labetalol hydrochloride
lah-bet-ah-lol
(Normodyne, Trandate)
Do not confuse Trandate with tramadol or Trental.
FIXED-COMBINATION(S)
Normozide: labetalol/hydrochlorothiazide (a diuretic): 100 mg/25 mg; 200 mg/25 mg; 300 mg/25 mg.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Alpha-, beta-adrenergic blocker. CLINICAL: Antihypertensive.
ACTION
An antihypertensive that blocks alpha1-, beta1-, and beta2-(large doses) adrenergic receptor sites. Large doses increase airway resistance. Therapeutic Effect: Slows sinus heart rate; decreases peripheral vascular resistance, cardiac output, and BP.
PHARMACOKINETICS
Route Onset Peak Duration
IV 2U5 min 5U15 min 2U4 hr
Completely absorbed from the GI tract. Protein binding: 50%. Undergoes first-pass metabolism. Metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: PO , 6U8 hr; IV, 5.5 hr.
USES
Management of mild, moderate, severe hypertension. May be used alone or in combination with other antihypertensives. OFF-LABEL: Control of hypotension during surgery, treatment of chronic angina pectoris.
PRECAUTIONS
CONTRAINDICATIONS: Bronchial asthma, cardiogenic shock, overt cardiac failure, second- or third-degree heart block, severe bradycardia, uncontrolled CHF, other conditions associated with severe and prolonged hypotension. CAUTIONS: Medication-controlled CHF, nonallergic bronchospastic disease (chronic bronchitis, emphysema), hepatic or cardiac impairment, pheochromocytoma, diabetes mellitus.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Drug crosses placenta. Small amount distributed in breast milk. Pregnancy Category C (D if used in second or third trimester). Children: Safety and efficacy not established. Elderly: Age-related peripheral vascular disease may increase susceptibility to decreased peripheral circulation.
INTERACTIONS
DRUG: Diuretics, other antihypertensives: May increase hypotensive effect. Insulin, oral hypoglycemics: May mask symptoms of hypoglycemia and prolong hypoglycemic effect of these drugs. MAOIs: May produce hypertension. Sympathomimetics, xanthines: May mutually inhibit effects. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum antinuclear antibody titer and BUN, serum LDH, lipoprotein, alkaline phosphatase, bilirubin, creatinine, potassium, triglyceride, uric acid, AST, and ALT levels.
AVAILABILITY (Rx)
TABLETS (NORMODYNE, TRANDATE): 100 mg, 200 mg, 300 mg. INJECTION (TRANDATE): 5 mg/ml.
ADMINISTRATION/HANDLING
L IV
O ALERT P Patient must be in supine position for IV administration and for 3 hr after receiving medication (substantial drop in BP upon standing should be expected).
Reconstitution N For IV infusion, dilute 200 mg in 160 ml D5W, 0.9% NaCl, lactated Ringer's, or any combination thereof to provide concentration of 1 mg/ml.
Rate of administration N For IV push, give over 2 min at 10-min intervals. N For IV infusion, administer at rate of 2 mg/min (2 ml/min) initially. Rate is adjusted according to BP. N Monitor BP immediately before and q5U10min during IV administration (maximum effect occurs within 5 min).
Storage N Store at room temperature. N After dilution, IV solution is stable for 24 hr. N Solution appears clear, colorless to light yellow. N Discard if precipitate forms or discoloration occurs.
N Give without regard to food. N Tablets may be crushed.
IV INCOMPATIBILITIES
Amphotericin B complex (Abelcet, AmBisome, Amphotec), ceftriaxone (Rocephin), furosemide (Lasix), heparin, nafcillin (Nafcil), thiopental.
IV COMPATIBILITIES
Aminophylline, amiodarone (Cordarone), calcium gluconate, diltiazem (Cardizem), dobutamine (Dobutrex), dopamine (Intropin), enalapril (Vasotec), fentanyl (Sublimaze), hydromorphone (Dilaudid), lidocaine, lorazepam (Ativan), magnesium sulfate, midazolam (Versed), milrinone (Primacor), morphine, nitroglycerin, norepinephrine (Levophed), potassium chloride, potassium phosphate, propofol (Diprivan).
INDICATIONS/ROUTES/DOSAGE
HYPERTENSION
SEVERE HYPERTENSION, HYPERTENSIVE EMERGENCY
IV: ADULTS: Initially, 20 mg. Additional doses of 20U80 mg may be given at 10-min intervals, up to total dose of 300 mg.
IV INFUSION: ADULTS: Initially, 2 mg/min up to total dose of 300 mg.
SIDE EFFECTS
FREQUENT: Drowsiness, difficulty sleeping, unusual fatigue or weakness, diminished sexual ability, transient scalp tingling. OCCASIONAL: Dizziness, dyspnea, peripheral edema, depression, anxiety, constipation, diarrhea, nasal congestion, nausea, vomiting, abdominal discomfort. RARE: Altered taste, dry eyes, increased urination, paresthesia.
ADVERSE REACTIONS/TOXIC EFFECTS
Labetalol administration may precipitate or aggravate CHF because of decreased myocardial stimulation. Abrupt withdrawal may precipitate ischemic heart disease, producing sweating, palpitations, headache, and tremor. May mask signs and symptoms of acute hypoglycemia (tachycardia, BP changes) in patients with diabetes.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Assess baseline renal and liver function tests. Assess BP, apical pulse immediately before drug administration (if pulse is 60/min or less or systolic BP is lower than 90 mm Hg, withhold medication, contact physician).
INTERVENTION/EVALUATION
Monitor BP for hypotension. Assess pulse for quality, irregular rate, bradycardia. Monitor EKG for cardiac arrhythmias. Monitor pattern of bowel activity and stool consistency. Assist with ambulation if dizziness occurs. Assess for evidence of CHF: dyspnea (particularly on exertion or lying down), night cough, peripheral edema, distended neck veins. Monitor I&O (increase in weight, decrease in urine output may indicate CHF).
PATIENT/FAMILY TEACHING
N Do not discontinue drug except upon advice of physician (abrupt discontinuation may precipitate heart failure). N Compliance with therapy regimen is essential to control hypertension, arrhythmias. N Avoid tasks that require alertness, motor skills until response to drug is established. N Report shortness of breath, excessive fatigue, weight gain, prolonged dizziness or headache. N Do not use nasal decongestants, OTC cold preparations (stimulants) without physician approval.
lamotrigine
lam-oh-trih-jeen
(Apo-Lamotrigine J, Lamictal, Lamictal CD)
Do not confuse lamotrigine with lamivudine.
CLASSIFICATION
CLINICAL: Anticonvulsants.
ACTION
An anticonvulsant whose exact mechanism is unknown. May block voltage-sensitive sodium channels, thus stabilizing neuronal membranes and regulating presynaptic transmitter release of excitatory amino acids. Therapeutic Effect: Reduces seizure activity.
USES
Adjunctive therapy in adults and children with partial seizures, treatment of adults and children with generalized seizures of Lennox-Gastaut syndrome. Conversion to monotherapy in adults treated with another enzyme-inducing antiepileptic drug (EIAED). Long-term maintenance treatment of bipolar disorder.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Renal/hepatic/cardiac impairment. Pregnancy Category C.
INTERACTIONS
DRUG: Carbamazepine, phenobarbital, phenytoin, primidone, valproic acid: Decrease lamotrigine blood concentration. Carbamazepine, valproic acid: May increase serum levels of these drugs. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
TABLETS: 25 mg, 100 mg, 150 mg, 200 mg. TABLETS (CHEWABLE): 2 mg, 5 mg, 25 mg.
ADMINISTRATION/HANDLING
N Give without regard to food.
INDICATIONS/ROUTES/DOSAGE
SEIZURE CONTROL IN PATIENTS RECEIVING ENZYME-INDUCING ANTIEPILEPTIC DRUG (EIAEDS), BUT NOT VALPROIC ACID
PO: ADULTS, ELDERLY, CHILDREN OLDER THAN 12 YR: Recommended as add-on therapy: 50 mg once a day for 2 wk, followed by 100 mg/day in 2 divided doses for 2 wk. Maintenance: Dosage may be increased by 100 mg/day every week, up to 300U500 mg/day in 2 divided doses. CHILDREN 2U12 YR: 0.6 mg/kg/day in 2 divided doses for 2 wk, then 1.2 mg/kg/day in 2 divided doses for wk 3 and 4. Maintenance: 5U15 mg/kg/day. Maximum: 400 mg/day.
SEIZURE CONTROL IN PATIENTS RECEIVING COMBINATION THERAPY OF EIAEDS AND VALPROIC ACID
CONVERSION TO MONOTHERAPY FOR PATIENTS RECEIVING EIAED
CONVERSION TO MONOTHERAPY FOR PATIENTS RECEIVING VALPROIC ACID
BIPOLAR DISORDER IN PATIENTS RECEIVING EIAED
BIPOLAR DISORDER IN PATIENTS RECEIVING VALPROIC ACID
PO: ADULTS, ELDERLY: 25 mg/day every other day for 2 wk, then 25 mg/day for 2 wk, then 50 mg/day for 1 wk, then 100 mg/day. Usual maintenance dose with valproic acid: 100 mg/day.
DISCONTINUATION THERAPY
ADULTS, CHILDREN OLDER THAN 12 YR: A dosage reduction of approximately 50% per week over at least 2 wk is recommended.
SIDE EFFECTS
FREQUENT: Dizziness (38%), headache (29%), diplopia (28%), ataxia (22%), nausea (19%), blurred vision (16%), somnolence, rhinitis (14%). OCCASIONAL (10%U5%): Rash, pharyngitis, vomiting, cough, flu-like symptoms, diarrhea, dysmenorrhea, fever, insomnia, dyspepsia. RARE: Constipation, tremor, anxiety, pruritus, vaginitis, hypersensitivity reaction.
ADVERSE REACTIONS/TOXIC EFFECTS
Abrupt withdrawal may increase seizure frequency. Serious rashes, including Stevens-Johnson syndrome, requiring hospitalization and discontinuation of treatment have been reported.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Review history of seizure disorder (type, onset, intensity, frequency, duration, level of consciousness [LOC]), drug history (especially other anticonvulsants), other medical conditions (e.g., renal impairment). Provide safety precautions, quiet, dark environment.
INTERVENTION/EVALUATION
Report to physician promptly if evidence of rash occurs (drug discontinuation may be necessary). Assist with ambulation if dizziness, ataxia occurs. Assess for clinical improvement (decreased intensity/frequency of seizures). Assess for visual abnormalities, headache.
PATIENT/FAMILY TEACHING
N Take medication only as prescribed; do not abruptly withdraw medication after long-term therapy. N Avoid alcohol, tasks that require alertness, motor skills until response to drug is established. N Carry identification card/bracelet to note anticonvulsant therapy. N Strict maintenance of drug therapy is essential for seizure control. N Report any rash, fever, swelling of glands to physician. N May cause photosensitivity reaction; avoid exposure to sunlight, artificial light.
terbinafine hydrochloride
ter-been-a-feen
(Apo-Terbinafine J, Lamisil, Lamisil AT, Novo-Terbinafine J)
Do not confuse terbinafine with terbutaline or Lamisil with Lamictal.
CLASSIFICATION
CLINICAL: Antifungal.
ACTION
A fungicidal antifungal that inhibits the enzyme squalene epoxidase, thereby interfering with fungal biosynthesis. Therapeutic Effect: Results in death of fungal cells.
PHARMACOKINETICS
Well absorbed following PO administration. Protein binding: 99%. Metabolized by liver. Primarily excreted in urine; minimal elimination in feces. Half-life: (oral): 36 hr, (topical): 22U26 hr.
USES
Systemic: Treatment of onychomycosis (fungal disease of nails due to dermatophytes). Topical: Treatment of tinea cruris (jock itch), t. pedis (athlete's foot), t. corporis (ringworm).
PRECAUTIONS
CONTRAINDICATIONS: Oral: Children younger than 12 yr, preexisting hepatic or renal impairment (creatinine clearance of 50 ml/min or less). CAUTIONS: None known.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Distributed in breast milk. Pregnancy Category B. Children: Safety and efficacy not established. Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Alcohol, other hepatotoxic medications: May increase the risk of hepatotoxicity. Hepatic enzyme inducers, including rifampin: May increase terbinafine clearance. Hepatic enzyme inhibitors, including cimetidine: May decrease terbinafine clearance. HERBAL: None known. FOOD: None known. LAB VALUES: May increase AST and ALT levels.
AVAILABILITY (Rx)
TABLETS (LAMISIL): 250 mg. CREAM (LAMISIL AT): 1%. TOPICAL SOLUTION (LAMISIL, LAMISIL AT): 1%. TOPICAL SPRAY (LAMISIL AT): 1%.
INDICATIONS/ROUTES/DOSAGE
TINEA PEDIS
TOPICAL: ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: Apply twice a day until signs and symptoms significantly improve.
TINEA CRURIS, TINEA CORPORIS
TOPICAL: ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: Apply 1U2 times a day until signs and symptoms significantly improve.
ONYCHOMYCOSIS
TINEA VERSICOLOR
TOPICAL SOLUTION: ADULTS, ELDERLY: Apply to the affected area twice a day for 7 days.
SYSTEMIC MYCOSIS
SIDE EFFECTS
FREQUENT (13%): Oral: Headache. OCCASIONAL (6%U3%): Abdominal pain, flatulence, urticaria, visual disturbance. Oral: Diarrhea, rash, dyspepsia, pruritus, taste disturbance, nausea. Topical: Irritation, burning, pruritus, dryness.
ADVERSE REACTIONS/TOXIC EFFECTS
Hepatobiliary dysfunction (including cholestatic hepatitis), serious skin reactions, and severe neutropenia occur rarely. Ocular lens and retinal changes have been noted.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Serum liver function tests should be obtained in patients receiving treatment for longer than 6 wk.
INTERVENTION/EVALUATION
Check for therapeutic response. Discontinue medication, notify physician if local reaction occurs (irritation, redness, swelling, itching, oozing, blistering, burning). Monitor serum liver function in patients receiving treatment for longer than 6 wk.
PATIENT/FAMILY TEACHING
N Keep areas clean, dry; wear light clothing to promote ventilation. N Separate personal items. N Avoid topical cream contact with eyes, nose, mouth, other mucous membranes. N Rub well into affected, surrounding area. N Do not cover with occlusive dressing. N Notify physician if skin irritation, diarrhea
lamivudine
lah-mih-view-deen
(Epivir, Epivir-HBV, Heptovir J)
Do not confuse lamivudine with lamotrigine.
FIXED-COMBINATION(S)
Combivir: lamivudine/zidovudine (an antiviral): 150 mg/300 mg. Epzicom: lamivudine/abacavir (an antiviral): 300 mg/600 mg. Trizivir: lamivudine/zidovudine/abacavir (an antiviral): 150 mg/300 mg/300 mg.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Nucleoside reverse transcriptase inhibitors. CLINICAL: Antiviral.
ACTION
An antiviral that inhibits HIV reverse transcriptase by viral DNA chain termination. Also inhibits RNA- and DNA-dependent DNA polymerase, an enzyme necessary for HIV replication. Therapeutic Effect: Interrupts HIV replication, slowing the progression of HIV infection.
PHARMACOKINETICS
Rapidly and completely absorbed from the GI tract. Protein binding: less than 36%. Widely distributed (crosses the blood-brain barrier). Primarily excreted unchanged in urine. Not removed by hemodialysis or peritoneal dialysis. Half-life: 11U15 hr (intracellular), 2U11 hr (serum, adults), 1.7U2 hr (serum, children), (increased in impaired renal function).
USES
Epivir: Treatment of HIV infection in combination with other antiretroviral agents. Epivir HBV: Treatment for chronic hepatitis B. OFF-LABEL: Prophylaxis in health care workers at risk of acquiring HIV after occupational exposure.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Peripheral neuropathy or history of peripheral neuropathy, history of pancreatitis in children, renal impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Drug crosses placenta. Unknown if distributed in breast milk. Breast-feeding not recommended (possibility of HIV transmission). Pregnancy Category C. Children: Safety and efficacy not established in those younger than 3 mo. Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Co-trimoxazole: Increases lamivudine blood concentration. HERBAL: St. John's
AVAILABILITY (Rx)
ORAL SOLUTION: 5 mg/ml (Epivir-HBV), 10 mg/ml (Epivir). TABLETS: 100 mg (Epivir-HBV), 150 mg (Epivir), 300 mg (Epivir).
ADMINISTRATION/HANDLING
N Give without regard to meals.
INDICATIONS/ROUTES/DOSAGE
HIV INFECTION (IN COMBINATION WITH OTHER ANTIRETROVIRALS)
CHRONIC HEPATITIS B
DOSAGE IN RENAL IMPAIRMENT
Dosage and frequency are modified based on creatinine clearance.
Creatinine Clearance (ml/min) Dosage
50 ml/min or higher 150 mg twice a day
30U49 ml/min 150 mg once a day
15U29 ml/min 150 mg first dose, then 100 mg once a day
5U14 ml/min 150 mg first dose, then 50 mg once a day
Less than 5 ml/min 50 mg first dose, then 25 mg once a day
SIDE EFFECTS
FREQUENT: Headache (35%), nausea (33%), malaise and fatigue (27%), nasal disturbances (20%), diarrhea, cough (18%), musculoskeletal pain, neuropathy (12%), insomnia (11%), anorexia, dizziness, fever or chills (10%). OCCASIONAL: Depression (9%); myalgia (8%); abdominal cramps (6%); dyspepsia, arthralgia (5%).
ADVERSE REACTIONS/TOXIC EFFECTS
Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported. Pancreatitis occurs in 13% of pediatric patients. Anemia, neutropenia, and thrombocytopenia occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Establish baseline lab values, especially renal function.
INTERVENTION/EVALUATION
Monitor serum creatinine, amylase, lipase, BUN. Assess for headache, nausea, cough. Monitor pattern of bowel activity and stool consistency. Modify diet or administer laxative as needed. Assess for dizziness, sleep pattern. If pancreatitis in children occurs, movement aggravates abdominal pain; sitting up, flexing at the waist relieves the pain.
PATIENT/FAMILY TEACHING
N Continue therapy for full length of treatment. N Doses should be evenly spaced. N Inform patient lamivudine is not a cure for HIV/AIDS nor does it reduce risk of transmission to others; patient may continue to experience illnesses, including opportunistic infections. N Avoid tasks requiring alertness, motor skills until response to drug is established. N Advise parents to closely monitor pediatric patients for symptoms of pancreatitis (severe, steady abdominal pain often radiating to the back, clammy skin, hypotension; nausea or vomiting may accompany abdominal pain).
lansoprazole H
lan-so-prah-zoll
(Prevacid, Prevacid IV, Prevacid Solu-Tab)
Do not confuse Prevacid with Pepcid, Pravachol, or Prevpac.
FIXED-COMBINATION(S)
Prevacid NapraPac: lansoprazole/naproxen (an NSAID): 15 mg/375 mg; 15 mg/500 mg.
CLASSIFICATION
CLINICAL: Proton pump inhibitor.
ACTION
A proton pump inhibitor that selectively inhibits the parietal cell membrane enzyme system (hydrogen-potassium adenosine triphosphatase) or proton pump. Therapeutic Effect: Suppresses gastric acid secretion.
PHARMACOKINETICS
Route Onset Peak Duration
Rapid and complete absorption (food may decrease absorption) once drug has left stomach. Protein binding: 97%. Distributed primarily to gastric parietal cells and converted to two active metabolites. Extensively metabolized in the liver. Eliminated in bile and urine. Not removed by hemodialysis. Half-life: 1.5 hr (increased in the elderly and in those with hepatic impairment).
USES
Short-term treatment (4 wk and less) for healing, symptomatic relief of active duodenal ulcer, short-term treatment (8 wk and less) for healing, symptomatic relief of erosive esophagitis. Long-term treatment of pathologic hypersecretory conditions, including Zollinger-Ellison syndrome. Short-term treatment (8 wk and less) of active gastric ulcer, H. pyloriUassociated duodenal ulcer, maintenance treatment for healed duodenal ulcer. Treatment for gastroesophageal reflux disease (GERD), NSAID-associated gastric ulcer. IV: Short-term treatment of erosive esophagitis.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if distributed in breast milk. Pregnancy Category B. Children: Safety and efficacy not established. Elderly: No age-related precautions noted but doses greater than 30 mg not recommended.
INTERACTIONS
DRUG: Ampicillin, digoxin, iron salts, ketoconazole: May interfere with the absorption of ampicillin, digoxin, iron salts, and ketoconazole. Sucralfate: May delay the absorption of lansoprazole. HERBAL: None known. FOOD: None known. LAB VALUES: May increase LDH, serum alkaline phosphatase, bilirubin, cholesterol, creatinine, AST, ALT, triglyceride, and uric acid levels. May produce abnormal albumin/globulin ratio, electrolyte balance, and platelet, RBC, and WBC counts. May increase Hgb and Hct.
AVAILABILITY (Rx)
CAPSULES (DELAYED-RELEASE [PREVACID]): 15 mg, 30 mg. GRANULES FOR ORAL SUSPENSION (PREVACID): 15 mg/pack; 30 mg/pack. INJECTION POWDER FOR RECONSTITUTION (PREVACID IV): 30 mg. ORALLY-DISINTEGRATING TABLETS (PREVACID SOLU-TAB): 15 mg, 30 mg.
ADMINISTRATION/HANDLING
L IV
N Store at room temperature. N Infuse over 30 min.
N Give while fasting or before meals (food diminishes absorption). N Do not chew or crush delayed-release capsules. N If patient has difficulty swallowing capsules, open capsules, sprinkle granules on 1 tbsp of applesauce, swallow immediately.
N May give via oral syringe or nasogastric tube. N May dissolve in 4 ml water (15 mg) or 10 ml (30 mg).
INDICATIONS/ROUTES/DOSAGE
DUODENAL ULCER
EROSIVE ESOPHAGITIS
IV: ADULTS, ELDERLY: 30 mg once a day for up to 7 days. Switch to oral lansoprazole therapy as soon as patient can tolerate oral route.
GASTRIC ULCER
NSAID GASTRIC ULCER
HEALED DUODENAL ULCER, GASTROESOPHAGEAL REFLUX DISEASE
USUAL PEDIATRIC DOSAGE
CHILDREN 3 MOU14 YR, WEIGHING MORE THAN 20 KG: 30 mg once daily. CHILDREN 3 MOU14 YR, WEIGHING 10U20 KG: 15 mg once daily. CHILDREN 3 MOU14 YR, WEIGHING LESS THAN 10 KG: 7.5 mg once daily.
H. PYLORI INFECTION
PATHOLOGIC HYPERSECRETORY CONDITIONS (INCLUDING ZOLLINGER-ELLISON SYNDROME)
SIDE EFFECTS
OCCASIONAL (3%U2%): Diarrhea, abdominal pain, rash, pruritus, altered appetite. RARE (1%): Nausea, headache.
ADVERSE REACTIONS/TOXIC EFFECTS
Bilirubinemia, eosinophilia, and hyperlipemia occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Obtain baseline lab values. Assess drug history, especially use of sucralfate.
INTERVENTION/EVALUATION
Monitor ongoing laboratory results. Assess for therapeutic response (i.e., relief of GI symptoms). Question if diarrhea, abdominal pain, nausea occurs.
PATIENT/FAMILY TEACHING
N Do not chew or crush delayed-release capsules. N For patients who have difficulty swallowing capsules, open capsules, sprinkle granules on 1 tbsp of applesauce, swallow immediately.
lidocaine hydrochloride A
lye-doe-kane
(Anestacaine, Anestacon, Ela-Max, Ela-Max Plus, Laryng-O-Jet Spray, L-Caine, Lida Mantle, Lidoderm, Lidoject 1, Lidoject 2, LidoSite, LMX 4, LMX 4 with Tegaderm, LMX 5, Truxacaine, UAD Caine, Xylocaine, Xylocaine 10% Oral, Xylocaine Dental Cartridges, Xylocaine HCl For Spinal, Xylocaine Jelly, Xylocaine-MPF, Xylocaine Topical, Xylocaine Viscous, Xylocaine Viscous Topical Solution J, Xylocard J, Zilactin-L J)
FIXED-COMBINATION(S)
EMLA: lidocaine/prilocaine (an anesthetic): 2.5%/2.5%. Lidocaine with epinephrine: lidocaine/epinephrine (a sympathomimetic): 2%/1:50,000; 1%/1:100,000; 1%/1:200,000; 0.5%/1:200,000. Lidosite: lidocaine/epinephrine, (a sympathomimetic): 10%/0.1%.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Amide anesthetic. CLINICAL: Antiarrhythmic, anesthetic.
ACTION
An amide anesthetic that inhibits conduction of nerve impulses. Therapeutic Effect: Causes temporary loss of feeling and sensation. Also an antiarrhythmic that decreases depolarization, automaticity, excitability of the ventricle during diastole by direct action. Therapeutic Effect: Inhibits ventricular arrhythmias.
PHARMACOKINETICS
Route Onset Peak Duration
IV 30U90 sec N/A 10U20 min
Local anesthetic 2.5 min N/A 30U60 min
–
Completely absorbed after IM administration. Protein binding: 60% to 80%. Widely distributed. Metabolized in the liver. Primarily excreted in urine. Minimally removed by hemodialysis. Half-life: 1U2 hr.
USES
Antiarrhythmic: Rapid control of acute ventricular arrhythmias following MI, cardiac catheterization, cardiac surgery, digitalis-induced ventricular arrhythmias. Local anesthetic: Infiltration/nerve block for dental or surgical procedures, childbirth. Topical Anesthetic: Local skin disorders (minor burns, insect bites, prickly heat, skin manifestations of chickenpox, abrasions). Mucous membranes (local anesthesia of oral, nasal, laryngeal mucous membranes; local anesthesia of respiratory, urinary tracts; relief of discomfort of pruritus ani, hemorrhoids, pruritus vulvae). Dermal Patch: Treatment of shingles-related skin pain.
PRECAUTIONS
CONTRAINDICATIONS: Adams-Stokes syndrome, hypersensitivity to amide-type local anesthetics, septicemia (spinal anesthesia), supraventricular arrhythmias, Wolff-Parkinson-White syndrome. CAUTIONS: Hepatic disease, marked hypoxia, severe respiratory depression, hypovolemia, heart block, bradycardia, atrial fibrillation.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Distributed in breast milk. Pregnancy Category B. Children: No age-related precautions noted. Elderly: More sensitive to adverse effects. Dose, rate of infusion should be reduced. Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Anticonvulsants: May increase cardiac depressant effects. Beta-adrenergic blockers: May increase risk of toxicity. Local anesthetics: Amount absorbed from all formulations may be increased. Other antiarrhythmics: May increase cardiac effects. HERBAL: None known. FOOD: None known. LAB VALUES: IM lidocaine may increase creatine kinase (CK) level (used to diagnose acute MI). Therapeutic serum level is 1.5 to 6 mcg/ml; toxic serum level is greater than 6 mcg/ml.
AVAILABILITY (Rx)
INJECTION (FOR CONTINUOUS INFUSION [XYLOCAINE]): 4% w/v (40 mg/ml), 10% w/v (100 mg/ml), 20% w/v (200 mg/ml). INJECTION (WITH DEXTROSE FOR CONTINUOUS INFUSION): 0.1% w/v (1 mg/ml), 0.2% w/v (2 mg/ml), 0.4% w/v (4 mg/ml), 0.8% w/v (8 mg/ml). INJECTION (FOR DIRECT INJECTION [XYLOCAINE]): 1% w/v (10 mg/ml), 2% w/v (20 mg/ml). INJECTABLE SOLUTION: 0.5% (Xylocaine HCl), 1% (Anestacaine, L-Caine, Lidoject 1, Truxacaine, UAD Caine, Xylocaine HCl, Xylocaine-MPF), 1.5% (Xylocaine HCl, Xylocaine-MPF), 2% (Anestacaine, Lidoject 2, Truxacaine, Xylocaine Dental Cartridges, Xylocaine HCl, Xylocaine-MPF), 4% (Xylocaine HCl, Xylocaine-MPF), 10% (Xylocaine), 20% (Xylocaine). OINTMENT (XYLOCAINE TOPICAL): 5%. CREAM: 3% (Lida Mantle), 4% (Ela-Max, Ela-Max Plus, LMX 4, LMX 4 with Tegaderm), 5% (LMX 5). GEL (ANESTACON, XYLOCAINE JELLY, XYLOCAINE TOPICAL): 2%. TOPICAL SPRAY (XYLOCAINE 10% ORAL): 10%. TOPICAL SOLUTION: 2% (Xylocaine Viscous), 4% (Xylocaine Topical). TOPICAL FILM (LIDODERM): 5%. TOPICAL LOTION (LIDA MANTLE): 3%. DERMAL PATCH (LIDODERM): 5%. KIT (LARYNG-O-JET SPRAY): 4%.
ADMINISTRATION/HANDLING
O ALERT P Resuscitative equipment, drugs (including O2) must always be readily available when administering lidocaine by any route.
L IV
O ALERT P Use only lidocaine without preservative, clearly marked for IV use.
Reconstitution N For IV infusion, prepare solution by adding 1 g to 1 L D5W to provide concentration of 1 mg/ml (0.1%). N Commercially available preparations of 0.2%, 0.4%, and 0.8% may be used for IV infusion. Maximum concentration: 4 g/250 ml.
Rate of administration N For IV push, use 1% (10 mg/ml) or 2% (20 mg/ml). N Administer IV push at rate of 25U50 mg/min. N Administer for IV infusion at rate of 1U4 mg/min (1U4 ml); use volume control IV set.
Storage N Store at room temperature.
IM
N Use 10% (100 mg/ml); clearly identify lidocaine that is for IM use. N Give in deltoid muscle (serum level is significantly higher than if injection is given in gluteus muscle or lateral thigh).
TOPICAL
N Not for ophthalmic use. N For skin disorders, apply directly to affected area or put on gauze or bandage, which is then applied to the skin. N For mucous membrane use, apply to desired area as per manufacturer's insert. N Administer the lowest dosage possible that still provides anesthesia.
IV INCOMPATIBILITIES
Amphotericin B complex (Abelcet, AmBisome, Amphotec), thiopental.
IV COMPATIBILITIES
Aminophylline, amiodarone (Cordarone), calcium gluconate, digoxin (Lanoxin), diltiazem (Cardizem), dobutamine (Dobutrex), dopamine (Intropin), enalapril (Vasotec), furosemide (Lasix), heparin, insulin, nitroglycerin, potassium chloride.
INDICATIONS/ROUTES/DOSAGE
RAPID CONTROL OF ACUTE VENTRICULAR ARRHYTHMIAS AFTER AN MI, CARDIAC CATHETERIZATION, CARDIAC SURGERY, OR DIGITALIS-INDUCED VENTRICULAR ARRHYTHMIAS
IM: ADULTS, ELDERLY: 300 mg (or 4.3 mg/kg). May repeat in 60U90 min.
IV: ADULTS, ELDERLY: Initially, 50U100 mg (1 mg/kg) IV bolus at rate of 25U50 mg/min. May repeat in 5 min. Give no more than 200U300 mg in 1 hr. Maintenance: 20U50 mcg/kg/min (1U4 mg/min) as IV infusion. CHILDREN, INFANTS: Initially, 0.5U1 mg/kg IV bolus; may repeat but total dose not to exceed 3U5 mg/kg. Maintenance: 10U50 mcg/kg/min as IV infusion.
DENTAL OR SURGICAL PROCEDURES, CHILDBIRTH
INFILTRATION, NERVE BLOCK: ADULTS: Local anesthetic dosage varies with procedure, degree of anesthesia, vascularity, duration. Maximum dose: 4.5 mg/kg. Do not repeat within 2 hr.
LOCAL SKIN DISORDERS (MINOR BURNS, INSECT BITES, PRICKLY HEAT, SKIN MANIFESTATIONS OF CHICKENPOX, ABRASIONS), AND MUCOUS MEMBRANE DISORDERS (LOCAL ANESTHESIA OF ORAL, NASAL, AND LARYNGEAL MUCOUS MEMBRANES; LOCAL ANESTHESIA OF RESPIRATORY, URINARY TRACT; RELIEF OF DISCOMFORT OF PRURITUS ANI, HEMORRHOIDS, PRURITUS VULVAE)
TOPICAL: ADULTS, ELDERLY: Apply to affected areas as needed.
TREATMENT OF SHINGLES-RELATED SKIN PAIN
TOPICAL (DERMAL PATCH): ADULTS, ELDERLY: Apply to intact skin over most painful area (up to 3 applications once for up to 12 hr in a 24-hr period).
SIDE EFFECTS
CNS effects are generally dose-related and of short duration. OCCASIONAL: IM: Pain at injection site. Topical: Burning, stinging, tenderness at application site. RARE: Generally with high dose: Drowsiness; dizziness; disorientation; light-headedness; tremors; apprehension; euphoria; sensation of heat, cold, or numbness; blurred or double vision; ringing or roaring in ears (tinnitus); nausea.
ADVERSE REACTIONS/TOXIC EFFECTS
Although serious adverse reactions to lidocaine are uncommon, high dosage by any route may produce cardiovascular depression, bradycardia, hypotension, arrhythmias, heart block, cardiovascular collapse, and cardiac arrest. There is a potential for malignant hyperthermia. CNS toxicity may occur, especially with regional anesthesia use, progressing rapidly from mild side effects to tremors, somnolence, seizures, vomiting, and respiratory depression. Methemoglobinemia (evidenced by cyanosis) has occurred following topical application of lidocaine for teething discomfort and laryngeal anesthetic spray.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Question for hypersensitivity to lidocaine, amide anesthetics. Obtain baseline BP, pulse, respirations, EKG, serum electrolytes.
INTERVENTION/EVALUATION
Monitor EKG, vital signs closely during and following drug administration for cardiac performance. If EKG shows arrhythmias, prolongation of PR interval or QRS complex, inform physician immediately. Assess pulse for irregularity, quality, bradycardia. Assess BP for evidence of hypotension. Monitor for therapeutic serum level (1.5U6 mcg/ml). For lidocaine given by all routes, monitor vital signs, patient's level of consciousness (LOC). Drowsiness should be considered a warning sign of high serum levels of lidocaine. Therapeutic serum level: 1.5U6 mcg/ml; toxic serum level: greater than 6 mcg/ml.
PATIENT/FAMILY TEACHING
N Local anesthesia: Ensure that patient understands loss of feeling or sensation, need for protection until anesthetic wears off (e.g., no ambulation, including special positions for some regional anesthesia). N Oral mucous membrane anesthesia: Do not eat, drink, chew gum for 1 hr after application (swallowing reflex may be impaired, increasing risk of aspiration; numbness of tongue or buccal mucosa may lead to bite trauma).
leflunomide
lee-flew-no-mide
(Arava)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Immunomodulatory agent. CLINICAL: Anti-inflammatory.
ACTION
An immunomodulatory agent that inhibits dihydroorotate dehydrogenase, the enzyme involved in autoimmune process that leads to rheumatoid arthritis. Therapeutic Effect: Reduces signs and symptoms of rheumatoid arthritis and slows structural damage.
PHARMACOKINETICS
Well absorbed after PO administration. Protein binding: greater than 99%. Metabolized to active metabolite in the GI wall and liver. Excreted through both renal and biliary systems. Not removed by hemodialysis. Half-life: 16 days.
USES
Treatment of active rheumatoid arthritis. Improve physical function in patients with rheumatoid arthritis.
PRECAUTIONS
CONTRAINDICATIONS: Pregnancy or plans to become pregnant. CAUTIONS: Hepatic or renal impairment, positive hepatitis B or C serology, those with immunodeficiency or bone marrow dysplasias, breast-feeding mothers.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Can cause fetal harm. Unknown if excreted in breast milk. Avoid use in breast-feeding mothers. Pregnancy Category X. Children: Safety and efficacy not established in those younger than 18 yr. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Rifampin: Increases the blood concentration of leflunomide. Warfarin: May increase the effects of warfarin. HERBAL: None known. FOOD: None known. LAB VALUES: May increase hepatic enzyme levels, especially AST, and ALT.
AVAILABILITY (Rx)
TABLETS: 10 mg, 20 mg.
ADMINISTRATION/HANDLING
N Give without regard to food.
INDICATIONS/ROUTES/DOSAGE
RHEUMATOID ARTHRITIS
SIDE EFFECTS
FREQUENT (20%U10%): Diarrhea, respiratory tract infection, alopecia, rash, nausea.
ADVERSE REACTIONS/TOXIC EFFECTS
Transient thrombocytopenia and leukopenia occur rarely. Rare cases of severe hepatic injury, including cases with fatal outcome, have been reported during treatment.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Question for possibility of pregnancy (Pregnancy Category X). Assess limitations in activities of daily living due to rheumatoid arthritis.
INTERVENTION/EVALUATION
Monitor tolerance to medication. Assess symptomatic relief of rheumatoid arthritis (relief of pain; improved range of motion, grip strength, mobility). Monitor liver function tests.
PATIENT/FAMILY TEACHING
N May take without regard to food. N Improvement may take longer than 8 wk. N Avoid pregnancy (Pregnancy Category X).
leuprolide acetate A
–––––––––––––––––––––––––––––––––––––––––––––
loo-proe-lide
(Lupron, Lupron Depot, Lupron Depot-Gyn, Lupron Depot-Ped, Viadur)
Do not confuse leuprolide or Lupron with Lopurin or Nuprin.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Gonadotropin-releasing hormone analogue. CLINICAL: Antineoplastic.
ACTION
A gonadotropin-releasing hormone analogue and antineoplastic agent that stimulates the release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the anterior pituitary gland. Therapeutic Effect: Produces pharmacologic castration and decreases the growth of abnormal prostate tissue in males; causes endometrial tissue to become inactive and atrophic in females; and decreases the rate of pubertal development in children with central precocious puberty.
PHARMACOKINETICS
Rapidly and well absorbed after subcutaneous administration. Absorbed slowly after IM administration. Protein binding: 43%U49%. Half-life: 3U4 hr.
USES
Palliative treatment of advanced prostate carcinoma. Management of endometriosis as initial or treatment of recurrent symptoms. Pre-operative treatment of anemia caused by uterine leiomyomata (fibroids). Treatment of central precocious puberty.
PRECAUTIONS
CONTRAINDICATIONS: Lactation, pernicious anemia, pregnancy, undiagnosed vaginal bleeding. Eligard 7.5 mg is contraindicated in patients with hypersensitivity to GnRH, GnRH agonist analogs or any of the components, 30 mg Lupron Depot contraindicated in women, the implant form is contraindicated in women and children. CAUTIONS: Long-term use in children.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Depot: Contraindicated in pregnancy. May cause spontaneous abortion. Pregnancy Category X. Children: Long-term safety not established. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum prostatic acid phosphatase (PAP) levels. Initially increases, then decreases, serum testosterone concentration.
AVAILABILITY (Rx)
IMPLANT (VIADUR): 65 mg. INJECTION DEPOT FORMULATION: 3.75 mg (Lupron Depot), 7.5 mg (Eligard, Lupron Depot, Lupron Depot-Ped), 11.25 mg (Lupron Depot, Lupron Depot-Ped, Lupron Depot-Gyn), 15 mg (Lupron Depot-Ped), 22.5 mg (Eligard, Lupron Depot), 30 mg (Lupron Depot). INJECTION SOLUTION (LUPRON): 5 mg/ml.
ADMINISTRATION/HANDLING
O ALERT P May be carcinogenic, mutagenic, teratogenic. Handle with extreme care during preparation/administration.
IM
Lupron Depot N Store at room temperature. N Protect from light, heat. N Do not freeze vials. N Reconstitute only with diluent provided. Follow instructions for mixing provided by the manufacturer. N Do not use needles less than 22 gauge; use syringes provided by the manufacturer (0.5 ml low-dose insulin syringes may be used as an alternative). N Administer immediately.
Eligard N Refrigerate. N Allow to warm to room temperature before reconstitution. N Follow instructions for mixing provided by the manufacturer. N Following reconstitution, administer within 30 min.
SUBCUTANEOUS
Lupron N Refrigerate vials. N Injection appears clear, colorless. N Discard if precipitate forms or solution appears discolored. N Administer into deltoid muscle, anterior thigh, or abdomen.
INDICATIONS/ROUTES/DOSAGE
ADVANCED PROSTATIC CARCINOMA
IM (LUPRON DEPOT): ADULTS, ELDERLY: 7.5 mg every month or 22.5 mg q3mo or 30 mg q4mo.
SUBCUTANEOUS (ELIGARD): ADULTS, ELDERLY: 7.5 mg every month or 22.5 mg q3mo or 30 mg q4mo.
SUBCUTANEOUS (LUPRON): ADULTS, ELDERLY: 1 mg/day.
SUBCUTANEOUS (VIADUR): ADULTS, ELDERLY: 65 mg implanted q12mo.
ENDOMETRIOSIS
IM (LUPRON DEPOT): ADULTS, ELDERLY: 3.75 mg/mo for up to 6 mo or 11.25 mg q3mo for up to 2 doses.
UTERINE LEIOMYOMATA
IM (WITH IRON [LUPRON DEPOT]): ADULTS, ELDERLY: 3.75 mg/mo for up to 3 mo or 11.25 mg as a single injection.
PRECOCIOUS PUBERTY
IM (LUPRON DEPOT): CHILDREN: 0.3 mg/kg/dose every 28 days. Minimum: 7.5 mg. If down regulation is not achieved, titrate upward in 3.75-mg increments q4wk.
SUBCUTANEOUS (LUPRON): CHILDREN: 20U45 mcg/kg/day. Titrate upward by 10 mcg/kg/day if down regulation is not achieved.
SIDE EFFECTS
FREQUENT: Hot flashes (ranging from mild flushing to diaphoresis). Females: Amenorrhea, spotting. OCCASIONAL: Arrhythmias; palpitations; blurred vision; dizziness; edema; headache; burning or itching, or swelling at injection site; nausea; insomnia; weight gain. Females: Deepening voice, hirsutism, decreased libido, increased breast tenderness, vaginitis, altered mood. Males: Constipation, decreased testicle size, gynecomastia, impotence, decreased appetite, angina. RARE: Males: Thrombophlebitis.
ADVERSE REACTIONS/TOXIC EFFECTS
Signs and symptoms of metastatic prostatic carcinoma (such as bone pain, dysuria or hematuria, and weakness or paresthesia of the lower extremities) occasionally worsen 1U2 wk after the initial dose but then subside with continued therapy. Pulmonary embolism and MI occur rarely.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Question for possibility of pregnancy before initiating therapy (Pregnancy Category X). Obtain serum testosterone, PAP levels periodically during therapy. Serum testosterone and PAP levels should increase during first week of therapy. Testosterone level then should decrease to baseline level or less within 2 wk, PAP level within 4 wk.
INTERVENTION/EVALUATION
Monitor for arrhythmias, palpitations. Assess for peripheral edema. Assess sleep pattern. Monitor for visual difficulties. Assist with ambulation if dizziness occurs. Offer antiemetics if nausea occurs.
PATIENT/FAMILY TEACHING
N Hot flashes tend to decrease during continued therapy. N Temporary exacerbation of signs and symptoms of disease may occur during first few wk of therapy. N Use contraceptive measures during therapy. N Inform physician if regular menstruation persists, pregnancy occurs. N Avoid tasks that require alertness, motor skills until response to drug is established (potential for dizziness).
levalbuterol
lee-val-bwet-err-all
(Xopenex, Xopenex HFA)
Do not confuse Xopenex with Xanax.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Sympathomimetic. CLINICAL: Bronchodilator.
ACTION
A sympathomimetic that stimulates beta2-adrenergic receptors in the lungs resulting in relaxation of bronchial smooth muscle. Therapeutic Effect: Relieves bronchospasm and reduces airway resistance.
PHARMACOKINETICS
Route Onset Peak Duration
Inhalation 10U17 min 1.5 hr 5U6 hr
Metabolized in the liver to inactive metabolite. Half-life: 3.3U4 hr.
USES
Treatment, prevention of bronchospasm due to reversible obstructive airway disease.
PRECAUTIONS
CONTRAINDICATIONS: History of hypersensitivity to sympathomimetics. CAUTIONS: Cardiovascular disorders (e.g., cardiac arrhythmias), seizures, hypertension, hyperthyroidism, diabetes mellitus.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Unknown if distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established in those younger than 12 yr. Elderly: Lower initial dosages recommended.
INTERACTIONS
DRUG: Beta blockers: Antagonize the effects of levalbuterol. Digoxin: May increase the risk of arrhythmias. MAOIs, tricyclic antidepressants: May potentiate cardiovascular effects. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum potassium level.
AVAILABILITY (Rx)
SOLUTION FOR NEBULIZATION: 0.31 in 3-ml vials, 0.63 mg in 3-ml vials, 1.25 mg in 3-ml vials. INHALATION AEROSOL: 45 mcg/activation.
ADMINISTRATION/HANDLING
NEBULIZATION
N No diluent necessary. N Protect from light and excessive heat. Store at room temperature. N Once foil is opened, use within 2 wk. N Discard if solution is not colorless. N Do not mix with other medications. N Give over 5U15 min.
INDICATIONS/ROUTES/DOSAGE
TREATMENT AND PREVENTION OF BRONCHOSPASM
NEBULIZATION: ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: Initially, 0.63 mg 3 times a day 6U8 hr apart. May increase to 1.25 mg 3 times a day with dose monitoring. CHILDREN 3U11 YR: Initially 0.31 mg 3 times a day. Maximum: 0.63 mg 3 times a day.
INHALATION: ADULTS, ELDERLY, CHILDREN 4 YR AND OLDER: 1U2 inhalations q4U6h.
SIDE EFFECTS
FREQUENT: Tremor, nervousness, headache, throat dryness and irritation. OCCASIONAL: Cough, bronchial irritation. RARE: Somnolence, diarrhea, dry mouth, flushing, diaphoresis, anorexia.
ADVERSE REACTIONS/TOXIC EFFECTS
Excessive sympathomimetic stimulation may produce palpitations, extrasystoles, tachycardia, chest pain, a slight increase in BP followed by a substantial decrease, chills, diaphoresis, and blanching of skin. Too-frequent or excessive use may lead to decreased bronchodilating effectiveness and severe, paradoxical bronchoconstriction.
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 and rate of pulse, EKG, serum potassium, ABG determinations. Assess lung sounds for wheezing (bronchoconstriction), rales.
PATIENT/FAMILY TEACHING
N Increase fluid intake (decreases lung secretion viscosity). N Rinsing mouth with water immediately after inhalation may prevent mouth/throat dryness. N Avoid excessive use of caffeine derivatives (chocolate, coffee, tea, cola, cocoa). N Notify physician if palpitations, tachycardia, chest pain, tremors, dizziness, headache occurs.
levofloxacin H
levo-flox-a-sin
(Iquix, Levaquin, Levaquin Leva-Pak, Quixin)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Fluoroquinolone. CLINICAL: Antibiotic.
ACTION
A fluoroquinolone that inhibits the DNA enzyme gyrase in susceptible microorganisms, interfering with bacterial cell replication and repair. Therapeutic Effect: Bactericidal.
PHARMACOKINETICS
Well absorbed after both PO and IV administration. Protein binding: 24%U8%. Penetrates rapidly and extensively into leukocytes, epithelial cells, and macrophages. Lung concentrations are 2U5 times higher than those of plasma. Eliminated unchanged in the urine. Partially removed by hemodialysis. Half-life: 8 hr.
USES
Treatment of acute bacterial exacerbation of chronic bronchitis, acute bacterial sinusitus, community-acquired pneumonia, nosocomial pneumonia, acute maxillary sinusitis, complicated UTIs, acute pyelonephritis, uncomplicated mild to moderate skin and skin-structure infections, prostatitis. Ophthalmic: Treatment of superficial infections to conjunctiva (0.5%), cornea (1.5%). Treatment of susceptible infections due to S. pneumoniae, S. aureus, E. faecalis, H. influenzae, M. catarrhalis, serratia marcescens, K. pneumoniae, E. coli, P. mirabilis, P. aeruginosa, C. pneumoniae, Legionella pneumophila, Mycoplasma pneumoniae including acute bacterial sinusitis. OFF-LABEL: Anthrax, gonorrhea, pelvic inflammatory disease (PID).
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to other fluoroquinolones or nalidixic acid. CAUTIONS: Suspected CNS disorders, seizure disorder, renal impairment, bradycardia, cardiomyopathy, hypokalemia, hypomagnesemia.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Excreted in breast milk. Avoid use in pregnancy. Pregnancy Category C. Children: Safety and efficacy not established in those younger than 18 yr. Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Antacids, iron preparations, sucralfate, zinc: Decrease levofloxacin absorption. NSAIDs: May increase the risk of CNS stimulation or seizures. HERBAL: None known. FOOD: None known. LAB VALUES: May alter blood glucose levels.
AVAILABILITY (Rx)
ORAL SOLUTION: 25 mg/ml. TABLETS (LEVAQUIN, LEVAQUIN LEVA-PAK): 250 mg, 500 mg, 750 mg. INJECTION (LEVAQUIN): 500-mg/20-ml vials. PREMIXED SOLUTION (LEVAQUIN): 25 mg/ml, 250 mg/50 ml, 500 mg/100 ml, 750 mg/150 ml. OPHTHALMIC SOLUTION: 0.5% (Iquix), 1.5% (Quixin).
ADMINISTRATION/HANDLING
L IV
Reconstitution N For infusion using single-dose vial, withdraw desired amount (10 ml for 250 mg, 20 ml for 500 mg). Dilute each 10 ml (250 mg) with minimum 40 ml 0.9% NaCl, D5W.
Rate of administration N Administer slowly, over not less than 60 min.
Storage N Available in single-dose 20-ml (500-mg) vials and premixed with D5W, ready to infuse.
N Do not administer antacids (aluminum, magnesium), sucralfate, iron or multivitamin preparations with zinc within 2 hr of levofloxacin administration (significantly reduces levofloxacin absorption). N Encourage intake of cranberry juice, citrus fruits (acidifies urine). N Give without regard to food.
OPHTHALMIC
N Place a gloved finger on lower eyelid, pull out until a pocket is formed between eye and lower lid. Hold dropper above pocket, place correct number of drops into pocket. N Close eye gently. Apply digital pressure to lacrimal sac for 1U2 min (minimizes drainage into nose and throat, reducing risk of systemic effects).
IV INCOMPATIBILITIES
Furosemide (Lasix), heparin, insulin, nitroglycerin, propofol (Diprivan).
IV COMPATIBILITIES
Aminophylline, dobutamine (Dobutrex), dopamine (Intron), fentanyl (Sublimaze), lidocaine, lorazepam (Ativan), morphine.
INDICATIONS/ROUTES/DOSAGE
BACTERIAL SINUSITIS
BRONCHITIS
COMMUNITY-ACQUIRED PNEUMONIA
PNEUMONIA, NOSOCOMIAL
ACUTE MAXILLARY SINUSITIS
SKIN AND SKIN-STRUCTURE INFECTIONS
PROSTATITIS
IV, PO : ADULTS, ELDERLY: 500 mg q24h for 28 days.
UNCOMPLICATED UTI
IV, PO : ADULTS, ELDERLY: 250 mg q24h for 3 days.
UTIs, ACUTE PYELONEPHRITIS
BACTERIAL CONJUNCTIVITIS
OPHTHALMIC: ADULTS, ELDERLY, CHILDREN 1 YR AND OLDER: 1U2 drops q2h for 2 days (up to 8 times a day), then 1U2 drops q4h for 5 days.
CORNEAL ULCER
OPHTHALMIC: ADULTS, ELDERLY, CHILDREN OLDER THAN 5 YR: Days 1U3: Instill 1U2 drops q30min to 2 hours while awake and 4U6 hours after retiring. Days 4 through completion: 1U2 drops q1U4h while awake.
DOSAGE IN RENAL IMPAIRMENT
For bronchitis, pneumonia, sinusitis, and skin and skin-structure infections, dosage and frequency are modified based on creatinine clearance.
Creatinine Clearance Dosage
50U80 ml/min No change
20U49 ml/min 500 mg initially, then 250 mg q24h
10U19 ml/min 500 mg initially, then 250 mg q48h
Dialysis 500 mg initially, then 250 mg q48h. For UTIs and pyelonephritis, dosage and frequency are modified based on creatinine clearance.
Creatinine Clearance Dosage
20 ml/min No change
10U19 ml/min 250 mg initially, then 250 mg q48h
SIDE EFFECTS
OCCASIONAL (3%U1%): Diarrhea, nausea, abdominal pain, dizziness, drowsiness, headache, light-headedness. Ophthalmic: Local burning or discomfort, margin crusting, crystals or scales, foreign body sensation, ocular itching, altered taste. RARE (less than 1%): Flatulence; altered taste; pain; inflammation or swelling in calves, hands, or shoulder; chest pain; difficulty breathing; palpitations; edema; tendon pain. Ophthalmic: Corneal staining, keratitis, allergic reaction, eyelid swelling, tearing, reduced visual acuity.
ADVERSE REACTIONS/TOXIC EFFECTS
Antibiotic-associated colitis and other superinfections may occur from altered bacterial balance. Hypersensitivity reactions, including photosensitivity (as evidenced by rash, pruritus, blisters, edema, and burning skin), have occurred in patients receiving fluoroquinolones.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Question for hypersensitivity to levofloxacin, other fluoroquinolones.
INTERVENTION/EVALUATION
Monitor blood glucose, renal and liver function tests. Report hypersensitivity reaction: skin rash, urticaria, pruritus, photosensitivity promptly. Be alert for superinfection (e.g., genital or anal pruritus, ulceration or changes in oral mucosa, moderate to severe diarrhea, new or increased fever). Provide symptomatic relief for nausea. Evaluate food tolerance, altered taste.
PATIENT/FAMILY TEACHING
N Drink 6U8 glasses of fluid a day (citrus, cranberry juice acidifies urine). N Avoid tasks that require alertness, motor skills until response to drug is established (may cause dizziness, drowsiness). N Notify physician if tendon pain or swelling, palpitations, chest pain, difficulty breathing, persistent diarrhea occurs.
levetiracetam F
leva-tir-ass eh-tam
(Keppra)
Do not confuse Keppra with Kaletra.
CLASSIFICATION
CLINICAL: Anticonvulsant.
ACTION
An anticonvulsant that inhibits burst firing without affecting normal neuronal excitability. Therapeutic Effect: Prevents seizure activity.
USES
Adjunctive therapy in treatment of partial-onset seizures in adults and children with epilepsy.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Renal impairment. Pregnancy Category C.
INTERACTIONS
DRUG: None known. HERBAL: Ginkgo biloba: May decrease anticonvulsant effectiveness. FOOD: None known. LAB VALUES: May increase blood Hgb level, Hct, and RBC and WBC counts.
AVAILABILITY (Rx)
ORAL SOLUTION: 100 mg/ml. TABLETS: 250 mg, 500 mg, 750 mg.
ADMINISTRATION/HANDLING
N Give without regard to food.
INDICATIONS/ROUTES/DOSAGE
PARTIAL-ONSET SEIZURES
DOSAGE IN RENAL IMPAIRMENT
Dosage is modified based on creatinine clearance.
SIDE EFFECTS
FREQUENT (15%U10%): Somnolence, asthenia, headache, infection. OCCASIONAL (9%U3%): Dizziness, pharyngitis, pain, depression, nervousness, vertigo, rhinitis, anorexia. RARE (less than 3%): Amnesia, anxiety, emotional lability, cough, sinusitis, anorexia, diplopia.
ADVERSE REACTIONS/TOXIC EFFECTS
Acute psychosis and seizures have been reported. Sudden discontinuance increases the risk of seizure activity.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Review history of seizure disorder (intensity, frequency, duration, level of consciousness [LOC]). Initiate seizure precautions. Assess for hypersensitivity to levetiracetam, renal function tests.
INTERVENTION/EVALUATION
Observe for recurrence of seizure activity. Assess for clinical improvement (decrease in intensity/frequency of seizures). Monitor renal function tests. Assist with ambulation if dizziness occurs.
PATIENT/FAMILY TEACHING
N Somnolence, drowsiness usually diminish with continued therapy. N Avoid tasks that require alertness, motor skills until response to drug is established. N Do not abruptly discontinue medication (may precipitate seizures). N Strict maintenance of drug therapy is essential for seizure control.
levothyroxine H
lee-voe-thye-rox-een
(Eltroxin J, Levo-T, Levothroid, Levoxyl, Novothyrox J, Synthroid, Unithroid)
Do not confuse levothyroxine with liothyronine.
FIXED-COMBINATION(S)
With liothyronine, T3 (Thyrolar).
CLASSIFICATION
PHARMACOTHERAPEUTIC: Synthetic isomer of thyroxine. CLINICAL: Thyroid hormone (T4).
ACTION
A synthetic isomer of thyroxine involved in normal metabolism, growth, and development, especially of the CNS in infants. Possesses catabolic and anabolic effects. Therapeutic Effect: Increases basal metabolic rate, enhances gluconeogenesis and stimulates protein synthesis.
PHARMACOKINETICS
Variable, incomplete absorption from the GI tract. Protein binding: greater than 99%. Widely distributed. Deiodinated in peripheral tissues, minimal metabolism in the liver. Eliminated by biliary excretion. Half-life: 6U7 days.
USES
Treatment of hypothyroidism, myxedema coma, pituitary thyroid-stimulating hormone (TSH) suppression.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to tablet components, such as tartrazine; allergy to aspirin; lactose intolerance; MI and thyrotoxicosis uncomplicated by hypothyroidism; treatment of obesity. CAUTIONS: Elderly, angina pectoris, hypertension, other cardiovascular disease.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Drug does not cross placenta. Minimal excretion in breast milk. Pregnancy Category A. Children: No age-related precautions noted. Caution in neonates in interpreting thyroid function tests. Elderly: May be more sensitive to thyroid effects; individualized dosage recommended.
INTERACTIONS
DRUG: Cholestyramine, colestipol: May decrease the absorption of levothyroxine. Estrogens: May cause a decrease in serum-free thyroxine concentration. Oral anticoagulants: May alter the effects of oral anticoagulants. Sympathomimetics: May increase the risk of coronary insufficiency and the effects of levothyroxine. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
TABLETS: (LEVO-T, LEVOTHROID, LEVOXYL, SYNTHROID, UNITHROID): 0.025 mg, 0.05 mg, 0.075 mg, 0.088 mg, 0.1 mg, 0.112 mg, 0.125 mg, 0.137 mg, 0.15 mg, 0.175 mg, 0.2 mg, 0.3 mg. INJECTION (SYNTHROID): 200 mcg, 500 mcg.
ADMINISTRATION/HANDLING
O ALERT P Do not interchange brands (problems with bioequivalence between manufacturers).
L IV
Reconstitution N Reconstitute 200-mcg or 500-mcg vial with 5 ml 0.9% NaCl to provide a concentration of 40 or 100 mcg/ml, respectively; shake until clear.
Rate of administration N Use immediately and discard unused portions. N Give each 100 mcg or less over 1 min.
Storage N Store vials at room temperature.
N Give at same time each day to maintain hormone levels. N Administer before breakfast to prevent insomnia. N Tablets may be crushed.
IV INCOMPATIBILITIES
Do not use or mix with other IV solutions.
INDICATIONS/ROUTES/DOSAGE
HYPOTHYROIDISM
MYXEDEMA COMA
IV: ADULTS, ELDERLY: Initially, 300U500 mcg. Maintenance: 75U100 mcg/day.
PITUITARY TSH SUPPRESSION
SIDE EFFECTS
OCCASIONAL: Reversible hair loss at the start of therapy (in children). RARE: Dry skin, GI intolerance, rash, hives, pseudotumor cerebri or severe headache in children.
ADVERSE REACTIONS/TOXIC EFFECTS
Excessive dosage produces signs and symptoms of hyperthyroidism, including weight loss, palpitations, increased appetite, tremors, nervousness, tachycardia, hypertension, headache, insomnia, and menstrual irregularities. Cardiac arrhythmias occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Question for hypersensitivity to tartrazine, aspirin, lactose. Obtain baseline weight, vital signs. Signs and symptoms of diabetes mellitus, diabetes insipidus, adrenal insufficiency, hypopituitarism may become intensified. Treat with adrenocortical steroids before thyroid therapy in coexisting hypothyroidism and hypoadrenalism.
INTERVENTION/EVALUATION
Monitor pulse for rate, rhythm (report pulse of 100 or marked increase). Observe for tremors, anxiety. Assess appetite, sleep pattern.
PATIENT/FAMILY TEACHING
N Do not discontinue drug therapy; replacement for hypothyroidism is lifelong. N Follow-up office visits, thyroid function tests are essential. N Take medication at the same time each day, preferably in the morning. N Monitor pulse for rate, rhythm; report irregular rhythm or pulse rate over 100 beats/min. N Do not change brands. N Notify physician promptly of chest pain, weight loss, anxiety or tremors, insomnia. N Children may have reversible hair loss, increased aggressiveness during the first few months of therapy. N Full therapeutic effect may take 1U3 wk.
lithium carbonate
lith-ee-um
(Duralith J, Eskalith, Eskalith CR, Lithobid)
lithium citrate
–––––––––––––––––––––––––––––––––––––––––––––
(Cibalith-S)
Do not confuse Lithobid with Levbid, Lithostat, or Lithotabs.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Psychotherapeutic. CLINICAL: Antimanic, antidepressant, vascular headache prophylactic.
ACTION
A psychotherapeutic agent that affects the storage, release, and reuptake of neurotransmitters. Antimanic effect may result from increased norepinephrine reuptake and serotonin receptor sensitivity. Therapeutic Effect: Produces antimanic and antidepressant effects.
PHARMACOKINETICS
Rapidly and completely absorbed from the GI tract. Primarily excreted unchanged in urine. Removed by hemodialysis. Half-life: 18U24 hr (increased in elderly).
USES
Prophylaxis, treatment of acute mania, manic phase of bipolar disorder (manic depressive illness). OFF-LABEL: Prevention of vascular headache; treatment of depression, neutropenia.
PRECAUTIONS
CONTRAINDICATIONS: Debilitated patients, severe cardiovascular disease, severe dehydration, severe renal disease, severe sodium depletion. CAUTIONS: Cardiovascular disease, thyroid disease, elderly.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Freely crosses placenta. Distributed in breast milk. Pregnancy Category D. Children: May increase bone formation or density (alter parathyroid hormone concentrations). Elderly: More susceptible to develop lithium-induced goiter or clinical hypothyroidism, CNS toxicity. Increased thirst, urination more frequent; lower dosage recommended.
INTERACTIONS
DRUG: Antithyroid medications, iodinated glycerol, potassium iodide: May increase the effects of these drugs. Diuretics, NSAIDs: May increase lithium serum concentration and risk of toxicity. Haloperidol: May increase extrapyramidal symptoms and the risk of neurologic toxicity. Molindone: May increase the risk of neurotoxicity. Phenothiazines: May decrease the absorption of phenothiazines, increase the intracellular concentration and renal excretion of lithium, and increase delirium and extrapyramidal symptoms. Antiemetic effect of some phenothiazines may mask early signs of lithium toxicity. HERBAL: None known. FOOD: None known. LAB VALUES: May increase blood glucose, immunoreactive parathyroid hormone, and serum calcium levels. Therapeutic serum level is 0.6U1.2 mEq/L; toxic serum level is greater than 1.5 mEq/L.
AVAILABILITY (Rx)
CAPSULES: 150 mg, 300 mg, 600 mg. SYRUP: 300 mg/ml. TABLETS: 300 mg. TABLETS (CONTROLLED-RELEASE): 450 mg. TABLETS (SLOW-RELEASE): 300 mg.
ADMINISTRATION/HANDLING
N Preferable to administer with meals or milk. N Do not crush, chew, or break slow-release or film-coated tablets.
INDICATIONS/ROUTES/DOSAGE
O ALERT P During acute phase, a therapeutic serum lithium concentration of 1U1.4 mEq/L is required. For long-term control, the desired level is 0.5U1.3 mEq/L. Monitor serum drug concentration and clinical response to determine proper dosage.
PREVENTION OR TREATMENT OF ACUTE MANIA, MANIC PHASE OF BIPOLAR DISORDER (MANIC-DEPRESSIVE ILLNESS)
SIDE EFFECTS
O ALERT P Side effects are dose related and seldom occur at lithium serum levels less than 1.5 mEq/L.
OCCASIONAL: Fine hand tremor, polydipsia, polyuria, mild nausea. RARE: Weight gain, bradycardia or tachycardia, acne, rash, muscle twitching, cold and cyanotic extremities, pseudotumor cerebri (eye pain, headache, tinnitus, vision disturbances).
ADVERSE REACTIONS/TOXIC EFFECTS
A lithium serum concentration of 1.5U2.0 mEq/L may produce vomiting, diarrhea, drowsiness, confusion, incoordination, coarse hand tremor, muscle twitching, and T-wave depression on EKG. A lithium serum concentration of 2.0U2.5 mEq/L may result in ataxia, giddiness, tinnitus, blurred vision, clonic movements, and severe hypotension. Acute toxicity may be characterized by seizures, oliguria, circulatory failure, coma, and death.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Serum lithium levels should be tested q3U4 days during initial phase of therapy, q1U2mo thereafter, and weekly if there is no improvement of disorder or adverse effects occur.
INTERVENTION/EVALUATION
Serum lithium testing should be performed as close as possible to 12th hr following last dose. Besides serum lithium concentration levels, clinical assessment of therapeutic effect, tolerance to drug effect is necessary for correct dosing-level management. Assess behavior, appearance, emotional status, response to environment, speech pattern, thought content. Monitor serum lithium concentrations, differential count, urinalysis, creatinine clearance. Assess for increased urine output, persistent thirst. Report polyuria, prolonged vomiting, diarrhea, fever to physician (may need to temporarily reduce or discontinue dosage). Monitor for signs of lithium toxicity. Assess for therapeutic response (interest in surroundings, improvement in self-care, increased ability to concentrate, relaxed facial expression). Monitor lithium levels q3U4 days at initiation of therapy (then q1U2mo). Levels obtained 8U12 hr postdose. Monitor renal, hepatic, thyroid, cardiovascular function; CBC with differential; serum electrolytes. Therapeutic serum level: 0.6U1.2 mEq/L; toxic serum level: greater than 1.5 mEq/L.
PATIENT/FAMILY TEACHING
N Limit alcohol, caffeine intake. N Avoid tasks requiring coordination until CNS effects of drug are known. N May cause dry mouth. N Maintain steady salt and fluid intake (avoid dehydration). N Inform physician if vomiting, diarrhea, muscle weakness, tremors, drowsiness, ataxia occurs. N Serum level monitoring is necessary to determine proper dose.
loratadine H
low-rah-tah-deen
(Alavert, Claritin, Claritin RediTab, Dimetapp, Tavist ND)
FIXED-COMBINATION(S)
Claritin-D: loratadine/pseudoephedrine (a sympathomimetic): 5 mg/120 mg; 10 mg/240 mg.
CLASSIFICATION
PHARMACOTHERAPEUTIC: H1 antagonist. CLINICAL: Antihistamine.
ACTION
A long-acting antihistamine that competes with histamine for H1 receptor sites on effector cells. Therapeutic Effect: Prevents allergic responses mediated by histamine, such as rhinitis, urticaria, and pruritus.
PHARMACOKINETICS
Route Onset Peak Duration
Rapidly and almost completely absorbed from the GI tract. Protein binding: 97%; metabolite, 73%U77%. Distributed mainly to the liver, lungs, GI tract, and bile. Metabolized in the liver to active metabolite; undergoes extensive first-pass metabolism. Eliminated in urine and feces. Not removed by hemodialysis. Half-life: 8.4 hr; metabolite, 28 hr (increased in elderly and hepatic impairment).
USES
Relief of nasal and non-nasal symptoms of seasonal allergic rhinitis (hayfever). Treatment of idiopathic chronic urticaria (hives). OFF-LABEL: Adjunct treatment of bronchial asthma.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to loratadine or its ingredients. CAUTIONS: Hepatic impairment, breast-feeding women. Safety in children unknown.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Excreted in breast milk. Pregnancy Category B. Children/Elderly: More sensitive to anticholinergic effects (e.g., dry mouth, nose, throat).
INTERACTIONS
DRUG: Clarithromycin, erythromycin, fluconazole, ketoconazole: May increase the loratadine blood concentration. HERBAL: None known. FOOD: All foods: Delay the absorption of loratadine. LAB VALUES: May suppress wheal and flare reactions to antigen skin testing unless the drug is discontinued 4 days before testing.
AVAILABILITY (Rx)
SYRUP (CLARITIN): 10 mg/10 ml. TABLETS (ALAVERT, CLARITIN, TAVIST ND): 10 mg. TABLETS (RAPIDLY-DISINTEGRATING [ALAVERT, CLARITIN REDITAB]): 10 mg.
ADMINISTRATION/HANDLING
N Preferably give on an empty stomach (food delays absorption).
INDICATIONS/ROUTES/DOSAGE
ALLERGIC RHINITIS, URTICARIA
DOSAGE IN RENAL AND HEPATIC IMPAIRMENT
SIDE EFFECTS
FREQUENT (12%U8%): Headache, fatigue, somnolence. OCCASIONAL (3%): Dry mouth, nose, or throat. RARE: Photosensitivity.
ADVERSE REACTIONS/TOXIC EFFECTS
Abnormal hepatic function, including jaundice, hepatitis, and hepatic necrosis; alopecia; anaphylaxis; breast enlargement; erythema multiforme; peripheral edema; and seizures have been reported.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Assess lung sounds for wheezing, skin for urticaria, other allergy symptoms.
INTERVENTION/EVALUATION
For upper respiratory allergies, increase fluids to decrease viscosity of secretions, offset thirst, replenish loss of fluids from increased diaphoresis. Monitor symptoms for therapeutic response.
PATIENT/FAMILY TEACHING
N Drink plenty of water (may cause dry mouth). N Avoid alcohol. N Avoid tasks that require alertness, motor skills until response to drug is established (may cause drowsiness). N May cause photosensitivity reactions (avoid direct expo
lorazepam H
low-raz-ah-pam
(Apo-Lorazepam J, Ativan, Lorazepam Intensol, Novo-Lorazem J)
Do not confuse lorazepam with Alprazolam.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Benzodiazepine (Schedule IV). CLINICAL: Antianxiety, sedative-hypnotic, antiemetic, skeletal muscle relaxant, amnesiac, anticonvulsant, antitremor.
ACTION
A benzodiazepine that enhances the action of the inhibitory neurotransmitter gamma-aminobutyric acid in the CNS, affecting memory, as well as motor, sensory, and cognitive function. Therapeutic Effect: Produces anxiolytic, anticonvulsant, sedative, muscle relaxant, and antiemetic effects.
PHARMACOKINETICS
Route Onset Peak Duration
IV 15U30 min N/A 8U12 hr
IM 30U60 min N/A 8U12 hr
Well absorbed after PO and IM administration. Protein binding: 85%. Widely distributed. Metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 10U20 hr.
USES
Management of anxiety, seizures, status epilepticus, preanesthesia for desired amnesia. OFF-LABEL: Treatment of alcohol withdrawal, panic disorders, skeletal muscle spasms, chemotherapy-induced nausea or vomiting, tension headache, tremors; adjunctive treatment before endoscopic procedures (diminishes patient recall).
PRECAUTIONS
CONTRAINDICATIONS: Angle-closure glaucoma, preexisting CNS depression, severe hypotension, severe uncontrolled pain. CAUTIONS: Neonates, renal or hepatic impairment, compromised pulmonary function, concomitant CNS depressant use.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: May cross placenta. May be distributed in breast milk. May increase risk of fetal abnormalities if administered during first trimester of pregnancy. Chronic ingestion during pregnancy may produce fetal toxicity, withdrawal symptoms, CNS depression in neonates. Pregnancy Category D. Children: Safety and efficacy not established in those younger than 12 yr. Elderly: Use small initial doses with gradual increases to avoid ataxia or excessive sedation.
INTERACTIONS
DRUG: Alcohol, other CNS depressants: May increase CNS depression. HERBAL: Kava kava, valerian: May increase CNS depression. FOOD: None known. LAB VALUES: None known. Therapeutic serum drug level is 50U240 ng/ml; toxic serum drug level is unknown.
AVAILABILITY (Rx)
TABLETS: 0.5 mg, 1 mg, 2 mg. INJECTION: 2 mg/ml, 4 mg/ml. ORAL SOLUTION (LORAZEPAM INTENSOL): 2 mg/ml.
ADMINISTRATION/HANDLING
L IV
Reconstitution N Dilute with equal volume of sterile water for injection, To dilute prefilled 0.9% NaCl, or D5W. syringe, remove air from half-filled syringe, aspirate equal volume of diluent, pull plunger back slightly to allow for mixing, gently invert syringe several times (do not shake vigorously).
Rate of administration N Give by IV push into tubing of free-flowing IV infusion (0.9% NaCl, D5W) at a rate not to exceed 2 mg/min.
Storage N Refrigerate parenteral form. N Do not use if precipitate forms or solution appears discolored. N Avoid freezing.
IM
N Give deep IM into large muscle mass.
N Give with food. N Tablets may be crushed.
IV INCOMPATIBILITIES
Aldesleukin (Proleukin), aztreonam (Azactam), idarubicin (Idamycin), ondansetron (Zofran), sufentanil (Sufenta).
IV COMPATIBILITIES
Bumetanide (Bumex), cefepime (Maxipime), diltiazem (Cardizem), dobutamine (Dobutrex), dopamine (Intropin), heparin, labetalol (Normodyne, Trandate), milrinone (Primacor), norepinephrine (Levophed), piperacillin and tazobactam (Zosyn), potassium, propofol (Diprivan).
INDICATIONS/ROUTES/DOSAGE
ANXIETY
IV: ADULTS, ELDERLY: 0.02U0.06 mg/kg q2U6h.
IV INFUSION: ADULTS, ELDERLY: 0.01U0.1 mg/kg/h.
INSOMNIA DUE TO ANXIETY
PREOPERATIVE SEDATION
IV: ADULTS, ELDERLY: 0.044 mg/kg 15U20 min before surgery. Maximum total dose: 2 mg.
IM: ADULTS, ELDERLY: 0.05 mg/kg 2 hr before procedure. Maximum total dose: 4 mg.
STATUS EPILEPTICUS
IV: ADULTS, ELDERLY: 4 mg over 2U5 min. May repeat in 10U15 min. Maximum: 8 mg in 12Uhr period. CHILDREN: 0.1 mg/kg over 2U5 min. May give second dose of 0.05 mg/kg in 15U20 min. Maximum: 4 mg. NEONATES: 0.05 mg/kg. May repeat in 10U15 min.
SIDE EFFECTS
FREQUENT: Somnolence (initially in the morning), ataxia, confusion. OCCASIONAL: Blurred vision, slurred speech, hypotension, headache. RARE: Paradoxical CNS restlessness or excitement in elderly or debilitated.
ADVERSE REACTIONS/TOXIC EFFECTS
Abrupt or too-rapid withdrawal may result in pronounced restlessness, irritability, insomnia, hand tremor, abdominal or muscle cramps, diaphoresis, vomiting, and seizures. Overdose results in somnolence, confusion, diminished reflexes, and coma.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Offer emotional support to anxious patient. Patient must remain recumbent for up to 8 hr (individualized) following parenteral administration to reduce hypotensive effect. Assess motor responses (agitation, trembling, tension), autonomic responses (cold or clammy hands, diaphoresis).
INTERVENTION/EVALUATION
Monitor BP, respiratory rate, heart rate, CBC with differential, liver function tests. For those on long-term therapy, liver and renal function tests, blood counts should be performed periodically. Assess for paradoxical reaction, particularly during early therapy. Evaluate for therapeutic response: calm facial expression, decreased restlessness, insomnia. Therapeutic serum level: 50U240 ng/ml; toxic serum level: N/A.
PATIENT/FAMILY TEACHING
N Drowsiness usually disappears during continued therapy. N Avoid tasks that require alertness, motor skills until response to drug is established. N Smoking reduces drug effectiveness. N Do not abruptly withdraw medication after long-term therapy. N Do not use alcohol, CNS depressants. N Contraception recommended for long-term therapy. N Notify physician at once if pregnancy is suspected.
losartan
lo-sar tan
(Cozaar)
Do not confuse Cozaar with Zocor.
FIXED-COMBINATION(S)
Hyzaar: losartan/hydrochlorothiazide (a diuretic): 50 mg/12.5 mg; 100 mg/12.5 mg; 100 mg/25 mg.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Angiotensin II receptor antagonist. CLINICAL: Antihypertensive.
ACTION
An angiotensin II receptor, type AT1, antagonist that blocks vasoconstrictor and aldosterone-secreting effects of angiotensin II, inhibiting the binding of angiotensin II to the AT1 receptors. Therapeutic Effect: Causes vasodilation, decreases peripheral resistance, and decreases BP.
PHARMACOKINETICS
Route Onset Peak Duration
Well absorbed after PO administration. Protein binding: 98%. Undergoes first-pass metabolism in the liver to active metabolites. Excreted in urine and via the biliary system. Not removed by hemodialysis. Half-life: 2 hr, metabolite: 6U9 hr.
USES
Treatment of hypertension. Used alone or in combination with other antihypertensives. Treatment of diabetic nephropathy, prevention of stroke. OFF-LABEL: CHF, erythrocytosis.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Renal/hepatic impairment, renal arterial stenosis.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Has caused fetal/neonatal morbidity, mortality. Potential for adverse effects on breast-fed infant. Do not breast-feed. Pregnancy Category C (D if used in second or third trimesters). Children: Safety and efficacy not established. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Cimetidine: May increase the effects of losartan. Ketoconazole, troleandomycin: May inhibit the effects of these drugs. Lithium: May increase lithium blood concentration and risk of lithium toxicity. Phenobarbital, rifampin: May decrease the effects of losartan. HERBAL: None known. FOOD: Grapefruit, grapefruit juice: May alter the absorption of losartan. LAB VALUES: May increase BUN, serum alkaline phosphatase, serum bilirubin, serum creatinine, AST, and ALT levels. May decrease blood Hgb and Hct levels.
AVAILABILITY (Rx)
TABLETS: 25 mg, 50 mg, 100 mg.
ADMINISTRATION/HANDLING
N May give without regard to food. N Do not crush or break tablets.
INDICATIONS/ROUTES/DOSAGE
HYPERTENSION
NEPHROPATHY
STROKE REDUCTION
HYPERTENSION IN PATIENTS WITH IMPAIRED HEPATIC FUNCTION
SIDE EFFECTS
FREQUENT (8%): Upper respiratory tract infection. OCCASIONAL (4%U2%): Dizziness, diarrhea, cough. RARE (1% or less): Insomnia, dyspepsia, heartburn, back and leg pain, muscle cramps, myalgia, nasal congestion, sinusitis.
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 for possibility of pregnancy (see Pregnancy/Lactation). Assess medication history (especially diuretic).
INTERVENTION/EVALUATION
Maintain hydration (offer fluids frequently). Assess for evidence of upper respiratory infection, cough. Assist with ambulation if dizziness occurs. Monitor bowel activity and stool consistency. Monitor BP, pulse.
PATIENT/FAMILY TEACHING
N Inform female patient regarding consequences of second- and third-trimester exposure to losartan. N Report pregnancy to physician as soon as possible. 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), chest pain. N Do not take OTC cold preparations, nasal decongestants. N Do not stop taking medication.
lovastatin
lo-va-sta-tin
(Altocor, Mevacor)
Do not confuse lovastatin with Leustatin or Livostin, or Mevacor with Mivacron.
FIXED-COMBINATION(S)
Advicor: lovastatin/niacin: 20 mg/500 mg; 20 mg/750 mg; 20 mg/1,000 mg.
CLASSIFICATION
PHARMACOTHERAPEUTIC: HMG-CoA reductase inhibitor. CLINICAL: Anti-hyperlipidemic.
ACTION
An antihyperlipidemic that inhibits HMG-CoA reductase, the enzyme that catalyzes the early step in cholesterol synthesis. Therapeutic Effect: Decreases LDL cholesterol, VLDL cholesterol, plasma triglycerides; increases HDL cholesterol.
PHARMACOKINETICS
Route Onset Peak Duration
Incompletely absorbed from the GI tract (increased on empty stomach). Protein binding: 95%. Hydrolyzed in the liver to active metabolite. Primarily eliminated in feces. Not removed by hemodialysis. Half-life: 1.1U1.7 hr.
USES
Decreases elevated serum total and LDL cholesterol in primary hypercholesterolemia; primary prevention of coronary artery disease. Adjunct to diet in adolescent patients (10U17 yr) with heterozygous familial hypercholesterolemia. Slows progression of coronary atherosclerosis in patients with coronary heart disease.
PRECAUTIONS
CONTRAINDICATIONS: Active liver disease, pregnancy, unexplained elevated liver function tests. CAUTIONS: History of heavy or chronic alcohol use; renal impairment; concomitant use of cyclosporine, fibrates, niacin.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Contraindicated in pregnancy (suppression of cholesterol biosynthesis may cause fetal toxicity) and lactation. Unknown if drug is distributed in breast milk. Pregnancy Category X. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Cyclosporine, erythromycin, gemfibrozil, immunosuppressants, niacin: Increases the risk of acute renal failure and rhabdomyolysis. Erythromycin, itraconazole, ketoconazole: May increase lovastatin blood concentration causing severe muscle inflammation, myalgia, and weakness. HERBAL: None known. FOOD: Grapefruit juice: Large amounts of grapefruit juice may increase risk of side effects, such as myalgia and weakness. LAB VALUES: May increase serum creatine kinase and serum transaminase concentrations.
AVAILABILITY (Rx)
TABLETS (MEVACOR): 10 mg, 20 mg, 40 mg. TABLETS (EXTENDED-RELEASE [ALTOCOR]): 20 mg, 40 mg, 60 mg.
ADMINISTRATION/HANDLING
N Give with meals.
INDICATIONS/ROUTES/DOSAGE
ATHEROSCLEROSIS, CORONARY ARTERY DISEASE
HYPERCHOLESTEROLEMIA
HETEROZYGOUS FAMILIAL HYPERCHOLESTEROLEMIA
SIDE EFFECTS
Generally well tolerated. Side effects usually mild and transient. FREQUENT (9%U5%): Headache, flatulence, diarrhea, abdominal pain or cramps, rash and pruritus. OCCASIONAL (4%U3%): Nausea, vomiting, constipation, dyspepsia. RARE (2%U1%): Dizziness, heartburn, myalgia, blurred vision, eye irritation.
ADVERSE REACTIONS/TOXIC EFFECTS
There is a potential for cataract development. Lovastatin occasionally produces myopathy manifested as muscle pain, tenderness or weakness with elevated creatine kinase. Myopathy may take the form of rhabdomyolysis fatalities.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Question for possibility of pregnancy before initiating therapy (Pregnancy Category X). Assess baseline lab results: serum cholesterol, triglycerides, liver function tests.
INTERVENTION/EVALUATION
Determine pattern of bowel activity. Monitor for headache, dizziness, blurred vision. Assess for rash, pruritus. Monitor serum cholesterol, triglyceride levels for therapeutic response. Be alert for malaise, muscle cramping/weakness.
PATIENT/FAMILY TEACHING
N Take with meals. N Follow special diet (important part of treatment). N Periodic lab tests are essential part of therapy. N Avoid grapefruit juice. N Inform physician of severe gastric upset, vision changes, myalgia or weakness, changes in color of urine/stool, yellowing of eyes or skin, unusual bruising.
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