benazepril
ben-ayz-ah-prill
(Lotensin)
Do not confuse benazepril with Benadryl, or Lotensin with Loniten or lovastatin.
FIXED-COMBINATION(S)
Lotensin HCT: benazepril/hydrochlorothiazide (a diuretic): 5 mg/625 mg; 10 mg/12.5 mg; 20 mg/12.5 mg; 20 mg/25 mg. Lotrel: benazepril/amlodipine (a calcium blocker): 2.5 mg/10 mg; 5 mg/10 mg; 5 mg/20 mg; 10 mg/20 mg.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Angiotensin-converting enzyme (ACE) inhibitor. CLINICAL: Antihypertensive.
ACTION
ACE inhibitor that decreases the rate of conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. Reduces peripheral arterial resistance. Therapeutic Effect: Lowers BP.
PHARMACOKINETICS
Route Onset Peak Duration
Partially absorbed from the GI tract. Protein binding: 97%. Metabolized in the liver to active metabolite. Primarily excreted in urine. Minimal removal by hemodialysis. Half-life: 35 min; metabolite 10U11 hr.
USES
Treatment of hypertension. Used alone or in combination with other antihypertensives. OFF-LABEL: Treatment of CHF.
PRECAUTIONS
CONTRAINDICATIONS: History of angioedema from previous treatment with ACE inhibitors, pregnancy. CAUTIONS: Renal impairment, sodium depletion, diuretic therapy, dialysis, hypovolemia, coronary or cerebrovascular insufficiency, hepatic impairment, diabetes mellitus.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Unknown if distributed in breast milk. May cause fetal, neonatal mortality or morbidity. Pregnancy Category C (D if used in second or third trimester). Children: Safety and efficacy not established. Elderly: May be more sensitive to hypotensive effects.
INTERACTIONS
DRUG: Alcohol, antihypertensives, diuretics: May increase the effects of benazepril. Lithium: May increase the lithium blood concentration and risk of lithium toxicity. NSAIDs: May decrease the effects of benazepril. 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 potassium, AST, and ALT levels. May decrease serum sodium levels. May cause positive ANA titer.
AVAILABILITY (Rx)
TABLETS: 5 mg, 10 mg, 20 mg, 40 mg.
ADMINISTRATION/HANDLING
N Give without regard to food.
INDICATIONS/ROUTES/DOSAGE
HYPERTENSION (MONOTHERAPY)
PO: ADULTS: Initially, 10 mg/day. Maintenance: 20U40 mg/day as single or in 2 divided doses. Maximum: 80 mg/day. ELDERLY: Initially, 5U10 mg/day. Range: 20U40 mg/day.
HYPERTENSION (COMBINATION THERAPY)
PO: ADULTS: Discontinue diuretic 2U3 days prior to initiating benazepril, then dose as noted above. If unable to discontinue diuretic, begin benazepril at 5 mg/day.
USUAL PEDIATRIC DOSAGE
PO: CHILDREN 6 YR AND OLDER: Initially, 0.2 mg/kg/day. Range: 0.1U0.6 mg/kg/day. Maximum: 40 mg/day.
DOSAGE IN RENAL IMPAIRMENT
For adult patients with creatinine clearance less than 30 ml/min, initially, 5 mg/day titrated up to maximum of 40 mg/day.
SIDE EFFECTS
FREQUENT (6%U3%): Cough, headache, dizziness. OCCASIONAL (2%): Fatigue, somnolence or drowsiness, nausea. RARE (less than 1%): Rash, fever, myalgia, diarrhea, loss of taste.
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 (swelling of the face and lips) 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 patients with history of renal disease.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Obtain BP immediately before each dose, in addition to regular monitoring (be alert to fluctuations). If excessive reduction in BP occurs, place patient in supine position with legs elevated. In patients with renal impairment, autoimmune disease, or taking drugs that affect leukocytes or immune response, CBC should be performed before therapy begins and q2wk for 3 mo, then periodically thereafter.
INTERVENTION/EVALUATION
Assist with ambulation if dizziness occurs. Monitor BP, renal function, urinary protein, leukocyte count.
PATIENT/FAMILY TEACHING
N To reduce hypotensive effect, rise slowly from lying to sitting position, permit legs to dangle from bed momentarily before standing. N Full therapeutic effect may take 2U4 wk. N Skipping doses or noncompliance with drug therapy may produce severe, rebound hypertension.
beractant
burr-act-ant
(Survanta Intratracheal)
Do not confuse Survanta with Sufenta.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Natural bovine lung extract. CLINICAL: Pulmonary surfactant.
ACTION
A natural bovine lung extract that reduces alveolar surface tension, stabilizing alveoli. Therapeutic Effect: Improves lung compliance and respiratory gas exchange.
PHARMACOKINETICS
Not absorbed systemically.
USES
Prevention and treatment (rescue) of respiratory distress syndrome (RDS—hyaline membrane disease) in premature infants. Oxygenation improves within minutes of administration.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Those at risk for circulatory overload. This drug is for use only in neonates. Pregnancy Category: This drug is not indicated for use in pregnant women.
INTERACTIONS
DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
INTRATRACHEAL SUSPENSION FOR INHALATION: 25-mg/ml vials.
ADMINISTRATION/HANDLING
INTRATRACHEAL
Administration N Instill through catheter inserted into infant's endotracheal tube. Do not instill into main stem bronchus. N Monitor for bradycardia, decreased O2 saturation during administration. Stop dosing procedure if these effects occur; begin appropriate measures before reinstituting therapy.
Storage N Refrigerate vials. N Warm by standing vial at room temperature for 20 min or warm in hand 8 min. N If settling occurs, gently swirl vial (do not shake) to redisperse. N After warming, may return to refrigerator within 8 hr one time only. N Each vial should be injected with a needle only one time; discard unused portions. N Color appears off-white to light brown.
INDICATIONS/ROUTES/DOSAGE
PREVENTION AND RESCUE TREATMENT OF RDS OR HYALINE MEMBRANE DISEASE IN PREMATURE INFANTS
INTRATRACHEAL: INFANTS: 100 mg of phospholipids/kg birth weight (4 ml/kg). Give within 15 min of birth if infant weighs less than 1,250 g and has evidence of surfactant deficiency; give within 8 hr when RDS is confirmed by X-ray and requires mechanical ventilation. May repeat 6 hr or longer after preceding dose. Maximum: 4 doses in the first 48 hr of life.
SIDE EFFECTS
FREQUENT: Transient bradycardia, oxygen (O2) desaturation, increased carbon dioxide (CO2) retention. OCCASIONAL: Endotracheal tube reflux. RARE: Apnea, endotracheal tube blockage, hypotension or hypertension, pallor, vasoconstriction.
ADVERSE REACTIONS/TOXIC EFFECTS
Life-threatening nosocomial sepsis may occur.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Drug must be administered in highly supervised setting. Clinicians caring for neonate must be experienced with intubation, ventilator management. Offer emotional support to parents.
INTERVENTION/EVALUATION
Monitor infant with arterial or transcutaneous measurement of systemic O2, CO2. Assess lung sounds for rales, moist breath sounds.
bevacizumab A
be-vah-ciz-you-mab
(Avastin)
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Mono
ACTION
An antineoplastic that binds to and inhibits vascular endothelial growth factor, a protein that plays a major role in the formation of new blood vessels to tumors. Therapeutic Effect: Inhibits metastatic disease progression.
PHARMACOKINETICS
Clearance varies by body weight, gender, and tumor burden. Half-life: 20 days (range, 11U50 days).
USES
Combination chemotherapy with 5-FU for first-line treatment of patients with metastatic carcinoma of the colon or rectum. OFF-LABEL: Adjunctive therapy in breast cancer, malignant mesotheiloma, prostate cancer, renal cell carcinoma.
PRECAUTIONS
CONTRAINDICATIONS: GI perforation, hypertensive crisis, nephrotic syndrome, recent hemoptysis, serious bleeding, wound dehiscence requiring medical intervention. CAUTIONS: Hypertension, proteinuria, CHF, epistaxis, renal insufficiency.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Teratogenic. Potential for fertility impairment. May decrease maternal and fetal body weight; increase risk of skeletal fetal abnormalities. Do not breast-feed. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: Higher incidence of severe adverse reactions in patients older than 65 yr.
INTERACTIONS
DRUG: None known. HERBAL: None known FOOD: None known. LAB VALUES: May decrease serum potassium, sodium, and Hgb levels; Hct; and WBC and platelet counts.
AVAILABILITY (Rx)
INJECTION: 25-mg/ml vial.
ADMINISTRATION/HANDLING
L IV
O ALERT P Do not give by IV push or bolus.
Reconstitution N Withdraw amount of bevacizumab for a dose of 5 mg/kg and dilute in 100 ml 0.9% NaCl. N Discard any unused portion.
Rate of administration N Infuse IV over 90 min following chemotherapy. N If first infusion is well tolerated, second infusion may be administered over 60 min. N If 60-min infusion is well tolerated, all subsequent infusion may be administered over 30 min.
Storage N Refrigerate vials. N Diluted solution may be stored for up to 8 hr if refrigerated.
D IV INCOMPATIBILITIES
Don't mix bevacizumab with dextrose solutions.
INDICATIONS/ROUTES/DOSAGE
FIRST-LINE TREATMENT OF METASTATIC CARCINOMA OF THE COLON OR RECTUM IN COMBINATION WITH 5-FU
IV: ADULTS, ELDERLY: 5 mg/kg once every 14 days.
SIDE EFFECTS
FREQUENT (73%U25%): Asthenia, vomiting, anorexia, hypertension, epistaxis, stomatitis, constipation, headache, dyspnea. OCCASIONAL (21%U15%): Altered taste, dry skin, exfoliative dermatitis, dizziness, flatulence, excessive lacrimation, skin discoloration, weight loss, myalgia. RARE (8%U6%): Nail disorder, skin ulcer, alopecia, confusion, abnormal gait, dry mouth.
ADVERSE REACTIONS/TOXIC EFFECTS
UTIs, manifested as urinary frequency or urgency and proteinuria, occur frequently. CHF, deep vein thrombosis, GI perforation, wound dehiscence, hypertensive crisis, nephrotic syndrome, and severe hemorrhage are the most serious reactions that occur. Anemia, neutropenia, and thrombocytopenia occur occasionally. Hypersensitivity reactions occur rarely.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Monitor BP regularly during treatment. Assess for proteinuria with urinalysis. For those with 2+ or greater urine dipstick reading, a 24-hr urine collection is advisable. Monitor CBC, serum potassium and sodium levels at regular intervals during therapy.
INTERVENTION/EVALUATION
Assess for asthenia (loss of strength, energy). Assist with ambulation if asthenia occurs. Monitor for fever, chills, abdominal pain. Offer antiemetic 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 anyone who recently received a live virus vaccine. N Avoid crowds, those with infection. N Warn female patient of childbearing age of potential fetal risk if pregnancy occurs.
bicalutamide A
by-kale-yew-tah-myd
(Casodex)
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Antiandrogen hormone. CLINICAL: Antineoplastic.
ACTION
An antiandrogen antineoplastic agent that competitively inhibits androgen action by binding to androgen receptors in target tissue. Therapeutic Effect: Decreases growth of prostatic carcinoma.
PHARMACOKINETICS
Well absorbed from the GI tract. Protein binding: 96%. Metabolized in the liver to inactive metabolite. Excreted in urine and feces. Not removed by hemodialysis. Half-life: 5.8 days.
USES
Treatment of advanced metastatic prostatic carcinoma (in combination with luteinizing hormone-releasing hormone [LHRH] agonistic analogues—i.e., leuprolide). Treatment with both drugs must be started at same time.
PRECAUTIONS
CONTRAINDICATIONS: Women, especially women who may become pregnant. CAUTIONS: Moderate to severe hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: May inhibit spermatogenesis, not used in women. Pregnancy Category X. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Warfarin: May increase warfarin's effects. HERBAL: None known. FOOD: None known. LAB VALUES: May increase BUN level and serum alkaline phosphatase, bilirubin, AST, and ALT levels. May decrease blood Hgb level and WBC count.
AVAILABILITY (Rx)
TABLETS: 50 mg.
ADMINISTRATION/HANDLING
PO
N Give without regard to food. N Take at same time each day.
INDICATIONS/ROUTES/DOSAGE
PROSTATIC CARCINOMA
PO: ADULTS, ELDERLY: 50U100 mg once a day in morning or evening, given concurrently with an LHRH analogue or after surgical castration.
SIDE EFFECTS
FREQUENT: Hot flashes (49%), breast pain (38%), muscle pain (27%), constipation (17%), asthenia (15%), diarrhea (10%), nausea (11%). OCCASIONAL (9%U8%): Nocturia, abdominal pain, peripheral edema. RARE (7%U3%): Vomiting, weight loss, dizziness, insomnia, rash, impotence, gynecomastia.
ADVERSE REACTIONS/TOXIC EFFECTS
Sepsis, CHF, hypertension, iron deficiency anemia, interstitial pneumonitis, and pulmonary fibrosis may occur. Severe hepatotoxicity occurs rarely within the first 3U4 mo of treatment. Cases of death due to severe hepatic injury have been reported.
NURSING CONSIDERATIONS
INTERVENTION/EVALUATION
Perform periodic liver function tests. If transaminases increase over 2 times the upper limit of normal, discontinue treatment. Monitor for diarrhea, nausea, vomiting.
PATIENT/FAMILY TEACHING
N Do not stop taking medication (both drugs must be continued). N Take medications at same time each day. N Explain possible expectancy of frequent side effects. N Contact physician for persistent nausea, vomiting.
bisacodyl
bise-ah-co-dahl
(Alophen, Apo-Bisacodyl J, Dulcolax, Fleet, Gentlax, Modane, Veracolate)
Do not confuse Veracolate with Accolate or Modane with Mudrane.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: GI stimulant. CLINICAL: Laxative.
ACTION
A GI stimulant that has a direct effect on colonic smooth musculature by stimulating the intramural nerve plexi. Therapeutic Effect: Promotes fluid and ion accumulation in the colon increasing peristalsis and producing a laxative effect.
PHARMACOKINETICS
Route Onset Peak Duration
PO 6U12 hr N/A N/A
Rectal 15U60 min N/A N/A
Minimal absorption following oral and rectal administration. Absorbed drug is excreted in urine; remainder is eliminated in feces.
USES
Treatment of constipation, colonic evacuation before examinations or procedures.
PRECAUTIONS
CONTRAINDICATIONS: Abdominal pain, appendicitis, intestinal obstruction, nausea, undiagnosed rectal bleeding, vomiting. CAUTIONS: Excessive use may lead to fluid, electrolyte imbalance.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category C. Children: Avoid in children younger than 6 yr (usually unable to describe symptoms or more severe side effects). Elderly: Repeated use may cause weakness, orthostatic hypotension due to electrolyte loss.
INTERACTIONS
DRUG: Antacids, cimetidine, famotidine, ranitidine: May cause rapid dissolution of bisacodyl, producing abdominal cramping, and vomiting. Oral medications: May decrease transit time of concurrently administered oral medications, decreasing absorption of bisacodyl. HERBAL: None known. FOOD: Milk: May cause rapid dissolution of bisacodyl. LAB VALUES: None known.
AVAILABILITY (OTC)
TABLETS (ENTERIC-COATED [DULCOLAX, FLEET]): 5 mg. RECTAL ENEMA (FLEET): 10 mg/1.25 oz. SUPPOSITORIES (DULCOLAX, FLEET): 10 mg.
ADMINISTRATION/HANDLING
PO
N Give on empty stomach (faster action). N Offer 6U8 glasses of water a day (aids stool softening). N Administer tablets whole; do not chew or crush. N Avoid giving within 1 hr of antacids, milk, other oral medication.
RECTAL, ENEMA
N Shake enema and remove orange protective shield from tip before administering. N Position patient on left side with left knee slightly bent and the right leg drawn up, or in knee-chest position. N The diaphragm at base of tube prevents reflux and assures controlled flow of the enema solution. N The enema should be used at room temperature.
RECTAL, SUPPOSITORY
N If suppository is too soft, chill for 30 min in refrigerator or run cold water over foil wrapper. N Moisten suppository with cold water before inserting well into rectum.
INDICATIONS/ROUTES/DOSAGE
TREATMENT OF CONSTIPATION
PO: ADULTS, CHILDREN OLDER THAN 12 YR: 5U15 mg as needed. Maximum: 30 mg. CHILDREN 3U12 YR: 5U10 mg or 0.3 mg/kg at bedtime or after breakfast. ELDERLY: Initially, 5 mg/day.
RECTAL, ENEMA: ADULTS, CHILDREN OLDER THAN 12 YR: One 1.25 oz bottle in a single daily dose.
RECTAL, SUPPOSITORY: ADULTS, CHILDREN OLDER THAN 12 YR: 10 mg to induce bowel movement. CHILDREN 2U12 YR: 5U10 mg as a single dose. CHILDREN YOUNGER THAN 2 YR: 5 mg. ELDERLY: 5U10 mg/day.
SIDE EFFECTS
FREQUENT: Some degree of abdominal discomfort, nausea, mild cramps, faintness. OCCASIONAL: Rectal administration: burning of rectal mucosa, mild proctitis.
ADVERSE REACTIONS/TOXIC EFFECTS
Long-term use may result in laxative dependence, chronic constipation, and loss of normal bowel function. Prolonged use or overdose may result in electrolyte or metabolic disturbances (such as hypokalemia, hypocalcemia, and metabolic acidosis or alkalosis), as well as persistent diarrhea, vomiting, muscle weakness, malabsorption, and weight loss.
INTERVENTION/EVALUATION
Encourage adequate fluid intake. Assess bowel sounds for peristalsis. Monitor pattern of daily bowel activity and stool consistency; record time of evacuation. Assess for abdominal disturbances. Monitor serum electrolytes in those exposed to prolonged, frequent, or excessive use of medication.
PATIENT/FAMILY TEACHING
N Institute measures to promote defecation: increase fluid intake, exercise, high-fiber diet. N Do not take antacids, milk, or other medication within 1 hr of taking medication (decreased effectiveness). N Report unrelieved constipation, rectal bleeding, muscle pain or cramps, dizziness, weakness.
bivalirudin A
bye-vail-ih-rhu-din
(Angiomax)
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Thrombin inhibitor. CLINICAL: Anticoagulant.
ACTION
An anticoagulant that specifically and reversibly inhibits thrombin by binding to its receptor sites. Therapeutic Effect: Decreases acute ischemic complications in patients with unstable angina pectoris.
PHARMACOKINETICS
Route Onset Peak Duration
IV Immediate N/A 1 hr
Primarily eliminated by kidneys. Twenty-five percent removed by hemodialysis. Half-life: 25 min (increased in moderate to severe renal impairment).
USES
Anticoagulant in patients with unstable angina undergoing percutaneous transluminal coronary angioplasty (PTCA) in conjunction with aspirin. Patients with heparin induced thrombocytopenia (HIT) and thrombosis syndrome (HITTS) while undergoing percutaneous coronary intervention.
PRECAUTIONS
CONTRAINDICATIONS: Active major bleeding. CAUTIONS: Conditions associated with increased risk of bleeding (e.g., bacterial endocarditis, recent major bleeding, cerebrovascular accident [CVA], stroke, intracerebral surgery, hemorrhagic diathesis, severe hypertension, severe renal or hepatic impairment, recent major surgery).
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug is distributed in breast milk or crosses placenta. Pregnancy Category B. Children: Safety and efficacy not established. Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Platelet aggregation inhibitors other than aspirin, thrombolytics warfarin: May increase the risk of bleeding complications. HERBAL: Ginkgo biloba: May increase the risk of bleeding. FOOD: None known. LAB VALUES: Prolongs aPTT and PT.
AVAILABILITY (Rx)
INJECTION, POWDER FOR RECONSTITUTION: 250 mg.
ADMINISTRATION/HANDLING
L IV
Reconstitution N To each 250-mg vial add 5 ml sterile water for injection. N Gently swirl until all material is dissolved. N Further dilute each vial in 50 ml D5W or 0.9% NaCl to yield final concentration of 5 mg/ml (1 vial in 50 ml, 2 vials in 100 ml, 5 vials in 250 ml). N If low-rate infusion is used after the initial infusion, reconstitute the 250-mg vial with added 5 ml sterile water for injection. N Gently swirl until all material is dissolved. N Further dilute each vial in 500 ml D5W or 0.9% NaCl to yield final concentration of 0.5 mg/ml. N Produces a clear, colorless solution (do not use if cloudy or contains a precipitate).
Rate of administration N Adjust IV infusion based on aPTT or patient's body weight.
Storage N Store unreconstituted vials at room temperature. N Reconstituted solution may be refrigerated for 24 hr or less. N Diluted drug with a concentration of 0.5U5 mg/ml is stable at room temperature for 24 hr or less.
D IV INCOMPATIBILITIES
Do not mix with other medications.
INDICATIONS/ROUTES/DOSAGE
ANTICOAGULANT IN PATIENTS WITH UNSTABLE ANGINA, HITS, or HITTS WHO ARE UNDERGOING PTCA IN CONJUNCTION WITH ASPIRIN
IV: ADULTS, ELDERLY: 0.75 mg/kg as IV bolus followed by IV infusion at rate of 1.75 mg/kg/hr for duration of procedure. After initial 4-hr infusion is completed, may give additional IV infusion at rate of 0.2 mg/kg/hr for 20 hr or less, if necessary.
DOSAGE IN RENAL IMPAIRMENT
GFR Dosage Reduced by
30U59 ml/min 20%
10U29 ml/min 60%
Dialysis 90%
SIDE EFFECTS
FREQUENT (42%): Back pain. OCCASIONAL (15%U12%): Nausea, headache, hypotension, generalized pain. RARE (8%U4%): Injection site pain, insomnia, hypertension, anxiety, vomiting, pelvic or abdominal pain, bradycardia, nervousness, dyspepsia, fever, urine retention.
ADVERSE REACTIONS/TOXIC EFFECTS
A hemorrhagic event occurs rarely and is characterized by a fall in BP or Hct.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Assess CBC, bleeding time, renal function. Determine initial BP.
INTERVENTION/EVALUATION
Monitor aPTT, Hct, urine and stool culture for occult blood, renal function studies. Assess for decrease in BP, increase in pulse rate. Question for increase in amount of discharge during menses. Assess urine for hematuria.
budesonide
byew-des-oh-nyd
(Entocort EC, Pulmicort Respules, Pulmicort Turbuhaler, Rhinocort, Rhinocort Aqua)
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Glucocorticosteroid. CLINICAL: Anti-inflammatory, antiallergy.
ACTION
A glucocorticoid that inhibits the accumulation of inflammatory cells and decreases and prevents tissues from responding to the inflammatory process. Therapeutic Effect: Relieves symptoms of allergic rhinitis or Crohn's disease. Maintenance of clinical remission of mild to moderate Crohn's disease.
PHARMACOKINETICS
Minimally absorbed from nasal tissue; moderately absorbed from inhalation. Protein binding: 88%. Primarily metabolized in the liver. Half-life: 2U3 hr.
USES
Nasal: Management of seasonal or perennial allergic rhinitis, nonallergic rhinitis. Inhalation: Maintenance or prophylaxis therapy for bronchial asthma. Oral: Treatment of mild to moderate active Crohn's disease. Maintenance of clinical remission of mild to moderate Crohn's disease. OFF-LABEL: Treatment of vasomotor, rhinitis.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to any corticosteroid or its components, persistently positive sputum cultures for Candida albicans, primary treatment of status asthmaticus, systemic fungal infections, untreated localized infection involving nasal mucosa. CAUTIONS: Adrenal insufficiency, cirrhosis, glaucoma, hypothyroidism, untreated infection, osteoporosis, tuberculosis.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category B. Children: Prolonged treatment or high dosages may decrease short-term growth rate, cortisol secretion. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Bupropion: May lower the seizure threshold. Itraconazole, ketoconazole: May increase the plasma concentration of budesonide. HERBAL: None known. FOOD: Grapefruit, grapefruit juice: May increase the systemic exposure of budesonide. LAB VALUES: None known.
AVAILABILITY (Rx)
CAPSULES (ENTOCORT EC): 3 mg. POWDER FOR ORAL INHALATION (PULMICORT TURBUHALER): 200 mcg per inhalation. SUSPENSION FOR ORAL INHALATION (PULMICORT RESPULES): 0.25 mg/2 ml; 0.5 mg/2 mg. NASAL SPRAY (RHINOCORT AQUA): 32 mcg/spray.
ADMINISTRATION/HANDLING
INHALATION
N Shake container well. Instruct patient to exhale completely, place mouthpiece between lips, inhale, hold breath as long as possible before exhaling. N Allow at least 1 min between inhalations. N Rinse mouth after each use to decrease dry mouth, hoarseness.
INTRANASAL
N Instruct patient to clear nasal passages before use. N Tilt head slightly forward. N Insert spray tip into nostril, pointing toward nasal passages, away from nasal septum. N Spray into 1 nostril while holding other nostril closed, instruct patient to concurrently inspire through nostril to allow medication as high into nasal passages as possible.
INDICATIONS/ROUTES/DOSAGE
RHINITIS
INTRANASAL (RHINOCORT AQUA): ADULTS, ELDERLY, CHILDREN 6 YR AND OLDER: 1 spray in each nostril once a day. Maximum: 8 sprays/day for adults and children 12 yr and older; 4 sprays/day for children younger than 12 yr.
BRONCHIAL ASTHMA
NEBULIZATION: CHILDREN 6 MOU8 YR: 0.25U1 mg/day titrated to lowest effective dosage.
INHALATION: ADULTS, ELDERLY, CHILDREN 6 YR AND OLDER: Initially, 200U400 mcg twice a day. Maximum: Adults: 800 mcg twice a day. Children: 400 mcg twice a day.
CROHN'S DISEASE
PO: ADULTS, ELDERLY: 9 mg once a day for up to 8 wk.
SIDE-EFFECTS
FREQUENT (greater than 3%): Nasal: Mild nasopharyngeal irritation, burning, stinging, or dryness; headache; cough. Inhalation: Flu-like symptoms, headache, pharyngitis. OCCASIONAL (3%U1%): Nasal: Dry mouth, dyspepsia, rebound congestion, rhinorrhea, loss of taste. Inhalation: Back pain, vomiting, altered taste, voice changes, abdominal pain, nausea, dyspepsia.
ADVERSE REACTIONS/TOXIC EFFECTS
An acute hypersensitivity reaction marked by urticaria, angioedema, and severe bronchospasm, occurs rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Question for hypersensitivity to any corticosteroids, components.
INTERVENTION/EVALUATION
Monitor for relief of symptoms.
PATIENT/FAMILY TEACHING
N Improvement noted in 24 hr, but full effect may take 3U7 days. N Contact physician if no improvement in symptoms, sneezing, nasal irritation occurs.
bumetanide
byew-met-ah-nide
(Bumex, Burinex J)
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Loop. CLINICAL: Diuretic.
ACTION
A loop diuretic that enhances excretion of sodium, chloride, and to lesser degree, potassium, by direct action at the ascending limb of the loop of Henle and in the proximal tubule. Therapeutic Effect: Produces diuresis.
PHARMACOKINETICS
Route Onset Peak Duration
PO 30U60 min 60U120 min 4U6 hr
IV Rapid 15U30 min 2U3 hr
IM 40 min 60U120 min 4U6 hr
Completely absorbed from the GI tract (absorption decreased in CHF and nephrotic syndrome). Protein binding: 94%U96%. Partially metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 1U1.5 hr.
USES
Treatment of edema associated with CHF, chronic renal failure (including nephrotic syndrome), hepatic cirrhosis with ascites, treatment of acute pulmonary edema. OFF-LABEL: Treatment of hypercalcemia, hypertension.
PRECAUTIONS
CONTRAINDICATIONS: Anuria, hepatic coma, severe electrolyte depletion. CAUTIONS: Hypersensitivity to sulfonamides, renal/hepatic impairment, diabetes mellitus, elderly/debilitated.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug is distributed in breast milk. Pregnancy Category C (D if used in pregnancy-induced hypertension). Children: Safety and efficacy not established. Elderly: May be more sensitive to hypotension/electrolyte effects. Increased risk for circulatory collapse or thrombolytic episode. Age-related renal impairment may require reduced or extended dosage interval.
INTERACTIONS
DRUG: Amphotericin B, nephrotoxic and ototoxic medications: May increase the risk of nephrotoxicity and ototoxicity. Anticoagulants, heparin: May decrease the effects of these drugs. Lithium: May increase the risk of lithium toxicity. Other hypokalemia-causing medications: May increase the risk of hypokalemia. HERBAL: None known. FOOD: None known. LAB VALUES: May increase blood glucose, BUN, serum uric acid, and urinary phosphate levels. May decrease serum calcium, chloride, magnesium, potassium, and sodium levels.
AVAILABILITY (Rx)
TABLETS: 0.5 mg, 1 mg, 2 mg. INJECTION: 0.25 mg/ml.
ADMINISTRATION/HANDLING
L IV
Rate of administration N May give undiluted but is compatible with D5W, 0.9% NaCl, or lactated Ringer's solution. N Administer IV push over 1U2 min. N May give through Y tube or 3-way stopcock. N May give as continuous infusion.
Storage N Store at room temperature. N Stable for 24 hr if diluted.
PO
N Give with food to avoid GI upset, preferably with breakfast (may prevent nocturia).
D IV INCOMPATIBILITY
Midazolam (Versed).
IV COMPATIBILITIES
Aztreonam (Azactam), cefepime (Maxipime), diltiazem (Cardizem), dobutamine (Dobutrex), furosemide (Lasix), lorazepam (Ativan), milrinone (Primacor), morphine, piperacillin and tazobactam (Zosyn), propofol (Diprivan).
INDICATIONS/ROUTES/DOSAGE
EDEMA
PO: ADULTS, CHILDREN OLDER THAN 18 YR: 0.5U2 mg as a single dose in the morning. May repeat at q4U5hr. ELDERLY: 0.5 mg/day, increased as needed.
IV, IM: ADULTS, ELDERLY: 0.5U2 mg/dose; may repeat in 2U3 hr. Or 0.5U1 mg/hr by continuous IV infusion.
HYPERTENSION
PO: ADULTS, ELDERLY: Initially, 0.5 mg/day. Range: 1U4 mg/day. Maximum: 5 mg/day. Larger doses may be given 2U3 doses/day.
USUAL PEDIATRIC DOSAGE
IV, IM, PO: CHILDREN: 0.015U0.1 mg/kg/dose q6U24h. Maximum: 10 mg/day.
SIDE EFFECTS
EXPECTED: Increased urinary frequency and urine volume. FREQUENT: Orthostatic hypotension, dizziness. OCCASIONAL: Blurred vision, diarrhea, headache, anorexia, premature ejaculation, impotence, dyspepsia. RARE: Rash, urticaria, pruritus, asthenia, muscle cramps, nipple tenderness.
ADVERSE REACTIONS/TOXIC EFFECTS
Vigorous diuresis may lead to profound water and electrolyte depletion, resulting in hypokalemia, hyponatremia, dehydration, coma, and circulatory collapse. Ototoxicity—manifested as deafness, vertigo, or tinnitus—may occur, especially in patients with severe renal impairment and those taking other ototoxic drugs. Blood dyscrasias and acute hypotensive episodes have been reported.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Check vital signs, especially BP for hypotension, before administration. Assess baseline electrolytes; particularly check for low serum potassium. Assess edema, skin turgor, mucous membranes for hydration status. Initiate I&O.
INTERVENTION/EVALUATION
Continue to monitor BP, vital signs, electrolytes, I&O, weight. Note extent of diuresis. Watch for changes from initial assessment (hypokalemia may result in muscle strength changes, tremor, muscle cramps, altered mental status, cardiac arrhythmias; hyponatremia may result in confusion, thirst, cold/clammy skin).
PATIENT/FAMILY TEACHING
N Expect increased frequency and volume of urination. N Report hearing abnormalities (e.g., sense of fullness in ears, tinnitus) to physician. N Eat foods high in potassium such as whole grains (cereals), legumes, meat, bananas, apricots, orange juice, potatoes (white, sweet), raisins. N Get up slowly from sitting/lying position.
*buPROPion H
byew-pro-peon
(Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban SR, Zyban SR Refill)
Do not confuse bupropion with buspirone, Wellbutrin with Wellcovorin or Wellferon, or Zyban with Zagam.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Aminoketone. CLINICAL: Antidepressant, smoking cessation aid.
ACTION
An aminoketone that blocks the reuptake of neurotransmitters, including serotonin and norepinephrine at CNS presynaptic membranes, increasing their availability at postsynaptic receptor sites. Also reduces the firing rate of noradrenergic neurons. Therapeutic Effect: Relieves depression and nicotine withdrawal symptoms.
PHARMACOKINETICS
Rapidly absorbed from the GI tract. Protein binding: 84%. Crosses the blood-brain barrier. Undergoes extensive first-pass metabolism in the liver to active metabolite. Primarily excreted in urine. Half-life: 14 hr.
USES
Treatment of depression, particularly endogenous depression, exhibited as persistent and prominent dysphoria (occurring nearly every day for at least 2 wk) manifested by 4 of 8 symptoms: change in appetite, change in sleep pattern, increased fatigue, impaired concentration, feelings of guilt or worthlessness, loss of interest in usual activities, psychomotor agitation or retardation, or suicidal tendencies. Also used to assist in smoking cessation. OFF-LABEL: Treatment of attention deficit hyperactivity disorder in adults and children.
PRECAUTIONS
CONTRAINDICATIONS: Current or prior diagnosis of anorexia nervosa or bulimia, seizure disorder, use within 14 days of MAOIs, concomitant use of other bupropion products. CAUTIONS: History of seizure, cranial trauma; those currently taking antipsychotics, antidepressants; impaired renal, hepatic function.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category B. Children: More sensitive to increased dosage, toxicity, increased risk of suicidal ideation, worsening of depression. Safety and efficacy not established in those younger than 18 yr. Elderly: More sensitive to anticholinergic, sedative, cardiovascular effects. Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Alcohol, lithium, ritonavir, steroids, trazodone, tricyclic antidepressants: May increase the risk of seizures. Fosphenytoin, phenytoin, phenobarbital: May decrease the effectiveness of bupropion. Haloperidol: May increase plasma levels of haloperidol. Levodopa: May increase the risk of adverse effects including nausea, vomiting, excitation, restlessness, and postural tremor. MAOIs: May increase the risk of neuroleptic malignant syndrome and acute bupropion toxicity. HERBAL: None known. FOOD: None known. LAB VALUES: May decrease serum WBC count.
AVAILABILITY (Rx)
TABLETS (WELLBUTRIN): 75 mg, 100 mg. TABLETS (EXTENDED-RELEASE [WELLBUTRIN XL]): 150 mg, 300 mg. TABLETS (SUSTAINED-RELEASE [WELLBUTRIN SR]): 100 mg, 150 mg, 200 mg. TABLETS (SUSTAINED-RELEASE [ZYBAN SR, ZYBAN SR REFILL]): 150 mg.
ADMINISTRATION/HANDLING
PO
N Give with or without food (give with food to reduce GI irritation). N Give at least 4-hr interval for immediate onset and 8-hr interval for sustained-release tablet to avoid seizures. N Avoid bedtime dosage (decreases risk of insomnia). N Do not crush sustained-release preparations.
INDICATIONS/ROUTES/DOSAGE
DEPRESSION
PO (IMMEDIATE RELEASE): ADULTS: Initially, 100 mg twice a day. May increase to 100 mg 3 times a day no sooner than 3 days after beginning therapy. Maximum: 450 mg/day. ELDERLY: 37.5 mg twice a day. May increase by 37.5 mg q3U4 days. Maintenance: Lowest effective dosage.
PO (SUSTAINED-RELEASE): ADULTS: Initially, 150 mg/day as a single dose in the morning. May increase to 150 mg twice a day as early as day 4 after beginning therapy. Maximum: 400 mg/day. ELDERLY: Initially, 50U100 mg/day. May increase by 50U100 mg/day q3U4 days. Maintenance: Lowest effective dosage.
PO (EXTENDED-RELEASE): ADULTS: 150 mg once a day. May increase to 300 mg once a day. Maximum: 450 mg a day.
SMOKING CESSATION
PO: ADULTS: Initially, 150 mg a day for 3 days; then 150 mg twice a day for 7U12 wk.
DOSAGE IN LIVER IMPAIRMENT
Mild-moderate: use caution, reduce dosage. Severe: use extreme caution, maximum dose. Wellbutrin: 75 mg/day. Wellbutrin SR: 100 mg/day or 150 mg every other day. Wellbutrin XL: 150 mg every other day. Zyban: 150 mg every other day.
SIDE EFFECTS
FREQUENT (32%U18%): Constipation, weight gain or loss, nausea, vomiting, anorexia, dry mouth, headache, diaphoresis, tremor, sedation, insomnia, dizziness, agitation. OCCASIONAL (10%U5%): Diarrhea, akinesia, blurred vision, tachycardia, confusion, hostility, fatigue.
ADVERSE REACTIONS/TOXIC EFFECTS
The risk of seizures increases in patients taking more than 150 mg/dose of bupropion, in patients with a history of bulimia or seizure disorders and in patients discontinuing drugs that may lower the seizure threshold.
NURSING CONSIDERATION
BASELINE ASSESSMENT
For those on long-term therapy, liver and renal function tests should be performed periodically.
INTERVENTION/EVALUATION
Closely supervise suicidal-risk patient during early therapy (as depression lessens, energy level improves, increasing suicide potential). Assess appearance, behavior, speech pattern, level of interest, mood.
PATIENT/FAMILY TEACHING
N Full therapeutic effect may be noted in 4 wk. N Avoid tasks that require alertness, motor skills until response to drug is established.
bumetanide
byew-met-ah-nide
(Bumex, Burinex J)
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Loop. CLINICAL: Diuretic
ACTION
A loop diuretic that enhances excretion of sodium, chloride, and to lesser degree, potassium, by direct action at the ascending limb of the loop of Henle and in the proximal tubule. Therapeutic Effect: Produces diuresis.
PHARMACOKINETICS
Route Onset Peak Duration
PO 30U60 min 60U120 min 4U6 hr
IV Rapid 15U30 min 2U3 hr
IM 40 min 60U120 min 4U6 hr
Completely absorbed from the GI tract (absorption decreased in CHF and nephrotic syndrome). Protein binding: 94%U96%. Partially metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 1U1.5 hr.
USES
Treatment of edema associated with CHF, chronic renal failure (including nephrotic syndrome), hepatic cirrhosis with ascites, treatment of acute pulmonary edema. OFF-LABEL: Treatment of hypercalcemia, hypertension.
PRECAUTIONS
CONTRAINDICATIONS: Anuria, hepatic coma, severe electrolyte depletion. CAUTIONS: Hypersensitivity to sulfonamides, renal/hepatic impairment, diabetes mellitus, elderly/debilitated.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug is distributed in breast milk. Pregnancy Category C (D if used in pregnancy-induced hypertension). Children: Safety and efficacy not established. Elderly: May be more sensitive to hypotension/electrolyte effects. Increased risk for circulatory collapse or thrombolytic episode. Age-related renal impairment may require reduced or extended dosage interval.
INTERACTIONS
DRUG: Amphotericin B, nephrotoxic and ototoxic medications: May increase the risk of nephrotoxicity and ototoxicity. Anticoagulants, heparin: May decrease the effects of these drugs. Lithium: May increase the risk of lithium toxicity. Other hypokalemia-causing medications: May increase the risk of hypokalemia. HERBAL: None known. FOOD: None known. LAB VALUES: May increase blood glucose, BUN, serum uric acid, and urinary phosphate levels. May decrease serum calcium, chloride, magnesium, potassium, and sodium levels.
AVAILABILITY (Rx)
TABLETS: 0.5 mg, 1 mg, 2 mg. INJECTION: 0.25 mg/ml.
ADMINISTRATION/HANDLING
L IV
Rate of administration N May give undiluted but is compatible with D5W, 0.9% NaCl, or lactated Ringer's solution. N Administer IV push over 1U2 min. N May give through Y tube or 3-way stopcock. N May give as continuous infusion.
Storage N Store at room temperature. N Stable for 24 hr if diluted.
PO
N Give with food to avoid GI upset, preferably with breakfast (may prevent nocturia).
D IV INCOMPATIBILITY
Midazolam (Versed).
IV COMPATIBILITIES
Aztreonam (Azactam), cefepime (Maxipime), diltiazem (Cardizem), dobutamine (Dobutrex), furosemide (Lasix), lorazepam (Ativan), milrinone (Primacor), morphine, piperacillin and tazobactam (Zosyn), propofol (Diprivan).
INDICATIONS/ROUTES/DOSAGE
EDEMA
PO: ADULTS, CHILDREN OLDER THAN 18 YR: 0.5U2 mg as a single dose in the morning. May repeat at q4U5hr. ELDERLY: 0.5 mg/day, increased as needed.
IV, IM: ADULTS, ELDERLY: 0.5U2 mg/dose; may repeat in 2U3 hr. Or 0.5U1 mg/hr by continuous IV infusion.
HYPERTENSION
PO: ADULTS, ELDERLY: Initially, 0.5 mg/day. Range: 1U4 mg/day. Maximum: 5 mg/day. Larger doses may be given 2U3 doses/day.
USUAL PEDIATRIC DOSAGE
IV, IM, PO: CHILDREN: 0.015U0.1 mg/kg/dose q6U24h. Maximum: 10 mg/day.
SIDE EFFECTS
EXPECTED: Increased urinary frequency and urine volume. FREQUENT: Orthostatic hypotension, dizziness. OCCASIONAL: Blurred vision, diarrhea, headache, anorexia, premature ejaculation, impotence, dyspepsia. RARE: Rash, urticaria, pruritus, asthenia, muscle cramps, nipple tenderness.
ADVERSE REACTIONS/TOXIC EFFECTS
Vigorous diuresis may lead to profound water and electrolyte depletion, resulting in hypokalemia, hyponatremia, dehydration, coma, and circulatory collapse. Ototoxicity—manifested as deafness, vertigo, or tinnitus—may occur, especially in patients with severe renal impairment and those taking other ototoxic drugs. Blood dyscrasias and acute hypotensive episodes have been reported.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Check vital signs, especially BP for hypotension, before administration. Assess baseline electrolytes; particularly check for low serum potassium. Assess edema, skin turgor, mucous membranes for hydration status. Initiate I&O.
INTERVENTION/EVALUATION
Continue to monitor BP, vital signs, electrolytes, I&O, weight. Note extent of diuresis. Watch for changes from initial assessment (hypokalemia may result in muscle strength changes, tremor, muscle cramps, altered mental status, cardiac arrhythmias; hyponatremia may result in confusion, thirst, cold/clammy skin).
PATIENT/FAMILY TEACHING
N Expect increased frequency and volume of urination. N Report hearing abnormalities (e.g., sense of fullness in ears, tinnitus) to physician. N Eat foods high in potassium such as whole grains (cereals), legumes, meat, bananas, apricots, orange juice, potatoes (white, sweet), raisins. N Get up slowly from sitting/lying position.
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