taking combination drug therapy with a sulfonylurea or insulin, have a source of glucose available to treat symptoms of low blood sugar.
rosuvastatin calcium
ross-uh-vah-stah-tin
(Crestor)
CLASSIFICATION
PHARMACOTHERAPEUTIC: HMG-CoA reductase inhibitor. CLINICAL: Antihyperlipidemic.
ACTION
An antihyperlipidemic that interferes with cholesterol biosynthesis by inhibiting the conversion of the enzyme HMG-CoA to mevalonate, a precursor to cholesterol. Therapeutic Effect: Decreases LDL cholesterol, VLDL, and plasma triglyceride levels, increases HDL concentration.
PHARMACOKINETICS
Protein binding: 88%. Minimal hepatic metabolism. Primarily eliminated in the feces. Half-life: 19 hr (increased in patients with severe renal dysfunction).
USES
Adjunct to diet therapy to decrease elevated total and LDL cholesterol concentrations in patients with primary hypercholesterolemia (types IIa and IIb), lowers serum triglyceride levels, increases HDL.
PRECAUTIONS
CONTRAINDICATIONS: Active hepatic disease, breast-feeding, pregnancy, unexplained, persistent elevations of serum transaminase levels. CAUTIONS: Anticoagulant therapy, history of hepatic disease, substantial alcohol consumption, major surgery, severe acute infection, trauma, hypotension, severe metabolic or endocrine disorders, severe electrolyte imbalances, uncontrolled seizures.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Contraindicated in pregnancy (suppression of cholesterol biosynthesis may cause fetal toxicity), lactation. Risk of serious adverse reactions in breast-feeding infants. Pregnancy Category X. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Cyclosporine, gemfibrozil, niacin: Increases the risk of myopathy with cyclosporine, gemfibrozil, and niacin. Erythromycin: Reduces the plasma concentration of erythromycin. Ethinylestradiol, norgestrel: Increases the plasma concentrations of ethinylestradiol and norgestrel. Warfarin: Enhances anticoagulant effect. HERBAL: St. John's
AVAILABILITY (Rx)
TABLETS: 5 mg, 10 mg, 20 mg, 40 mg.
ADMINISTRATION/HANDLING
N Give without regard to meals. Usually administered in the evening.
INDICATIONS/ROUTES/DOSAGE
HYPERLIPIDEMIA, DYSLIPIDEMIA
RENAL IMPAIRMENT (CREATININE CLEARANCE LESS THAN 30 ml/min)
CONCURRENT CYCLOSPORINE USE
CONCURRENT LIPID-LOWERING THERAPY
SIDE EFFECTS
Rosuvastatin is generally well tolerated. Side effects are usually mild and transient. OCCASIONAL (9%U3%): Pharyngitis, headache, diarrhea, dyspepsia, including heartburn and epigastric distress, nausea. RARE (less than 3%): Myalgia, asthenia or unusual fatigue and weakness, back pain, jaundice.
ADVERSE REACTIONS/TOXIC EFFECTS
Cases of rhabdomyolysis have been reported. Lens opacities may occur. Hypersensitivity reaction and hepatitis occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Question for possibility of pregnancy before initiating therapy (Pregnancy Category X). Assess baseline lab results: serum cholesterol, triglycerides, liver function tests.
INTERVENTION/EVALUATION
Monitor serum cholesterol, triglyceride results for therapeutic response. Lipid levels should be monitored within 2U4 wk of initiation of therapy or change in dosage. Monitor liver function tests. Liver function tests should be performed at 12 wk following the initiation of therapy and any elevation of dose, and periodically (e.g. semiannually) thereafter. Monitor creatine phosphokinase (CPK) if myopathy is suspected. Determine pattern of bowel activity and stool consistency. Assess for headache, sore throat. Be alert for myalgia/weakness.
PATIENT/FAMILY TEACHING
N Use appropriate contraceptive measures (Pregnancy Category X). N Periodic lab tests are essential part of therapy. N Maintain appropriate diet (important part of treatment). N Report side effects (cramps, muscle pain, weakness, especially with fever).
No comments:
Post a Comment