ibuprofen H
eye-byoo-pro-fen
(Advil, Advil Pediatric, Apo-Ibuprofen, Children's Advil, Children's Motrin, Ibu, Ibu-4, Ibu-6, Ibu-8, Ibu-Tab, Junior Advil, Junior Strength Motrin, Motrin, Novoprofen J, Pediacare Fever)
FIXED-COMBINATION(S)
Children's Advil Cold: ibuprofen/pseudoephedrine (a nasal decongestant): 100 mg/15 mg per 5 ml. Combunox: ibuprofen/oxycodone (a narcotic analgesic): 400 mg/5 mg. Reprexain CIII: ibuprofen/hydrocodone: 200 mg/5 mg. Vicoprofen: ibuprofen/hydrocodone (a narcotic analgesic): 200 mg/7.5 mg.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Nonsteroidal anti-inflammatory. CLINICAL: Antirheumatic, analgesic, antipyretic, antidysmenorrheal, vascular headache suppressant.
ACTION
An NSAID that inhibits prostaglandin synthesis. Also produces vasodilation by acting centrally on the heat-regulating center of the hypothalamus. Therapeutic Effect: Produces analgesic and anti-inflammatory effects and decreases fever.
PHARMACOKINETICS
Route Onset Peak Duration
Rapidly absorbed from the GI tract. Protein binding: greater than 90%. Metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 2U4 hr.
USES
Treatment of inflammatory diseases, rheumatoid disorders (e.g., juvenile rheumatoid arthritis), mild to moderate pain, migraine pain, fever, dysmenorrhea, gouty arthritis. OFF-LABEL: Treatment of psoriatic arthritis, vascular headaches.
PRECAUTIONS
CONTRAINDICATIONS: Active peptic ulcer, chronic inflammation of GI tract, GI bleeding disorders or ulceration, history of hypersensitivity to aspirin or NSAIDs. CAUTIONS: CHF, hypertension, renal or hepatic impairment, dehydration, GI disease (e.g., bleeding, ulcers), concurrent anticoagulant use.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Avoid use during third trimester (may adversely affect fetal cardiovascular system: premature closure of ductus arteriosus). Pregnancy Category B (D if used in third trimester or near delivery). Children: Safety and efficacy not established in those younger than 6 mo. Elderly: GI bleeding and ulceration more likely to cause serious adverse effects. Age-related renal impairment may increase risk of hepatic or renal toxicity; reduced dosage recommended.
INTERACTIONS
DRUG: Antihypertensives, diuretics: May decrease the effects of these drugs. Aspirin, other salicylates: May increase the risk of GI side effects such as bleeding. Bone marrow depressants: May increase the risk of hematologic reactions. Heparin, oral anticoagulants, thrombolytics: May increase the effects of these drugs. Lithium: May increase the blood concentration and risk of toxicity of lithium. Methotrexate: May increase the risk of methotrexate toxicity. Probenecid: May increase the ibuprofen blood concentration. HERBAL: Feverfew: May decrease the effects of feverfew. Ginkgo biloba: May increase the risk of bleeding. FOOD: None known. LAB VALUES: May prolong bleeding time. May alter blood glucose level. May increase BUN level, and serum creatinine, potassium, AST, and ALT levels. May decrease blood Hgb and Hct.
AVAILABILITY (Rx)
CAPLETS (ADVIL, MENADOL, MOTRIN): 200 mg. CAPSULES (ADVIL, ADVIL MIGRAINE): 200 mg. GELCAPS (ADVIL, MOTRIN IB): 200 mg. TABLETS: 200 mg (Advil, Motrin IB [OTC]), 400 mg (Ibu, Ibu-4, Ibu-6, Ibu-8, Ibu-Tab, Motrin), 600 mg (Ibu, Ibu-4, Ibu-6, Ibu-8, Ibu-Tab, Motrin), 800 mg (Ibu, Ibu-4, Ibu-6, Ibu-8, Ibu-Tab, Motrin). TABLETS (CHEWABLE): 50 mg (Children's Advil, Children-Motrin), 100 mg (Junior Advil, Junior Strength Motrin). ORAL SUSPENSION (ADVIL, CHILDREN'S ADVIL, CHILDREN'S MOTRIN): 100 mg/5 ml (OTC). ORAL DROPS (ADVIL PEDIATRIC, INFANT ADVIL, INFANT MOTRIN, CHILDREN'S MOTRIN, PEDIACARE FEVER): 40 mg/ml.
ADMINISTRATION/HANDLING
N Do not crush or break enteric-coated form. N Give with food, milk, antacids if GI distress occurs.
INDICATIONS/ROUTES/DOSAGE
ACUTE OR CHRONIC RHEUMATOID ARTHRITIS, OSTEOARTHRITIS, MIGRAINE PAIN, GOUTY ARTHRITIS
MILD TO MODERATE PAIN, PRIMARY DYSMENORRHEA
FEVER, MINOR ACHES OR PAIN
JUVENILE ARTHRITIS
SIDE EFFECTS
OCCASIONAL (9%U3%): Nausea with or without vomiting, dyspepsia, dizziness, rash. RARE (less than 3%): Diarrhea or constipation, flatulence, abdominal cramps or pain, pruritus.
ADVERSE REACTIONS/TOXIC EFFECTS
Acute overdose may result in metabolic acidosis. Rare reactions with long-term use include peptic ulcer disease, GI bleeding, gastritis, a severe hepatic reaction (cholestasis, jaundice), nephrotoxicity (dysuria, hematuria, proteinuria, nephrotic syndrome), and a severe hypersensitivity reaction (particularly in patients with systemic lupus erythematosus or other collagen diseases).
NURSING CONSIDERATION
BASELINE ASSESSMENT
Assess onset, type, location, duration of pain or inflammation. Inspect appearance of affected joints for immobility, deformities, skin condition. Assess temperature.
INTERVENTION/EVALUATION
Monitor for evidence of nausea, dyspepsia. Monitor CBC, liver and renal function tests. Monitor pattern of daily bowel activity and stool consistency. Assess skin for evidence of rash. Evaluate for therapeutic response: relief of pain, stiffness, swelling; increased joint mobility; reduced joint tenderness; improved grip strength. Monitor temperature for fever.
PATIENT/FAMILY TEACHING
N Avoid aspirin, alcohol during therapy (increases risk of GI bleeding). N If GI upset occurs, take with food, milk, antacids. N Do not crush or chew enteric-coated tablet. N May cause dizziness. N Avoid tasks that require alertness, motor skills until response to drug is established.
interleukin-2 (aldesleukin) A
in-tur-lew-kin
(IL-2, Proleukin)
Do not confuse interleukin-2 with interferon 2.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Biologic response modifier. CLINICAL: Antineoplastic.
ACTION
A biological response modifier that acts like human recombinant interleukin-2, promoting proliferation, differentiation, and recruitment of T and B cells, lymphokine-activated and natural cells, and thymocytes. Therapeutic Effect: Enhances cytolytic activity in lymphocytes.
PHARMACOKINETICS
Primarily distributed into plasma, lymphocytes, lungs, liver, kidney, and spleen. Metabolized to amino acids in the cells lining the kidneys. Half-life: 85 min.
USES
Treatment of metastatic renal cell carcinoma, metastatic melanoma. OFF-LABEL: Treatment of colorectal cancer, Kaposi's sarcoma, non-Hodgkin's lymphoma.
PRECAUTIONS
CONTRAINDICATIONS: Abnormal pulmonary function or thallium stress test results, bowel ischemia or perforation, coma or toxic psychosis lasting longer than 48 hr, GI bleeding requiring surgery, intubation lasting more than 72 hr, organ allografts, pericardial tamponade, renal dysfunction requiring dialysis for longer than 72 hr, repetitive or difficult-to-control seizures; retreatment in those who experience any of the following toxicities: angina, MI, recurrent chest pain with EKG changes, sustained ventricular tachycardia, uncontrolled or unresponsive cardiac rhythm disturbances. EXTREME CAUTION: Patients with normal thallium stress tests and pulmonary function tests who have history of prior cardiac or pulmonary disease. CAUTIONS: Patients with fixed requirements for large volumes of fluid (e.g., those with hypercalcemia), history of seizures.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Avoid use in those of either sex not practicing effective contraception. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: Age-related renal impairment may require dosage adjustment; will not tolerate toxicity.
INTERACTIONS
DRUG: Antihypertensives: May increase hypotensive effect. Cardiotoxic, hepatotoxic, myelotoxic, or nephrotoxic medications: May increase the risk of toxicity. Glucocorticoids: May decrease the effects of interleukin-2. HERBAL: None known. FOOD: None known. LAB VALUES: May increase BUN and serum alkaline phosphatase, bilirubin, creatinine, AST, and ALT levels. May decrease serum calcium, magnesium, phosphorus, potassium, and sodium levels.
AVAILABILITY (Rx)
POWDER FOR INJECTION (PROLEUKIN): 22 million units (1.3 mg) (18 million units/ml when reconstituted).
ADMINISTRATION/HANDLING
O ALERT P Hold administration in patients who develop moderate to severe lethargy or somnolence (continued administration may result in coma).
L IV
Reconstitution N Reconstitute 22 million units vial with 1.2 ml sterile water for injection to provide concentration of 18 million units/ml. Bacteriostatic water for injection or NaCl should not be used to reconstitute because of increased aggregation. N During reconstitution, direct the sterile water for injection at the side of vial. Swirl contents gently to avoid foaming. Do not shake.
Rate of administration N Further dilute dose in 50 ml D5W and infuse over 15 min. Do not use an in-line filter. N Solution should be warmed to room temperature before infusion. N Monitor diligently for drop in mean arterial BP (sign of capillary leak syndrome [CLS]). Continued treatment may result in significant hypotension (less than 90 mm Hg or a 20 mm Hg drop from baseline systolic pressure), edema, pleural effusion, altered mental status.
Storage N Refrigerate vials; do not freeze. N Reconstituted solution is stable for 48 hr refrigerated or at room temperature (refrigeration preferred).
IV INCOMPATIBILITIES
Ganciclovir (Cytovene), pentamidine (Pentam), prochlorperazine (Compazine), promethazine (Phenergan).
IV COMPATIBILITIES
Calcium gluconate, dopamine (Intropin), heparin, lorazepam (Ativan), magnesium, potassium.
INDICATIONS/ROUTES/DOSAGE
METASTATIC MELANOMA, METASTATIC RENAL CELL CARCINOMA
IV: ADULTS 18 YR AND OLDER: 600,000 units/kg q8h for 14 doses; followed by 9 days of rest, then another 14 doses for a total of 28 doses per course. Course may be repeated after rest period of at least 7 wk from date of hospital discharge.
SIDE EFFECTS
Side effects are generally self-limiting and reversible within 2U3 days after discontinuing therapy. FREQUENT (89%U48%): Fever, chills, nausea, vomiting, hypotension, diarrhea, oliguria or anuria, mental status changes, irritability, confusion, depression, sinus tachycardia, pain (abdominal, chest, back), fatigue, dyspnea, pruritus. OCCASIONAL (47%U17%): Edema, erythema, rash, stomatitis, anorexia, weight gain, infection (UTI, injection site, catheter tip), dizziness. RARE (15%U4%): Dry skin, sensory disorders (vision, speech, taste), dermatitis, headache, arthralgia, myalgia, weight loss, hematuria, conjunctivitis, proteinuria.
ADVERSE REACTIONS/TOXIC EFFECTS
Anemia, thrombocytopenia, and leukopenia occur commonly. GI bleeding and pulmonary edema occur occasionally. Capillary leak syndrome results in hypotension (systolic pressure less than 90 mm Hg or a 20-mm Hg drop from baseline systolic pressure), extravasation of plasma proteins and fluid into extravascular space, and loss of vascular tone. It may result in cardiac arrhythmias, angina, MI, and respiratory insufficiency. Other rare reactions include fatal malignant hyperthermia, cardiac arrest, cerebrovascular accident (CVA), pulmonary emboli, bowel perforation, gangrene, and severe depression leading to suicide.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Patients with bacterial infection and with indwelling central lines should be treated with antibiotic therapy before treatment begins. All patients should be neurologically stable with a negative CT scan before treatment begins. CBC, blood chemistries (including electrolytes), renal and liver function tests, chest x-ray should be performed before therapy begins and daily thereafter.
INTERVENTION/EVALUATION
Monitor CBC with differential, platelets, electrolytes, renal and hepatic functions, weight, pulse oximetry. Determine serum amylase concentration frequently during therapy. Discontinue medication at first sign of hypotension and hold for moderate to severe lethargy (physician must decide whether therapy should continue). Assess altered mental status (irritability, confusion, depression), weight gain/loss. Maintain strict I&O. Assess for extravascular fluid accumulation (rales in lungs, edema in dependent areas).
PATIENT/FAMILY TEACHING
N Nausea may decrease during therapy. N At home, increase fluid intake (protects against renal impairment). N Do not have immunizations without physician's approval (drug lowers body resistance). N Avoid exposure to persons with infection. N Contact physician if fever, chills, lower back pain, difficulty with urination, unusual bleeding or bruising, black tarry stools, blood in urine, pinpoint red spots on skin occur. N Report symptoms of depression or suicidal ideation immediately.
imatinib mesylate A
ih-mah-tin-ib
(Gleevec)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Protein tyrosine kinase inhibitor. CLINICAL: Antineoplastic.
ACTION
Inhibits Bcr-Abl tyrosine kinase, an enzyme created by the Philadelphia
PHARMACOKINETICS
Well absorbed after PO administration. Binds to plasma proteins, particularly albumin. Metabolized in the liver. Eliminated mainly in the feces as metabolites. Half-life: 18 hr.
USES
Treatment of CML in blast crisis, accelerated phase, or in chronic phase after failure of interferon-alpha therapy. Treatment of GI stromal tumors (GIST).
PRECAUTIONS
CONTRAINDICATIONS: Pregnancy. CAUTIONS: Hepatic or renal impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Has potential for severe teratogenic effects. Avoid breast-feeding. Pregnancy Category D. Children: Safety and efficacy not established. Elderly: Increased frequency of fluid retention.
INTERACTIONS
DRUG: Carbamazepine, dexamethasone, phenobarbital, phenytoin, rifampicin: Decrease imatinib plasma concentration. Clarithromycin, erythromycin, itraconazole, ketoconazole: Increase imatinib plasma concentration. Cyclosporine, pimozide: May alter the therapeutic effects of these drugs. Dihydropyridine calcium channel blockers, simvastatin, triazolo-benzodiazepines: May increase the blood concentration of these drugs. Live virus vaccines: May potentiate viral replication, increase vaccine side effects, and decrease the patient's antibody response to the vaccine. Warfarin: Reduces the effect of warfarin. HERBAL: St. John's
AVAILABILITY (Rx)
TABLETS: 100 mg, 400 mg. CAPSULES: 100 mg.
ADMINISTRATION/HANDLING
N Give with a meal and a large glass of water.
INDICATIONS/ROUTES/DOSAGE
CML
GI STROMAL TUMORS
SIDE EFFECTS
FREQUENT (68%U24%): Nausea, diarrhea, vomiting, headache, fluid retention (periorbital, lower extremities), rash, musculoskeletal pain, muscle cramps, arthralgia. OCCASIONAL (23%U10%): Abdominal pain, cough, myalgia, fatigue, fever, anorexia, dyspepsia, constipation, night sweats, pruritus. RARE (less than 10%): Nasopharyngitis, petechiae, asthenia, epistaxis.
ADVERSE REACTIONS/TOXIC EFFECTS
Severe fluid retention (manifested as pleural effusion, pericardial effusion, pulmonary edema, and ascites) and hepatotoxicity occur rarely. Neutropenia and thrombocytopenia are expected responses to the drug. Respiratory toxicity, manifested as dyspnea and pneumonia, may occur.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Obtain CBC weekly for first month, biweekly for second month, and periodically thereafter. Monitor liver function tests (serum transaminase, bilirubin, alkaline phosphatase) before beginning treatment and monthly thereafter.
INTERVENTION/EVALUATION
Assess periorbital area, lower extremities for early evidence of fluid retention. Monitor for unexpected rapid weight gain. Offer antiemetics to control nausea, vomiting. Monitor pattern of bowel activity and stool consistency. Monitor CBC for evidence of neutropenia, thrombocytopenia; assess liver function tests for hepatotoxicity. Duration of neutropenia or thrombocytopenia ranges from 2U4 wk.
PATIENT/FAMILY TEACHING
N Avoid crowds, those with known infection. N Avoid contact with anyone who recently received live virus vaccine; do not receive vaccinations. N Take with food and a full glass of water.
isosorbide dinitrate
–––––––––––––––––––––––––––––––––––––––––––––
eye-sew-sore-bide
Apo-ISDN J, Cedocard J, Dilatrate, Dilatrate-SR, ISDN, Isochron, Isordil, Isordil Tembids, Isordil Titradose, Sorbitrate
isosorbide mononitrate
–––––––––––––––––––––––––––––––––––––––––––––
Imdur, ISMO, Monoket
Do not confuse Isordil with Isuprel or Plendil, or Imdur with Inderal or K-Dur.
FIXED-COMBINATION(S)
BiDil: isosorbide/hydralazine, (a vasodilator): 20 mg/37.5 mg.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Nitrate. CLINICAL: Antianginal.
ACTION
A nitrate that stimulates intracellular cyclic guanosine monophosphate. Therapeutic Effect: Relaxes vascular smooth muscle of both arterial and venous vasculature. Decreases preload and afterload.
PHARMACOKINETICS
Route Onset Peak Duration
Dinitrate
Sublingual 2U5 min N/A 1U2 hr
Oral (Chewable) 2U5 min N/A 1U2 hr
Oral 15U40 min N/A 4U6 hr
Oral 30 min N/A 12 hr
(Sustained-Release)
Mononitrate
Oral 60 min N/A N/A
(Extended-Release)
Dinitrate poorly absorbed and metabolized in the liver to its activate metabolite isosorbide mononitrate. Mononitrate well absorbed after PO administration. Excreted in urine and feces. Half-life: Dinitrate, 1U4 hr; mononitrate, 4 hr.
USES
Prophylaxis, treatment of angina pectoris. OFF-LABEL: CHF, dysphagia, pain relief, relief of esophageal spasm with gastroesophageal reflux.
PRECAUTIONS
CONTRAINDICATIONS: Closed-angle glaucoma, GI hypermotility or malabsorption (extended-release tablets), head trauma, hypersensitivity to nitrates, increased intracranial pressure, orthostatic hypotension, severe anemia (extended-release tablets). CAUTIONS: Acute MI, hepatic or renal disease, glaucoma (contraindicated in closed-angle glaucoma), blood volume depletion from diuretic therapy, systolic BP less than 90 mm Hg.
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: May be more sensitive to hypotensive effects. Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Alcohol, antihypertensives, vasodilators: May increase risk of orthostatic hypotension. HERBAL: None known. FOOD: None known. LAB VALUES: May increase urine catecholamine and urine vanillylmandelic acid levels.
AVAILABILITY (Rx)
CAPSULES (SUSTAINED-RELEASE [DILATRATE, ISORDIL TEMBIDS]): 40 mg. TABLETS: 5 mg (ISDN, Isordil, Isordil Titradose), 10 mg (ISDN, ISMO, Isordil, Isordil Titradose, Monoket), 20 mg (ISDN, ISMO, Isordil, Isordil Titradose, Monoket), 30 mg (ISDN, Isordil, Isordil Titradose), 40 mg (ISDN, Isordil, Isordil Titradose). TABLETS (CHEWABLE [SORBITRATE]): 5 mg, 10 mg. TABLETS (EXTENDED-RELEASE [IMDUR]): 30 mg, 60 mg, 120 mg. TABLETS (SUBLINGUAL [ISORDIL]): 2.5 mg, 5 mg, 10 mg.
ADMINISTRATION/HANDLING
N Best if taken on an empty stomach. N Oral tablets may be crushed. N Do not crush or break sublingual or extended-release form. N Do not crush chewable form before administering.
SUBLINGUAL
N Do not crush or chew sublingual tablets. N Dissolve tablets under tongue; do not swallow.
INDICATIONS/ROUTES/DOSAGE
ANGINA
SIDE EFFECTS
FREQUENT: Burning and tingling at oral point of dissolution (sublingual), headache (possibly severe) occurs mostly in early therapy, diminishes rapidly in intensity, and usually disappears during continued treatment, transient flushing of face and neck, dizziness (especially if patient is standing immobile or is in a warm environment), weakness, orthostatic hypotension, nausea, vomiting, restlessness. OCCASIONAL: GI upset, blurred vision, dry mouth.
ADVERSE REACTIONS/TOXIC EFFECTS
Blurred vision or dry mouth may occur (drug should be discontinued). Isosorbide administration may cause severe orthostatic hypotension manifested by fainting, pulselessness, cold or clammy skin, and diaphoresis. Tolerance may occur with repeated, prolonged therapy, but may not occur with the extended-release form. Minor tolerance may be seen with intermittent use of sublingual tablets. High dosage tends to produce severe headache.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Record onset, type (sharp, dull, squeezing), radiation, location, intensity, duration of anginal pain; precipitating factors (exertion, emotional stress). If headache occurs during management therapy, administer medication with meals.
INTERVENTION/EVALUATION
Assist with ambulation if lightheadedness, dizziness occurs. Assess for facial or neck flushing. Monitor number of anginal episodes, orthostatic BP.
PATIENT/FAMILY TEACHING
N Do not chew or crush sublingual or sustained-release forms. N Take sublingual tablets while sitting down. N Notify physician if angina persists for longer than 20 min. N Rise slowly from lying to sitting position, dangle legs momentarily before standing. N Take oral form on empty stomach (however, if headache occurs during management therapy, take medication with meals). N Dissolve sublingual tablet under tongue; do not swallow. N Take at first signal of angina. N If pain not relieved within 5 min, dissolve second tablet under tongue. N Repeat if no relief in another 5 min. N If pain continues, contact physician. N Expel from mouth any remaining sublingual tablet after pain is completely relieved. N Do not change from one brand of drug to another. N Avoid alcohol (intensifies hypotensive effect). N If alcohol is ingested soon after taking nitrates, possible acute hypotensive episode (marked drop in BP, vertigo, pallor) may occur.
imipenem/cilastatin sodium
im-ih-peh-nem/sill-as-tah-tin
(Primaxin IM, Primaxin IV)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Fixed-combination carbapenem. CLINICAL: Antibiotic.
ACTION
A fixed-combination carbapenem. Imipenem penetrates the bacterial cell membrane and binds to penicillin-binding proteins, inhibiting cell wall synthesis. Cilastatin competitively inhibits the enzyme dehydropeptidase, preventing renal metabolism of imipenem. Therapeutic Effect: Produces bacterial cell death.
PHARMACOKINETICS
Readily absorbed after IM administration. Protein binding: 13%U21%. Widely distributed. Metabolized in the kidneys. Primarily excreted in urine. Removed by hemodialysis. Half-life: 1 hr (increased in impaired renal function).
USES
Treatment of susceptible infections due to gram-negative, gram-positive and anaerobic organisms including respiratory tract, skin and skin-structure, gynecologic, bone or joint, intra-abdominal, complicated or uncomplicated urinary tract infections; endocarditis; polymicrobic infections; septicemia; serious nosocomial infections.
PRECAUTIONS
CONTRAINDICATIONS: IM: Severe shock or heart block, hypersensitivity to local anesthetics of the amide type. IV: Patients with meningitis. CAUTIONS: History of seizures, sensitivity to penicillins, renal impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Distributed in cord blood, amniotic fluid, breast milk. Pregnancy Category C. Children: No precautions noted. Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: May increase BUN level and serum alkaline phosphatase, bilirubin, creatinine, LDH, AST and ALT levels. May decrease Hct and Hgb levels.
AVAILABILITY (Rx)
IV INJECTION (PRIMAXIN IV): 250 mg, 500 mg. IM INJECTION (PRIMAXIN IM): 500 mg, 750 mg.
ADMINISTRATION/HANDLING
L IV
Reconstitution N Dilute each 250- or 500-mg vial with 100 ml D5W; 0.9% NaCl.
Rate of administration N Give by intermittent IV infusion (piggyback). Do not give IV push. N Infuse over 20U30 min (1-g dose over 40U60 min). N Observe patient during initial 30 min of first-time infusion for possible hypersensitivity reaction.
Storage N Solution appears colorless to yellow; discard if solution turns brown. N IV infusion (piggyback) is stable for 4 hr at room temperature, 24 hr if refrigerated. N Discard if precipitate forms.
IM
N Prepare with 1% lidocaine without epinephrine; 500-mg vial with 2 ml, 750-mg vial with 3 ml lidocaine HCl. N Administer suspension within 1 hr of preparation. N Do not mix with any other medications. N Inject deep in large muscle mass.
D IV INCOMPATIBILITIES
Allopurinol (Aloprim), amphotericin B complex (Abelcet, AmBisome, Amphotec), fluconazole (Diflucan).
IV COMPATIBILITIES
Diltiazem (Cardizem), insulin, propofol (Diprivan), total parenteral nutrition (TPN).
INDICATIONS/ROUTES/DOSAGE
SERIOUS RESPIRATORY TRACT, SKIN ND SKIN-STRUCTURE, GYNECOLOGIC, BONE, JOINT, INTRA-ABDOMINAL, NOSOCOMIAL, AND POLYMICROBIC INFECTIONS; UTIs; ENDOCARDITIS; SEPTICEMIA
IV: ADULTS, ELDERLY: 2U4 g/day in divided doses q6h.
MILD TO MODERATE RESPIRATORY TRACT, SKIN AND SKIN-STRUCTURE, GYNECOLOGIC, BONE, JOINT, INTRA-ABDOMINAL, AND POLYMICROBIC INFECTIONS; UTIs; ENDOCARDITIS; SEPTICEMIA
IV: ADULTS, ELDERLY: 1U2 g/day in divided doses q6U8h. CHILDREN OLDER THAN 3 MOU12 YR: 60U100 mg/kg/day in divided doses q6h. Maximum: 4 g/day. CHILDREN 1U3 MO: 100 mg/kg/day in divided doses q6h. CHILDREN YOUNGER THAN 1 MO: 20U25 mg/kg/dose q8U24h.
IM: ADULTS, ELDERLY: 500U750 mg q12h.
DOSAGE IN RENAL IMPAIRMENT
Dosage and frequency are modified based on creatinine clearance and the severity of the infection.
Creatinine Clearance Dosage (IV)
31U70 ml/min 500 mg q8h
21U30 ml/min 500 mg q12h
5U20 ml/min 250 mg q12h
SIDE EFFECTS
OCCASIONAL (3%U2%): Diarrhea, nausea, vomiting. RARE (2%U1%): Rash.
ADVERSE REACTIONS/TOXIC EFFECTS
Antibiotic-associated colitis and other superinfections may occur. Anaphylactic reactions have been reported.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Question for history of allergies, particularly to beta-lactams, penicillins, cephalosporins. Inquire about history of seizures.
INTERVENTION/EVALUATION
Monitor renal, liver, hematologic function tests. Evaluate for phlebitis (heat, pain, red streaking over vein), pain at IV injection site. Assess for GI discomfort, nausea, vomiting. Determine pattern of bowel activity and stool consistency. Assess skin for rash. Be alert to tremors, possible seizures.
immune globulin IV (IGIV)
ih-mewn glah-byew-lin
(Carimune, Gamimune N 5%, Gamimune N 10%, Gammagard S/D, Gammar-P-IV, Gamunex, Iveegam EN, Octagam, Panglobulin, Polygam S/D, Sandoglobulin, Vivaglobin)
Do not confuse Sandoglobulin with Sandimmune or Sandostatin.
CLASSIFICATION
CLINICAL: Immune serum.
ACTION
An immune serum that increases antibody titer and antigen-antibody reaction. Therapeutic Effect: Provides passive immunity against infection; induces rapid increase in platelet count; produces anti-inflammatory effect.
PHARMACOKINETICS
Evenly distributed between intravascular and extravascular space. Half-life: 21U23 days.
USES
Treatment of patients with primary immunodeficiency syndromes, idiopathic thrombocytopenia purpura (ITP), Kawasaki
PRECAUTIONS
CONTRAINDICATIONS: Allergies to gamma globulin, thimerosal, or anti-IgA antibodies; isolated IgA deficiency. CAUTIONS: Cardiovascular disease, history of thrombosis, renal impairment, diabetes, volume depletion, sepsis, concomitant nephrotoxic drugs.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category C. Children/Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Live virus vaccines: May increase vaccine side effects, potentiate virus replication, and decrease the patient's antibody response to the vaccine. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
INJECTION SOLUTION: 5% (Gamimune N 5%, Octagam), 10% (Gammagard, Gamimune N 10%, Gamunex). INJECTION POWDER FOR RECONSTITUTION: 0.5 g (Iveegam EN), 1 g (Carimune, Gammar-P-IV, Iveegam EN, Panglobulin, Sandoglobulin), 2.5 g (Gammar-P-IV, Gammagard S/D, Iveegam EN, Polygam S/D, Sandoglobulin), 3 g (Carimune, Panglobulin, Sandoglobulin), 5 g (Gammar-P-IV, Gammagard S/D, Iveegam EN, Polygam S/D, Sandoglobulin), 6 g (Carimune, Panglobulin, Sandoglobulin), 10 g (Gammar-P-IV, Gammagard S/D, Polygam S/D, Sandoglobulin), 12 g (Carimune, Panglobulin, Sandoglobulin). SUBCUTANEOUS FORMULATION: (Vivaglobin) injection 160 mg/ml.
ADMINISTRATION/HANDLING
L IV
Reconstitution N Reconstitute only with diluent provided by manufacturer. N Discard partially used or turbid preparations.
Rate of administration N Give by infusion only. N After reconstituted, administer via separate tubing. N Avoid mixing with other medication or IV infusion fluids. N Rate of infusion varies with product used. N Monitor vital signs, BP diligently during and immediately after IV administration (precipitous fall in BP may indicate anaphylactic reaction). Stop infusion immediately. Epinephrine should be readily available.
Storage N Refer to individual IV preparations for storage requirements, stability after reconstitution.
D IV INCOMPATIBILITIES
Do not mix IGIV with any other medications.
INDICATIONS/ROUTES/DOSAGE
PRIMARY IMMUNODEFICIENCY SYNDROME
IV: ADULTS, ELDERLY, CHILDREN: 200U400 mg/kg once monthly.
SUBCUTANEOUS: ADULTS, ELDERLY: 100U200 mg/kg once weekly.
ITP
IV: ADULTS, ELDERLY, CHILDREN: 400U1,000 mg/kg/day for 2U5 days.
IV: ADULTS, ELDERLY, CHILDREN: 2 g/kg as a single dose.
CLL
IV: ADULTS, ELDERLY, CHILDREN: 400 mg/kg q3U4wk.
BONE MARROW TRANSPLANT
IV: ADULTS, ELDERLY, CHILDREN: 400U500 mg/kg/dose every week for 12 wk, then every month.
SIDE EFFECTS
FREQUENT: Tachycardia, backache, headache, arthralgia, myalgia. OCCASIONAL: Fatigue, wheezing, injection site rash or pain, leg cramps, urticaria, bluish lips and nailbeds, light-headedness.
ADVERSE REACTIONS/TOXIC EFFECTS
Anaphylactic reactions are rare, but the incidence increases with repeated injections of IGIV. Keep epinephrine readily available. Overdose may produce chest tightness, chills, diaphoresis, dizziness, facial flushing, nausea, vomiting, fever, and hypotension. Hypersensitivity reaction, characterized by anxiety, arthralgia, dizziness, flushing, myalgia, palpitations, and pruritus, occurs rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Inquire about history of exposure to disease for both patient and family as appropriate. Have epinephrine readily available. Well hydrate patient before use.
INTERVENTION/EVALUATION
Control rate of IV infusion carefully; too-rapid infusion increases risk of precipitous fall in BP, signs of anaphylaxis (facial flushing, chest tightness, chills, fever, nausea, vomiting, diaphoresis). Assess patient closely during infusion, especially first hour; monitor vital signs continuously. Stop infusion temporarily if aforementioned signs noted. For treatment of ITP, monitor platelets.
PATIENT/FAMILY TEACHING
N Explain rationale for therapy. N Rapid response, lasts 1U3 mo. N Inform physician if sudden weight gain, fluid retention, edema, decreased urine output, shortness of breath occur.
loperamide hydrochloride
loe-per-a-mide
(Apo-Loperamide J, Diarr-Eze J, Imodium, Imodium A-D, Loperacap J, Novo-Loperamide J)
Do not confuse Imodium with Indocin or Ionamin.
FIXED-COMBINATION(S)
Imodium Advanced: loperamide/simethicone (an antiflatulant): 2 mg/125 mg.
CLASSIFICATION
CLINICAL: Antidiarrheal.
ACTION
An antidiarrheal that directly affects the intestinal wall muscles. Therapeutic Effect: Slows intestinal motility and prolongs transit time of intestinal contents by reducing fecal volume, diminishing loss of fluid and electrolytes, and increasing viscosity and bulk of stool.
PHARMACOKINETICS
Poorly absorbed from the GI tract. Protein binding: 97%. Metabolized in the liver. Eliminated in feces and excreted in urine. Not removed by hemodialysis. Half-life: 9.1U14.4 hr.
USES
Controls, provides symptomatic relief of acute nonspecific diarrhea, chronic diarrhea associated with inflammatory bowel disease, traveler's diarrhea.
PRECAUTIONS
CONTRAINDICATIONS: Acute ulcerative colitis (may produce toxic megacolon), diarrhea associated with pseudomembranous enterocolitis due to broad-spectrum antibiotics or to organisms that invade intestinal mucosa (such as Escherichia coli, shigella, and salmonella), patients who must avoid constipation. CAUTIONS: Those with fluid or electrolyte depletion, hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category B. Children: Not recommended in those younger than 6 yr (infants younger than 3 mo more susceptible to CNS effects). Elderly: May mask dehydration, electrolyte depletion.
INTERACTIONS
DRUG: Opioid (narcotic) analgesics: May increase the risk of constipation. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
CAPSULES: 2 mg. LIQUID: 1 mg/5 ml (OTC). TABLETS: 2 mg (OTC).
ADMINISTRATION/HANDLING
ORAL LIQUID
N When administering the drug to children, use the accompanying plastic dropper to measure the liquid.
INDICATIONS/ROUTES/DOSAGE
ACUTE DIARRHEA
CHRONIC DIARRHEA
TRAVELER'S DIARRHEA
SIDE EFFECTS
RARE: Dry mouth, somnolence, abdominal discomfort, allergic reaction (such as rash and itching).
ADVERSE REACTIONS/TOXIC EFFECTS
Toxicity results in constipation, GI irritation, including nausea and vomiting, and CNS depression. Activated charcoal is used to treat loperamide toxicity.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Do not administer in presence of bloody diarrhea, temperature greater than 101°F.
INTERVENTION/EVALUATION
Encourage adequate fluid intake. Assess bowel sounds for peristalsis. Monitor pattern of bowel activity and stool consistency. Withhold drug, notify physician promptly in event of abdominal pain or distention, fever.
PATIENT/FAMILY TEACHING
N Do not exceed prescribed dose. N May cause dry mouth. N Avoid alcohol. N Avoid tasks that require alertness, motor skills until response to drug is established. N Notify physician if diarrhea does not stop within 3 days, abdominal distention or pain occurs, fever develops.
indinavir
in-din-oh-vir
(Crixivan)
Do not confuse indinavir with Denavir.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Protease inhibitor. CLINICAL: Antiviral.
ACTION
A protease inhibitor that suppresses HIV protease, an enzyme necessary for splitting viral polyprotein precursors into mature and infectious viral particles. Therapeutic Effect: Interrupts HIV replication, slowing the progression of HIV infection.
PHARMACOKINETICS
Rapidly absorbed after PO administration. Protein binding: 60%. Metabolized in the liver. Primarily excreted in urine. Unknown if removed by hemodialysis. Half-life: 1.8 hr (increased in impaired hepatic function).
USES
Treatment of HIV infection as part of a multidrug regimen (at least 3 anti-retroviral agents). OFF-LABEL: Prophylaxis following occupational exposure to HIV.
PRECAUTIONS
CONTRAINDICATIONS: Concurrent use with terfenadine, cisapride, astemizole, triazolam, midazolam, pimozide, ergot derivatives; nephrolithiasis. CAUTIONS: Renal or hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if excreted in breast milk. Breast-feeding not recommended in HIV-infected women. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: Information not available.
INTERACTIONS
DRUG: Ergot derivatives: May increase the risk of ergotism. Midazolam, triazolam: Increases the risk of arrhythmias and prolonged sedation. Pimozide: May increase the risk of cardiotoxicity. HERBAL: St. John's
AVAILABILITY (Rx)
CAPSULES: 100 mg, 200 mg, 333 mg, 400 mg.
ADMINISTRATION/HANDLING
N Store at room temperature. N Protect from moisture (capsules sensitive to moisture; keep in original bottle). N Best given without food but with water only (optimal absorption) 1 hr before or 2 hr following a meal but may give with water, skim milk, juice, coffee, tea, light meal (e.g., dry toast with jelly). N Do not give with meal high in fat, calories, protein. N If indinavir and didanosine re given concurrently, give at least 1 hr apart on an empty stomach.
INDICATIONS/ROUTES/DOSAGE
HIV INFECTION (IN COMBINATION WITH OTHER ANTIRETROVIRALS)
DOSAGE ADJUSTMENTS WHEN GIVEN CONCOMITANTLY: DELAVIRDINE, ITRACONAZOLE, KETOCONAZOLE: Reduce dose to 600 mg q8h. EFAVIRENZ: Increase dose to 1,000 mg q8h. LOPINAVIR/RITONAVIR: Reduce dose to 600 mg twice a day. NEVIRAPINE: Increase dose to 1,000 mg q8h. RIFABUTIN: Reduce rifabutin by ½ and increase indinavir to 1,000 mg q8h. RITONAVIR: 100U200 mg twice a day and indinavir 800 mg twice a day or ritonavir 400 mg twice a day and indinavir 400 mg twice a day.
HIV INFECTION IN PATIENTS WITH HEPATIC INSUFFICIENCY
SIDE EFFECTS
FREQUENT: Nausea (12%), abdominal pain (9%), headache (6%), diarrhea (5%). OCCASIONAL: Vomiting, asthenia, fatigue (4%); insomnia; accumulation of fat in waist, abdomen, or back of neck. RARE: Abnormal taste sensation, heartburn, symptomatic urinary tract disease, transient renal dysfunction.
ADVERSE REACTIONS/TOXIC EFFECTS
Nephrolithiasis (flank pain with or without hematuria) occurs in 4% of patients.
NURSING SONSIDERATION
BASELINE ASSESSMENT
Offer emotional support. Establish baseline lab values. Emphasize need for close monitoring of renal function (urinalysis, serum creatinine) during therapy.
INTERVENTION/EVALUATION
Encourage adequate hydration. Patient should drink 48 oz (1.5 L) of liquid for each 24 hr during therapy. Monitor for evidence of nephrolithiasis (flank pain, hematuria), contact physician if symptoms occur (therapy should be interrupted for 1U3 days). Monitor stool frequency and consistency. Assess for abdominal discomfort, headache. Monitor serum bilirubin, cholesterol, triglycerides, amylase, lipase, liver function tests, blood glucose, CD4 cell count, CBC.
PATIENT/FAMILY TEACHING
N Advise that indinavir is not a cure for HIV; condition may progress despite treatment. N If dose is missed, take next dose at regularly scheduled time (do not double the dose). N Best taken without food but water only (optimal absorption) 1 hr before or 2 hr following a meal but may take with water, skim milk, juice, coffee, tea, light carbohydrate meal. N Avoid the herb St. John's
infliximab
in-flicks-ih-mab
(Remicade)
Do not confuse Remicade with Reminyl.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Monoclonal antibody. CLINICAL: GI anti-inflammatory.
ACTION
A monoclonal antibody that binds to tumor necrosis factor (TNF), inhibiting functional activity of TNF. Reduces infiltration of inflammatory cells. Therapeutic Effect: Decreases inflamed areas of the intestine.
PHARMACOKINETICS
Route Onset Peak Duration
IV (Crohn's disease) 1U2 wk N/A 8U48 wk
IV (Rheumatoid 3U7 days N/A 6U12 wk
arthritis [RA])
Absorbed into the GI tissue; primarily distributed in the vascular compartment. Half-life: 9.5 days.
USES
Treatment of moderate to severe Crohn's disease, treatment of patients with fistulizing Crohn's disease for reduction in number of draining enterocutaneous fistula(s), ankylosing spondylitis. First-line treatment of rheumatoid arthritis (with methotrexate). Reducing signs and symptoms, achieving clinical remission and mucosal healing, eliminating steroid use in patients with moderate to severe active ulcerative colitis. Treatment of ankylosing spondylitis, reducing signs and symptoms of active arthritis in patients with psoriatic arthritis. OFF-LABEL: CHF, juvenile arthritis, psoriasis, reactive arthritis, sciatica.
PRECAUTIONS
CONTRAINDICATIONS: Sensitivity to murine proteins, sepsis, serious active infection. CAUTIONS: History of recurrent infections.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: Use cautiously due to higher rate of infection.
INTERACTIONS
DRUG: Immunosuppressants: May reduce frequency of infusion reactions and antibodies to infliximab. Live virus vaccines: May decrease immune response. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
POWDER FOR INJECTION: 100 mg.
ADMINISTRATION/HANDLING
L IV
Reconstitution N Reconstitute each vial with 10 ml sterile water for injection, using 21-gauge or smaller needle. Direct the stream of sterile water to the glass wall of the vial. N Swirl the vial gently to dissolve the contents. Do not shake. N Allow the solution to stand for 5 min. N Because infliximab is a protein, the solution may develop a few translucent particles; do not use if particles are opaque or foreign particles are present. N Solution should appear colorless to light yellow and opalescent; do not use if discolored. N Withdraw and waste a volume of 0.9% NaCl from a 250-ml bag to equal the volume of reconstituted solution to be injected into the 250-ml bag (approximately 10 ml). Total dose to be infused should equal 250 ml. N Slowly add the reconstituted infliximab solution to the 250-ml infusion bag. Gently mix. Infusion concentration should range between 0.4 and 4 mg/ml. N Begin infusion within 3 hr after reconstitution.
Rate of administration N Administer IV infusion over 2 hr, using set with a low protein-binding filter.
Storage N Refrigerate vials.
D IV INCOMPATIBILITIES
Do not infuse infliximab in the same IV line with other agents.
INDICATIONS/ROUTES/DOSAGE
CROHN'S DISEASE, MODERATE TO SEVERE, ULCERATIVE COLITIS, PSORIATIC ARTHRITIS
IV INFUSION: ADULTS, ELDERLY: Initially, 5 mg/kg at wk 0, 2, and 6. Maintenance: 5 mg/kg q8wk thereafter.
ANKYLOSING SPONDYLITIS
IV INFUSION: ADULTS, ELDERLY: Initially, 5 mg/kg at wk 0, 2, and 6. Maintenance: 5 mg/kg q6wk thereafter.
FISTULIZING CROHN'S DISEASE
IV INFUSION: ADULTS, ELDERLY: Initially, 5 mg/kg followed by additional 5-mg/kg doses at 2 and 6 wk after first infusion.
RHEUMATOID ARTHRITIS (RA)
IV INFUSION: ADULTS, ELDERLY: 3 mg/kg; followed by additional doses at 2 and 6 wk after first infusion. Then q8wk.
SIDE EFFECTS
FREQUENT (22%U10%): Headache, nausea, fatigue, fever. OCCASIONAL (9%U5%): Fever or chills during infusion, pharyngitis, vomiting, pain, dizziness, bronchitis, rash, rhinitis, cough, pruritus, sinusitis, myalgia, back pain. RARE (4%U1%): Hypotension or hypertension, paresthesia, anxiety, depression, insomnia, diarrhea, urinary tract infection.
ADVERSE REACTIONS/TOXIC EFFECTS
Serious infections, including sepsis, occur rarely. Hypersensitivity reaction, lupus-like syndrome, and severe hepatic reactions may occur.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Assess pattern of bowel activity and stool consistency. Check baseline hydration status: skin turgor for tenting mucous membranes, urinary status.
INTERVENTION/EVALUATION
Monitor urinalysis, erythrocyte sedimentation rate (ESR), BP. Monitor for signs of infection. Crohn's Disease: Monitor C-reactive protein, frequency of stools. Assess for abdominal pain. N Rheumatoid Arthritis: Monitor C-reactive protein. Assess for decreased pain, swollen joints, stiffness.
insulin A
in-sull-in
Rapid acting: INSULIN LISPRO: (Humalog), INSULIN ASPART: (Novolog), INSULIN GLULISINE: (Apidra), INSULIN INHALED: (Exubera), REGULAR INSULIN: (Humulin R, Novolin R)
Intermediate acting: NPH: (Humulin N, Novolin N, NPH Iletin II), LENTE: (Humulin L, Lente Iletin II, Novolin L)
Long acting: INSULIN DETEMIR: (Levemir), INSULIN GLARGINE: (Lantus Ultralente)
FIXED-COMBINATION(S)
Novolog Mix 70/30: aspart suspension 70% and aspart solution 30%. Humalog Mix 75/25: lispro suspension 75% and lispro solution 25%. Humulin Mix 50/50: NPH 50% and regular 50%. Humulin 70/30, Novolin 70/30: NPH 70% and rapid acting regular 30%.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Exogenous insulin. CLINICAL: Antidiabetic.
ACTION
An exogenous insulin that facilitates passage of glucose, potassium, and magnesium across the cellular membranes of skeletal and cardiac muscle and adipose tissue. Controls storage and metabolism of carbohydrates, protein, and fats. Promotes conversion of glucose to glycogen in the liver. Therapeutic Effect: Controls glucose levels in diabetic patients.
PHARMACOKINETICS
Drug Form Onset (hr) Peak (hr) Duration (hr)
Glulisine 0.25 1 3U5
Lispro 0.25 0.5U1.5 4U5
Insulin aspart 1/6 1U3 3U5
Regular 0.5U1 2U4 5U7
Inhaled 0.5U1 2U4 5U7
NPH 1U2 6U14 24+
Lente 1U3 6U14 24+
Insulin glargine N/A N/A 24
USES
Treatment of insulin-dependent type 1 diabetes mellitus; nonUinsulin-dependent type 2 diabetes mellitus when diet and weight control therapy has failed to maintain satisfactory blood glucose levels or in event of pregnancy, surgery, trauma, infection, fever, severe renal, hepatic, or endocrine dysfunction. Regular insulin used for emergency treatment of ketoacidosis, to promote passage of glucose across cell membrane in hyperalimentation, to facilitate intracellular shift of potassium in hyperkalemia.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity or insulin resistance may require change of type or species source of insulin.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Insulin is drug of choice for diabetes in pregnancy; close medical supervision is needed. Following delivery, insulin needs may drop for 24U72 hr, then rise to pre-pregnancy levels. Not secreted in breast milk; lactation may decrease insulin requirements. Pregnancy Category B. Children: No age-related precautions noted. Elderly: Decreased vision, fine motor tremors may lead to inaccurate self-dosing.
INTERACTIONS
O ALERT P Regular human insulin and digoxin are physically compatible for 3 hr in 0.9% sodium chloride. In dextrose 5% and water, a slight haze develops within 1 hr. Do not allow digoxin and insulin to come in contact with each in an IV for over 15 min. DRUG: Alcohol: May increase the effects of insulin. Beta-adrenergic blockers: May increase the risk of hyperglycemia or hypoglycemia; may mask signs and prolong periods of hypoglycemia. Glucocorticoids, thiazide diuretics: May increase blood glucose level. HERBAL: None known. FOOD: None known. LAB VALUES: May decrease serum magnesium, phosphate, and potassium concentrations.
AVAILABILITY
RAPID ACTING: Apidra, Exubera, Humulin R, Novolin R, Novolog, Humalog. INTERMEDIATE ACTING: Humulin L, Novolin L, Lente IIetin II, Humulin N, Novolin N, NPH IIletin II. LONG ACTING: Lantus Ultralente, Levemir. INTERMEDIATE- AND SHORT-ACTING MIXTURES: Humulin 50/50, Humulin 70/30, Humalog Mix 75/25, Humalog Mix 50/50, Novolin 70/30, Novolog Mix 70/30.
ADMINISTRATION/HANDLING
L IV (REGULAR)
N Use only if solution is clear. N May give undiluted.
SUBCUTANEOUS
N Store currently used insulin at room temperature (avoid extreme temperatures, direct sunlight). Store extra vials in refrigerator. N Discard unused vials if not used for several weeks N Give subcutaneously only. (Regular insulin is the only insulin that may be given IV, IM for ketoacidosis or in other specific situations). N Do not give cold insulin; warm to room temperature N Rotate vial gently between hands; do not shake. Regular insulin should be clear; no insulin should have precipitate or discoloration. N Usually administered approximately 30 min before a meal (Insulin Lispro is given up to 15 min before meals). Check blood glucose concentration before administration; dosage highly individualized. N When insulin is mixed, regular insulin is always drawn up first. Mixtures must be administered at once (binding can occur within 5 min). Humalog may be mixed with Humulin N, Humulin L. N Subcutaneous injections may be given in thigh, abdomen, upper arm, buttocks, upper back if there is adequate adipose tissue. N Rotation of injection sites is essential; maintain careful record. N For home situations, prefilled syringes are stable for 1 wk if refrigerated (this includes mixtures once they have stabilized, e.g., 15 min for NPH/Regular, 24 hr for Lente/Regular). Prefilled syringes should be stored in vertical or oblique position to avoid plugging; plunger should be pulled back slightly and the syringe rocked to remix the solution before injection.
D IV INCOMPATIBILITIES
Diltiazem (Cardizem), dopamine (Intropin), nafcillin (Nafcil).
IV COMPATIBILITIES
Amiodarone (Cordarone), ampicillin/sulbactam (Unasyn), cefazolin (Ancef), cimetidine (Tagamet), digoxin (Lanoxin): (physically compatible for 3 hr in 0.9% NaCl. In D5W, water, a slight haze develops within 1 hr.), dobutamine (Dobutrex), famotidine (Pepcid), gentamicin, heparin, magnesium sulfate, metoclopramide (Reglan), midazolam (Versed), milrinone (Primacor), morphine, nitroglycerin, potassium chloride, propofol (Diprivan), vancomycin (Vancocin).
INDICATIONS/ROUTES/DOSAGE
TREATMENT OF INSULIN-DEPENDENT TYPE 1 DIABETES MELLITUS AND NONUINSULIN-DEPENDENT TYPE 2 DIABETES MELLITUS WHEN DIET OR WEIGHT CONTROL HAS FAILED TO MAINTAIN SATISFACTORY BLOOD GLUCOSE LEVELS OR IN EVENT OF FEVER, INFECTION, PREGNANCY, SURGERY, OR TRAUMA, OR SEVERE ENDOCRINE, HEPATIC OR RENAL DYSFUNCTION; EMERGENCY TREATMENT OF KETOACIDOSIS (REGULAR INSULIN); TO PROMOTE PASSAGE OF GLUCOSE ACROSS CELL MEMBRANE IN HYPERALIMENTATION (REGULAR INSULIN): TO FACILITATE INTRACELLULAR SHIFT OF POTASSIUM IN HYPERKALEMIA (REGULAR INSULIN)
SUBCUTANEOUS: ADULTS, ELDERLY, CHILDREN: 0.5U1 unit/kg/day. ADOLESCENTS (DURING GROWTH SPURT): 0.8U1.2 unit/kg/day.
INHALATION: ADULTS, ELDERLY: 0.05 mg/kg before meals.
SIDE EFFECTS
OCCASIONAL: Localized redness, swelling, and itching caused by improper injection technique or allergy to cleansing solution or insulin. INFREQUENT: Somogyi effect, including rebound hyperglycemia with chronically excessive insulin dosages: systemic allergic reaction, marked by rash, angioedema, and anaphylaxis; lipodystrophy or depression at injection site due to breakdown of adipose tissue; lipohypertrophy or accumulation of subcutaneous tissue at injection site due to inadequate site rotation. RARE: Insulin resistance.
ADVERSE REACTIONS/TOXIC EFFECTS
Severe hypoglycemia caused by hyperinsulinism may occur with insulin overdose, decrease or delay of food intake, or excessive exercise and in those with brittle diabetes. Diabetic ketoacidosis may result from stress, illness, omission of insulin dose, or long-term poor insulin control.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Check blood glucose level. Discuss lifestyle to determine extent of learning, emotional needs.
INTERVENTION/EVALUATION
Assess for hypoglycemia (refer to pharmacokinetics table for peak times and duration): cool, wet skin, tremors, dizziness, headache, anxiety, tachycardia, numbness in mouth, hunger, diplopia. Check sleeping patient for restlessness, diaphoresis. Check for hyperglycemia: polyuria (excessive urine output), polyphagia (excessive food intake), polydipsia (excessive thirst), nausea or vomiting, dim vision, fatigue, deep or rapid breathing (Kussmaul respirations). Be alert to conditions altering glucose requirements: fever, increased activity or stress, surgical procedure.
PATIENT/FAMILY TEACHING
N Prescribed diet is an essential part of treatment; do not skip or delay meals. N Carry candy, sugar packets, other sugar supplements for immediate response to hypoglycemia. N Wear or carry medical alert identification. N Check with physician when insulin demands are altered (e.g., fever, infection, trauma, stress, heavy physical activity). N Do not take other medication without consulting physician. N Weight control, exercise, hygiene (including foot care), and not smoking are integral parts of therapy. N Protect skin, limit sun exposure. N Inform dentist, physician, surgeon of medication before any treatment is given.
interferon beta-1a
inn-ter-fear-on
(Avonex, Avonex Prefilled Syringe, Rebif)
Do not confuse interferon beta-1a with interferon beta-1b or Avonex with Avelox.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Biologic response modifier. CLINICAL: Multiple sclerosis agent.
ACTION
A biological response modifier that interacts with specific cell receptors found on the surface of human cells. Therapeutic Effect: Produces antiviral and immunoregulatory effects.
PHARMACOKINETICS
Peak serum levels attained 3U15 hr after IM administration. Biological markers increase within 12 hr and remain elevated for 4 days. Half-life: 10 hr (Avonex); 69 hr (Rebif).
USES
Treatment of relapsing multiple sclerosis to slow progression of physical disability, decrease frequency of clinical exacerbations. OFF-LABEL: Treatment of AIDS, AIDS-related Kaposi's sarcoma, condyloma acuminatum, malignant melanoma, renal cell carcinoma.
PRECAUTIONS
CONTRAINDICATIONS: Avonex: Hypersensitivity to natural or recombinant interferon beta, human albumin. Rebif: Hypersensitivity to natural or recombinant interferon, human albumin. CAUTIONS: Chronic progressive multiple sclerosis, children younger than 18 yr, depression.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Has abortifacient potential. Unknown if drug is distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: No information available.
INTERACTIONS
DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: May increase blood glucose and BUN levels, and serum alkaline phosphatase, bilirubin, calcium, AST, and ALT levels. May decrease blood Hgb level and neutrophil, platelet, and WBC counts.
AVAILABILITY (Rx)
INJECTION POWDER FOR RECONSTITUTION (AVONEX): 30 mcg. INJECTION SOLUTION (PREFILLED SYRINGE): 22 mcg/ml (Rebif), 30 mcg/0.5 ml (Avonex Prefilled Syringe), 44 mcg/ml (Rebif). TITRATION PACK (PREFILLED SYRINGE [REBIF]): 8.8 mcg and 22 mcg.
ADMINISTRATION/HANDLING
IM (AVONEX) SYRINGE
N Refrigerate syringe. N Allow to warm to room temperature before use. N Use within 12 hr after removing from refrigerator.
IM (AVONEX) VIAL
N Refrigerate vials. N Following reconstitution, may refrigerate again but use within 6 hr if refrigerated. N Reconstitute 30 mcg MicroPin (6.6 million international units) vial with 1.1 ml diluent (supplied by manufacturer). N Gently swirl to dissolve medication; do not shake. N Discard if discolored, contains particulate matter. N Discard unused portion (contains no preservative).
SUBCUTANEOUS (REBIF)
N Refrigerate. May store at room temperature up to 30 days. Avoid heat, light. Administer at same time of day 3 days each wk. Doses to be separated by at least 48 hr.
INDICATIONS/ROUTES/DOSAGE
RELAPSING-REMITTING MULTIPLE SCLEROSIS
IM (AVONEX): ADULTS: 30 mcg once weekly.
SUBCUTANEOUS (REBIF): ADULTS: Initially 8.8 mcg 3 times a week, may increase to 44 mcg 3 times a week over 4U6 wk.
SIDE EFFECTS
FREQUENT: Headache (67%), flu-like symptoms (61%), myalgia (34%), upper respiratory tract infection (31%), depression with suicidal thoughts (25%), generalized pain (24%), asthenia, chills (21%), sinusitis (18%), infection (11%). OCCASIONAL: Abdominal pain, arthralgia (9%), chest pain, dyspnea (6%), malaise, syncope (4%). RARE: Injection site reaction, hypersensitivity reaction (3%).
ADVERSE REACTIONS/TOXIC EFFECTS
Anemia occurs in 8% of patients. Severe hepatic injury, including hepatic failure, has been reported.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Obtain Hgb, CBC, platelet count, blood chemistries including liver function tests. Assess home situation for support of therapy.
INTERVENTION/EVALUATION
Assess for headache, flu-like symptoms, myalgia. Periodically monitor lab results, reevaluate injection technique. Assess for depression, suicidal ideation.
PATIENT/FAMILY TEACHING
N Do not change schedule or dosage without consultation with physician. N Instruct on correct reconstitution of product and administration, including aseptic technique. N Provide puncture-resistant container for used needles, syringes; explain proper disposal. N Explain that injection site reactions may occur. N These do not require discontinuation of therapy, but note type and extent carefully.
interleukin-2 (aldesleukin) A
in-tur-lew-kin
(IL-2, Proleukin)
Do not confuse interleukin-2 with interferon 2.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Biologic response modifier. CLINICAL: Antineoplastic.
ACTION
A biological response modifier that acts like human recombinant interleukin-2, promoting proliferation, differentiation, and recruitment of T and B cells, lymphokine-activated and natural cells, and thymocytes. Therapeutic Effect: Enhances cytolytic activity in lymphocytes.
PHARMACOKINETICS
Primarily distributed into plasma, lymphocytes, lungs, liver, kidney, and spleen. Metabolized to amino acids in the cells lining the kidneys. Half-life: 85 min.
USES
Treatment of metastatic renal cell carcinoma, metastatic melanoma. OFF-LABEL: Treatment of colorectal cancer, Kaposi's sarcoma, non-Hodgkin's lymphoma.
PRECAUTIONS
CONTRAINDICATIONS: Abnormal pulmonary function or thallium stress test results, bowel ischemia or perforation, coma or toxic psychosis lasting longer than 48 hr, GI bleeding requiring surgery, intubation lasting more than 72 hr, organ allografts, pericardial tamponade, renal dysfunction requiring dialysis for longer than 72 hr, repetitive or difficult-to-control seizures; retreatment in those who experience any of the following toxicities: angina, MI, recurrent chest pain with EKG changes, sustained ventricular tachycardia, uncontrolled or unresponsive cardiac rhythm disturbances. EXTREME CAUTION: Patients with normal thallium stress tests and pulmonary function tests who have history of prior cardiac or pulmonary disease. CAUTIONS: Patients with fixed requirements for large volumes of fluid (e.g., those with hypercalcemia), history of seizures.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Avoid use in those of either sex not practicing effective contraception. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: Age-related renal impairment may require dosage adjustment; will not tolerate toxicity.
INTERACTIONS
DRUG: Antihypertensives: May increase hypotensive effect. Cardiotoxic, hepatotoxic, myelotoxic, or nephrotoxic medications: May increase the risk of toxicity. Glucocorticoids: May decrease the effects of interleukin-2. HERBAL: None known. FOOD: None known. LAB VALUES: May increase BUN and serum alkaline phosphatase, bilirubin, creatinine, AST, and ALT levels. May decrease serum calcium, magnesium, phosphorus, potassium, and sodium levels.
AVAILABILITY (Rx)
POWDER FOR INJECTION (PROLEUKIN): 22 million units (1.3 mg) (18 million units/ml when reconstituted).
ADMINISTRATION/HANDLING
O ALERT P Hold administration in patients who develop moderate to severe lethargy or somnolence (continued administration may result in coma).
L IV
Reconstitution N Reconstitute 22 million units vial with 1.2 ml sterile water for injection to provide concentration of 18 million units/ml. Bacteriostatic water for injection or NaCl should not be used to reconstitute because of increased aggregation. N During reconstitution, direct the sterile water for injection at the side of vial. Swirl contents gently to avoid foaming. Do not shake.
Rate of administration N Further dilute dose in 50 ml D5W and infuse over 15 min. Do not use an in-line filter. N Solution should be warmed to room temperature before infusion. N Monitor diligently for drop in mean arterial BP (sign of capillary leak syndrome [CLS]). Continued treatment may result in significant hypotension (less than 90 mm Hg or a 20 mm Hg drop from baseline systolic pressure), edema, pleural effusion, altered mental status.
Storage N Refrigerate vials; do not freeze. N Reconstituted solution is stable for 48 hr refrigerated or at room temperature (refrigeration preferred).
D IV INCOMPATIBILITIES
Ganciclovir (Cytovene), pentamidine (Pentam), prochlorperazine (Compazine), promethazine (Phenergan).
IV COMPATIBILITIES
Calcium gluconate, dopamine (Intropin), heparin, lorazepam (Ativan), magnesium, potassium.
INDICATIONS/ROUTES/DOSAGE
METASTATIC MELANOMA, METASTATIC RENAL CELL CARCINOMA
IV: ADULTS 18 YR AND OLDER: 600,000 units/kg q8h for 14 doses; followed by 9 days of rest, then another 14 doses for a total of 28 doses per course. Course may be repeated after rest period of at least 7 wk from date of hospital discharge.
SIDE EFFECTS
Side effects are generally self-limiting and reversible within 2U3 days after discontinuing therapy. FREQUENT (89%U48%): Fever, chills, nausea, vomiting, hypotension, diarrhea, oliguria or anuria, mental status changes, irritability, confusion, depression, sinus tachycardia, pain (abdominal, chest, back), fatigue, dyspnea, pruritus. OCCASIONAL (47%U17%): Edema, erythema, rash, stomatitis, anorexia, weight gain, infection (UTI, injection site, catheter tip), dizziness. RARE (15%U4%): Dry skin, sensory disorders (vision, speech, taste), dermatitis, headache, arthralgia, myalgia, weight loss, hematuria, conjunctivitis, proteinuria.
ADVERSE REACTIONS/TOXIC EFFECTS
Anemia, thrombocytopenia, and leukopenia occur commonly. GI bleeding and pulmonary edema occur occasionally. Capillary leak syndrome results in hypotension (systolic pressure less than 90 mm Hg or a 20-mm Hg drop from baseline systolic pressure), extravasation of plasma proteins and fluid into extravascular space, and loss of vascular tone. It may result in cardiac arrhythmias, angina, MI, and respiratory insufficiency. Other rare reactions include fatal malignant hyperthermia, cardiac arrest, cerebrovascular accident (CVA), pulmonary emboli, bowel perforation, gangrene, and severe depression leading to suicide.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Patients with bacterial infection and with indwelling central lines should be treated with antibiotic therapy before treatment begins. All patients should be neurologically stable with a negative CT scan before treatment begins. CBC, blood chemistries (including electrolytes), renal and liver function tests, chest x-ray should be performed before therapy begins and daily thereafter.
INTERVENTION/EVALUATION
Monitor CBC with differential, platelets, electrolytes, renal and hepatic functions, weight, pulse oximetry. Determine serum amylase concentration frequently during therapy. Discontinue medication at first sign of hypotension and hold for moderate to severe lethargy (physician must decide whether therapy should continue). Assess altered mental status (irritability, confusion, depression), weight gain/loss. Maintain strict I&O. Assess for extravascular fluid accumulation (rales in lungs, edema in dependent areas).
PATIENT/FAMILY TEACHING
N Nausea may decrease during therapy. N At home, increase fluid intake (protects against renal impairment). N Do not have immunizations without physician's approval (drug lowers body resistance). N Avoid exposure to persons with infection. N Contact physician if fever, chills, lower back pain, difficulty with urination, unusual bleeding or bruising, black tarry stools, blood in urine, pinpoint red spots on skin occur. N Report symptoms of depression or suicidal ideation immediately.
ipratropium bromide
ih-prah-trow-pea-um
(Apo-Ipravent J, Atrovent, Novo-Ipramide J, Nu-Ipratropium J, PMS-Ipratropium J)
Do not confuse Atrovent with Alupent.
FIXED-COMBINATION(S)
Combivent, Duoneb: ipratropime/albuterol (a bronchodilator): Aerosol: 18 mcg/103 mcg per actuation. Solution: 0.5 ml/2.5 ml per 3 ml.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Anticholinergic. CLINICAL: Bronchodilator.
ACTION
An anticholinergic that blocks the action of acetylcholine at parasympathetic sites in bronchial smooth muscle. Therapeutic Effect: Causes bronchodilation and inhibits nasal secretions.
PHARMACOKINETICS
Route Onset Peak Duration
Inhalation 1U3 min 1Uhr 4U6 hr
Minimal systemic absorption after inhalation. Metabolized in the liver (systemic absorption). Primarily eliminated in feces. Half-life: 1.5U4 hr.
USES
Inhalation: Maintenance treatment of bronchospasm due to chronic obstructive pulmonary disease (COPD), bronchitis, emphysema, asthma. Not to be used for immediate bronchospasm relief. Nasal Spray: Rhinorrhea (0.03% associated with perineal rhinitis, 0.06% associated with common cold), seasonal allergy.
PRECAUTIONS
CONTRAINDICATIONS: History of hypersensitivity to atropine, soya lecithin, or related food products such as soybean and peanut. CAUTIONS: Narrow-angle glaucoma, prostatic hypertrophy, bladder neck obstruction.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if distributed in breast milk. Pregnancy Category B. Children/Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Cromolyn inhalation solution: Avoid mixing these drugs because they form a precipitate. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
ORAL INHALATION: 18 mcg/actuation. AEROSOL SOLUTION FOR INHALATION: 0.02%. NASAL SPRAY: 0.03%, 0.06%.
ADMINISTRATION/HANDLING
INHALATION
N Shake container well. N Exhale completely through mouth; place mouthpiece into mouth, close lips, holding inhaler upright. N Inhale deeply through mouth while fully depressing the top of canister. Hold breath as long as possible before exhaling slowly. N Wait 2 min before inhaling second dose (allows for deeper bronchial penetration). N Rinse mouth with water immediately after inhalation (prevents mouth/throat dryness).
NASAL
N Store at room temperature. N Initial pump priming requires 7 actuations of the pump. N If used regularly as recommended, no further priming is required. If not used for more than 24 hr, the pump will require 2 actuations, or if not used for more than 7 days, the pump will require 7 actuations to reprime.
INDICATIONS/ROUTES/DOSAGE
BRONCHOSPASM
INHALATION: ADULTS, ELDERLY: 2 inhalations 4 times a day. Maximum: 12 inhalations/day. CHILDREN 3U14 YR: 1U2 inhalations 3 times a day. Maximum: 6 inhalations/day.
NEBULIZATION: ADULTS, ELDERLY: 500 mcg 3U4 times a day. CHILDREN: 125U250 mcg 3 times a day.
RHINORRHEA (PERENNIAL ALLERGIC AND NON-ALLERGIC RHINITIS)
INTRANASAL (0.03%): ADULTS, ELDERLY, CHILDREN 6 YR AND OLDER: 2 sprays per nostril 2U3 times a day.
RHINORRHEA (COMMON COLD)
INTRANASAL (0.06%): ADULTS, ELDERLY: 2 sprays per nostril 3U4 times a day for up to 4 days. CHILDREN 5 YR AND OLDER: 2 sprays per nostril 3 times a day for up to 4 days.
RHINORRHEA (SEASONAL ALLERGY)
INTRANASAL (0.06%): ADULTS, ELDERLY, CHILDREN 5 YR AND OLDER: 2 sprays per nostril 4 times a day for up to 3 wk.
SIDE EFFECTS
FREQUENT: Inhalation (6%U3%): Cough, dry mouth, headache, nausea. Nasal: Dry nose and mouth, headache, nasal irritation. OCCASIONAL: Inhalation (2%): Dizziness, transient increased bronchospasm. RARE (less than 1%): Inhalation: Hypotension, insomnia, metallic or unpleasant taste, palpitations, urine retention. Nasal: Diarrhea or constipation, dry throat, abdominal pain, stuffy nose.
ADVERSE REACTIONS/TOXIC EFFECTS
Worsening of angle-closure glaucoma, acute eye pain, and hypotension occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Offer emotional support (high incidence of anxiety due to difficulty in breathing, sympathomimetic response to drug).
INTERVENTION/EVALUATION
Monitor rate, depth, rhythm, type of respiration; quality, 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, sternal, intercostal retractions, hand tremor. Evaluate for clinical improvement (quieter, slower respirations, relaxed facial expression, cessation of retractions).
PATIENT/FAMILY TEACHING
N Increase fluid intake (decreases lung secretion viscosity). N Do not take more than 2 inhalations at any one time (excessive use may produce paradoxical bronchoconstriction or a decreased bronchodilating effect). N Rinsing mouth with water immediately after inhalation may prevent mouth and throat dryness. N Avoid excessive use of caffeine derivatives (chocolate, coffee, tea, cola, cocoa).
irbesartan
ir-beh-sar-tan
(Avapro)
FIXED-COMBINATION(S)
Avalide: irbesartan/hydrochlorothiazide (a diuretic): 150 mg/12.5 mg; 300 mg/12.5 mg, 300 mg/25 mg.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Angiotensin II receptor antagonist. CLINICAL: Antihypertensive.
ACTION
An angiotensin II receptor, type AT1, antagonist that blocks the 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: 90%. Undergoes hepatic metabolism to inactive metabolite. Recovered primarily in feces and, to a lesser extent, in urine. Not removed by hemodialysis. Half-life: 11U15 hr.
USES
Treatment of hypertension alone or in combination with other antihypertensives. Treatment of diabetic nephropathy. OFF-LABEL: Treatment of atrial fibrillation, CHF.
PRECAUTIONS
CONTRAINDICATIONS: Bilateral renal artery stenosis, biliary cirrhosis or obstruction, primary hyperaldosteronism, severe hepatic insufficiency. CAUTIONS: Mild to moderate hepatic dysfunction, sodium/water depletion, CHF, unilateral renal artery stenosis, coronary artery disease.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug is distributed in breast milk. May cause fetal or neonatal morbidity or mortality. 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: Diuretics: Produce additive hypotensive effects. HERBAL: None known. FOOD: None known. LAB VALUES: May slightly increase BUN and serum creatinine levels. May decrease blood Hgb level.
AVAILABILITY (Rx)
TABLETS: 75 mg, 150 mg, 300 mg.
ADMINISTRATION/HANDLING
N Give without regard to meals.
INDICATIONS/ROUTES/DOSAGE
HYPERTENSION ALONE OR IN COMBINATION WITH OTHER ANTIHYPERTENSIVES
NEPHROPATHY
SIDE EFFECTS
OCCASIONAL (9%U3%): Upper respiratory tract infection, fatigue, diarrhea, cough. RARE (2%U1%): Heartburn, dizziness, headache, nausea, rash.
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. Question possibility of pregnancy (see Pregnancy Category). Assess medication history (especially diuretic therapy).
INTERVENTION/EVALUATION
Maintain hydration (offer fluids frequently). Assess for evidence of upper respiratory infection. Assist with ambulation if dizziness occurs. Monitor electrolytes, renal and liver function tests, urinalysis, BP, pulse. Assess for hypotension.
PATIENT/FAMILY TEACHING
N Inform female patient regarding consequences of second- and third-trimester exposure to irbesartan. N Avoid tasks that require alertness, motor skills until response to drug is established (possible dizziness effect). N Report any sign of infection (sore throat, fever). N Caution against exercising during hot weather (risk of dehydration, hypotension).
irinotecan A
eye-rin-oh-teh-can
(Camptosar)
CLASSIFICATION
PHARMACOTHERAPEUTIC: DNA topoisomerase inhibitor. CLINICAL: Antineoplastic.
ACTION
A DNA topoisomerase inhibitor that inhibits the action of topoisomerase I, an enzyme that allows DNA replication by producing reversible single-strand breaks in DNA that relieve torsional strain. Irinotecan prevents religation of the DNA strand, resulting in damage to double-strand DNA and cell death. Therapeutic Effect: Kills cancer cells.
PHARMACOKINETICS
Metabolized to active metabolite in the liver after IV administration. Protein binding: 95% (metabolite). Excreted in urine and eliminated by biliary route. Half-life: 6 hr; metabolite, 10 hr.
USES
Treatment of metastatic carcinoma of colon or rectum in patients whose disease has recurred or progressed after 5-fluorouracil-based therapy. OFF-LABEL: NonUsmall cell lung cancer, refractory solid tumor configuration, untreated rhabdomyosarcoma.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Patient previously receiving pelvic or abdominal irradiation (increased risk of myelosuppression), elderly older than 65 yr.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: May cause fetal harm. Unknown if distributed in breast milk; discontinue breast-feeding. Pregnancy Category C (first trimester), D (second and third trimester). Children: Safety and efficacy not established. Elderly: Risk of diarrhea significantly increased.
INTERACTIONS
DRUG: Diuretics: May increase the risk of dehydration from vomiting and diarrhea. Laxatives: May increase the severity of diarrhea. 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. Prochlorperazine: May increase akathisia. HERBAL: St. John's
AVAILABILITY (Rx)
INJECTION: 20 mg/ml.
ADMINISTRATION/HANDLING
L IV
Reconstitution N Dilute in D5W (preferred) or 0.9% NaCl to concentration of 0.12 to 1.1 mg/ml.
Rate of administration N Administer all doses as IV infusion over 90 min. N Assess for extravasation (flush site with sterile water, apply ice if extravasation occurs).
Storage N Store vials at room temperature, protect from light. N Solution diluted in D5W is stable for 48 hr if refrigerated. N Use within 24 hr if refrigerated or 6 hr if kept at room temperature. N Do not refrigerate solution if diluted with 0.9% NaCl.
IV INCOMPATIBILITY
Gemcitabine (Gemzar).
INDICATIONS/ROUTES/DOSAGE
CARCINOMA OF THE COLON
IV: ADULTS, ELDERLY: Initially, 125 mg/m2 once weekly for 4 wk, followed by a rest period of 2 wk. Additional courses may be repeated q6wk. Dosage may be adjusted in 25U50 mg/m2 increments to as high as 150 mg/m2 or as low as 50 mg/m2.
SIDE EFFECTS
EXPECTED: Nausea (64%), alopecia (49%), vomiting (45%), diarrhea (32%). FREQUENT: Constipation, fatigue (29%); fever (28%); asthenia (25%); skeletal pain (23%); abdominal pain, dyspnea (22%). OCCASIONAL: Anorexia (19%); headache, stomatitis (18%); rash (16%).
ADVERSE REACTIONS/TOXIC EFFECTS
Myelosuppression characterized as neutropenia occurs in 97% of patients; severe neutropenia—neutrophil count less than 50/mm3—occurs in 78% of patients. Thrombocytopenia, anemia, and sepsis are common reactions.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Offer emotional support to patient and family. Assess hydration status, electrolytes, CBC before each dose. Premedicate with antiemetics on day of treatment, starting at least 30 min before administration.
INTERVENTION/EVALUATION
Assess for early signs of diarrhea (preceded by complaints of diaphoresis, abdominal cramping). Monitor hydration status, I&O, electrolytes, CBC, Hgb, platelets. Monitor infusion site for signs of inflammation. Inform patient of possibility of alopecia. Assess skin for evidence of rash.
PATIENT/FAMILY TEACHING
N Inform patient of possible late diarrhea causing dehydration, electrolyte depletion. N Provide antiemetic and antidiarrheal regimen for subsequent use. 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. N Avoid crowds, those with infections.
isosorbide dinitrate
eye-sew-sore-bide
Apo-ISDN J, Cedocard J, Dilatrate, Dilatrate-SR, ISDN, Isochron, Isordil, Isordil Tembids, Isordil Titradose, Sorbitrate
isosorbide mononitrate
Imdur, ISMO, Monoket
Do not confuse Isordil with Isuprel or Plendil, or Imdur with Inderal or K-Dur.
FIXED-COMBINATION(S)
BiDil: isosorbide/hydralazine, (a vasodilator): 20 mg/37.5 mg.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Nitrate. CLINICAL: Antianginal.
ACTION
A nitrate that stimulates intracellular cyclic guanosine monophosphate. Therapeutic Effect: Relaxes vascular smooth muscle of both arterial and venous vasculature. Decreases preload and afterload.
PHARMACOKINETICS
Route Onset Peak Duration
Dinitrate
Sublingual 2U5 min N/A 1U2 hr
Oral (Chewable) 2U5 min N/A 1U2 hr
Oral 15U40 min N/A 4U6 hr
Oral 30 min N/A 12 hr
(Sustained-Release)
Mononitrate
Oral 60 min N/A N/A
(Extended-Release)
Dinitrate poorly absorbed and metabolized in the liver to its activate metabolite isosorbide mononitrate. Mononitrate well absorbed after PO administration. Excreted in urine and feces. Half-life: Dinitrate, 1U4 hr; mononitrate, 4 hr.
USES
Prophylaxis, treatment of angina pectoris. OFF-LABEL: CHF, dysphagia, pain relief, relief of esophageal spasm with gastroesophageal reflux.
PRECAUTIONS
CONTRAINDICATIONS: Closed-angle glaucoma, GI hypermotility or malabsorption (extended-release tablets), head trauma, hypersensitivity to nitrates, increased intracranial pressure, orthostatic hypotension, severe anemia (extended-release tablets). CAUTIONS: Acute MI, hepatic or renal disease, glaucoma (contraindicated in closed-angle glaucoma), blood volume depletion from diuretic therapy, systolic BP less than 90 mm Hg.
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: May be more sensitive to hypotensive effects. Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Alcohol, antihypertensives, vasodilators: May increase risk of orthostatic hypotension. HERBAL: None known. FOOD: None known. LAB VALUES: May increase urine catecholamine and urine vanillylmandelic acid levels.
AVAILABILITY (Rx)
CAPSULES (SUSTAINED-RELEASE [DILATRATE, ISORDIL TEMBIDS]): 40 mg. TABLETS: 5 mg (ISDN, Isordil, Isordil Titradose), 10 mg (ISDN, ISMO, Isordil, Isordil Titradose, Monoket), 20 mg (ISDN, ISMO, Isordil, Isordil Titradose, Monoket), 30 mg (ISDN, Isordil, Isordil Titradose), 40 mg (ISDN, Isordil, Isordil Titradose). TABLETS (CHEWABLE [SORBITRATE]): 5 mg, 10 mg. TABLETS (EXTENDED-RELEASE [IMDUR]): 30 mg, 60 mg, 120 mg. TABLETS (SUBLINGUAL [ISORDIL]): 2.5 mg, 5 mg, 10 mg.
ADMINISTRATION/HANDLING
N Best if taken on an empty stomach. N Oral tablets may be crushed. N Do not crush or break sublingual or extended-release form. N Do not crush chewable form before administering.
SUBLINGUAL
N Do not crush or chew sublingual tablets. N Dissolve tablets under tongue; do not swallow.
INDICATIONS/ROUTES/DOSAGE
ANGINA
SIDE EFFECTS
FREQUENT: Burning and tingling at oral point of dissolution (sublingual), headache (possibly severe) occurs mostly in early therapy, diminishes rapidly in intensity, and usually disappears during continued treatment, transient flushing of face and neck, dizziness (especially if patient is standing immobile or is in a warm environment), weakness, orthostatic hypotension, nausea, vomiting, restlessness. OCCASIONAL: GI upset, blurred vision, dry mouth.
ADVERSE REACTIONS/TOXIC EFFECTS
Blurred vision or dry mouth may occur (drug should be discontinued). Isosorbide administration may cause severe orthostatic hypotension manifested by fainting, pulselessness, cold or clammy skin, and diaphoresis. Tolerance may occur with repeated, prolonged therapy, but may not occur with the extended-release form. Minor tolerance may be seen with intermittent use of sublingual tablets. High dosage tends to produce severe headache.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Record onset, type (sharp, dull, squeezing), radiation, location, intensity, duration of anginal pain; precipitating factors (exertion, emotional stress). If headache occurs during management therapy, administer medication with meals.
INTERVENTION/EVALUATION
Assist with ambulation if lightheadedness, dizziness occurs. Assess for facial or neck flushing. Monitor number of anginal episodes, orthostatic BP.
PATIENT/FAMILY TEACHING
N Do not chew or crush sublingual or sustained-release forms. N Take sublingual tablets while sitting down. N Notify physician if angina persists for longer than 20 min. N Rise slowly from lying to sitting position, dangle legs momentarily before standing. N Take oral form on empty stomach (however, if headache occurs during management therapy, take medication with meals). N Dissolve sublingual tablet under tongue; do not swallow. N Take at first signal of angina. N If pain not relieved within 5 min, dissolve second tablet under tongue. N Repeat if no relief in another 5 min. N If pain continues, contact physician. N Expel from mouth any remaining sublingual tablet after pain is completely relieved. N Do not change from one brand of drug to another. N Avoid alcohol (intensifies hypotensive effect). N If alcohol is ingested soon after taking nitrates, possible acute hypotensive episode (marked drop in BP, vertigo, pallor) may occur.
itraconazole
eye-tra-con-ah-zoll
(Sporanox)
Do not confuse Sporanox with Suprax.
CLASSIFICATION
CLINICAL: Antifungal.
ACTION
A fungistatic antifungal that inhibits the synthesis of ergosterol, a vital component of fungal cell formation. Therapeutic Effect: Damages the fungal cell membrane, altering its function.
PHARMACOKINETICS
Moderately absorbed from the GI tract. Absorption is increased if the drug is taken with food. Protein binding: 99%. Widely distributed, primarily in the fatty tissue, liver, and kidneys. Metabolized in the liver to active metabolite. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 21 hr; metabolite, 12 hr.
USES
Treatment of aspergillosis, blastomycosis, esophageal and oropharyngeal candidiasis, empiric treatment in febrile neutropenia, histoplasmosis, onychomycosis. OFF-LABEL: Suppression of histoplasmosis; treatment of disseminated sporotrichosis, fungal pneumonia and septicemia, or ringworm of the hand.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to fluconazole, ketoconazole, or miconazole. CAUTIONS: Hepatitis, HIV-infected patients, patients with achlorhydria, hypochlorhydria (decreases absorption), hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Antacids, didanosine, H2 antagonists: May decrease itraconazole absorption. Buspirone, cyclosporine, digoxin, lovastatin, simvastatin: May increase blood concentration of these drugs. Oral anticoagulants: May increase the effect of oral anticoagulants. Phenytoin, rifampin: May decrease itraconazole blood concentration. HERBAL: None known. FOOD: Grapefruit, grapefruit juice: May alter itraconazole absorption. LAB VALUES: May increase serum LDH serum alkaline phosphatase, serum bilirubin, AST, and ALT levels. May decrease serum potassium level.
AVAILABILITY (Rx)
CAPSULES: 100 mg. ORAL SOLUTION: 10 mg/ml. INJECTION: 10 mg/ml (25-ml ampule).
ADMINISTRATION/HANDLING
L IV
Reconstitution N Use only components provided by manufacturer. N Do not dilute with any other diluent. N Add full contents of ampule (250 mg/10 ml) to infusion bag provided (50 ml 0.9% NaCl). N Mix gently.
Rate of administration N Infuse over 60 min using extension line and infusion set provided. N After administration, flush infusion set with 15U20 ml 0.9% NaCl over 30 sec to 15 min. N Discard entire infusion line.
Storage N Store at room temperature. Do not freeze.
N Give capsules with food (increases absorption). N Give solution on an empty stomach.
IV INCOMPATIBILITIES
O ALERT P Dilution compatibility of itraconazole with any solution other than 0.9% NaCl is unknown. Don't mix with D5W or lactated Ringer's solution. Not for IV bolus administration. Don't administer any medication in same bag or through same IV line as itraconazole.
INDICATIONS/ROUTES/DOSAGE
BLASTOMYCOSIS, HISTOPLASMOSIS
IV: ADULTS, ELDERLY: 200 mg twice a day for 4 doses, then 200 mg once a day.
ASPERGILLOSIS
IV: ADULTS, ELDERLY: 200 mg twice a day for 4 doses, then 200 mg once a day.
ESOPHAGEAL CANDIDIASIS
OROPHARYNGEAL CANDIDIASIS
FEBRILE NEUTROPENIA
IV: ADULTS, ELDERLY: 200 mg twice a day for 4 doses, then 200 mg for up to 14 days. Then give PO 200 mg twice a day until neutropenia resolves.
ONYCHOMYCOSIS (FINGERNAIL)
ONYCHOMYCOSIS (TOENAIL)
SIDE EFFECTS
FREQUENT (11%U9%): Nausea, rash. OCCASIONAL (5%U3%): Vomiting, headache, diarrhea, hypertension, peripheral edema, fatigue, fever. RARE (2% or less): Abdominal pain, dizziness, anorexia, pruritus.
ADVERSE REACTIONS/TOXIC EFFECTS
Hepatitis (as evidenced by anorexia, abdominal pain, unusual fatigue or weakness, jaundice skin or sclera, and dark urine) occurs rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Determine baseline temperature, liver function tests. Assess allergies.
INTERVENTION/EVALUATION
Assess for signs, symptoms of hepatic dysfunction. Monitor hepatic enzyme test results in patients with preexisting hepatic dysfunction.
PATIENT/FAMILY TEACHING
N Take capsules with food, liquids if GI distress occurs. N Therapy will continue for at least 3 mo, until lab tests, clinical presentation indicate infection is controlled. N Immediately report the following: unusual fatigue, yellow skin, dark urine, pale stool, anorexia, nausea, vomiting. N Avoid grapefruits and grapefruit juice.
immune globulin IV (IGIV)
ih-mewn glah-byew-lin
(Carimune, Gamimune N 5%, Gamimune N 10%, Gammagard S/D, Gammar-P-IV, Gamunex, Iveegam EN, Octagam, Panglobulin, Polygam S/D, Sandoglobulin, Vivaglobin)
Do not confuse Sandoglobulin with Sandimmune or Sandostatin.
CLASSIFICATION
CLINICAL: Immune serum.
ACTION
An immune serum that increases antibody titer and antigen-antibody reaction. Therapeutic Effect: Provides passive immunity against infection; induces rapid increase in platelet count; produces anti-inflammatory effect.
PHARMACOKINETICS
Evenly distributed between intravascular and extravascular space. Half-life: 21U23 days.
USES
Treatment of patients with primary immunodeficiency syndromes, idiopathic thrombocytopenia purpura (ITP), Kawasaki
PRECAUTIONS
CONTRAINDICATIONS: Allergies to gamma globulin, thimerosal, or anti-IgA antibodies; isolated IgA deficiency. CAUTIONS: Cardiovascular disease, history of thrombosis, renal impairment, diabetes, volume depletion, sepsis, concomitant nephrotoxic drugs.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category C. Children/Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Live virus vaccines: May increase vaccine side effects, potentiate virus replication, and decrease the patient's antibody response to the vaccine. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
INJECTION SOLUTION: 5% (Gamimune N 5%, Octagam), 10% (Gammagard, Gamimune N 10%, Gamunex). INJECTION POWDER FOR RECONSTITUTION: 0.5 g (Iveegam EN), 1 g (Carimune, Gammar-P-IV, Iveegam EN, Panglobulin, Sandoglobulin), 2.5 g (Gammar-P-IV, Gammagard S/D, Iveegam EN, Polygam S/D, Sandoglobulin), 3 g (Carimune, Panglobulin, Sandoglobulin), 5 g (Gammar-P-IV, Gammagard S/D, Iveegam EN, Polygam S/D, Sandoglobulin), 6 g (Carimune, Panglobulin, Sandoglobulin), 10 g (Gammar-P-IV, Gammagard S/D, Polygam S/D, Sandoglobulin), 12 g (Carimune, Panglobulin, Sandoglobulin). SUBCUTANEOUS FORMULATION: (Vivaglobin) injection 160 mg/ml.
ADMINISTRATION/HANDLING
L IV
Reconstitution N Reconstitute only with diluent provided by manufacturer. N Discard partially used or turbid preparations.
Rate of administration N Give by infusion only. N After reconstituted, administer via separate tubing. N Avoid mixing with other medication or IV infusion fluids. N Rate of infusion varies with product used. N Monitor vital signs, BP diligently during and immediately after IV administration (precipitous fall in BP may indicate anaphylactic reaction). Stop infusion immediately. Epinephrine should be readily available.
Storage N Refer to individual IV preparations for storage requirements, stability after reconstitution.
IV INCOMPATIBILITIES
Do not mix IGIV with any other medications.
INDICATIONS/ROUTES/DOSAGE
PRIMARY IMMUNODEFICIENCY SYNDROME
IV: ADULTS, ELDERLY, CHILDREN: 200U400 mg/kg once monthly.
SUBCUTANEOUS: ADULTS, ELDERLY: 100U200 mg/kg once weekly.
ITP
IV: ADULTS, ELDERLY, CHILDREN: 400U1,000 mg/kg/day for 2U5 days.
IV: ADULTS, ELDERLY, CHILDREN: 2 g/kg as a single dose.
CLL
IV: ADULTS, ELDERLY, CHILDREN: 400 mg/kg q3U4wk.
BONE MARROW TRANSPLANT
IV: ADULTS, ELDERLY, CHILDREN: 400U500 mg/kg/dose every week for 12 wk, then every month.
SIDE EFFECTS
FREQUENT: Tachycardia, backache, headache, arthralgia, myalgia. OCCASIONAL: Fatigue, wheezing, injection site rash or pain, leg cramps, urticaria, bluish lips and nailbeds, light-headedness.
ADVERSE REACTIONS/TOXIC EFFECTS
Anaphylactic reactions are rare, but the incidence increases with repeated injections of IGIV. Keep epinephrine readily available. Overdose may produce chest tightness, chills, diaphoresis, dizziness, facial flushing, nausea, vomiting, fever, and hypotension. Hypersensitivity reaction, characterized by anxiety, arthralgia, dizziness, flushing, myalgia, palpitations, and pruritus, occurs rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Inquire about history of exposure to disease for both patient and family as appropriate. Have epinephrine readily available. Well hydrate patient before use.
INTERVENTION/EVALUATION
Control rate of IV infusion carefully; too-rapid infusion increases risk of precipitous fall in BP, signs of anaphylaxis (facial flushing, chest tightness, chills, fever, nausea, vomiting, diaphoresis). Assess patient closely during infusion, especially first hour; monitor vital signs continuously. Stop infusion temporarily if aforementioned signs noted. For treatment of ITP, monitor platelets.
PATIENT/FAMILY TEACHING
N Explain rationale for therapy. N Rapid response, lasts 1U3 mo. N Inform physician if sudden weight gain, fluid retention, edema, decreased urine output, shortness of breath occur.
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