tacrolimus
tack-row-lee-mus
(Prograf, Protopic)
Do not confuse Protopic with Protonix, Protopam, Protopin.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Immunologic agent. CLINICAL: Immunosuppressant.
ACTION
An immunologic agent that inhibits T-lymphocyte activation by binding to intracellular proteins, forming a complex, and inhibiting phosphatase activity. Therapeutic Effect: Suppresses the immunologically mediated inflammatory response; prevents organ transplant rejection.
PHARMACOKINETICS
Variably absorbed after PO administration (food reduces absorption). Protein binding: 75%U97%. Extensively metabolized in the liver. Excreted in urine. Not removed by hemodialysis. Half-life: 11.7 hr.
USES
Oral/injection: Prophylaxis of organ rejection in patients receiving allogeneic liver transplants, kidney transplants, heart transplant. Should be used concurrently with adrenal corticosteroids. Topical: Atopic dermatitis. OFF-LABEL: Prevention of organ rejection in patients receiving allogeneic bone marrow, heart, pancreas, pancreatic island cell, or small-bowel transplant, treatment of autoimmune disease, severe recalcitrant psoriasis.
PRECAUTIONS
O ALERT P There is a potential cancer risk in using topical Protoptic ointment. CONTRAINDICATIONS: Concurrent use with cyclosporine (increases the risk of nephrotoxicity), hypersensitivity to HCO-60 polyoxyl 60 hydrogenated castor oil (used in solution for injection). CAUTIONS: Immunosuppressed patients, renal or hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Neonatal hyperkalemia, renal dysfunction noted in neonates. Excreted in breast milk. Avoid breast-feeding. Pregnancy Category C. Children: May require higher dosages (decreased bioavailability, increased clearance). May make post-transplant lymphoproliferative disorder more common (especially in those younger than 3 yr). Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Aminoglycosides, amphotericin B, cisplatin: May increase the risk of renal dysfunction. Antacids: May decrease the absorption of tacrolimus. Antifungals, bromocriptine, calcium channel blockers, cimetidine, clarithromycin, cyclosporine, danazol, diltiazem, erythromycin, methylprednisolone, metoclopramide: Increase tacrolimus blood concentration. Carbamazepine, phenobarbital, phenytoin, rifamycin: Decrease tacrolimus blood concentration. Cyclosporine: Increases the risk of nephrotoxicity. Live virus vaccines: May potentiate virus replication, increase vaccine side effects, and decrease the patient's antibody response to the vaccine. Other immunosuppressants: May increase the risk of infection or lymphomas. HERBAL: Echinacea: May decrease the effects of tacrolimus. FOOD: Grapefruit, grapefruit juice: May alter the effects of the drug. LAB VALUES: May increase blood glucose, BUN, and serum creatinine levels, as well as WBC count. May decrease serum magnesium level and RBC and thrombocyte counts. May alter serum potassium level.
AVAILABILITY (Rx)
CAPSULES (PROGRAF): 0.5 mg, 1 mg, 5 mg. INJECTION (PROGRAF): 5 mg/ml. OINTMENT (PROTOPIC): 0.03%, 0.1%.
ADMINISTRATION/HANDLING
L IV
Reconstitution N Dilute with an appropriate amount (250U1,000 ml, depending on desired dose) 0.9% NaCl or D5W to provide a concentration between 0.004 and 0.02 mg/ml.
Rate of administration N Give as continuous IV infusion. N Continuously monitor patient for anaphylaxis for at least 30 min after start of infusion. N Stop infusion immediately at first sign of hypersensitivity reaction.
Storage N Store diluted infusion solution in glass or polyethylene containers and discard after 24 hr. N Do not store in a PVC container (decreased stability, potential for extraction).
N Administer on empty stomach. N Do not give with grapefruit or grapefruit juice or within 2 hr of antacids.
TOPICAL
N For external use only. N Do not cover with occlusive dressing. N Rub in gently and completely onto clean, dry skin.
D IV INCOMPATIBILITIES
No known drug incompatibilities. Do not mix tacrolimus with other medications if possible.
IV COMPATIBILITIES
Calcium gluconate, dexamethasone (Decadron), diphenhydramine (Benadryl), dobutamine (Dobutrex), dopamine (Intropin), furosemide (Lasix), heparin, hydromorphone (Dilaudid), insulin, leucovorin, lorazepam (Ativan), morphine, nitroglycerin, potassium chloride.
INDICATIONS/ROUTES/DOSAGE
PREVENTION OF LIVER TRANSPLANT REJECTION
IV: ADULTS, ELDERLY, CHILDREN: 0.03U0.05 mg/kg/day as continuous infusion.
PREVENTION OF KIDNEY TRANSPLANT REJECTION
IV: ADULTS, ELDERLY: 0.03U0.05 mg/kg/day as continuous infusion.
ATOPIC DERMATITIS
TOPICAL: ADULTS, ELDERLY, CHILDREN 2 YR AND OLDER: Apply 0.03% ointment to affected area twice a day. 0.1% ointment may be used in adults and the elderly. Continue until 1 wk after symptoms have cleared.
SIDE EFFECTS
FREQUENT (greater than 30%): Headache, tremor, insomnia, paresthesia, diarrhea, nausea, constipation, vomiting, abdominal pain, hypertension. OCCASIONAL (29%U10%): Rash, pruritus, anorexia, asthenia, peripheral edema, photosensitivity.
ADVERSE REACTIONS/TOXIC EFFECTS
Nephrotoxicity (characterized by increased serum creatinine level and decreased urine output), neurotoxicity (including tremor, headache, and mental status changes), and pleural effusion are common adverse reactions. Thrombocytopenia, leukocytosis, anemia, atelectasis, sepsis, and infection occur occasionally.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Assess medical history, especially renal function, and drug history, especially other immunosuppressants. Have aqueous solution of epinephrine 1:1,000 available at bedside as well as O2 before beginning IV infusion. Assess patient continuously for first 30 min following start of infusion and at frequent intervals thereafter.
INTERVENTION/EVALUATION
Closely monitor patients with impaired renal function. Monitor lab values, especially serum creatinine, potassium levels, CBC with differential, serum liver function tests. Monitor I&O closely. CBC should be performed weekly during first month of therapy, twice monthly during second and third months of treatment, then monthly throughout the first year. Report any major change in patient assessment.
PATIENT/FAMILY TEACHING
N Take dose at same time each day. N Avoid crowds, those with infection. N Inform physician if decreased urination, chest pain, headache, dizziness, respiratory infection, rash, unusual bleeding or bruising occurs. N Avoid exposure to sun, artificial light (may cause photosensitivity reaction).
tamoxifen citrate A
tam-ox-ih-feen
(Apo-Tamox J, Istubol, Nolvadex, Nolvadex-D J, Novo-Tamoxifen J, Soltamox, Tamofen J)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Nonsteroidal antiestrogen. CLINICAL: Antineoplastic.
ACTION
A nonsteroidal antiestrogen that competes with estradiol for estrogen-receptor binding sites in the breasts, uterus, and vagina. Therapeutic Effect: Inhibits DNA synthesis and estrogen response.
PHARMACOKINETICS
Well absorbed from the GI tract. Metabolized in the liver. Primarily eliminated in feces by biliary system. Half-life: 7 days.
USES
Adjunct treatment in advanced breast cancer, reduce risk of breast cancer in patients at high risk, reduce risk of invasive breast cancer in women with ductal carcinoma in situ (DCIS), metastatic breast cancer in women and men, treatment of melanoma, desmoid tumors. OFF-LABEL: Induction of ovulation.
PRECAUTIONS
CONTRAINDICATIONS: Concomitant coumarin-type therapy when used in the treatment of breast cancer in high-risk women, history of deep vein thrombosis or pulmonary embolism in high-risk women, pregnancy. CAUTIONS: Leukopenia, thrombocytopenia.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: If possible, avoid use during pregnancy, especially first trimester. May cause fetal harm. Unknown if distributed in breast milk. Breast-feeding not recommended. Pregnancy Category D. Children: Safe and effective in girls 2U10 yr with McCune Albright syndrome and precocious puberty. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Anticoagulants: May increase the risk of bleeding. Estrogens: May decrease the effects of tamoxifen. HERBAL: Red clover, St. John's
AVAILABILITY (Rx)
TABLETS (NOLVADEX): 10 mg, 20 mg. SOLTAMOX: Oral liquid.
ADMINISTRATION/HANDLING
N Give without regard to food.
INDICATIONS/ROUTES/DOSAGE
ADJUNCTIVE TREATMENT OF BREAST CANCER
PREVENTION OF BREAST CANCER IN HIGH-RISK WOMEN
SIDE EFFECTS
FREQUENT: Women (greater than 10%): Hot flashes, nausea, vomiting. OCCASIONAL: Women (9%U1%): Changes in menstruation, genital itching, vaginal discharge, endometrial hyperplasia or polyps. Men: Impotence, decreased libido. Men and women: Headache, nausea, vomiting, rash, bone pain, confusion, weakness, somnolence.
ADVERSE REACTIONS/TOXIC EFFECTS
Retinopathy, corneal opacity, and decreased visual acuity have been noted in patients receiving extremely high dosages (240U320 mg/day) for longer than 17 mo. There have been an increased number of incidences of endometrial changes, thromboembolic events, and uterine malignancies while using tamoxifen.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
An estrogen receptor assay should be done before therapy is begun. CBC, platelet count, serum calcium levels should be checked before and periodically during therapy.
INTERVENTION/EVALUATION
Be alert to increased bone pain and ensure adequate pain relief. Monitor I&O, weight. Observe for edema, especially of dependent areas. Assess for hypercalcemia (increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, deep bone/flank pain, renal stones).
PATIENT/FAMILY TEACHING
N Report vaginal bleeding/discharge/itching, leg cramps, weight gain, shortness of breath, weakness. N May initially experience increase in bone, tumor pain (appears to indicate good tumor response). N Contact physician if nausea/vomiting continues at home. N Nonhormonal contraceptives are recommended during treatment.
tamsulosin hydrochloride
tam-sool-o-sin
(Flomax)
Do not confuse Flomax with Fosamax or Volmax.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Alpha1-adrenergic blocker. CLINICAL: Benign prostatic hyperplasia agent.
ACTION
An alpha1 antagonist that targets receptors around bladder neck and prostate capsule. Therapeutic Effect: Relaxes smooth muscle and improves urinary flow and symptoms of prostatic hyperplasia.
PHARMACOKINETICS
Well absorbed and widely distributed. Protein binding: 94%U99%. Metabolized in the liver. Primarily excreted in urine. Unknown if removed by hemodialysis. Half-life: 9U13 hr.
USES
Treatment of symptoms of benign prostatic hyperplasia.
PRECAUTIONS
CONTRAINDICATIONS: Concurrent use of sildenafil, tadalafil, or vardenafil. CAUTIONS: Renal impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Not indicated for use in women. Pregnancy Category B (Not indicated for use in women.). Children: Not indicated in this patient population. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Other alpha-adrenergic blocking agents (such as cimetidine, doxazosin, prazosin, terazosin): May increase the alpha-blockade effects of both drugs. Warfarin: May alter the effects of warfarin. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
CAPSULES: 0.4 mg.
ADMINISTRATION/HANDLING
N Give at the same time each day, 30 min after the same meal. N Do not crush or open capsule unless directed by physician.
INDICATIONS/ROUTES/DOSAGE
BENIGN PROSTATIC HYPERPLASIA
SIDE EFFECTS
FREQUENT (9%U7%): Dizziness, somnolence. OCCASIONAL (5%U3%): Headache, anxiety, insomnia, orthostatic hypotension. RARE (less than 2%): Nasal congestion, pharyngitis, rhinitis, nausea, vertigo, impotence.
ADVERSE REACTIONS/TOXIC EFFECTS
First-dose syncope (hypotension with sudden loss of consciousness) may occur within 30U90 min after administration of initial dose and may be preceded by tachycardia (pulse rate of 120U160 beats/min).
NURSING CONSIDERATION
BASELINE ASSESSMENT
Question for sensitivity to tamsulosin, use of other alpha-adrenergic blocking agents, warfarin.
INTERVENTION/EVALUATION
Assist with ambulation if dizziness occurs. Monitor renal function, BP.
PATIENT/FAMILY TEACHING
N Take at the same time each day, 30 min after the same meal. N Use caution when getting up from sitting or lying position. N Avoid tasks that require alertness, motor skills until response to drug is established. N Do not chew, crush, open capsule.
tegaserod
teh-gas-er-od
(Zelnorm)
CLASSIFICATION
PHARMACOTHERAPEUTIC: 5-HT4 receptor partial agonist. CLINICAL: Anti-irritable bowel syndrome (IBS) agent.
ACTION
An anti-irritable bowel syndrome (IBS) agent that binds to 5-HT4 receptors in the GI tract. Therapeutic Effect: Triggers a peristaltic reflex in the gut, increasing bowel motility.
PHARMACOKINETICS
Rapidly absorbed. Widely distributed. Protein binding: 98%. Metabolized by hydrolysis in the stomach and by oxidation and conjugation of the primary metabolite. Primarily excreted in feces. Half-life: 11 hr.
USES
Short-term treatment of women with IBS whose primary bowel symptom is constipation. Treatment of chronic constipation in those younger than 65 yr.
PRECAUTIONS
CONTRAINDICATIONS: Abdominal adhesions, diarrhea, history of bowel obstruction, moderate to severe hepatic impairment, severe renal impairment, suspected sphincter of Oddi dysfunction, symptomatic gallbladder disease. CAUTIONS: None known.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if distributed in breast milk. Pregnancy Category B. 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)
TABLETS: 2 mg, 6 mg.
ADMINISTRATION/HANDLING
N Give before meals. N Tablets may be crushed.
INDICATIONS/ROUTES/DOSAGE
IBS
CHRONIC CONSTIPATION
SIDE EFFECTS
FREQUENT (greater than 5%): Headache, abdominal pain, diarrhea, nausea, flatulence. OCCASIONAL (5%U2%): Dizziness, migraine, back pain, extremity pain.
ADVERSE REACTIONS/TOXIC EFFECTS
Ischemic colitis, mesenteric ischemia, gangrenous bowel, rectal bleeding, syncope, hypotension, hypovolemia, electrolyte disorders, suspected sphincter of Oddi spasm, bile duct stone, cholecystitis with elevated transaminases, and hypersensitivity reaction including rash, urticaria, pruritus and serious allergic Type I reactions have been reported.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Assess for diarrhea (avoid use in these patients).
INTERVENTION/EVALUATION
Assess for improvement in symptoms (relief from bloating, cramping, urgency, abdominal discomfort).
PATIENT/FAMILY TEACHING
N Take before meals. N Inform physician of new or worsening episodes of abdominal pain, severe diarrhea.
telithromycin
teh-lith-row-my-sin
(Ketek, Ketek Pak)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Ketolide. CLINICAL: Antibiotic.
ACTION
A ketolide that blocks protein synthesis by binding to ribosomal receptor sites on the bacterial cell wall. Therapeutic Effect: Bactericidal.
PHARMACOKINETICS
Protein binding: 60%U70%. More of drug is concentrated in WBCs than in plasma, and drug is eliminated more slowly from WBCs than from plasma. Partially metabolized by the liver. Minimally excreted in feces and urine. Half-life: 10 hr.
USES
Treatment of susceptible infections due to S. aureus, S. pneumoniae, H. influenzae, M. catarrhalis, C. pneumoniae, M. pneumoniae including acute bacterial exacerbation of chronic bronchitis, acute bacterial sinusitis, community-acquired pneumonia. OFF-LABEL: Treatment of tonsillitis and pharyngitis due to S. pyogenes.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to macrolide antibiotics, concurrent use of cisapride or pimozide. CAUTIONS: Renal/hepatic impairment, hypokelemia, hypomagnesemia, clinically significant bradycardia, QT prolongation, myasthenia gravis, those receiving class IA or III antiarrhythmics.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta. May be distributed in breast milk. Pregnancy Category C. Children: Safety and effectiveness not established. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Atorvastatin, digoxin, lovastatin, metoprolol, pimozide, simvastatin, theophylline: May increase the blood concentration and toxicity of these drugs. Carbamazepine, phenobarbital, phenytoin, rifampin: May decrease the blood concentration of telithromycin. Cisapride: Increases blood concentration of cisapride, resulting in significantly increased QT interval. Itraconazole, ketoconazole: May increase the blood concentration of telithromycin. Sotalol: Decreases the blood concentration of sotalol. HERBAL: None known. FOOD: None known. LAB VALUES: May increase platelet count and AST and ALT levels.
AVAILABILITY (Rx)
TABLETS (KETEK, KETEK PAK): 400 mg.
ADMINISTRATION/HANDLING
N Store at room temperature. N Do not break or crush film-coated tablets. N Give without regard to food.
INDICATIONS/ROUTES/DOSAGE
CHRONIC BRONCHITIS, SINUSITIS
COMMUNITY-ACQUIRED PNEUMONIA
SIDE EFFECTS
OCCASIONAL (11%U4%): Diarrhea, nausea, headache, dizziness. RARE (3%U2%): Vomiting, loose stools, altered taste, dry mouth, flatulence, visual disturbances.
ADVERSE REACTIONS/TOXIC EFFECTS
Hepatic dysfunction, severe hypersensitivity reaction, and atrial arrhythmias occur rarely. Antibiotic-associated colitis and other superinfections may result from altered bacterial balance.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Question patient for concurrent use of cisapride or pimozide (contraindicated).
INTERVENTION/EVALUATION
Determine pattern of bowel activity/stool consistency. Give with food if nausea occurs. Assess hepatic function panel for evidence of hepatotoxicity.
PATIENT/FAMILY TEACHING
N Avoid quick changes in viewing between objects in the distance and objects nearby (drug may produce temporary difficulty in focusing that may last several hours after the first or second dose). N Avoid tasks that require alertness, motor skills until response to drug is established.
telmisartan
tel-meh-sar-tan
(Micardis)
FIXED-COMBINATION(S)
Micardis HCT: telmisartan/hydrochlorothiazide (a diuretic): 40 mg/12.5 mg; 80 mg/12.5 mg.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Angiotensin II receptor antagonist. CLINICAL: Antihypertensive.
ACTION
An angiotensin II receptor, type AT1, antagonist that blocks vasoconstrictor and aldosterone-secreting effects of angiotensin II, inhibiting the binding of angiotensin II to the AT1 receptors. Therapeutic Effect: Causes vasodilation, decreases peripheral resistance, and decreases BP.
PHARMACOKINETICS
Rapidly and completely absorbed after PO administration. Protein binding: greater than 99%. Undergoes metabolism in the liver to inactive metabolite. Excreted in feces. Unknown if removed by hemodialysis. Half-life: 24 hr.
USES
Treatment of hypertension alone or in combination with other antihypertensives. OFF-LABEL: Treatment of CHF.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Volume-depleted patients, hepatic or renal impairment, renal artery stenosis (unilateral or bilateral).
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: May cause fetal harm. Unknown if drug is excreted in breast milk. Pregnancy Category C (D if used in second or third trimester). Children: Safety and efficacy not established. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Digoxin: Increases digoxin plasma concentration. Warfarin: Slightly decreases warfarin plasma concentration HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum creatinine level. May decrease blood Hgb and Hct levels.
AVAILABILITY (Rx)
TABLETS: 20 mg, 40 mg, 80 mg.
ADMINISTRATION/HANDLING
N Give without regard to meals.
INDICATIONS/ROUTES/DOSAGE
HYPERTENSION
SIDE EFFECTS
OCCASIONAL (7%U3%): Upper respiratory tract infection, sinusitis, back or leg pain, diarrhea. RARE (1%): Dizziness, headache, fatigue, nausea, heartburn, myalgia, cough, peripheral edema.
ADVERSE REACTIONS/TOXIC EFFECTS
Overdosage may manifest as hypotension and tachycardia. Bradycardia occurs less often.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Obtain BP, apical pulse immediately before each dose, in addition to regular monitoring (be alert to fluctuations). If excessive reduction in BP occurs, place patient in supine position, feet slightly elevated. Assess medication history (especially diuretic). Question for history of hepatic or renal impairment, renal artery stenosis. Obtain BUN, serum creatinine, Hgb, vital signs, particularly BP, pulse rate.
INTERVENTION/EVALUATION
Monitor BP, pulse, serum electrolytes, renal function.
PATIENT/FAMILY TEACHING
N Monitor during initial doses for hypotension. N Avoid tasks that require alertness, motor skills until response to drug is established (possible dizziness effect). N Maintain proper fluid intake. N Inform female patient regarding consequences of second- and third-trimester exposure to telmisartan. N Report pregnancy to physician as soon as possible. N Report any sign of infection (sore throat, fever). N Discuss need for lifelong BP control. N Caution against excessive exertion during hot weather (risk of dehydration, hypotension).
temazepam
tem-az-eh-pam
(Apo-Temazepam J, Novo-Temazepam J, PMS-Temazepam J, Restoril)
Do not confuse Restoril with Vistaril or Zestril.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Benzodiazepine (Schedule IV). CLINICAL: Sedative-hypnotic.
ACTION
A benzodiazepine that enhances the action of the inhibitory neurotransmitter gamma-aminobutyric acid, resulting in CNS depression. Therapeutic Effect: Induces sleep.
PHARMACOKINETICS
Well absorbed from the GI tract. Protein binding: 96%. Widely distributed. Crosses the blood-brain barrier. Metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 4U18 hr.
USES
Short-term treatment of insomnia (5 wk or less). Reduces sleep-induction time, number of nocturnal awakenings; increases length of sleep. OFF-LABEL: Treatment of anxiety, depression, panic attacks.
PRECAUTIONS
CONTRAINDICATIONS: Angle-closure glaucoma; CNS depression; pregnancy or breast-feeding; severe, uncontrolled pain; sleep apnea. CAUTIONS: Mental impairment, patients with drug dependence potential.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. May be distributed in breast milk. Chronic ingestion during pregnancy may produce withdrawal symptoms, CNS depression in neonates. Pregnancy Category X. Children: Not recommended in those younger than 18 yr. Elderly: Use small initial doses with gradual dosage increases to avoid ataxia, excessive sedation.
INTERACTIONS
DRUG: Alcohol, other CNS depressants: May increase CNS depression. HERBAL: Kava kava, valerian: May increase CNS depression FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
CAPSULES: 7.5 mg, 15 mg, 22.5 mg, 30 mg.
ADMINISTRATION/HANDLING
N Give without regard to meals. N Capsules may be emptied and mixed with food.
INDICATIONS/ROUTES/DOSAGE
INSOMNIA
SIDE EFFECTS
FREQUENT: Somnolence, sedation, rebound insomnia (may occur for 1U2 nights after drug is discontinued), dizziness, confusion, euphoria. OCCASIONAL: Asthenia, anorexia, diarrhea. RARE: Paradoxical CNS excitement or restlessness (particularly in elderly or debilitated patients).
ADVERSE REACTIONS/TOXIC EFFECTS
Abrupt or too-rapid withdrawal may result in pronounced restlessness, irritability, insomnia, hand tremor, abdominal or muscle cramps, vomiting, diaphoresis, and seizures. Overdose results in somnolence, confusion, diminished reflexes, respiratory depression, and coma.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Question for possibility of pregnancy before initiating therapy (Pregnancy Category X). Assess BP, pulse, respirations immediately before administration. Raise bed rails. Provide environment conducive to sleep (back rub, quiet environment, low lighting).
INTERVENTION/EVALUATION
Assess sleep pattern of patient. Assess elderly or debilitated for paradoxical reaction, particularly during early therapy. Monitor respiratory, cardiovascular, mental status. Evaluate for therapeutic response: decrease in number of nocturnal awakenings, increase in length of sleep.
PATIENT/FAMILY TEACHING
N Avoid alcohol, other CNS depressants. N May cause daytime drowsiness. N Avoid tasks that require alertness, motor skills until response to drug is established. N Take about 30 min before bedtime. N Inform physician if pregnant or planning to become pregnant.
temozolomide A
teh-moe-zoll-oh-mide
(Temodal J, Temodar)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Imidazotetrazine derivative. CLINICAL: Antineoplastic.
ACTION
An imidazotetrazine derivative that acts as a prodrug and is converted to a highly active cytotoxic metabolite. Its cytotoxic effect is associated with methylation of DNA. Therapeutic Effect: Inhibits DNA replication, causing cell death.
PHARMACOKINETICS
Rapidly and completely absorbed after PO administration. Protein binding: 15%. Peak plasma concentration occurs in 1 hr. Penetrates the blood-brain barrier. Eliminated primarily in urine and, to a much lesser extent, in feces. Half-life: 1.6-1.8 hr.
USES
Treatment of adults with refractory anaplastic astrocytoma, newly diagnosed glioblastoma multiforme concomitantly with radiotherapy and then as maintenance therapy. OFF-LABEL: Malignant glioma, malignant melanoma.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to dacarbazine, pregnancy. CAUTIONS: Severe renal/hepatic impairment, bacterial/viral infection, elderly.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: May cause fetal harm. May produce malformation of external organs, soft tissue, skeleton. If possible, avoid use during pregnancy. Unknown if drug is excreted in breast milk. Pregnancy Category D. Children: Safety and efficacy not established. Elderly: Those older than 70 yr may experience a higher risk of developing grade 4 neutropenia and grade 4 thrombocytopenia.
INTERACTIONS
DRUG: Live virus vaccines: May potentiate virus replication, increase vaccine side effects, and decrease the patient's antibody response to the vaccine. Valproic acid: Decreases the clearance of temozolomide. HERBAL: None known. FOOD: All foods: Decrease the rate of drug absorption. LAB VALUES: May decrease blood Hgb levels and neutrophil, platelet, and WBC counts.
AVAILABILITY (Rx)
CAPSULES: 5 mg, 20 mg, 100 mg, 250 mg.
ADMINISTRATION/HANDLING
N Food reduces rate, extent of absorption; increases risk of nausea, vomiting. N For best results, administer at bedtime. N Swallow capsule whole with glass of water. If unable to swallow, open capsule and mix with applesauce, apple juice. N Avoid exposure to medication during handling (cytotoxic).
INDICATIONS/ROUTES/DOSAGE
ANAPLASTIC ASTROCYTOMA
GLIOBLASTOMA MULTIFORME
SIDE EFFECTS
FREQUENT (53%U33%): Nausea, vomiting, headache, fatigue, constipation, seizure. OCCASIONAL (16%U10%): Diarrhea, asthenia, fever, dizziness, peripheral edema, incoordination, insomnia. RARE (9%U5%): Paraesthesia, drowsiness, anorexia, urinary incontinence, anxiety, pharyngitis, cough.
ADVERSE REACTIONS/TOXIC EFFECTS
Elderly patients and women are at increased risk for developing severe myelosuppression, characterized by neutropenia and thrombocytopenia and usually occurring within the first few cycles. Neutrophil and platelet counts reach their nadirs approximately 26U28 days after administration and recover within 14 days of the nadir. Opportunistic infection characterized as pneumocystis carinii pneumonia occurs rarely.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Before dosing, absolute neutrophil count (ANC) must be greater than 1,500 and platelet count greater than 100,000. Potential for nausea, vomiting readily controlled with antiemetic therapy.
INTERVENTION/EVALUATION
Obtain CBC on day 22 (21 days after the first dose) or within 48 hr of that day and weekly until ANC is greater than 1,500 and platelet count is greater than 100,000. Monitor for hematologic toxicity (fever, sore throat, signs of local infection, unusual ecchymoses/bleeding from any site), symptoms of anemia (excessive fatigue, weakness).
PATIENT/FAMILY TEACHING
N To reduce nausea/vomiting, take temozolomide on an empty stomach. N Do not open capsules. N Promptly report fever, sore throat, signs of local infection, unusual bruising/bleeding from any site. N Avoid crowds, those with infection. N Do not have immunizations without physician's approval. N Avoid pregnancy.
tenecteplase A
ten-eck-teh-place
(TNKase)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Tissue plasminogen activator. CLINICAL: Thrombolytic.
ACTION
A tissue plasminogen activator produced by recombinant DNA that binds to fibrin and converts plasminogen to plasmin. Initiates fibrinolysis by degrading fibrin clots, fibrinogen, other plasma proteins. Therapeutic Effect: Exerts thrombolytic action.
PHARMACOKINETICS
Extensively distributed to tissues. Completely eliminated by hepatic metabolism. Half-life: 11U20 min.
USES
Treatment and reduction of mortality associated with acute myocardial infarction (AMI).
PRECAUTIONS
CONTRAINDICATIONS: Active internal bleeding, aneurysm, AV malformation, bleeding diathesis, history of cerebrovascular accident (CVA), intracranial or intraspinal surgery or trauma within past 2 mo, intracranial neoplasm, severe uncontrolled hypertension. CAUTIONS: Patients who previously received tenecteplase, severe hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: May have increased risk of intracranial hemorrhage, stroke, major bleeding; caution advised.
INTERACTIONS
DRUG: Anticoagulants (such as heparin, warfarin), aspirin, dipyridamole, glycoprotein IIb/IIIa inhibitors: Increase the risk of bleeding. HERBAL: Ginkgo biloba: May increase the risk of bleeding. FOOD: None known. LAB VALUES: Decreases plasminogen and fibrinogen levels during infusion, decreasing clotting time and confirming presence of lysis. Decreases Hct and Hgb.
AVAILABILITY (Rx)
POWDER FOR INJECTION: 50 mg.
ADMINISTRATION/HANDLING
L IV
Reconstitution N Add 10 ml sterile water for injection without preservative to vial to provide concentration of 5 mg/ml. N Gently swirl until dissolved. Do not shake. N If foaming occurs, vial should be left undisturbed for several minutes.
Rate of administration N Administer as IV push over 5 sec.
Storage N Store at room temperature. N If possible, use immediately but may refrigerate up to 8 hr after reconstitution. N Appears as colorless to pale yellow solution. Do not use if discolored or contains particulates. N Discard after 8 hr.
D IV INCOMPATIBILITIES
Do not mix with other medications.
INDICATIONS/ROUTES/DOSAGE
ACUTE MI
IV: ADULTS: Dosage is based on patient's weight. Treatment should be initiated as soon as possible after onset of symptoms.
SIDE EFFECTS
FREQUENT: Bleeding (major, 4.7%; minor, 21.8%).
ADVERSE REACTIONS/TOXIC EFFECTS
Bleeding at internal sites may occur, including intracranial, retroperitoneal, GI, GU, and respiratory sites. Lysis or coronary thrombi may produce atrial or ventricular arrhythmias and stroke.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Obtain baseline BP, apical pulse. Record weight. Evaluate 12-lead EKG, cardiac enzymes, serum electrolytes. Assess Hgb, Hct, platelet count, thrombin (TT), aPTT, PT, fibrinogen level before therapy is instituted. Type and hold blood.
INTERVENTION/EVALUATION
Continuous cardiac monitoring for arrhythmias, BP, pulse, respirations q15min until stable, then hourly. Check peripheral pulses, heart and lung sounds. Monitor chest pain relief; notify physician of continuation/recurrence (note location, type, intensity). Assess for overt or occult blood in any body substance. Monitor aPTT per protocol. Maintain BP. Avoid any trauma that might increase risk of bleeding (e.g., injections, shaving). Assess neurologic status with vital signs.
tenofovir
ten-oh-foh-veer
(Viread)
FIXED-COMBINATION(S)
Truvada: tenofovir/emtricitabine (an antiretroviral agent): 300 mg/200 mg.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Nucleotide analogue. CLINICAL: Antiviral.
ACTION
A nucleotide analogue that inhibits HIV reverse transcriptase by being incorporated into viral DNA, resulting in DNA chain termination. Therapeutic Effect: Slows HIV replication and reduces HIV RNA levels (viral load).
PHARMACOKINETICS
Bioavailability in fasted patients is approximately 25%. High-fat meals increase the bioavailability. Protein binding: 0.7%U7.2%. Excreted in urine. Removed by hemodialysis. Half-life: Unknown.
USES
Treatment of HIV-1 infection in combination with other antiretroviral agents.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Hepatic or renal impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed is breast milk. Pregnancy Category B. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Didanosine: May increase didanosine blood concentration. Indinavir, lamivudine, lopinavir, ritonavir: May decrease the blood concentrations of these drugs. HERBAL: None known. FOOD: High-fat food: Increases tenofovir bioavailability. LAB VALUES: May elevate liver function test results. May alter serum creatine kinase (CK), GGT, uric acid, AST, ALT, and triglyceride levels as well as creatinine clearance.
AVAILABILITY (Rx)
TABLETS: 300 mg.
ADMINISTRATION/HANDLING
N Give with food.
INDICATIONS/ROUTES/DOSAGE
HIV INFECTION (IN COMBINATION WITH OTHER ANTIRETROVIRALS)
DOSAGE IN RENAL IMPAIRMENT
SIDE EFFECTS
OCCASIONAL: GI disturbances (diarrhea, flatulence, nausea, vomiting).
ADVERSE REACTIONS/TOXIC EFFECTS
Lactic acidosis and hepatomegaly with steatosis occur rarely, but may be severe.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Obtain baseline laboratory testing, especially serum liver function tests, triglycerides before beginning tenofovir therapy and at periodic intervals during therapy. Offer emotional support to patient and family.
INTERVENTION/EVALUATION
Closely monitor for evidence of GI discomfort. Monitor pattern of bowel activity and stool consistency. Monitor CBC, Hgb, reticulocyte count, serum liver function, CD4 cell count, HIV, RNA plasma levels.
PATIENT/FAMILY TEACHING
N Continue therapy for full length of treatment. N Tenofovir is not a cure for HIV infection, nor does it reduce risk of transmission to others. N Take with a meal (increases absorption). N Inform physician if persistent abdominal pain, nausea, vomiting occurs.
terbinafine hydrochloride
ter-been-a-feen
(Apo-Terbinafine J, Lamisil, Lamisil AT, Novo-Terbinafine J)
Do not confuse terbinafine with terbutaline or Lamisil with Lamictal.
CLASSIFICATION
CLINICAL: Antifungal.
ACTION
A fungicidal antifungal that inhibits the enzyme squalene epoxidase, thereby interfering with fungal biosynthesis. Therapeutic Effect: Results in death of fungal cells.
PHARMACOKINETICS
Well absorbed following PO administration. Protein binding: 99%. Metabolized by liver. Primarily excreted in urine; minimal elimination in feces. Half-life: (oral): 36 hr, (topical): 22U26 hr.
USES
Systemic: Treatment of onychomycosis (fungal disease of nails due to dermatophytes). Topical: Treatment of tinea cruris (jock itch), t. pedis (athlete's foot), t. corporis (ringworm).
PRECAUTIONS
CONTRAINDICATIONS: Oral: Children younger than 12 yr, preexisting hepatic or renal impairment (creatinine clearance of 50 ml/min or less). CAUTIONS: None known.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Distributed in breast milk. Pregnancy Category B. Children: Safety and efficacy not established. Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Alcohol, other hepatotoxic medications: May increase the risk of hepatotoxicity. Hepatic enzyme inducers, including rifampin: May increase terbinafine clearance. Hepatic enzyme inhibitors, including cimetidine: May decrease terbinafine clearance. HERBAL: None known. FOOD: None known. LAB VALUES: May increase AST and ALT levels.
AVAILABILITY (Rx)
TABLETS (LAMISIL): 250 mg. CREAM (LAMISIL AT): 1%. TOPICAL SOLUTION (LAMISIL, LAMISIL AT): 1%. TOPICAL SPRAY (LAMISIL AT): 1%.
INDICATIONS/ROUTES/DOSAGE
TINEA PEDIS
TOPICAL: ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: Apply twice a day until signs and symptoms significantly improve.
TINEA CRURIS, TINEA CORPORIS
TOPICAL: ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: Apply 1U2 times a day until signs and symptoms significantly improve.
ONYCHOMYCOSIS
TINEA VERSICOLOR
TOPICAL SOLUTION: ADULTS, ELDERLY: Apply to the affected area twice a day for 7 days.
SYSTEMIC MYCOSIS
SIDE EFFECTS
FREQUENT (13%): Oral: Headache. OCCASIONAL (6%U3%): Abdominal pain, flatulence, urticaria, visual disturbance. Oral: Diarrhea, rash, dyspepsia, pruritus, taste disturbance, nausea. Topical: Irritation, burning, pruritus, dryness.
ADVERSE REACTIONS/TOXIC EFFECTS
Hepatobiliary dysfunction (including cholestatic hepatitis), serious skin reactions, and severe neutropenia occur rarely. Ocular lens and retinal changes have been noted.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Serum liver function tests should be obtained in patients receiving treatment for longer than 6 wk.
INTERVENTION/EVALUATION
Check for therapeutic response. Discontinue medication, notify physician if local reaction occurs (irritation, redness, swelling, itching, oozing, blistering, burning). Monitor serum liver function in patients receiving treatment for longer than 6 wk.
PATIENT/FAMILY TEACHING
N Keep areas clean, dry; wear light clothing to promote ventilation. N Separate personal items. N Avoid topical cream contact with eyes, nose, mouth, other mucous membranes. N Rub well into affected, surrounding area. N Do not cover with occlusive dressing. N Notify physician if skin irritation, diarrhea occurs.
testosterone
tess-toss-ter-one
(Andriol J, Androderm, AndroGel, Andro LA 200, Andropository J, Delatestryl, Depandro 100, Depotest J, Depo-Testosterone, Everone J, FIRST-Testosterone, FIRST-Testosterone MC, Striant, Testim, Testoderm, Testoprel, Testro AQ, Testro-L.A., Virilon IM J)
Do not confuse testosterone with testolactone.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Androgen. CLINICAL: Sex hormone.
ACTION
A primary endogenous androgen that promotes growth and development of male sex organs and maintains secondary sex characteristics in androgen-deficient males. Therapeutic Effect: Helps relieve androgen deficiency.
PHARMACOKINETICS
Well absorbed after IM administration. Protein binding: 98%. Undergoes first-pass metabolism in the liver. Primarily excreted in urine. Unknown if removed by hemodialysis. Half-life: 10U20 min.
USES
Injection: Treatment of delayed male puberty, male hypogonadism, inoperable female breast cancer. Pellet: Treatment of delayed male puberty, male hypogonadism. Buccal, transdermal: Male hypogonadism.
PRECAUTIONS
CONTRAINDICATIONS: Breast-feeding, cardiac impairment, hypercalcemia, pregnancy, prostate or breast cancer in males, severe hepatic or renal disease. CAUTIONS: Renal or hepatic dysfunction, diabetes.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Contraindicated during lactation. Pregnancy Category X. Children: Safety and efficacy not established; use with caution. Elderly: May increase risk of hyperplasia or stimulate growth of occult prostate carcinoma.
INTERACTIONS
DRUG: Hepatotoxic medications: May increase the risk of hepatotoxicity. Oral anticoagulants: May increase the effects of oral anticoagulants. HERBAL: None known. FOOD: None known. LAB VALUES: May increase blood Hgb level and Hct, as well as serum LDL, alkaline phosphatase, bilirubin, calcium, potassium, sodium, and AST levels. May decrease serum HDL level.
AVAILABILITY (Rx)
CYPIONATE INJECTION (DEPO-TESTOSTERONE): 100 mg/ml, 200 mg/ml. ETHANATE INJECTION (ANDRO LA 200, DELATESTRYL, TESTRO-L.A.): 200 mg/ml. PROPIONATE INJECTION SOLUTION (DEPANDRO 100): 100 mg/ml. INTRAMUSCULAR SOLUTION: 50 mg/ml (Testro), 100 mg/ml (Testro AQ). SUBCUTANEOUS PELLETS (TESTOPEL): 75 mg. TOPICAL GEL: 25 mg/2.5 g (AndroGel) 50 mg/5 g (AndroGel, Testim). TOPICAL CREAM (FIRST-TESTOSTERONE MC): 2%. TOPICAL OINTMENT (FIRST-TESTOSTERONE): 2%. TRANSDERMAL PATCH: 2.5 mg/day (Androderm), 4 mg/day (Testoderm), 5 mg/day (Androderm), 6 mg/day (Testoderm). BUCCAL (STRIANT): 30 mg.
ADMINISTRATION/HANDLING
IM
N Give deep in gluteal muscle. N Do not give IV. N Warming or shaking redissolves crystals that may form in long-acting preparations. N Wet needle of syringe may cause solution to become cloudy; this does not affect potency.
BUCCAL (STRIANT)
N Apply to gum area (above incisor tooth). N Not affected by food, tooth brushing, gum, chewing, alcoholic beverages. N Remove before placing new system.
TRANSDERMAL
Testoderm N Apply to clean, dry scrotal skin that has been dry-shaved (optimal skin contact). Testoderm TTS may be applied to arm, back, upper buttock.
Androderm N Apply to clean, dry area on skin on back, abdomen, upper arms, thighs. N Do not apply to bony prominences (e.g., shoulder) or oily, damaged, irritated skin. Do not apply to scrotum. N Rotate application site with 7-day interval to same site.
TRANSDERMAL GEL
(Androgel, Testim) N Apply (morning preferred) to clean, dry, intact skin of shoulder, upper arms (Androgel may also be applied to abdomen). N Upon opening packet(s), squeeze entire contents into palm of hand and immediately apply to application site. N Allow to dry N Do not apply to genitals.
INDICATIONS/ROUTES/DOSAGE
MALE HYPOGONADISM
IM: ADULTS: 50U400 mg q2U4wk. ADOLESCENTS: Initially 40U50 mg/m2/dose monthly until growth rate falls to prepubertal levels. 100 mg/m2/dose until growth ceases. Maintenance virilizing dose: 100 mg/m2/dose twice a month.
SUBCUTANEOUS (PELLETS): ADULTS, ADOLESCENTS: 150U450 mg q3U6mo.
TRANSDERMAL (PATCH [TESTODERM]): ADULTS, ELDERLY: Start therapy with 6 mg/day patch. Apply patch to scrotal skin.
TRANSDERMAL (PATCH [TESTODERM TTS]): ADULTS, ELDERLY: Apply TTS patch to arm, back, or upper buttocks.
TRANSDERMAL (PATCH [ANDRODERM]): ADULTS, ELDERLY: Start therapy with 5 mg/day patch applied at night. Apply patch to abdomen, back, thighs, or upper arms.
TRANSDERMAL (GEL [ANDROGEL]): ADULTS, ELDERLY: Initial dose of 5 mg delivers 50 mg testosterone and is applied once daily to the abdomen, shoulders, or upper arms. May increase to 7.5 g, then to 10 g, if necessary.
TRANSDERMAL (GEL [TESTIM]): ADULTS, ELDERLY: Initial dose of 5 g delivers 50 mg testosterone and is applied once a day to the shoulders or upper arms. May increase to 10 g.
BUCCAL SYSTEM (STRIANT): ADULTS, ELDERLY: 30 mg q12h.
DELAYED PUBERTY
IM: ADULTS: 50U200 mg q2U4wk. ADOLESCENTS: 40U50 mg/m2/dose every month for 6 mo.
SUBCUTANEOUS (PELLETS): ADULTS, ADOLESCENTS: 150U450 mg q3U6mo.
BREAST CARCINOMA
IM (TESTOSTERONE AQUEOUS): ADULTS: 50U100 mg 3 times a week.
IM (TESTOSTERONE CYPIONATE OR TESTOSTERONE ETHANATE): ADULTS: 200U400 mg q2U4wk.
IM (TESTOSTERONE PROPIONATE): ADULTS: 50U100 mg 3 times a week.
SIDE EFFECTS
FREQUENT: Gynecomastia, acne. Females: Hirsutism, amenorrhea or other menstrual irregularities, deepening of voice, clitoral enlargement that may not be reversible when drug is discontinued. OCCASIONAL: Edema, nausea, insomnia, oligospermia, priapism, male-pattern baldness, bladder irritability, hypercalcemia (in immobilized patients or those with breast cancer), hypercholesterolemia, inflammation and pain at IM injection site. Transdermal: Pruritus, erythema, skin irritation. RARE: Polycythemia (with high dosage), hypersensitivity.
ADVERSE REACTIONS/TOXIC EFFECTS
Peliosis hepatitis (presence of blood-filled cysts in parenchyma of liver), hepatic neoplasms, and hepatocellular carcinoma have been associated with prolonged high-dose therapy. Anaphylactic reactions occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Establish baseline weight, BP, Hgb, Hct. Check serum liver function, electrolytes, cholesterol. Wrist x-rays may be ordered to determine bone maturation in children.
INTERVENTION/EVALUATION
Weigh daily and report weekly gain of more than 5 lb; evaluate for edema. Monitor I&O. Check BP at least twice a day. Assess serum electrolytes, cholesterol, Hgb, Hct (periodically for high dosage), liver function test results, radiologic exam of wrist and hand (when using in prepubertal children). With breast cancer or immobility, check for hypercalcemia (lethargy, muscle weakness, confusion, irritability). Ensure adequate intake of protein, calories. Assess for virilization. Monitor sleep patterns. Check injection site for redness, swelling, pain.
PATIENT/FAMILY TEACHING
N Regular visits to physician and monitoring tests are necessary. N Do not take any other medications without consulting physician. N Teach diet high in protein, calories. N Food may be better tolerated in small, frequent feedings. N Weigh daily, report 5 lb/wk gain. N Notify physician if nausea, vomiting, acne, pedal edema occurs. N Females: Promptly report menstrual irregularities, hoarseness, deepening of voice. N Males: Report frequent erections, difficulty urinating, gynecomastia.
thalidomide
thah-lid-owe-mide
(Thalomid)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Immunomodulator. CLINICAL: Immunosuppressive agent.
ACTION
An immunomodulator whose exact mechanism is unknown. Has sedative, anti-inflammatory, and immunosuppressive activity, which may be due to selective inhibition of the production of tumor necrosis factor-alpha. Therapeutic Effect: Improves muscle wasting in HIV patients; reduces local and systemic effects of leprosy.
PHARMACOKINETICS
Protein binding: 55%. Metabolism and elimination are not known. Half-life: 5U7 hr.
USES
Treatment of leprosy. OFF-LABEL: Prevention and treatment of discoid lupus erythematosus, erythema fultiforme, graft vs host reactions following bone marrow transplantation, rheumatoid arthritis; treatment of Behcet's syndrome, Crohn's disease, GI bleeding, multiple myeloma, pruritus, recurrent aphthous ulcers in HIV patients, wasting syndrome associated with HIV or cancer.
PRECAUTIONS
CONTRAINDICATIONS: Neutropenia, peripheral neuropathy; pregnancy. CAUTIONS: History of seizures.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Contraindicated in women who are or may become pregnant and who are not using two required types of birth control or who are not continually abstaining from heterosexual sexual contact. Can cause severe birth defects, fetal death. Unknown if distributed in breast milk. Pregnancy Category X. Children: Safety and efficacy not established in children under 12 yr. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Alcohol, other CNS depressants: May increase sedative effects. Medications associated with peripheral neuropathy (such as isoniazid, lithium, metronidazole, phenytoin): May increase peripheral neuropathy. Medications that decrease effectiveness of hormonal contraceptives (such as carbamazepine, protease inhibitors, rifampin): May decrease the effectiveness of the contraceptive; patient must use two other methods of contraception. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
CAPSULES: 50 mg, 100 mg, 200 mg.
ADMINISTRATION/HANDLING
O ALERT P Thalidomide may be prescribed only by licensed prescribers who are registered in the S.T.E.P.S. program and understand the risk of teratogenicity if thalidomide is used during pregnancy. N Administer thalidomide with water at least 1 hr after the evening meal and, if possible, at bedtime because of the risk of developing somnolence.
INDICATIONS/ROUTES/DOSAGE
AIDS-RELATED MUSCLE WASTING
LEPROSY
SIDE EFFECTS
FREQUENT: Somnolence, dizziness, mood changes, constipation, dry mouth, peripheral neuropathy. OCCASIONAL: Increased appetite, weight gain, headache, loss of libido, edema of face and limbs, nausea, alopecia, dry skin, rash, hypothyroidism.
ADVERSE REACTIONS/TOXIC EFFECTS
Neutropenia, peripheral neuropathy, and thromboembolism occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Assess for hypersensitivity to thalidomide. Assess for pregnancy in females 24 hr before beginning thalidomide therapy (contraindicated). Determine use of other medications (many interactions).
INTERVENTION/EVALUATION
Monitor WBC, nerve conduction studies, HIV viral load. Observe for signs and symptoms of peripheral neuropathy. Perform pregnancy tests on women of childbearing potential. Perform the test weekly during the first 4 wk of use, then at 4Uwk intervals in women with regular menstrual cycles or q2wk in women with irregular menstrual cycles.
PATIENT/FAMILY TEACHING
N Avoid tasks requiring alertness, motor skills until response to drug is established. N Avoid use of alcoholic beverages, other drugs causing drowsiness. N Pregnancy test within 24 hr before starting thalidomide, then q2U4wk in women of childbearing age. N Discontinue and call physician if symptoms of peripheral neuropathy occur. N Advise male patients receiving thalidomide to always use a latex condom during any sexual contact with women of childbearing potential.
ticarcillin disodium/clavulanate potassium
tie-car-sill-in/klah-view-lan-ate
(Timentin)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Penicillin. CLINICAL: Antibiotic.
ACTION
Ticarcillin binds to bacterial cell walls, inhibiting cell wall synthesis. Clavulanate inhibits the action of bacterial beta-lactamase. Therapeutic Effect: Ticarcillin is bactericidal in susceptible organisms. Clavulanate protects ticarcillin from enzymatic degradation.
USES
Treatment of susceptible infections due to P. aeruginosa, E. coli, Enterobacter, Proteus, beta-lactamase producing S. aureus, M. catarrhalis, H. influenzae, Klebsiella, B. fragilis including septicemia, skin and skin-structure, bone, joint, lower respiratory tract, gynecologic, intra-abdominal, urinary tract infections.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to any penicillin or clavulanic acid. CAUTIONS: History of allergies (especially cephalosporins), renal impairment. Pregnancy Category B.
INTERACTIONS
DRUG: Anticoagulants, heparin, NSAIDs, thrombolytics: May increase the risk of hemorrhage with high dosages of ticarcillin. Probenecid: May increase ticarcillin blood concentration and risk of toxicity. HERBAL: None known. FOOD: None known. LAB VALUES: May increase bleeding time and serum alkaline phosphatase, bilirubin, creatinine, LDH, AST, and ALT levels. May decrease serum potassium, sodium, and uric acid levels. May cause a positive Coombs' test.
AVAILABILITY (Rx)
ADD-VANTAGE VIAL: 3.1 g. POWDER FOR INJECTION: 3.1 g. PREMIXED SOLUTION FOR INFUSION: 3.1 g/100 ml.
ADMINISTRATION/HANDLING
L IV
Reconstitution N Available in ready-to-use containers. N For IV infusion (piggyback), reconstitute each 3.1-g vial with 13 ml sterile water for injection or 0.9% NaCl to provide concentration of 200 mg ticarcillin and 6.7 mg clavulanic acid per ml. N Shake vial to assist reconstitution. N Further dilute with 50U100 ml D5W or 0.9% NaCl.
Rate of administration N Infuse over 30 min. N Because of potential for hypersensitivity and anaphylaxis, start initial dose at few drops/min, increase slowly to ordered rate. N Monitor patient first 10U15 min during initial dose, then check q10min.
Storage N Solution appears colorless to pale yellow (if solution darkens, indicates loss of potency). N Reconstituted IV infusion (piggyback) is stable for 24 hr at room temperature, 3 days if refrigerated. N Discard if precipitate forms.
D IV INCOMPATIBILITIES
Amphotericin B complex (Abelcet, AmBisome, Amphotec), vancomycin (Vancocin), total parenteral nutrition (TPN).
IV COMPATIBILITIES
Diltiazem (Cardizem), heparin, insulin, morphine, propofol (Diprivan).
INDICATIONS/ROUTES/DOSAGE
SKIN AND SKIN-STRUCTURE, BONE, JOINT, AND LOWER RESPIRATORY TRACT INFECTIONS; SEPTICEMIA; ENDOMETRIOSIS
IV: ADULTS, ELDERLY: 3.1 g (3 g ticarcillin) q4U6h. Maximum: 18U24 g/day. CHILDREN 3 MO AND OLDER: 200U300 mg (as ticarcillin) q4U6h.
UTIs
IV: ADULTS, ELDERLY: 3.1 g q6U8h.
DOSAGE IN RENAL IMPAIRMENT
Dosage interval is modified based on creatinine clearance.
SIDE EFFECTS
FREQUENT: Phlebitis or thrombophlebitis (with IV dose), rash, urticaria, pruritus, altered smell or taste. OCCASIONAL: Nausea, diarrhea, vomiting. RARE: Headache, fatigue, hallucinations, bleeding or ecchymosis.
ADVERSE REACTIONS/TOXIC EFFECTS
Overdosage may produce seizures and other neurologic reactions. Antibiotic-associated colitis and other superinfections may result from bacterial imbalance. Severe hypersensitivity reactions, including anaphylaxis, occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Question for history of allergies, especially penicillins, cephalosporins.
INTERVENTION/EVALUATION
Hold medication and promptly report rash (hypersensitivity), diarrhea (fever, abdominal pain, mucus and blood in stool may indicate antibiotic-associated colitis). Assess food tolerance. Provide mouth care, sugarless gum, hard candy to offset altered taste, smell. Evaluate IV site for phlebitis (heat, pain, red streaking over vein). Monitor I&O, urinalysis, renal function tests. Assess for overt bleeding, ecchymoses, swelling. Monitor hematology reports, serum electrolytes, particularly potassium. Be alert for superinfection: increased fever, sore throat, diarrhea, vomiting, stomatitis, anal/genital pruritus.
tinidazole
tin-nid-ah-zole
(Tindamax)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Nitroimidazole derivative. CLINICAL: Antiprotozoal.
ACTION
A nitroimidazole derivative that is converted to the active metabolite by reduction of cell extracts of Trichomonas. The active metabolite causes DNA damage in pathogens. Therapeutic Effect: Produces antiprotozoal effect.
PHARMACOKINETICS
Rapidly and completely absorbed. Protein binding: 12%. Distributed in all body tissues and fluids; crosses blood-brain barrier. Significantly metabolized. Primarily excreted in urine; partially eliminated in feces. Half-life: 12U14 hr.
USES
Treatment of intestinal amebiasis and amebic hepatic abscess, giardiasis, trichomoniasis.
PRECAUTIONS
CONTRAINDICATIONS: First trimester of pregnancy, hypersensitivity to nitroimidazole derivatives. CAUTIONS: CNS diseases, hepatic impairment, history of blood abnormalities.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Mutagenic, spermatogenic. Readily crosses placenta; distributed in breast milk. Contraindicated during first trimester. Pregnancy Category C. Children: Safety and efficacy in children younger than 3 yr not established. Elderly: Age-related hepatic impairment may require dosage adjustment.
INTERACTIONS
DRUG: Alcohol: May cause a disulfiram-type reaction. Cholestyramine, oxytetracycline: May decrease the effectiveness of tinidazole; separate dosage times. Cimetidine, fosphenytoin, ketoconazole, phenobarbital, rifampin: Decreases the metabolism of tinidazole. Cyclosporine, fluorouracil, lithium, phenytoin (IV), tacrolimus: May increase blood levels of these drugs. Disulfiram: May increase the risk of psychotic reactions (separate dose by 2 wk). Oral anticoagulants: Increase the risk of bleeding. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum LDH, triglyceride, AST, and ALT levels.
AVAILABILITY (Rx)
TABLETS: 250 mg, 500 mg.
ADMINISTRATION/HANDLING
N Store at room temperature. N Scored tablets may be crushed. N Give with food (minimizes incidence of epigastric distress).
INDICATIONS/ROUTES/DOSAGE
INTESTINAL AMEBIASIS
AMEBIC HEPATIC ABSCESS
GIARDIASIS
TRICHOMONIASIS
SIDE EFFECTS
OCCASIONAL (4%U2%): Metallic or bitter taste, nausea, weakness, fatigue or malaise. RARE (less than 2%): Epigastric distress, anorexia, vomiting, headache, dizziness, red-brown or darkened urine.
ADVERSE REACTIONS/TOXIC EFFECTS
Peripheral neuropathy, characterized by paresthesia, is usually reversible if tinidazole treatment is stopped as soon as neurologic symptoms appear. Superinfection, hypersensitivity reaction, and seizures occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Question for history of hypersensitivity to metronidazole or other nitroimidazole derivatives. Obtain specimens for diagnostic tests before giving first dose (therapy may begin before results are known).
INTERVENTION/EVALUATION
Be alert to neurologic symptoms: dizziness, numbness, tingling, paraesthesia of extremities. Assess for nausea, vomiting and initiate appropriate measures. Watch for onset of superinfection: ulceration or change of oral mucosa, furry tongue, vaginal discharge, genital or anal pruritus.
PATIENT/FAMILY TEACHING
N Take medication with food. N Avoid alcoholic beverages during therapy and for 3 days after completion of treatment. N Urine may be red-brown or dark. N Avoid alcohol-containing preparations, e.g., cough syrups, elixirs. N Avoid tasks that require alertness, motor skills until response to drug is established (may cause dizziness).
tiotropium bromide
tee-oh-trow-pea-um
(Spiriva)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Anticholinergic. CLINICAL: Bronchodilator.
ACTION
An anticholinergic that binds to recombinant human muscarinic receptors at the smooth muscle, resulting in long-acting bronchial smooth-muscle relaxation. Therapeutic Effect: Relieves bronchospasm.
PHARMACOKINETICS
Route Onset Peak Duration
Inhalation N/A N/A 24U36 hr
Binds extensively to tissue. Protein binding: 72%. Metabolized by oxidation. Excreted in urine. Half-life: 5U6 days.
USES
Long-term maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease (COPD), including chronic bronchitis, emphysema.
PRECAUTIONS
CONTRAINDICATIONS: History of hypersensitivity to atropine or its derivatives, including ipratropium. CAUTIONS: Narrow-angle glaucoma, prostatic hypertrophy, bladder neck obstruction.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: Higher frequency of dry mouth, constipation, UTI noted with increasing age.
INTERACTIONS
DRUG: Ipratropium: Concurrent administration with this drug is not recommended. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
POWDER FOR INHALATION: 18 mcg/capsule (in blister packs containing 6 capsules with inhaler).
ADMINISTRATION/HANDLING
INHALATION
N Open dustcap of HandiHaler by pulling it upward, then open the mouthpiece. N Place capsule in the center chamber and firmly close the mouthpiece until a click is heard, leaving the dustcap open. N Hold HandiHaler device with the mouthpiece upward, pressing the piercing button completely in once, and release. N Instruct patient to breathe out completely before breathing in slowly and deeply but at a rate sufficient to hear the capsule vibrate. N Have the patient hold breath as long as it is comfortable until exhaling slowly. N To ensure receiving the full dose, instruct patient to repeat once.
Storage N Store at room temperature. Do not expose capsules to extreme temperature or moisture. N Do not store capsules in HandiHaler device.
INDICATIONS/ROUTES/DOSAGE
COPD
INHALATION: ADULTS, ELDERLY: 18 mcg (1 capsule)/day via HandiHaler inhalation device.
SIDE EFFECTS
FREQUENT (16%U6%): Dry mouth, sinusitis, pharyngitis, dyspepsia, UTI, rhinitis. OCCASIONAL (5%U4%): Abdominal pain, peripheral edema, constipation, epistaxis, vomiting, myalgia, rash, oral candidiasis.
ADVERSE REACTIONS/TOXIC EFFECTS
Angina pectoris, depression, and flu-like symptoms occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Offer emotional support (high incidence of anxiety due to difficulty in breathing and sympathomimetic response to drug).
INTERVENTION/EVALUATION
Monitor rate, depth, rhythm, type of respiration; quality and rate of pulse. Assess lung sounds for rhonchi, wheezing, rales. Monitor ABGs. Observe lips, fingernails for cyanosis (blue or dusky color in light-skinned patients; gray in dark-skinned patients). Observe for clavicular retractions, hand tremor. Evaluate for clinical improvement (quieter, slower respirations, relaxed facial expression, cessation of clavicular retractions).
PATIENT/FAMILY TEACHING
N Increase fluid intake (decreases lung secretion viscosity). N Do not use more than 1 capsule for inhalation at any one time. N Rinsing mouth with water immediately after inhalation may prevent mouth and throat dryness, moniliasis. N Avoid excessive use of caffeine derivatives (chocolate, coffee, tea, cola, cocoa).
tizanidine
tye-zan-i-deen
(Zanaflex)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Skeletal muscle relaxant. CLINICAL: Antispastic.
ACTION
A skeletal muscle relaxant that increases presynaptic inhibition of spinal motor neurons mediated by alpha2-adrenergic agonists, reducing facilitation to postsynaptic motor neurons. Therapeutic Effect: Reduces muscle spasticity.
USES
Acute and intermittent management of muscle spasticity (spasms, stiffness, rigidity). OFF-LABEL: Low back pain, spasticity associated with multiple sclerosis or spinal cord injury, tension headaches, trigeminal neuralgia.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Renal or hepatic disease, hypotension, cardiac disease. Pregnancy Category C.
INTERACTIONS
DRUG: Alcohol, other CNS depressants: May increase CNS depressant effects. Antihypertensives: May increase tizanidine's hypotensive potential. Oral contraceptives: May reduce tizanidine clearance. Phenytoin: May increase serum levels and risk of toxicity of phenytoin. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum alkaline phosphatase, AST, and ALT levels.
AVAILABILITY (Rx)
TABLETS: 2 mg, 4 mg.
INDICATIONS/ROUTES/DOSAGE
MUSCLE SPASTICITY
SIDE EFFECTS
FREQUENT (49%U41%): Dry mouth, somnolence, asthenia. OCCASIONAL (16%U4%): Dizziness, UTI, constipation. RARE (3%): Nervousness, amblyopia, pharyngitis, rhinitis, vomiting, urinary frequency.
ADVERSE REACTIONS/TOXIC EFFECTS
Hypotension (a reduction in either diastolic or systolic BP) may be associated with bradycardia, orthostatic hypotension and, rarely, syncope. The risk of hypotension increases as dosage increases; BP may decrease within 1 hr after administration.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Record onset, type, location, duration of muscular spasm. Check for immobility, stiffness, swelling. Obtain baseline serum liver function tests, alkaline phosphatase, total bilirubin.
INTERVENTION/EVALUATION
Assist with ambulation at all times. For those on long-term therapy, serum liver and renal function tests should be performed periodically. Evaluate for therapeutic response (decreased intensity of skeletal muscle pain or tenderness, improved mobility, decrease in spasticity). To reduce risk of orthostatic hypotension, instruct patient to rise slowly from lying to sitting and from sitting to supine position.
PATIENT/FAMILY TEACHING
N Avoid tasks that require alertness, motor skills until response to drug is established. N Avoid sudden changes in posture. N May cause hypotension, sedation, impaired coordination.
tobramycin sulfate
tow-bra-my-sin
(AK-Tob, Apo-Tobramycin J, Nebcin, Nebcin Pediatric, PMS-Tobramycin, TOBI, Tobrex)
FIXED-COMBINATION(S)
TobraDex: tobramycin/dexamethasone (a steroid): 0.3%/0.1% per ml or per g. Zylet: tobramycin/loteprednol: 0.3%/0.5%.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Aminoglycoside. CLINICAL: Antibiotic.
ACTION
An aminoglycoside antibiotic that irreversibly binds to protein on bacterial ribosomes. Therapeutic Effect: Interferes with protein synthesis of susceptible microorganisms.
PHARMACOKINETICS
Rapid, complete absorption after IM administration. Protein binding: less than 30%. Widely distributed (doesn't cross the blood-brain barrier; low concentrations in cerebrospinal fluid (CSF). Excreted unchanged in urine. Removed by hemodialysis. Half-life: 2U4 hr (increased in impaired renal function and neonates; decreased in cystic fibrosis and febrile or burn patients).
USES
Treatment of susceptible infections due to P. aeruginosa, other gram negative organisms including skin and skin-structure, bone, joint, respiratory tract infections; postop, burn, intra-abdominal infections; complicated UTIs; septicemia; meningitis. Ophthalmic: Superficial eye infections: blepharitis, conjunctivitis, keratitis, corneal ulcers. Inhalation: Bronchopulmonary infections in patients with cystic fibrosis.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to other aminoglycosides (cross-sensitivity) and their components. CAUTIONS: Renal impairment, preexisting auditory or vestibular impairment, concomitant use of neuromuscular blocking agents.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Drug readily crosses placenta; is distributed in breast milk. May cause fetal nephrotoxicity. Ophthalmic form should not be used in breast-feeding mothers and only when specifically indicated in pregnancy. Pregnancy Category C (B, ophthalmic form). Children: Immature renal function in neonates and premature infants may increase risk of toxicity. Elderly: Age-related renal impairment may increase risk of toxicity; dosage adjustment recommended.
INTERACTIONS
DRUG: Nephrotoxic medications, other aminoglycosides, ototoxic medications: May increase the risk of nephrotoxicity and ototoxicity. Neuromuscular blockers: May increase neuromuscular blockade. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum bilirubin, BUN, serum creatinine, serum LDH, AST, and ALT levels. May decrease serum calcium, magnesium, potassium, and sodium concentrations. Therapeutic peak serum level is 5U20 mcg/ml; therapeutic trough serum level is 0.5U2 mcg/ml. Toxic peak serum level is greater than 20 mcg/ml; toxic trough serum level is greater than 2 mcg/ml.
AVAILABILITY (Rx)
INJECTION SOLUTION: 10 mg/ml (Nebcin Pediatric), 40 mg/ml (Nebcin). INJECTION POWDER FOR RECONSTITUTION (NEBCIN): 1.2 g. OPHTHALMIC OINTMENT (TOBREX): 0.3%. OPHTHALMIC SOLUTION (AKTob, TOBREX): 0.3%. NEBULIZATION SOLUTION (TOBI): 60 mg/ml.
ADMINISTRATION/HANDLING
O ALERT P Coordinate peak and trough lab draws with administration times.
L IV
Reconstitution N Dilute with 50U200 ml D5W, 0.9% NaCl. Amount of diluent for infants, children depends on individual need.
Rate of administration N Infuse over 20U60 min.
Storage N Store vials at room temperature. N Solutions may be discolored by light or air (does not affect potency).
IM
N To minimize discomfort, give deep IM slowly. N Less painful if injected into gluteus maximus rather than lateral aspect of thigh.
OPHTHALMIC
N Place finger on lower eyelid, pull out until a pocket is formed between eye and lower lid. N Hold dropper above pocket, place correct number of drops (¼U½ inch ointment) into pocket. Have patientt close eye gently. N Solution: Apply digital pressure to lacrimal sac for 1U2 min (minimizes drainage into nose and throat, reducing risk of systemic effects). N Ointment: Close eye for 1U2 min, rolling eyeball (increases contact area of drug to eye). N Remove excess solution or ointment around eye with tissue.
D IV INCOMPATIBILITIES
Amphotericin B complex (Abelcet, AmBisome, Amphotec), heparin, hetastarch (Hespan), indomethacin (Indocin), propofol (Diprivan), sargramostim (Leukine, Prokine).
IV COMPATIBILITIES
Amiodarone (Cordarone), calcium gluconate, diltiazem (Cardizem), furosemide (Lasix), hydromorphone (Dilaudid), insulin, magnesium sulfate, midazolam (Versed), morphine, theophylline, total parenteral nutrition (TPN).
INDICATIONS/ROUTES/DOSAGE
USUAL PARENTERAL DOSAGE
IV: ADULTS, ELDERLY: 3U6 mg/kg/day in 3 divided doses. Once daily dosing: 4U7 mg/kg every 24 hr. CHILDREN 7 DAYS AND OLDER: 6U7.5 mg/kg/day in 3U4 divided doses. CHILDREN YOUNGER THAN 7 DAYS: 2.5U4 mg/kg/day in 2 divided doses.
SUPERFICIAL EYE INFECTIONS, INCLUDING BLEPHARITIS, CONJUNCTIVITIS, KERATITIS, AND CORNEAL ULCERS
OPHTHALMIC OINTMENT: ADULTS, ELDERLY: Usual dosage, apply a thin strip to conjunctiva q8U12h (q3U4h for severe infections).
OPHTHALMIC SOLUTION: ADULTS, ELDERLY: Usual dosage, 1U2 drops in affected eye q4h (2 drops/hr for severe infections).
BRONCHOPULMONARY INFECTIONS IN PATIENTS WITH CYSTIC FIBROSIS
INHALATION SOLUTION: ADULTS: Usual dosage, 60U80 mg twice a day for 28 days, then off for 28 days. CHILDREN: 40U80 mg 2U3 times a day.
DOSAGE IN RENAL IMPAIRMENT
Dosage and frequency are modified based on the degree of renal impairment and the serum drug concentration. After a loading dose of 1U2 mg/kg, the maintenance dose and frequency are based on serum creatinine levels and creatinine clearance.
SIDE EFFECTS
OCCASIONAL: IM: Pain, induration. IV: Phlebitis, thrombophlebitis. Topical: Hypersensitivity reaction (fever, pruritus, rash, urticaria). Ophthalmic: Tearing, itching, redness, eyelid swelling. RARE: Hypotension, nausea, vomiting.
ADVERSE REACTIONS/TOXIC EFFECTS
Nephrotoxicity (as evidenced by increased BUN and serum creatinine levels and decreased creatinine clearance) may be reversible if the drug is stopped at the first sign of nephrotoxic symptoms. Irreversible ototoxicity (manifested as tinnitus, dizziness, ringing or roaring in ears, and hearing loss) and neurotoxicity (manifested as headache, dizziness, lethargy, tremor, and visual disturbances) occur occasionally. The risk of these reactions increases with higher dosages or prolonged therapy and when the solution is applied directly to the mucosa. Superinfections, particularly fungal infections, may result from bacterial imbalance with any administration route. Anaphylaxis may occur.
NURSING CONSIDEARTION
BASELINE ASSESSMENT
Dehydration must be treated before beginning parenteral therapy. Question for history of allergies, especially aminoglycosides and sulfite (and parabens for topical or ophthalmic routes). Establish baseline for hearing acuity.
INTERVENTION/EVALUATION
Monitor I&O (maintain hydration), urinalysis (casts, RBCs, WBCs, decrease in specific gravity). Monitor results of peak/trough blood tests. Therapeutic serum level: Peak: 5U20 mcg/ml; trough: 0.5U2 mcg/ml. Toxic serum level: Peak: over 20 mcg/ml; trough: over 2 mcg/ml. Be alert to ototoxic and neurotoxic symptoms. Evaluate IV site for phlebitis (heat, pain, red streaking over vein). Assess for rash. Be alert for superinfection, particularly genital or anal pruritus, changes of oral mucosa, diarrhea. When treating patients with neuromuscular disorders, assess respiratory response carefully. Ophthalmic: Assess for redness, swelling, itching, tearing.
PATIENT/FAMILY TEACHING
N Notify physician in event of any hearing, visual, balance, urinary problems, even after therapy is completed. N Ophthalmic: Blurred vision or tearing may occur briefly after application. N Contact physician if tearing, redness, irritation continues.
tolterodine tartrate
tol-tare-oh-deen
(Detrol, Detrol LA)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Muscarinic receptor antagonist. CLINICAL: Antispasmodic.
ACTION
An antispasmodic that exhibits potent antimuscarinic activity by interceding via cholinergic muscarinic receptors, thereby inhibiting urinary bladder contraction. Therapeutic Effect: Decreases urinary frequency, urgency.
PHARMACOKINETICS
Rapidly and well absorbed after PO administration. Protein binding: 96%. Extensively metabolized in the liver to active metabolite. Primarily excreted in urine. Unknown if removed by hemodialysis. Half-life: 1.9U3.7 hr.
USES
Treatment of overactive bladder in patients with symptoms of urinary frequency, urgency, incontinence.
PRECAUTIONS
CONTRAINDICATIONS: Gastric retention, uncontrolled angle-closure glaucoma, urine retention. CAUTIONS: Renal impairment, clinically significant bladder outflow obstruction (risk of urinary retention), GI obstructive disorders (e.g., pyloric stenosis [risk of gastric retention]), treated narrow-angle glaucoma.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug is distributed in breast milk. Breast-feeding not recommended. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Clarithromycin, erythromycin, itraconazole, ketoconazole, miconazole: May increase tolterodine blood concentration. Fluoxetine: May inhibit tolterodine metabolism. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
TABLETS (DETROL): 1 mg, 2 mg. CAPSULES (EXTENDED-RELEASE [DETROL LA]): 2 mg, 4 mg.
ADMINISTRATION/HANDLING
N May give without regard to food.
INDICATIONS/ROUTES/DOSAGE
OVERACTIVE BLADDER
DOSAGE IN SEVERE RENAL OR HEPATIC IMPAIRMENT
SIDE EFFECTS
FREQUENT (40%): Dry mouth. OCCASIONAL (11%U4%): Headache, dizziness, fatigue, constipation, dyspepsia (heartburn, indigestion, epigastric discomfort), upper respiratory tract infection, UTI, dry eyes, abnormal vision (accommodation problems), nausea, diarrhea. RARE (3%): Somnolence, chest or back pain, arthralgia, rash, weight gain, dry skin.
ADVERSE REACTIONS/TOXIC EFFECTS
Overdose can result in severe anticholinergic effects, including abdominal cramps, facial warmth, excessive salivation or lacrimation, diaphoresis, pallor, urinary urgency, blurred vision, and prolonged QT interval.
NURSING CONSIDEARTION
INTERVENTION/EVALUATION
Assist with ambulation if dizziness occurs. Question for visual changes. Monitor incontinence, postvoid residuals.
PATIENT/FAMILY TEACHING
N May cause blurred vision, dry eyes/mouth, constipation. N Inform physician of any confusion, altered mental status.
topiramate
toe-peer-a-mate
(Topamax)
Do not confuse topiramate or Topamax with Toprol XL, Tegretol, or Tegretol XL.
CLASSIFICATION
CLINICAL: G Anticonvulsant.
ACTION
An anticonvulsant that blocks repetitive, sustained firing of neurons by enhancing the ability of gamma-aminobutyric acid to induce an influx of chloride ions into the neurons; may also block sodium channels. Therapeutic Effect: Decreases seizure activity.
PHARMACOKINETICS
Rapidly absorbed after PO administration. Protein binding: 13%U17%. Not extensively metabolized. Primarily excreted unchanged in urine. Removed by hemodialysis. Half-life: 21 hr.
USES
Adjunctive therapy for the treatment of partial-onset seizures, tonic-clonic seizures, seizures associated with Lennox-Gastaut syndrome. Prevention of migraine. Initial monotherapy in patients 10 yr of age and older with partial or primary generalized tonic-clonic seizures. OFF-LABEL: Treatment of alcohol dependence.
PRECAUTIONS
CONTRAINDICATIONS: Bipolar disorder. CAUTIONS: Sensitivity to topiramate, hepatic/renal impairment, predisposition to renal calculi.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if distributed in breast milk. Pregnancy Category C. Children: No age-related precautions noted in those older than 2 yr. Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Alcohol, other CNS depressants: May increase CNS depression. Carbamazepine, phenytoin, valproic acid: May decrease topiramate blood concentration. Carbonic anhydrase inhibitors: May increase the risk of renal calculi. Oral contraceptives: May decrease the effectiveness of oral. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
CAPSULES (SPRINKLE): 15 mg, 25 mg. TABLETS: 25 mg, 50 mg, 100 mg, 200 mg.
ADMINISTRATION/HANDLING
N Do not break tablets (bitter taste). N Give without regard to meals. N Capsules may be swallowed whole or contents sprinkled on a teaspoonful of soft food and swallowed immediately; do not chew.
INDICATIONS/ROUTES/DOSAGE
ADJUNCTIVE TREATMENT OF PARTIAL SEIZURES, LENNOX-GASTANT SYNDROME, TONIC-CLONIC SEIZURES
MONOTHERAPY WITH PARTIAL, TONIC-CLONIC SEIZURES
MIGRAINE PREVENTION
DOSAGE IN RENAL IMPAIRMENT
Expect to reduce drug dosage by 50% in patients with tonic-clonic seizures who have a creatinine clearance of less than 70 ml/min.
SIDE EFFECTS
FREQUENT (30%U10%): Somnolence, dizziness, ataxia, nervousness, nystagmus, diplopia, paresthesia, nausea, tremor. OCCASIONAL (9%U3%): Confusion, breast pain, dysmenorrhea, dyspepsia, depression, asthenia, pharyngitis, weight loss, anorexia, rash, musculoskeletal pain, abdominal pain, difficulty with coordination, sinusitis, agitation, flu-like symptoms. RARE (3%U2%): Mood disturbances, such as irritability and depression; dry mouth; aggressive behavior.
ADVERSE REACTIONS/TOXIC EFFECTS
Psychomotor slowing, impaired concentration, language problems (such as word-finding difficulties), and memory disturbances occur occasionally. These reactions are generally mild to moderate but may be severe enough to require discontinuation of drug therapy.
NURSING CONSIDARATION
BASELINE ASSESSMENT
Review history of seizure disorder (intensity, frequency, duration, level of consciousness [LOC]). Initiate seizure precautions. Provide quiet, dark environment. Question for sensitivity to topiramate, pregnancy, use of other anticonvulsant medication (especially carbamazepine, valproic acid, phenytoin, carbonic anhydrase inhibitors). Assess serum renal function. Instruct patient to use alternative/additional means of contraception (topiramate decreases effectiveness of oral contraceptives).
INTERVENTION/EVALUATION
Observe frequently for recurrence of seizure activity. Assess for clinical improvement (decrease in intensity/frequency of seizures). Monitor serum renal function tests (BUN, creatinine). Assist with ambulation if dizziness occurs.
PATIENT/FAMILY TEACHING
N Avoid tasks that require alertness, motor skills until response to drug is established (may cause dizziness, drowsiness, impaired concentration). N Drowsiness usually diminishes with continued therapy. N Avoid use of alcohol, other CNS depressants. N Do not abruptly discontinue drug (may precipitate seizures). N Strict maintenance of drug therapy is essential for seizure control. N Do not break tablets (bitter taste). N Maintain adequate fluid intake (decreases risk of renal stone formation). N Inform physician if blurred vision, eye pain occurs.
topiramate
toe-peer-a-mate
(Topamax)
Do not confuse topiramate or Topamax with Toprol XL, Tegretol, or Tegretol XL.
CLASSIFICATION
CLINICAL: Anticonvulsant.
ACTION
An anticonvulsant that blocks repetitive, sustained firing of neurons by enhancing the ability of gamma-aminobutyric acid to induce an influx of chloride ions into the neurons; may also block sodium channels. Therapeutic Effect: Decreases seizure activity.
PHARMACOKINETICS
Rapidly absorbed after PO administration. Protein binding: 13%U17%. Not extensively metabolized. Primarily excreted unchanged in urine. Removed by hemodialysis. Half-life: 21 hr.
USES
Adjunctive therapy for the treatment of partial-onset seizures, tonic-clonic seizures, seizures associated with Lennox-Gastaut syndrome. Prevention of migraine. Initial monotherapy in patients 10 yr of age and older with partial or primary generalized tonic-clonic seizures. OFF-LABEL: Treatment of alcohol dependence.
PRECAUTIONS
CONTRAINDICATIONS: Bipolar disorder. CAUTIONS: Sensitivity to topiramate, hepatic/renal impairment, predisposition to renal calculi.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if distributed in breast milk. Pregnancy Category C. Children: No age-related precautions noted in those older than 2 yr. Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Alcohol, other CNS depressants: May increase CNS depression. Carbamazepine, phenytoin, valproic acid: May decrease topiramate blood concentration. Carbonic anhydrase inhibitors: May increase the risk of renal calculi. Oral contraceptives: May decrease the effectiveness of oral. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
CAPSULES (SPRINKLE): 15 mg, 25 mg. TABLETS: 25 mg, 50 mg, 100 mg, 200 mg.
ADMINISTRATION/HANDLING
N Do not break tablets (bitter taste). N Give without regard to meals. N Capsules may be swallowed whole or contents sprinkled on a teaspoonful of soft food and swallowed immediately; do not chew.
INDICATIONS/ROUTES/DOSAGE
ADJUNCTIVE TREATMENT OF PARTIAL SEIZURES, LENNOX-GASTANT SYNDROME, TONIC-CLONIC SEIZURES
MONOTHERAPY WITH PARTIAL, TONIC-CLONIC SEIZURES
MIGRAINE PREVENTION
DOSAGE IN RENAL IMPAIRMENT
Expect to reduce drug dosage by 50% in patients with tonic-clonic seizures who have a creatinine clearance of less than 70 ml/min.
SIDE EFFECTS
FREQUENT (30%U10%): Somnolence, dizziness, ataxia, nervousness, nystagmus, diplopia, paresthesia, nausea, tremor. OCCASIONAL (9%U3%): Confusion, breast pain, dysmenorrhea, dyspepsia, depression, asthenia, pharyngitis, weight loss, anorexia, rash, musculoskeletal pain, abdominal pain, difficulty with coordination, sinusitis, agitation, flu-like symptoms. RARE (3%U2%): Mood disturbances, such as irritability and depression; dry mouth; aggressive behavior.
ADVERSE REACTIONS/TOXIC EFFECTS
Psychomotor slowing, impaired concentration, language problems (such as word-finding difficulties), and memory disturbances occur occasionally. These reactions are generally mild to moderate but may be severe enough to require discontinuation of drug therapy.
NURSING CONSIDEARTION
BASELINE ASSESSMENT
Review history of seizure disorder (intensity, frequency, duration, level of consciousness [LOC]). Initiate seizure precautions. Provide quiet, dark environment. Question for sensitivity to topiramate, pregnancy, use of other anticonvulsant medication (especially carbamazepine, valproic acid, phenytoin, carbonic anhydrase inhibitors). Assess serum renal function. Instruct patient to use alternative/additional means of contraception (topiramate decreases effectiveness of oral contraceptives).
INTERVENTION/EVALUATION
Observe frequently for recurrence of seizure activity. Assess for clinical improvement (decrease in intensity/frequency of seizures). Monitor serum renal function tests (BUN, creatinine). Assist with ambulation if dizziness occurs.
PATIENT/FAMILY TEACHING
N Avoid tasks that require alertness, motor skills until response to drug is established (may cause dizziness, drowsiness, impaired concentration). N Drowsiness usually diminishes with continued therapy. N Avoid use of alcohol, other CNS depressants. N Do not abruptly discontinue drug (may precipitate seizures). N Strict maintenance of drug therapy is essential for seizure control. N Do not break tablets (bitter taste). N Maintain adequate fluid intake (decreases risk of renal stone formation). N Inform physician if blurred vision, eye pain occurs.
topotecan A
toe-poh-teh-can
(Hycamtin)
CLASSIFICATION
PHARMACOTHERAPEUTIC: DNA topoisomerase inhibitor. CLINICAL:
Antineoplastic.
ACTION
A DNA topoisomerase inhibitor that interacts with topoisomerase I, an enzyme that allows DNA replication by producing reversible single-strand breaks in DNA that relieve torsional strain. Topotecan prevents religation of the DNA strand, resulting in damage to double-strand DNA and cell death. Therapeutic Effect: Kills cancer cells.
PHARMACOKINETICS
Hydrolyzed to active form after IV administration. Protein binding: 35%. Excreted in urine. Half-life: 2U3 hr (increased in impaired renal function).
USES
Treatment of metastatic carcinoma of ovary after failure of initial or recurrent chemotherapy. Treatment of sensitive, relapsed small cell lung cancer. OFF-LABEL: Treatment of solid tumors including osteosarcoma, neuroblastoma, pediatric leukemia, rhabdomyosarcoma.
PRECAUTIONS
CONTRAINDICATIONS: Baseline neutrophil count less than 1,500 cells/mm3, breast-feeding, pregnancy, severe myelosuppression. CAUTIONS: Mild bone marrow depression, hepatic or renal impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: May cause fetal harm. Avoid pregnancy; breast-feeding not recommended. Pregnancy Category D. Children: Safety and efficacy not established. Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Cisplatin: May increase the severity of myelosuppression. Live virus vaccines: May potentiate virus replication, increase vaccine side effects, and decrease the patient's antibody response to the vaccine. Other bone marrow depressants: May increase the risk of myelosuppression. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum bilirubin, AST, and ALT levels. May decrease RBC, leukocyte, neutrophil, and platelet counts.
AVAILABILITY (Rx)
POWDER FOR INJECTION: 4 mg (single-dose vial).
ADMINISTRATION/HANDLING
O ALERT P Because topotecan may be carcinogenic, mutagenic, or teratogenic, handle the drug with extreme care during preparation and administration.
L IV
Reconstitution N Reconstitute each 4-mg vial with 4 ml sterile water for injection. N Further dilute with 50U100 ml 0.9% NaCl or D5W.
Rate of administration N Administer all doses as IV infusion over 30 min. N Extravasation associated with only mild local reactions (erythema, ecchymosis).
Storage N Store vials at room temperature in original cartons. N Reconstituted vials diluted for infusion stable at room temperature, ambient lighting for 24 hr.
D IV INCOMPATIBILITIES
Dexamethasone (Decadron), 5-fluorouracil, mitomycin (Mutamycin).
IV COMPATIBILITIES
Carboplatin (Paraplatin), cisplatin (Platinol AQ), cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), etoposide (VePesid), gemcitabine (Gemzar), granisetron (Kytril), ondansetron (Zofran), paclitaxel (Taxol), vincristine (Oncovin).
INDICATIONS/ROUTES/DOSAGE
OVARIAN CARCINOMA, SMALL-CELL LUNG CANCER
IV: ADULTS, ELDERLY: 1.5 mg/m2/day over 30 min for 5 consecutive days, beginning on day 1 of a 21-day course. Minimum of four courses recommended. If severe neutropenia (neutrophil count less than 1,500/mm2) occurs during treatment, reduce dose for subsequent courses by 0.25 mg/m2, or administer filgrastim (G-CSF) no sooner than 24 hr after the last dose of topotecan.
DOSAGE IN RENAL IMPAIRMENT
No dosage adjustment is necessary in patients with mild renal impairment (creatinine clearance of 40U60 ml/min). For moderate renal impairment (creatinine clearance of 20U39 ml/min), give 0.75 mg/m2.
SIDE EFFECTS
FREQUENT: Nausea (77%); vomiting (58%); diarrhea, total alopecia (42%); headache (21%); dyspnea (21%). OCCASIONAL: Paraesthesia (9%); constipation, abdominal pain (3%). RARE: Anorexia, malaise, arthralgia, asthenia, myalgia.
ADVERSE REACTIONS/TOXIC EFFECTS
Severe neutropenia (neutrophil count less than 500 cells/mm3) occurs in 60% of patients, usually during the first course of therapy. The neutrophil nadir usually occurs at a median of 11 days after starting therapy. Thrombocytopenia (platelet count less than 25,000/mm3) occurs in 26% of patients, and severe anemia (RBC count less than 8 g/dl) occurs in 40% of patients. The platelet and RBC nadirs usually occur at a median of 15 days after starting the first course of therapy.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Offer emotional support to patient and family. Assess CBC with differential, Hgb, platelet count before each dose. Myelosuppression may precipitate life-threatening hemorrhage, infection, anemia. If platelet count drops, minimize trauma to patient (e.g., IM injections, patient positioning). Premedicate with antiemetics on day of treatment, starting at least 30 min before administration.
INTERVENTION/EVALUATION
Assess for bleeding, signs of infection, anemia. Monitor hydration status, I&O, serum electrolytes (diarrhea, vomiting are common side effects). Monitor CBC with differential, Hgb, platelets for evidence of myelosuppression. Assess response to medication and provide interventions (e.g., small, frequent meals and antiemetics for nausea and vomiting). Question for complaints of headache. Assess breathing pattern for evidence of dyspnea.
PATIENT/FAMILY TEACHING
N Explain that alopecia is reversible but that new hair may have different color, texture. N Inform patient of possible late diarrhea causing dehydration, electrolyte depletion. N Provide antiemetic an dantidiarrheal regimen for subsequent use. N Notify physician if diarrhea, vomiting continues at home. N Do not have immunizations without physician's approval (drug lowers body's resistance). N Avoid contact with those who have recently received live virus vaccine.
tramadol hydrochloride
tray-mah-doal
(Ultram)
Do not confuse tramadol with Toradol, or Ultram with Ultane.
FIXED-COMBINATION(S)
Ultracet: tramadol/acetaminophen (a non-narcotic analgesic): 37.5 mg/325 mg.
CLASSIFICATION
CLINICAL: Analgesic.
ACTION
An analgesic that binds to mu-opioid receptors and inhibits reuptake of norepinephrine and serotonin. Reduces the intensity of pain stimuli reaching sensory nerve endings. Therapeutic Effect: Alters the perception of and emotional response to pain.
PHARMACOKINETICS
Rapidly and almost completely absorbed after PO administration. Protein binding: 20%. Extensively metabolized in the liver to active metabolite (reduced in patients with advanced cirrhosis). Primarily excreted in urine. Minimally removed by hemodialysis. Half-life: 6U7 hr.
USES
Management of moderate to moderately severe pain.
PRECAUTIONS
CONTRAINDICATIONS: Acute alcohol intoxication; concurrent use of centrally acting analgesics, hypnotics, opioids, or psychotropic drugs, hypersensitivity to opioids. EXTREME CAUTION: CNS depression, anoxia, advanced hepatic cirrhosis, epilepsy, respiratory depression, acute alcoholism, shock. CAUTIONS: Sensitivity to opioids, increased intracranial pressure (ICP), hepatic or renal impairment, acute abdominal conditions, opioid-dependent patients.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Alcohol, other CNS depressants: May increase CNS or respiratory depression and hypotension. Carbamazepine: Decreases tramadol blood concentration. MAOIs: May increase tramadol blood concentration and increase the risk of seizures. Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, opioids, neuroleptics: May increase the risk of seizures. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum creatinine, AST, and ALT hepatic levels. May decrease blood Hgb level. May cause proteinuria.
AVAILABILITY (Rx)
TABLETS: 50 mg. ORALLY-DISINTEGRATING TABLETS: 50 mg. EXTENDED-RELEASE TABLETS: 100 mg, 200 mg, 300 mg.
ADMINISTRATION/HANDLING
N Give without regard to meals.
INDICATIONS/ROUTES/DOSAGE
MODERATE TO MODERATELY SEVERE PAIN
DOSAGE IN RENAL IMPAIRMENT
For patients with creatinine clearance of less than 30 ml/min, increase dosing interval to q12h. Maximum: 200 mg/day.
DOSAGE IN HEPATIC IMPAIRMENT
Dosage is decreased to 50 mg q12h.
SIDE EFFECTS
FREQUENT (25%U15%): Dizziness or vertigo, nausea, constipation, headache, somnolence. OCCASIONAL (10%U5%): Vomiting, pruritus, CNS stimulation (such as nervousness, anxiety, agitation, tremor, euphoria, mood swings, and hallucinations), asthenia, diaphoresis, dyspepsia, dry mouth, diarrhea. RARE (less than 5%): Malaise, vasodilation, anorexia, flatulence, rash, blurred vision, urine retention or urinary frequency, menopausal symptoms.
ADVERSE REACTIONS/TOXIC EFFECTS
Seizures have been reported in patients receiving tramadol within the recommended dosage range. Overdose results in respiratory depression and seizures. Tramadol may have a prolonged duration of action and cumulative effect in patients with hepatic or renal impairment.
NURSING CONSIDARATION
BASELINE ASSESSMENT
Assess onset, type, location, duration of pain. Effect of medication is reduced if full pain recurs before next dose. Assess drug history, especially carbamazepine, CNS depressant medication, MAOIs. Review past medical history, especially epilepsy or seizures. Assess renal and Liver function lab values.
INTERVENTION/EVALUATION
Monitor pulse, BP. Assist with ambulation if dizziness, vertigo occurs. Dry crackers, cola may relieve nausea. Palpate bladder for urinary retention. Monitor pattern of daily bowel activity and stool consistency. Sips of tepid water may relieve dry mouth. Assess for clinical improvement, record onset of relief of pain.
PATIENT/FAMILY TEACHING
N May cause dependence. N Avoid alcohol, OTC medications (analgesics, sedatives). N May cause drowsiness, dizziness, blurred vision. N Avoid tasks requiring alertness, motor skills until response to drug is established. N Inform physician if severe constipation, difficulty breathing, excessive sedation, seizures, muscle weakness, tremors, chest pain, palpitations occur.
trandolapril
tran-doe-la-pril
(Mavik)
Do not confuse trandolapril with tramadol.
FIXED-COMBINATION(S)
Tarka: trandolapril/verapamil (a calcium channel blocker): 1 mg/240 mg; 2 mg/180 mg; 2 mg/240 mg; 4 mg/240 mg.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Angiotensin-converting enzyme (ACE) inhibitor. CLINICAL: Antihypertensive, CHF agent.
ACTION
An ACE inhibitor that suppresses the renin-angiotensin-aldosterone system and prevents the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor; may also inhibit angiotensin II at local vascular and renal sites. Decreases plasma angiotensin II, increases plasma renin activity, and decreases aldosterone secretion. Therapeutic Effect: Reduces peripheral arterial resistance and pulmonary capillary wedge pressure; improves cardiac output and exercise tolerance.
PHARMACOKINETICS
Slowly absorbed from the GI tract. Protein binding: 80%. Metabolized in the liver and GI mucosa to active metabolite. Primarily excreted in urine. Removed by hemodialysis. Half-life: 24 hr.
USES
Treatment of left ventricular dysfunction following MI. Treatment of hypertension. Used alone or in combination with other antihypertensives. OFF-LABEL: Treatment of systolic CHF.
PRECAUTIONS
CONTRAINDICATIONS: History of angioedema from previous treatment with ACE inhibitors, pregnancy. CAUTIONS: Renal impairment, CHF, hypovolemia, valvular stenosis, hyperkalemia.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Drug crosses placenta; is 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: No age-related precautions noted.
INTERACTIONS
DRUG: Alcohol, antihypertensives, diuretics: May increase the effects of trandolapril. Lithium: May increase lithium blood concentration and risk of lithium toxicity. NSAIDs: May decrease the effects of trandolapril. Potassium-sparing diuretics, potassium supplements: May cause hyperkalemia. HERBAL: None known. 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 (ANA) titer.
AVAILABILITY (Rx)
TABLETS: 1 mg, 2 mg, 4 mg.
ADMINISTRATION/HANDLING
N Give without regard to meals. N Tablets may be crushed.
INDICATIONS/ROUTES/DOSAGE
HYPERTENSION (WITHOUT DIURETIC)
HEART FAILURE OR LEFT VENTRICULAR DYSFUNCTION POST-MI
SIDE EFFECTS
FREQUENT (35%U23%): Dizziness, cough. OCCASIONAL (11%U3%): Hypotension, dyspepsia (heartburn, epigastric pain, indigestion), syncope, asthenia (loss of strength), tinnitus. RARE (less than 1%): Palpitations, insomnia, drowsiness, nausea, vomiting, constipation, flushed skin.
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
ACTION
An ACE inhibitor that suppresses the renin-angiotensin-aldosterone system and prevents the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor; may also inhibit angiotensin II at local vascular and renal sites. Decreases plasma angiotensin II, increases plasma renin activity, and decreases aldosterone secretion. Therapeutic Effect: Reduces peripheral arterial resistance and pulmonary capillary wedge pressure; improves cardiac output and exercise tolerance.
PHARMACOKINETICS
Slowly absorbed from the GI tract. Protein binding: 80%. Metabolized in the liver and GI mucosa to active metabolite. Primarily excreted in urine. Removed by hemodialysis. Half-life: 24 hr.
USES
Treatment of left ventricular dysfunction following MI. Treatment of hypertension. Used alone or in combination with other antihypertensives. OFF-LABEL: Treatment of systolic CHF.
PRECAUTIONS
CONTRAINDICATIONS: History of angioedema from previous treatment with ACE inhibitors, pregnancy. CAUTIONS: Renal impairment, CHF, hypovolemia, valvular stenosis, hyperkalemia.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Drug crosses placenta; is 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: No age-related precautions noted.
INTERACTIONS
DRUG: Alcohol, antihypertensives, diuretics: May increase the effects of trandolapril. Lithium: May increase lithium blood concentration and risk of lithium toxicity. NSAIDs: May decrease the effects of trandolapril. Potassium-sparing diuretics, potassium supplements: May cause hyperkalemia. HERBAL: None known. 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 (ANA) titer.
AVAILABILITY (Rx)
TABLETS: 1 mg, 2 mg, 4 mg.
ADMINISTRATION/HANDLING
N Give without regard to meals. N Tablets may be crushed.
INDICATIONS/ROUTES/DOSAGE
HYPERTENSION (WITHOUT DIURETIC)
HEART FAILURE OR LEFT VENTRICULAR DYSFUNCTION POST-MI
SIDE EFFECTS
FREQUENT (35%U23%): Dizziness, cough. OCCASIONAL (11%U3%): Hypotension, dyspepsia (heartburn, epigastric pain, indigestion), syncope, asthenia (loss of strength), tinnitus. RARE (less than 1%): Palpitations, insomnia, drowsiness, nausea, vomiting, constipation, flushed skin.
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). Serum renal function tests should be performed before therapy begins. In patients with renal impairment, autoimmune disease, or taking drugs that affect leukocytes or immune response, CBC and differential count should be performed before therapy begins and q2wk for 3 mo, then periodically thereafter.
INTERVENTION/EVALUATION
If excessive reduction in BP occurs, place patient in supine position with legs elevated. Assist with ambulation if dizziness occurs. Assess for urinary frequency. Auscultate lung sounds for rales, wheezing in those with CHF. Monitor urinalysis for proteinuria. Monitor serum potassium levels in those on concurrent diuretic therapy. Monitor pattern of daily bowel activity and stool consistency.
PATIENT/FAMILY TEACHING
N Do not discontinue medication. N Inform physician if sore throat, fever, swelling, palpitations, cough, chest pain, difficulty swallowing, swelling of face, vomiting, or diarrhea occurs. N To reduce hypotensive effect, rise slowly from lying to sitting position and permit legs to dangle from bed momentarily before standing. N Avoid tasks that require alertness, motor skills until response to drug is established (potential for dizziness, drowsiness). N Avoid potassium supplements and salt substitutes.
trastuzumab A
traz-two-zoo-mab
(Herceptin)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Monoclonal antibody. CLINICAL: Antineoplastic.
ACTION
Binds to the HER-2 protein, which is overexpressed in 25%U30% of primary breast cancers, thereby inhibiting proliferation of tumor cells. Therapeutic Effect: Inhibits the growth of tumor cells and mediates antibody-dependent cellular cytotoxicity.
PHARMACOKINETICS
Half-life: 5.8 days (range: 1U32 days).
USES
Treatment of metastatic breast cancer patients whose tumors overexpress HER-2 protein and who have received one or more chemotherapy regimens. May be used with paclitaxel without previous treatment for metastatic disease.
PRECAUTIONS
CONTRAINDICATIONS: Preexisting cardiac disease. CAUTIONS: Previous cardiotoxic drug or radiation therapy to chest wall, those with known hypersensitivity to trastuzumab.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if distributed in breast milk. Pregnancy Category B. Children: Safety and efficacy not established. Elderly: Age-related cardiac dysfunction may require dosage adjustment.
INTERACTIONS
DRUG: Cyclophosphamide, doxorubicin, epirubicin: May increase the risk of cardiac dysfunction. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
INJECTION, POWDER FOR RECONSTITUTION: 440 mg.
ADMINISTRATION/HANDLING
L IV
Reconstitution N Reconstitute with 20 ml bacteriostatic water for injection to yield concentration of 21 mg/ml. N Add calculated dose to 250 ml 0.9% NaCl (do not use D5W). N Gently mix contents in bag.
Rate of administration N Do not give IV push or bolus. N Give loading dose (4 mg/kg) over 90 min. Give maintenance infusion (2 mg/kg) over 30 min.
Storage N Refrigerate. N Reconstituted solution appears colorless to pale yellow. N Solution is stable for 28 days if refrigerated after reconstitution with bacteriostatic water for injection (if using sterile water for injection without preservative, use immediately; discard unused portions). N Stable for 24 hr in 0.9% NaCl if refrigerated.
D IV INCOMPATIBILITIES
Don't mix trastuzumab with any other medications or with D5W.
INDICATIONS/ROUTES/DOSAGE
BREAST CANCER
IV: ADULTS, ELDERLY: Initially, 4 mg/kg as a 30 to 90-min infusion, then 2 mg/kg weekly as a 30-min infusion.
SIDE EFFECTS
FREQUENT (greater than 20%): Pain, asthenia, fever, chills, headache, abdominal pain, back pain, infection, nausea, diarrhea, vomiting, cough, dyspnea. OCCASIONAL (15%U5%): Tachycardia, CHF, flu-like symptoms, anorexia, edema, bone pain, arthralgia, insomnia, dizziness, paresthesia, depression, rhinitis, pharyngitis, sinusitis. RARE (less than 5%): Allergic reaction, anemia, leukopenia, neuropathy, herpes simplex.
ADVERSE REACTIONS/TOXIC EFFECTS
Cardiomyopathy, ventricular dysfunction, and CHF occur rarely. Pancytopenia may occur.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Evaluate left ventricular function. Obtain baseline echocardiogram, EKG, multigated acquisition (MUGA) scan. CBC, platelet count should be obtained at baseline and at regular intervals during therapy.
INTERVENTION/EVALUATION
Frequently monitor for deteriorating cardiac function. Assess for asthenia (loss of strength, energy). Assist with ambulation if asthenia occurs. Monitor for fever, chills, abdominal pain, back pain. Offer antiemetics if nausea, vomiting occurs. Monitor pattern of daily bowel activity and stool consistency.
PATIENT/FAMILY TEACHING
N Do not have immunizations without physician's approval (lowers body's resistance). N Avoid contact with those who have recently taken oral polio vaccine. N Avoid crowds, those with infection.
trazodone hydrochloride
tray-zoe-done
(Apo-Trazodone J, Desyrel, Desyrel Dividose, Novo-Trazodone J, PMS-Trazodone J)
Do not confuse Desyrel with Delsym or Zestril.
CLASSIFICATION
CLINICAL: Antidepressant.
ACTION
An antidepressant that blocks the reuptake of serotonin at neuronal presynaptic membranes, increasing its availability at postsynaptic receptor sites. Therapeutic Effect: Relieves depression.
PHARMACOKINETICS
Well absorbed from the GI tract. Protein binding: 85%U95%. Metabolized in the liver. Primarily excreted in urine. Unknown if removed by hemodialysis. Half-life: 5U9 hr.
USES
Treatment of depression exhibited as persistent, prominent dysphoria (occurring nearly every day for at least 2 wk) manifested by 4 of 8 symptoms: appetite change, sleep pattern change, increased fatigue, impaired concentration, feelings of guilt or worthlessness, loss of interest in usual activities, psychomotor agitation or retardation, suicidal tendencies. OFF-LABEL: Treatment of neurogenic pain.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Cardiac disease, arrhythmias.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Drug crosses placenta; minimally distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established in those younger than 6 yr. Elderly: More likely to experience sedative, hypotensive effects; lower dosage recommended.
INTERACTIONS
DRUG: Alcohol, CNS depression-producing medications: May increase CNS depression. Antihypertensives: May increase the effects of antihypertensives. Digoxin, phenytoin: May increase the blood concentration of these drugs. Indinavir, ketoconazole, ritonavir: May increase the blood concentration and toxicity of trazodone. HERBAL: St. John's
AVAILABILITY (Rx)
TABLETS: 50 mg (Desyrel), 100 mg (Desyrel), 150 mg (Desyrel Dividose), 300 mg (Desyrel Dividose).
ADMINISTRATION/HANDLING
N Give shortly after snack, meal (reduces risk of dizziness, lightheadedness). N Tablets may be crushed.
INDICATIONS/ROUTES/DOSAGE
DEPRESSION
SIDE EFFECTS
FREQUENT (9%U3%): Somnolence, dry mouth, light-headedness, dizziness, headache, blurred vision, nausea, vomiting. OCCASIONAL (3%U1%): Nervousness, fatigue, constipation, generalized aches and pains, mild hypotension. RARE: Photosensitivity reaction.
ADVERSE REACTIONS/TOXIC EFFECTS
Priapism, diminished or improved libido, retrograde ejaculation, and impotence occur rarely. Trazodone appears to be less cardiotoxic than other antidepressants, although arrhythmias may occur in patients with pre-existing cardiac disease.
NURSING CONSIDERATION
BASELINE ASSESSMENT
For those on long-term therapy, serum liver and renal function tests, blood counts should be performed periodically. Elderly are more likely to experience sedative or hypotensive effects.
INTERVENTION/EVALUATION
Supervise suicidal-risk patient closely during early therapy (as depression lessens, energy level improves, increasing suicide potential). Assess appearance, behavior, speech pattern, level of interest, mood. Monitor WBC, neutrophil count (drug should be stopped if levels fall below normal). Assist with ambulation if dizziness, lightheadedness occurs.
PATIENT/FAMILY TEACHING
N Immediately discontinue medication, consult physician if priapism occurs. N May take after a meal or snack. N May take at bedtime if drowsiness occurs. N Change positions slowly to avoid hypotensive effect. N Tolerance to sedative and anticholinergic effects usually develops during early therapy. N Avoid tasks that require alertness, motor skills until response to drug is established. N Photosensitivity to sun may occur. N Dry mouth may be relieved by sugarless gum, sips of tepid water. N Report visual disturbances. N Do not abruptly discontinue medication. N Avoid alcohol.
triamcinolone
(Aristocort)
triamcinolone acetonide
(Acetocot, Aristocort, Aristocort A, Aristocort Forte, Aristospan Injection, Azmacort, Clinacort, Clinalog, Kenalog, Kenalog in Orabase, Kenalog-10, Kenalog-40, Ken-Jec 40, Nasacort AQ, TriAderm J, Triam-A, Triamcot, Triam-Forte, Triamonide 40, Triderm, Tri-Nasal, U-Tri-Lone)
triamcinolone diacetate
(Amcort, Aristocort Intralesional)
triamcinolone hexacetonide
(Aristospan)
trye-am-sin-oh-lone
Do not confuse triamcinolone with Triaminicin or Triaminicol.
FIXED-COMBINATION(S)
Myco-II, Mycolog II, Myco-Triacet: triamcinolone/nystatin (an antifungal): 0.1%/100,000 units/g.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Adrenocortical steroid. CLINICAL: Anti-inflammatory.
ACTION
An adrenocortical steroid that inhibits accumulation of inflammatory cells at inflammation sites, phagocytosis, lysosomal enzyme release and synthesis, and release of mediators of inflammation. Therapeutic Effect: Prevents or suppresses cell-mediated immune reactions. Decreases or prevents tissue response to inflammatory process.
USES
Inhalation: Long-term control of bronchial asthma. Nasal: Seasonal and perennial rhinitis. Oral: Immunosuppressant, relief of acute inflammation. Topical: Relief of inflammation and pruritus associated with corticoid-responsive dermatoses.
PRECAUTIONS
CONTRAINDICATIONS: Administration of live virus vaccines, especially smallpox vaccine; hypersensitivity to corticosteroids or tartrazine; IM injection or oral inhalation in children younger than 6 yr; peptic ulcer disease (except life-threatening situations); systemic fungal infection. Topical: Marked circulation impairment. CAUTIONS: History of tuberculosis (may reactivate disease), hypothyroidism, cirrhosis, non-specific ulcerative colitis, CHF, hypertension, psychosis, renal insufficiency. Prolonged therapy should be discontinued slowly. Pregnancy Category C (D if used in first trimester).
INTERACTIONS
DRUG: Amphotericin: May increase hypokalemia. Digoxin: May increase the risk of digoxin toxicity caused by hypokalemia. Diuretics, insulin, oral hypoglycemics, potassium supplements: May decrease the effects of these drugs. Hepatic enzyme inducers: May decrease the effects of triamcinolone. Live virus vaccines: May decrease the patient's antibody response to vaccine, increase vaccine side effects, and potentiate virus replication. HERBAL: None known. FOOD: None known. LAB VALUES: May increase blood glucose and serum lipid, amylase, and sodium levels. May decrease serum calcium, potassium, and thyroxine levels.
AVAILABILITY (Rx)
ORAL (TOPICAL PASTE [KENALOG IN ORABASE]): 0.1% or 5 g. TABLETS (ARISTOCORT): 4 mg, 8 mg. INHALATION (ORAL [AZMACORT]): 100 mcg/actuation. NASAL SPRAY: 50 mcg/inhalation (Tri-Nasal), 55 mcg/inhalation (Nasacort AQ). CREAM: 50 mcg/inhalation (Tri-Nasal), 55 mcg/inhalation (Nasacort AQ). OINTMENT (ARISTOCORT A, KENALOG): 0.025%, 0.1%. INJECTION (ACETONIDE): 10 mg/ml (Kenalog-10), 40 mg/ml (Acetocot, Clinalog, Kenalog-40, Ken-Jec 40, Triam-A, Triamcot, Triamonide 40, U-Tri-Lone). INJECTION (DIACETATE): 25 mg/ml (Aristocort), 40 mg/ml (Aristocort Forte, Clinacort, Triam-Forte). INJECTION (HEXACETONIDE [ARISTOSPAN INJECTION]): 5 mg/ml, 20 mg/ml.
ADMINISTRATION/HANDLING
IM
N Do not give IV. N Give deep IM in gluteus maximus.
N Give with food, milk. N Single doses given before 9 AM; multiple doses at evenly spaced intervals.
INHALATION
N Shake container well; exhale as completely as possible. N Instruct the patient to place mouthpiece fully into mouth, holding inhaler upright, inhale deeply and slowly while pressing the top of the canister, hold breath as long as possible before exhaling; then exhale slowly. N Wait 1 min between inhalations when multiple inhalations are ordered (allows for deeper bronchial penetration). N Rinse mouth with water immediately after inhalation.
TOPICAL
N Gently cleanse area before application. N Use occlusive dressings only as ordered. N Apply sparingly, rub into area thoroughly.
INDICATIONS/ROUTES/DOSAGE
IMMUNOSUPPRESSION, RELIEF OF ACUTE INFLAMMATION
IM (TRIAMCINOLONE ACETONIDE): ADULTS, ELDERLY: Initially, 2.5U60 mg/day.
IM (TRIAMCINOLONE DIACETATE): ADULTS, ELDERLY: 40 mg/wk.
IM (TRIAMCINOLONE HEXACETONIDE): ADULTS, ELDERLY: Initially, 2.5U40 mg up to 100 mg; 2U20 mg.
INTRA-ARTICULAR, INTRALESIONAL: ADULTS, ELDERLY: 5U40 mg.
CONTROL OF BRONCHIAL ASTHMA
INHALATION: ADULTS, ELDERLY: 2 inhalations 3U4 times a day. CHILDREN 6U12 YR: 1U2 inhalations 3U4 times a day. Maximum: 12 inhalations/day. Initially, 2.5U60 mg/day.
RHINITIS
INTRANASAL: ADULTS, ELDERLY, CHILDREN 6 YR AND OLDER: Initially, 2 sprays (55 mcg/spray) in each nostril once daily. Maintenance: 1 spray in each nostril once daily.
RELIEF OF INFLAMMATION OR PRURITUS ASSOCIATED WITH CORTICOID-RESPONSIVE DERMATOSES
TOPICAL: ADULTS, ELDERLY: 2U4 times a day. May give 1U2 times a day or as intermittent therapy.
SIDE EFFECTS
FREQUENT: Insomnia, dry mouth, heartburn, nervousness, abdominal distention, diaphoresis, acne, mood swings, increased appetite, facial flushing, delayed wound healing, increased susceptibility to infection, diarrhea or constipation. OCCASIONAL: Headache, edema, change in skin color, frequent urination. RARE: Tachycardia, allergic reaction (including rash and hives), mental changes, hallucinations, depression. Topical: Allergic contact dermatitis.
ADVERSE REACTIONS/TOXIC EFFECTS
Long-term therapy may cause muscle wasting in the arms or legs, osteoporosis, spontaneous fractures, amenorrhea, cataracts, glaucoma, peptic ulcer disease, and CHF.Abruptly withdrawing the drug following long-term therapy may cause anorexia, nausea, fever, headache, arthralgia, rebound inflammation, fatigue, weakness, lethargy, dizziness, and orthostatic hypotension. Anaphylaxis occurs rarely with parenteral administration. Suddenly discontinuing triamcinolone may be fatal. Blindness has occurred rarely after intralesional injection around face and head.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Question for hypersensitivity to any of the corticosteroids or tartrazine (Kenacort). Obtain baselines for height, weight, BP, serum glucose, electrolytes. Check results of initial tests (e.g., tuberculosis [TB] skin test, x-rays, EKG).
INTERVENTION/EVALUATION
Monitor I&O, daily weight, BP, serum glucose, electrolytes. Assess for edema. Check vital signs at least twice a day. Be alert to infection: pharyngitis, fever, vague symptoms. Watch for hypocalcemia (muscle twitching, cramps, positive Trousseau's or Chvostek's signs), hypokalemia (weakness, muscle cramps, paraesthesia [especially in lower extremities], nausea or vomiting, irritability, EKG changes). Assess emotional status, ability to sleep. For oral inhalation, check mucous membranes for signs of fungal infection. Monitor growth in children. Check lab results for blood coagulability, clinical evidence of thromboembolism. Provide assistance with ambulation.
PATIENT/FAMILY TEACHING
N Oral: Inform physician if sudden weight gain, facial edema, difficulty breathing, muscle weakness occurs. N Take oral medication with food or after meals. N Inform physician if condition worsens. N Do not stop medication without physician approval. N May cause dry mouth. N Avoid alcohol. N Inhalation: Do not take for acute asthma attack. N Rinse mouth to decrease risk of mouth soreness. N Inform physician if mouth lesions, sore mouth occurs (stomatitis). N Nasal: Report unusual cough or spasm, persistent nasal bleeding, burning, infection.
triamterene
try-am-ter-een
(Dyrenium)
Do not confuse triamterene with trimipramine.
FIXED-COMBINATION(S)
Dyazide, Maxzide: triamterene/hydrochlorothiazide (a diuretic): 37.5 mg/25 mg; 50 mg/25 mg; 75 mg/50 mg.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Potassium-sparing diuretic. CLINICAL: Antiedema.
ACTION
A potassium-sparing diuretic that inhibits sodium, potassium, ATPase. Interferes with sodium and potassium exchange in distal tubule, cortical collecting tubule, and collecting duct. Increases sodium and decreases potassium excretion. Also increases magnesium, decreases calcium loss. Therapeutic Effect: Produces diuresis and lowers BP.
PHARMACOKINETICS
Incompletely absorbed from the GI tract. Widely distributed. Metabolized in the liver. Primarily eliminated in feces via biliary route. Half-life: 1.5U2.5 hr (increased in renal impairment).
USES
Treatment of edema, hypertension. OFF-LABEL: Treatment adjunct for hypertension, prevention and treatment of hypokalemia.
PRECAUTIONS
CONTRAINDICATIONS: Anuria, drug-induced or preexisting hyperkalemia, progressive or severe renal disease, severe hepatic disease.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Drug crosses placenta; is distributed in breast milk. Breast-feeding is not advised. Pregnancy Category C (D if used in pregnancy-induced hypertension). Children: Safety and efficacy not established. Elderly: May be at increased risk for developing hyperkalemia.
INTERACTIONS
DRUG: Angiotensin-converting enzyme (ACE) inhibitors (such as captopril), potassium-containing medications, potassium supplements: May increase the risk of hyperkalemia. Anticoagulants, heparin: May decrease the effects of these drugs. Lithium: May decrease the clearance and increase the risk of toxicity of lithium. NSAIDs: May decrease the antihypertensive effect of triamterene. HERBAL: None known. FOOD: None known. LAB VALUES: May increase urinary calcium excretion; BUN and blood glucose levels; and serum calcium, creatinine, potassium, magnesium, and uric acid levels. May decrease serum sodium levels.
AVAILABILITY (Rx)
CAPSULES: 50 mg, 100 mg.
ADMINISTRATION/HANDLING
N Give with food if GI disturbances occur. N Do not crush, break capsules.
INDICATIONS/ROUTES/DOSAGE
EDEMA, HYPERTENSION
SIDE EFFECTS
OCCASIONAL: Fatigue, nausea, diarrhea, abdominal pain, leg cramps, headache. RARE: Anorexia, asthenia, rash, dizziness.
ADVERSE REACTIONS/TOXIC EFFECTS
Triamterene use may result in hyponatremia (somnolence, dry mouth, increased thirst, lack of energy) or severe hyperkalemia (irritability, anxiety, heaviness of legs, paresthesia, hypotension, bradycardia, EKG changes [tented T waves, widening QRS complex, ST segment depression]), particularly in those with renal impairment or diabetes, the elderly or severely ill patients. Agranulocytosis, nephrolithiasis, and thrombocytopenia occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Assess baseline serum electrolytes, particularly check for hypokalemia. Assess serum renal and liver function tests. Assess for edema (note location, extent), skin turgor, mucous membranes for hydration status. Assess muscle strength, mental status. Note skin temperature, moisture. Obtain baseline weight. Initiate strict I&O. Note pulse rate and regularity.
INTERVENTION/EVALUATION
Monitor BP, vital signs, serum electrolytes (particularly potassium), I&O, weight. Watch for changes from initial assessment (hyperkalemia may result in muscle strength changes, tremors, muscle cramps), altered mental status (orientation, alertness, confusion), cardiac arrhythmias. Weigh daily. Note extent of diuresis. Assess lung sounds for rhonchi, wheezing.
PATIENT/FAMILY TEACHING
N Take medication in the morning. N Expect increase in volume, frequency of urination. N Therapeutic effect takes several days to begin and can last for several days when drug is discontinued. N Avoid prolonged exposure to sunlight. N Report severe or persistent weakness, headache, dry mouth, nausea, vomiting, fever, sore throat, unusual bleeding/bruising. N Avoid excessive intake of food high in potassium or use of salt substitutes.
trospium chloride
trow-spee-um
(Sanctura)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Anticholinergic. CLINICAL: Antispasmotic.
ACTION
An anticholinergic that antagonizes the effect of acetylcholine on muscarinic receptors, producing parasympatholytic action. Therapeutic Effect: Reduces smooth muscle tone in the bladder.
PHARMACOKINETICS
Minimally absorbed after PO administration. Protein binding: 50%U85%. Distributed in plasma. Excreted mainly in feces and, to a lesser extent, in urine. Half-life: 20 hr.
USES
Treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, urinary frequency.
PRECAUTIONS
CONTRAINDICATIONS: Decreased GI motility, gastric retention, uncontrolled angle-closure glaucoma, urine retention. CAUTIONS: Renal or hepatic impairment, obstructive GI disorders, ulcerative colitis, intestinal atony, myasthenia gravis, narrow-angle glaucoma, significant bladder obstruction.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: Higher incidence of dry mouth, constipation, dyspepsia, UTI, urinary retention in those 75 yr and older.
INTERACTIONS
DRUG: Other anticholinergic agents: Increases the severity and frequency of side effects and may alter the absorption of other drugs because of anticholinergic effects on GI motility. Digoxin, metformin, morphine, pancuronium, procainamide, tenofovir, vancomycin: May increase trospium blood concentration. HERBAL: None known. FOOD: High-fat meals: May reduce trospium absorption. LAB VALUES: None known.
AVAILABILITY (Rx)
TABLETS: 20 mg.
ADMINISTRATION/HANDLING
N Store at room temperature. N Do not break or crush glossy-coated tablets. N Give at least 1 hr before meals or on an empty stomach.
INDICATIONS/ROUTES/DOSAGE
OVERACTIVE BLADDER
DOSAGE IN RENAL IMPAIRMENT
For patients with creatinine clearance less than 30 ml/min, dosage reduced to 20 mg once a day at bedtime.
SIDE EFFECTS
FREQUENT (20%): Dry mouth. OCCASIONAL (10%U4%): Constipation, headache. RARE (less than 2%): Fatigue, upper abdominal pain, dyspepsia, flatulence, dry eyes, urine retention.
ADVERSE REACTIONS/TOXIC EFFECTS
Overdose may result in severe anticholinergic effects, such as abdominal pain, nausea and vomiting, confusion, depression, diaphoresis, facial flushing, hypertension, hypotension, respiratory depression, irritability, lacrimation, nervousness, and restlessness. Supraventricular tachycardia and hallucinations occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Assess dysuria, urgency, frequency, incontinence.
INTERVENTION/EVALUATION
Monitor for symptomatic relief. Monitor I&O; palpate bladder for retention. Monitor pattern of bowel activity and stool consistency. Dry mouth may be relieved by sips of tepid water.
PATIENT/FAMILY TEACHING
N Report
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