naproxen H
na-prox-en
(EC-Naprosyn, Naprelan, Naprelan 375, Naprelan 500)
naproxen sodium
(Aflaxen, Aleve, Anaprox, Anaprox DS, Apo-Naprosyn J, Novo-Naprox J, Nu-Naprox J, Pamprin)
Do not confuse Aleve with Allese or Anaprox with Anaspaz.
FIXED-COMBINATION(S)
Prevacid NapraPac: naproxen/lansoprazole (proton pump inhibitor): 375 mg/15 mg, 500 mg/15 mg.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Nonsteroidal anti-inflammatory. CLINICAL: Analgesic, anti-inflammatory.
ACTION
An NSAID that produces analgesic and anti-inflammatory effects by inhibiting prostaglandin synthesis. Therapeutic Effect: Reduces the inflammatory response and intensity of pain.
PHARMACOKINETICS
Completely absorbed from the GI tract. Protein binding: 99%. Metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 13 hr.
USES
Treatment of acute or long-term mild to moderate pain, primary dysmenorrhea, rheumatoid arthritis, juvenile rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, acute gouty arthritis, bursitis, tendinitis. OFF-LABEL: Treatment of vascular headaches.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to aspirin, naproxen, or other NSAIDs. CAUTIONS: GI or cardiac disease, renal or hepatic impairment. Concurrent use of anticoagulants.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Distributed in breast milk. Avoid use during third trimester (may adversely affect fetal cardiovascular system: premature closing 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 2 yr. Children older than 2 yr at increased risk of skin rash. Elderly: Age-related renal impairment may increase risk of hepatic and renal toxicity; reduced dosage recommended. More likely to have serious adverse effects with GI bleeding/ulceration.
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 naproxen 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 and alter blood glucose level. May increase serum hepatic function test results. May decrease serum sodium and uric acid levels.
AVAILABILITY (Rx)
GELCAPS (ALEVE [OTC]): 220 mg naproxen sodium (equivalent to 200 mg naproxen). ORAL SUSPENSION (NAPROSYN): 125 mg/5 ml naproxen. TABLETS: 220 mg naproxen (Aleve [OTC]), 250 mg (Naprosyn), 275 mg naproxen sodium (equivalent to 250 mg naproxen) (Anaprox), 550 mg naproxen sodium (equivalent to 500 mg naproxen) (Aflaxen, Anaprox DS). TABLETS (CONTROLLED-RELEASE): 375 mg naproxen (EC-Naprosyn), 421 mg naproxen (Naprelan), 500 mg naproxen (EC-Naprosyn), 550 mg naproxen sodium (equivalent to 500 mg naproxen) (Naprelan).
ADMINISTRATION/HANDLING
PO
N Swallow enteric-coated form whole; scored tablets may be broken or crushed. N May give with food, milk, antacids if GI distress occurs.
INDICATIONS/ROUTES/DOSAGE
RHEUMATOID ARTHRITIS, OSTEOARTHRITIS, ANKYLOSING SPONDYLITIS
PO: ADULTS, ELDERLY: 250U500 mg naproxen (275U550 mg naproxen sodium) twice a day or 250 mg naproxen (275 mg naproxen sodium) in morning and 500 mg naproxen (550 mg naproxen sodium) in evening. Naprelan: 750U1,000 mg once a day.
ACUTE GOUTY ARTHRITIS
PO: ADULTS, ELDERLY: Initially, 750 mg naproxen (825 mg naproxen sodium), then 250 mg naproxen (275 mg naproxen sodium) q8h until attack subsides. Naprelan: Initially, 1,000U1,500 mg, then 1,000 mg once a day until attack subsides.
MILD TO MODERATE PAIN, DYSMENORRHEA, BURSITIS, TENDINITIS
PO: ADULTS, ELDERLY: Initially, 500 mg naproxen (550 mg naproxen sodium), then 250 mg naparoxen (275 mg naproxen sodium) q6U8h as needed. Maximum: 1.25 g/day naproxen (1.375 g/day naproxen sodium). Naprelan: 1,000 mg once a day.
JUVENILE RHEUMATOID ARTHRITIS
PO (NAPROXEN ONLY): CHILDREN: 10U15 mg/kg/day in 2 divided doses. Maximum: 1,000 mg/day.
OTC USES
PO: ADULTS 65 YR AND YOUNGER, CHILDREN 12 YR AND OLDER: 220 mg (200 mg naproxen sodium) q8U12h. May take 440 mg (200 mg naproxen sodium) as initial dose. ADULTS OLDER THAN 65 YR: 220 mg (200 mg naproxen sodium) q12h.
SIDE EFFECTS
FREQUENT (9%U4%): Nausea, constipation, abdominal cramps or pain, heartburn, dizziness, headache, somnolence. OCCASIONAL (3%U1%): Stomatitis, diarrhea, indigestion. RARE (less than 1%): Vomiting, confusion.
ADVERSE REACTIONS/TOXIC EFFECTS
Rare reactions with long-term use include peptic ulcer disease, GI bleeding, gastritis, severe hepatic reactions (cholestasis, jaundice), nephrotoxicity (dysuria, hematuria, proteinuria, nephrotic syndrome), and a severe hypersensitivity reaction (fever, chills, bronchospasm).
BASELINE ASSESSMENT
Assess onset, type, location, duration of pain or inflammation. Inspect appearance of affected joints for immobility, deformities, skin condition.
INTERVENTION/EVALUATION
Assist with ambulation if dizziness occurs. Monitor CBC, platelet count, serum renal and liver function tests, Hgb, pattern of daily bowel activity and stool consistency. Evaluate for therapeutic response: relief of pain, stiffness, swelling; increased joint mobility; reduced joint tenderness; improved grip strength.
PATIENT/FAMILY TEACHING
N Avoid tasks that require alertness, motor skills until response to drug is established. N If GI upset occurs, take with food, milk. N Avoid aspirin, alcohol during therapy (increases risk of GI bleeding). N Report headache, rash, visual disturbances, weight gain, black or tarry stools, persistent headache.
henylephrine hydrochloride A
en-ill-eh-frin
(AD-Nephrin, AK-Dilate, Despec-SF, Mydfrin, Neo-Synephrine, Neo-Synephrine Ophthalmic, Ocu-Phrin, Phenoptic, Prefrin, Rectasol, Sudafed PE Nasal Decongestant)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Sympathomimetic, alpha receptor stimulant. CLINICAL: Nasal decongestant, mydriatic, vasopressor.
ACTION
A sympathomimetic, alpha receptor stimulant that acts on the alpha-adrenergic receptors of vascular smooth muscle. Causes vasoconstriction of arterioles of nasal mucosa or conjunctiva, activates dilator muscle of the pupil to cause contraction, produces systemic arterial vasoconstriction. Therapeutic Effect: Decreases mucosal blood flow and relieves congestion and increases systolic BP.
PHARMACOKINETICS
Route Onset Peak Duration
IV Immediate N/A 15U20 min
IM 10U15 min N/A 0.5U2 hr
Subcutaneous 10U15 min N/A 1 hr
Minimal absorption after intranasal and ophthalmic administration. Metabolized in the liver and GI tract. Primarily excreted in urine. Half-life: 2.5 hr.
USES
Nasal: Topical application to nasal mucosa reduces nasal secretion, promoting drainage of sinus secretions. Ophthalmic: Topical application to conjunctiva relieves congestion, itching, minor irritation; whitens sclera of eye. Parenteral: Vascular failure in shock, drug-induced hypotension.
PRECAUTIONS
CONTRAINDICATIONS: Acute pancreatitis, heart disease, hepatitis, narrow-angle glaucoma, pheochromocytoma, severe hypertension, thrombosis, ventricular tachycardia. CAUTIONS: Hyperthyroidism, bradycardia, heart block, severe arteriosclerosis.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Distributed in breast milk. Pregnancy Category C. Children: May exhibit increased absorption, toxicity with nasal preparation. No age-related precautions noted with systemic use. Elderly: More likely to experience adverse effects.
INTERACTIONS
DRUG: Beta blockers: May have mutually inhibitory effects. Digoxin: May increase risk of arrhythmias. Ergonovine, oxytocin: May increase vasoconstriction. MAOIs: May increase vasopressor effects. Maprotiline, tricyclic antidepressants: May increase cardiovascular effects. Methyldopa: May decrease effects of methyldopa. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (OTC)
INJECTION: 1% (10 mg/ml). NASAL SOLUTION DROPS (NEO-SYNEPHRINE): 0.5%, 1%. NASAL SPRAY (NEO-SYNEPHRINE): 0.25%, 0.5%, 1%. OPHTHALMIC SOLUTION: 0.12% (AK-Nephrin), 2.5% (AK-Dilate, Mydfrin, Neofrin, Neo-Synephrine Ophthalmic, Ocu-Phrin, Phenoptic), 10% (AK-Dilate, Ocu-Phrin, Neo-Synephrine). ORAL LIQUID (DESPEC-SF): 5 mg/5 ml. TABLETS (SUDAFED PE NASAL DECONGESTANT): 10 mg.
ADMINISTRATION/HANDLING
L IV
Reconstitution N For IV push, dilute 1 ml of 10 mg/ml solution with 9 ml sterile water for injection to provide a concentration of 1 mg/ml. N For IV infusion, dilute 10-mg vial with 500 ml D5W or 0.9% NaCl to provide a concentration of 2 mcg/ml. Maximum concentration: 500 mg/250 ml.
Rate of administration N For IV push, give over 20U30 sec. N For IV infusion, give as per physician order.
Storage N Store vials at room temperature.
NASAL
N Instruct the patient to blow his or her nose before administering medication. N Tilt the patient's head, apply drops in 1 nostril. Keep the patient in the same position and wait 5 min before applying drops in other nostril. N Sprays should be administered into each nostril with head erect. N The patient should sniff briskly while squeezing container and wait 3U5 min before blowing nose gently. N Rinse tip of spray bottle.
OPHTHALMIC
N Instruct patient to tilt head backward, look up. N Gently pull lower lid down to form pouch and instill medication. N Do not touch tip of applicator to lids or any surface. N When lower lid is released, have patient keep eye open without blinking for at least 30 sec. N Apply gentle finger pressure to lacrimal sac (bridge of the nose, inside corner of the eye) for 1U2 min. N Remove excess solution around eye with tissue. N Wash hands immediately to remove medication on hands.
IV INCOMPATIBILITY
Thiopentothal (Pentothal).
IV COMPATIBILITIES
Amiodarone (Cordarone), dobutamine (Dobutrex), lidocaine, potassium chloride, propofol (Diprivan).
INDICATIONS/ROUTES/DOSAGE
NASAL DECONGESTANT
NASAL SPRAY, NASAL SOLUTION, NASAL TABLET: ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: 2U3 drops or 1U2 sprays of 0.25%U0.5% solution into each nostril q4h as needed, or 1 tablet q4h as needed (not more than 6 doses/24 hr. CHILDREN 6U11 YR: 2U3 drops or 1U2 sprays of 0.25% solution into each nostril q4h as needed. CHILDREN YOUNGER THAN 6 YR: 1 drop of 0.125% solution (dilute 0.5% solution with 0.9% NaCl to achieve 0.125%) in each nostril. Repeat q2U4h as needed. Do not use for more than 3 days.
CONJUNCTIVAL CONGESTION, ITCHING, AND MINOR IRRITATION; WHITENING OF SCLERA
OPHTHALMIC: ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: 1U2 drops of 0.12% solution q3U4h.
HYPOTENSION, SHOCK
IM, SUBCUTANEOUS: ADULTS, ELDERLY: 2U5 mg/dose q1U2h. CHILDREN: 0.1 mg/kg/dose q1U2h. Maximum: 5 mg.
IV BOLUS: ADULTS, ELDERLY: 0.1U0.5 mg/dose q10U15 min as needed. CHILDREN: 5U20 mcg/kg/dose q10U15min.
IV INFUSION: ADULTS, ELDERLY: 100U180 mcg/min. When BP is stabilized, maintenance rate: 40U60 mcg/min. CHILDREN: 0.1U0.5 mcg/kg/min. Titrate to desired effect.
SIDE EFFECTS
FREQUENT: Nasal: Rebound nasal congestion due to overuse, especially when used longer than 3 days. OCCASIONAL: Mild CNS stimulation (restlessness, nervousness, tremors, headache, insomnia, particularly in those hypersensitive to sympathomimetics, such as elderly patients). Nasal: Stinging, burning, drying of nasal mucosa. Ophthalmic: Transient burning or stinging, brow ache, blurred vision.
ADVERSE REACTIONS/TOXIC EFFECTS
Large doses may produce tachycardia and palpitations (particularly in those with cardiac disease), light-headedness, nausea, and vomiting. Overdose in those older than 60 yr may result in hallucinations, CNS depression, and seizures. Prolonged nasal use may produce chronic swelling of nasal mucosa and rhinitis.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
If phenylephine 10% ophthalmic is instilled into denuded or damaged corneal epithelium, corneal clouding may result.
INTERVENTION/EVALUATION
Monitor BP, heart rate.
PATIENT/FAMILY TEACHING
N Discontinue drug if adverse reactions occur. N Do not use for nasal decongestion for longer than 5 days, (rebound congestion). N Discontinue drug if insomnia, dizziness, weakness, tremor, palpitations occur. N Nasal: Stinging or burning of nasal mucosa may occur. N Opthalmic: Blurring of vision with eye instillation generally subsides with continued therapy. N Discontinue medication if redness or swelling of eyelids, itching appears.
nesiritide A
ness-ear-ih-tide
(Natrecor)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Brain natriuretic peptide. CLINICAL: Endogenous hormone.
ACTION
A brain natriuretic peptide that facilitates cardiovascular homeostasis and fluid status through counterregulation of the renin-angiotensin-aldosterone system, stimulating cyclic guanosine monophosphate, thereby leading to smooth-muscle cell relaxation. Therapeutic Effect: Promotes vasodilation, natriuresis, and diuresis, correcting CHF.
PHARMACOKINETICS
Route Onset Peak Duration
IV 15U 30 min 1U2 hr 4 hr
Excreted primarily in the heart by the left ventricle. Metabolized by the natriuretic neutral endopeptidase enzymes on the vascular luminal surface. Half-life: 18U23 min.
USES
Treatment of acutely decompensated CHF in patients who have dyspnea at rest or with minimal activity.
PRECAUTIONS
CONTRAINDICATIONS: Cardiogenic shock, systolic BP less than 90 mm Hg. CAUTIONS: Significant valvular stenosis, restrictive/obstructive cardiomyopathy, constrictive pericarditis, pericardial tamponade, suspected low cardiac filling pressures, atrial/ventricular arrhythmias/conduction defects, hypotension, hepatic/renal insufficiency.
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: No age-related precautions noted.
INTERACTIONS
DRUG: ACE inhibitors, IV nitroglycerin, milrinone, nitroprusside: May increase risk of hypotension. Arsenic trioxide: May increase the risk of QT prolongation. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
INJECTION POWDER FOR RECONSTITUTION: 1.5 mg/5-ml vial.
ADMINISTRATION/HANDLING
O ALERT P Do not mix with other injections or infusions. Do not give IM.
L IV
Reconstitution N Reconstitute one 1.5-mg vial with 5 ml D5W or 0.9% NaCl, 0.2% NaCl or any combination thereof. Swirl or rock gently, add to 250-ml bag D5W or 0.9% NaCl, 0.2% NaCl, or any combination thereof yielding a solution of 6 mcg/ml.
Rate of administration N Give as an IV bolus over approx. 60 sec initially, followed by continuous IV infusion.
Storage N Store vial at room temperature. Once reconstituted, use within 24 hr at room temperature or refrigerated.
IV INCOMPATIBILITIES
Sodium metabisulfite, bumetanide (Bumex), enalapril (Vasotec), ethacrynic acid (Edecrin), furosemide (Lasix), heparin, hydralazine (Apresoline), insulin.
INDICATIONS/ROUTES/DOSAGE
TREATMENT OF ACUTELY DECOMPENSATED CHF IN PATIENTS WITH DYSPNEA AT REST OR WITH MINIMAL ACTIVITY
IV BOLUS: ADULTS, ELDERLY: 2 mcg/kg followed by a continuous IV infusion of 0.01 mcg/kg/min. At intervals of 3 hr or longer, may be increased by 0.005 mcg/kg/min (preceded by a bolus of 1 mcg/kg), up to a maximum of 0.03 mcg/kg/min.
SIDE EFFECTS
FREQUENT (11%): Hypotension. OCCASIONAL (8%U2%): Headache, nausea, bradycardia. RARE (1% or less): Confusion, paresthesia, somnolence, tremor.
ADVERSE REACTIONS/TOXIC EFFECTS
Ventricular arrhythmias, including ventricular tachycardia, atrial fibrillation, AV node conduction abnormalities, and angina pectoris occur rarely.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Obtain BP immediately before each dose, in addition to regular monitoring (be alert to fluctuations). If excessive reduction in BP occurs, place patient in supine position with legs elevated.
INTERVENTION/EVALUATION
Monitor BP, pulse rate for hypotension frequently during therapy. Hypotension is dose-limiting and dose-dependent. With physician, establish parameters for adjusting rate or stopping infusion. Maintain accurate I&O; measure urine output frequently. Immediately notify physician of decreased urine output, cardiac arrhythmias, significant decrease in BP or heart rate.
PATIENT/FAMILY TEACHING
N Report chest pain, palpitations.
nelfinavir
nel-fin-eh-veer
(Viracept)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Protease inhibitor. CLINICAL: Antiviral.
ACTION
Inhibits the activity of HIV-1 protease, the enzyme necessary for the formation of infectious HIV. Therapeutic Effect: Formation of immature noninfectious viral particles rather than HIV replication.
PHARMACOKINETICS
Well absorbed after PO administration (absorption increased with food). Protein binding: 98%. Metabolized in the liver. Highly bound to plasma proteins. Eliminated primarily in feces. Unknown if removed by hemodialysis. Half-life: 3.5U5 hr.
USES
Treatment of HIV infection in combination with other antiretrovirals. OFF-LABEL: HIV, postexposure prophylaxis.
PRECAUTIONS
CONTRAINDICATIONS: Concurrent administration with midazolam, rifampin, or triazolam. CAUTIONS: Hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if distributed in breast milk. Pregnancy Category B. Children: No age-related precautions noted in those older than 2 yr. Elderly: No information available.
INTERACTIONS
DRUG: Alcohol, psychoactive drugs: May produce additive CNS effects. Anticonvulsants, rifabutin, rifampin: Decrease nelfinavir plasma concentration. Indinavir, saquinavir: Increases plasma concentration of these drugs. Oral contraceptives: Decreases the effects of these drugs. Ritonavir: Increases nelfinavir plasma concentration. HERBAL: St. John's wort: May decrease plasma concentration and effects of nelfinavir. FOOD: All foods: Increase nelfinavir plasma concentration. LAB VALUES: May decrease Hgb values and neutrophil and WBC counts. May increase serum creatine kinase (CK), AST, and ALT levels.
AVAILABILITY (Rx)
POWDER FOR ORAL SUSPENSION: 50 mg/g. TABLETS: 250 mg, 625 mg.
ADMINISTRATION/HANDLING
PO
N Give with food (light meal, snack). N Mix oral powder with small amount of water, milk, formula, soy formula, soy milk, dietary supplement. N Entire contents must be consumed in order to ingest full dose. N Do not mix with acidic food, orange juice, apple juice, applesauce (bitter taste), or with water in original oral powder container.
INDICATIONS/ROUTES/DOSAGE
HIV INFECTION
PO: ADULTS: 750 mg (three 250-mg tablets) 3 times a day or 1,250 mg twice a day in combination with nucleoside analogues (enhances antiviral activity). CHILDREN 2U13 YR: 45U55 mg/kg twice a day or 25U30 mg/kg 3 times a day. Maximum: 2,500 mg/day.
SIDE EFFECTS
FREQUENT (20%): Diarrhea. OCCASIONAL (7%U3%): Nausea, rash. RARE (2%U1%): Flatulence, asthenia.
ADVERSE REACTIONS/TOXIC EFFECTS
Diabetes mellitus and hyperglycemia occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Check hematology, liver function tests for accurate baseline.
INTERVENTION/EVALUATION
Monitor pattern of bowel activity and stool consistency. Monitor hepatic enzyme studies for abnormalities. Be alert to development of opportunistic infections, (e.g., fever, chills, cough, myalgia).
PATIENT/FAMILY TEACHING
N Take with food (optimizes absorption). N Take medication every day as prescribed. N Doses should be evenly spaced around the clock. N Do not alter dose or discontinue medication without informing physician. N Medication is not a cure for HIV infection nor does it reduce risk of transmission to others; patient may continue to experience illnesses, including opportunistic infections.
nicotine
nik-o-teen
(Commit, Habitrol J, NicoDerm J, NicoDerm CQ, NicoDerm CQ Clear, Nicorette, Nicorette Plus J, Nicotrol, Nicotrol NS, Nicotrol Patch J, Nictrol Inhaler)
Do not confuse Nicoderm with Nitroderm.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Cholinergic-receptor agonist. CLINICAL: Smoking deterrent.
ACTION
A cholinergic-receptor agonist that binds to acetylcholine receptors, producing both stimulating and depressant effects on the peripheral and central nervous systems. Therapeutic Effect: Provides a source of nicotine during nicotine withdrawal and reduces withdrawal symptoms.
PHARMACOKINETICS
Absorbed slowly after transdermal administration. Protein binding: 5%. Metabolized in the liver. Excreted primarily in urine. Half-life: 4 hr.
USES
An alternative, less potent form of nicotine (without tar, carbon monoxide, carcinogenic substances of tobacco) used as part of a smoking cessation program.
PRECAUTIONS
CONTRAINDICATIONS: Immediate post-MI period, life-threatening arrhythmias, severe or worsening angina. CAUTIONS: Hyperthyroidism, pheochromocytoma, insulin-dependent diabetes mellitus, severe renal impairment, eczematous dermatitis, oral or pharyngeal inflammation, esophagitis, peptic ulcer (delays healing in peptic ulcer disease).
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Passes freely into breast milk. Use of cigarettes, nicotine gum associated with decrease in fetal breathing movements. Pregnancy Category D (transdermal). Children: Not recommended. Elderly: Age-related decrease in cardiac function may require dosage adjustment.
INTERACTIONS
DRUG: Beta-adrenergic blockers, bronchodilators (such as theophylline), insulin, propoxyphene: May increase the effects of these drugs. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (OTC)
CHEWING GUM (NICORETTE): 2 mg, 4 mg. LOZENGE (COMMIT): 2 mg, 4 mg. TRANSDERMAL PATCH (NICODERM CQ, NICOTROL): 5 mg/16 hr, 7 mg/24 hr, 10 mg/16 hr, 14 mg/24 hr, 21 mg/24 hr mg. NASAL SPRAY (NICOTROL NS): 0.5 mg/spray. INHALATION (NICOTROL INHALER): 10 mg cartridge.
ADMINISTRATION/HANDLING
GUM
N Do not swallow. N Chew 1 piece when urge to smoke present. N Chew slowly and intermittently for 30 min. N Chew until distinctive nicotine taste (peppery) or slight tingling in mouth perceived, then stop; when tingling almost gone (about 1 min) repeat chewing procedure (this allows constant slow buccal absorption). N Too rapid chewing may cause excessive release of nicotine, resulting in adverse effects similar to oversmoking (e.g., nausea, throat irritation).
INHALER
N Insert cartridge into mouthpiece. N Puff on nicotine cartridge mouthpiece for 20 min.
TRANSDERMAL
N Apply promptly upon removal from protective pouch (prevents evaporation, loss of nicotine). Use only intact pouch. Do not cut patch. N Apply only once/day to hairless, clean, dry skin on upper body or outer arm. N Replace daily; rotate sites; do not use same site within 7 days; do not use same patch longer than 24 hr. N Wash hands with water alone after applying patch (soap may increase nicotine absorption). N Discard used patch by folding patch in half (sticky side together), placing in pouch of new patch, and throwing away in such a way as to prevent child or pet accessibility.
INDICATIONS/ROUTES/DOSAGE
SMOKING CESSATION AID TO RELIEVE NICOTINE WITHDRAWAL SYMPTOMS
PO (CHEWING GUM): ADULTS, ELDERLY: Usually, 10U12 pieces/day. Maximum: 30 pieces/day.
PO (LOZENGE): O ALERT P For those who smoke the first cigarette within 30 min of waking, administer the 4 mg-lozenge; otherwise administer the 2-mg lozenge. ADULTS, ELDERLY: One 4-mg or 2-mg lozenge q1U2h for the first 6 wk; 1 lozenge q2U4h for wk 7U9; and 1 lozenge q4U8h for wk 10U12. Maximum: 1 lozenge at a time, 5 lozenges/6 hr, 20 lozenges/day.
TRANSDERMAL: ADULTS, ELDERLY WHO SMOKE 10 CIGARETTES OR MORE PER DAY: Follow the guidelines below. Step 1: 21 mg/day for 4U6 wk. Step 2: 14 mg/day for 2 wk. Step 3: 7 mg/day for 2 wk. ADULTS, ELDERLY WHO SMOKE LESS THAN 10 CIGARETTES PER DAY: Follow the guidelines below. Step 1: 14 mg/day for 6 wk. Step 2: 7 mg/day for 2 wk. PATIENTS WEIGHING LESS THAN 100 LB, PATIENTS WITH A HISTORY OF CARDIOVASCULAR DISEASE: Initially, 14 mg/day for 4U6 wk, then 7 mg/day for 2U4 wk.
TRANSDERMAL (NICOTROL): ADULTS, ELDERLY: One patch a day for 6 wk.
NASAL: ADULTS, ELDERLY: 1U2 doses/hr (1 dose = 2 sprays [1 in each nostril]= 1 mg). Maximum: 5 doses (5 mg)/hr; 40 doses (40 mg)/day.
INHALER (NICOTROL): ADULTS, ELDERLY: Puff on nicotine cartridge mouthpiece for about 20 min as needed.
SIDE EFFECTS
FREQUENT: All forms: Hiccups, nausea. Gum: Mouth or throat soreness, nausea, hiccups. Transdermal: Erythema, pruritus, or burning at application site. OCCASIONAL: All forms: Eructation, GI upset, dry mouth, insomnia, diaphoresis, irritability. Gum: Hiccups, hoarseness. Inhaler: Mouth or throat irritation, cough. RARE: All forms: Dizziness, myalgia, arthralgia.
ADVERSE REACTIONS/TOXIC EFFECTS
Overdose produces palpitations, tachyarrhythmias, seizures, depression, confusion, diaphoresis, hypotension, rapid or weak pulse, and dyspnea. Lethal dose for adults is 40U60 mg. Death results from respiratory paralysis.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Screen, evaluate those with coronary heart disease (history of MI, angina pectoris), serious cardiac arrhythmias, Buerger's disease, Prinzmetal's variant angina.
INTERVENTION/EVALUATION
Monitor smoking habit, BP, pulse, sleep pattern, skin for erythema, pruritus, burning at application site if transdermal system used.
PATIENT/FAMILY TEACHING
N Instruct patient on proper application of transdermal system. N Inform patient to chew gum slowly to avoid jaw ache and maximize benefit. N Inform physician if persistent rash, itching occurs with patch. N Do not smoke while wearing patches.
*NIFEdipine
nye-fed-i-peen
(Adalat CC, Adalat FT J, Adalat P.A. J, Apo-Nifed J, Nifedical XL, Novo-Nifedin J, Procardia, Procardia XL)
Do not confuse nifedipine with nicardipine or nimodipine.
CLASSIFICATION
PHARMACOTHERAPEUTIC: Calcium channel blocker. CLINICAL: Antianginal, antihypertensive.
ACTION
An antianginal and antihypertensive agent that inhibits calcium ion movement across cell membranes, depressing contraction of cardiac and vascular smooth muscle. Therapeutic Effect: Increases heart rate and cardiac output. Decreases systemic vascular resistance and BP.
PHARMACOKINETICS
Rapidly, completely absorbed from the GI tract. Protein binding: 92%U98%. Undergoes first-pass metabolism in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 2U5 hr.
USES
Treatment of angina due to coronary artery spasm (Prinzmetal's variant angina), chronic stable angina (effort-associated angina). Extended-Release: Treatment of essential hypertension. OFF-LABEL: Treatment of Raynaud's phenomenon.
PRECAUTIONS
CONTRAINDICATIONS: Advanced aortic stenosis, severe hypotension. CAUTIONS: Renal or hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Insignificant amount distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Beta blockers: May have additive effect. Digoxin: May increase digoxin blood concentration. Hypokalemia-producing agents (such as furosemide and certain other diuretics): May increase risk of arrhythmias. HERBAL: None known. FOOD: Grapefruit, grapefruit juice: May increase nifedipine plasma concentration. LAB VALUES: May cause positive ANA and direct Coombs' test.
AVAILABILITY (Rx)
CAPSULES (PROCARDIA): 10 mg. TABLETS (EXTENDED-RELEASE): 30 mg (Adalat CC, Nifedical XL, Procardia XL), 60 mg (Adalat CC, Nifedical XL, Procardia XL), 90 mg (Adalat CC, Procardia XL).
ADMINISTRATION/HANDLING
PO
N Do not crush or break extended-release tablet. N Give without regard to meals. N Grapefruit juice may alter absorption.
SUBLINGUAL
N Capsule must be punctured, chewed, and/or squeezed to express liquid into mouth.
INDICATIONS/ROUTES/DOSAGE
PRINZMETAL'S VARIANT ANGINA, CHRONIC STABLE (EFFORT-ASSOCIATED) ANGINA
PO: ADULTS, ELDERLY: Initially, 10 mg 3 times a day. Increase at 7- to 14-day intervals. Maintenance: 10 mg 3 times a day up to 30 mg 4 times a day.
PO (EXTENDED-RELEASE): ADULTS, ELDERLY: Initially, 30U60 mg/day. Maintenance: Up to 120 mg/day.
ESSENTIAL HYPERTENSION
PO (EXTENDED-RELEASE): ADULTS, ELDERLY: Initially, 30U60 mg/day. Maintenance: Up to 120 mg/day.
SIDE EFFECTS
FREQUENT (30%U11%): Peripheral edema, headache, flushed skin, dizziness. OCCASIONAL (12%U6%): Nausea, shakiness, muscle cramps and pain, somnolence, palpitations, nasal congestion, cough, dyspnea, wheezing. RARE (5%U3%): Hypotension, rash, pruritus, urticaria, constipation, abdominal discomfort, flatulence, sexual difficulties.
ADVERSE REACTIONS/TOXIC EFFECTS
Nifedipine may precipitate CHF and MI in patients with cardiac disease and peripheral ischemia. Overdose produces nausea, somnolence, confusion, and slurred speech.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Concurrent therapy of sublingual nitroglycerin may be used for relief of anginal pain. Record onset, type (sharp, dull, squeezing), radiation, location, intensity, duration of anginal pain; precipitating factors (exertion, emotional stress). Check BP for hypotension immediately before giving medication.
INTERVENTION/EVALUATION
Assist with ambulation if lightheadedness, dizziness occurs. Assess for peripheral edema. Assess skin for flushing. Monitor serum hepatic enzyme tests.
PATIENT/FAMILY TEACHING
N Rise slowly from lying to sitting position, permit legs to dangle from bed momentarily before standing to reduce hypotensive effect. N Contact physician or nurse if palpitations, shortness of breath, pronounced dizziness, nausea occurs. N Avoid alcohol, concomitant grapefruit or grapefruit juice use.
nitrofurantoin sodium
ny-tro-feur-an-toyn
(Apo-Nitrofurantoin J, Furadantin, Macrobid, Macrodantin, Nitro Macro, Novo-Furan J)
CLASSIFICATION
PHARMACOTHERAPEUTIC: Antibacterial. CLINICAL: UTI prophylaxis.
ACTION
An antibacterial UTI agent that inhibits the synthesis of bacterial DNA, RNA, proteins, and cell walls by altering or inactivating ribosomal proteins. Therapeutic Effect: Bacteriostatic (bactericidal at high concentrations).
PHARMACOKINETICS
Microcrystalline form rapidly and completely absorbed; macrocrystalline form more slowly absorbed. Food increases absorption. Protein binding: 40%. Primarily concentrated in urine and kidneys. Metabolized in most body tissues. Primarily excreted in urine. Removed by hemodialysis. Half-life: 20U60 min.
USES
Treatment of UTIs, initial and chronic. OFF-LABEL: Prevention of bacterial UTIs.
PRECAUTIONS
CONTRAINDICATIONS: Anuria, oliguria, substantial renal impairment (creatinine clearance less than 40 ml/min); infants younger than 1 mo old because of the risk of hemolytic anemia. CAUTIONS: Renal impairment, diabetes mellitus, electrolyte imbalance, anemia, vitamin B deficiency, debilitated (greater risk of peripheral neuropathy), G6PD deficiency (greater risk of hemolytic anemia).
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Readily crosses placenta. Distributed in breast milk. Contraindicated at term and during lactation when infant suspected of having G6PD deficiency. Pregnancy Category B. Children: No age-related precautions noted in those older than 1 mo. Elderly: More likely to develop acute pneumonitis and peripheral neuropathy. Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Hemolytics: May increase the risk of nitrofurantoin toxicity. Neurotoxic medications: May increase the risk of neurotoxicity. Probenecid: May increase blood concentration and toxicity of nitrofurantoin. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
CAPSULES (MACROCRYSTALLINE, MONOHYDRATE [MACROBID]): 100 mg. CAPSULES (MACROCRYSTALLINE [MACRODANTIN, NITRO MACRO]): 25 mg, 50 mg, 100 mg. ORAL SUSPENSION (MICROCRYSTALLINE [FURADANTIN]): 25 mg/5 ml.
ADMINISTRATION/HANDLING
PO
N Give with food, milk to enhance absorption, reduce GI upset.
INDICATIONS/ROUTES/DOSAGE
UTIs
PO (FURADANTIN, MACRODANTIN): ADULTS, ELDERLY: 50U100 mg q6h. Maximum: 400 mg/day. CHILDREN: 5U7 mg/kg/day in divided doses q6h. Maximum: 400 mg/day.
PO (MACROBID): ADULTS, ELDERLY: 100 mg twice a day. Maximum: 400 mg/day.
LONG-TERM PREVENTION OF UTIs
PO: ADULTS, ELDERLY: 50U100 mg at bedtime. CHILDREN: 1U2 mg/kg/day as a single dose. Maximum: 100 mg/day.
SIDE EFFECTS
FREQUENT: Anorexia, nausea, vomiting, dark urine. OCCASIONAL: Abdominal pain, diarrhea, rash, pruritus, urticaria, hypertension, headache, dizziness, drowsiness. RARE: Photosensitivity, transient alopecia, asthmatic exacerbation in those with history of asthma.
ADVERSE REACTIONS/TOXIC EFFECTS
Superinfection, hepatotoxicity, peripheral neuropathy (may be irreversible), Stevens-Johnson syndrome, permanent pulmonary function impairment, and anaphylaxis occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Question for history of asthma. Evaluate lab test results for renal and hepatic baseline values.
INTERVENTION/EVALUATION
Monitor I&O, renal function results. Determine pattern of bowel activity. Assess skin for rash, urticaria. Be alert for numbness or tingling, especially of lower extremities (may signal onset of peripheral neuropathy). Observe for signs of hepatotoxicity (fever, rash, arthralgia, hepatomegaly). Perform respiratory assessment: auscultate lungs, check for cough, chest pain, difficulty breathing.
PATIENT/FAMILY TEACHING
N Urine may become dark yellow/brown. N Take with food, milk for best results and to reduce GI upset. N Complete full course of therapy. N Avoid sun and ultraviolet light; use sunscreens, wear protective clothing. N Notify physician if cough, fever, chest pain, difficult breathing, numbness or tingling of fingers or toes occurs. N Rare occurrence of alopecia is transient.
nizatidine
ni-za-ti-deen
(Apo-Nizatidine J, Axid, Axid AR)
Do not confuse Axid with Ansaid.
CLASSIFICATION
PHARMACOTHERAPEUTIC: H2 receptor antagonist. CLINICAL: Antiulcer, gastric acid secretion inhibitor.
ACTION
An antiulcer agent and gastric acid secretion inhibitor that inhibits histamine action at histamine 2 receptors of parietal cells. Therapeutic Effect: Inhibits basal and nocturnal gastric acid secretion.
PHARMACOKINETICS
Rapidly, well absorbed from the GI tract. Protein binding: 35%. Metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 1U2 hr (increased with impaired renal function).
USES
Short-term treatment of active duodenal ulcer, active benign gastric ulcer. Prevention of duodenal ulcer recurrence. Treatment of gastroesophageal reflux disease (GERD), including erosive esophagitis. OTC for prevention of meal induced heartburn, acid indigestion, and sour stomach. OFF-LABEL: Gastric hypersecretory conditions, multiple endocrine adenoma, Zollinger-Ellison syndrome, weight gain reduction in patients taking Zyprexa.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to other H2-antagonists. CAUTIONS: Renal/hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category B. Children: Safety and efficacy not established in those younger than 12 yr. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Antacids: May decrease the absorption of nizatidine. Ketoconazole: May decrease the absorption of ketoconazole. HERBAL: None known. FOOD: None known. LAB VALUES: Interferes with skin tests using allergen extracts. May increase serum alkaline phosphatase, AST, and ALT levels.
AVAILABILITY (Rx)
CAPSULES: 75 mg (Axid AR [OTC]), 150 mg (Axid), 300 mg (Axid). ORAL SOLUTION (AXID): 15 mg/ml.
ADMINISTRATION/HANDLING
PO
N Give without regard to meals. Best given after meals or at bedtime. N Do not administer within 1 hr of magnesium- or aluminum-containing antacids (decreases absorption). N May give right before eating for heartburn prevention.
INDICATIONS/ROUTES/DOSAGE
ACTIVE DUODENAL ULCER
PO: ADULTS, ELDERLY: 300 mg at bedtime or 150 mg twice a day.
PREVENTION OF DUODENAL ULCER RECURRENCE
PO: ADULTS, ELDERLY: 150 mg at bedtime.
GASTROESOPHAGEAL REFLUX DISEASE
PO: ADULTS, ELDERLY: 150 mg twice a day.
ACTIVE BENIGN GASTRIC ULCER
PO: ADULTS, ELDERLY: 150 mg twice a day or 300 mg at bedtime.
PO, ORAL SOLUTION: CHILDREN 12 YR AND OLDER: 2 tsp twice a day.
DYSPEPSIA
PO: ADULTS, ELDERLY: 75 mg 30U60 min before meals; no more than 2 tablets a day.
DOSAGE IN RENAL IMPAIRMENT
Dosage adjustment is based on creatinine clearance.
SIDE EFFECTS
OCCASIONAL (2%): Somnolence, fatigue. RARE (1%): Diaphoresis, rash.
ADVERSE REACTIONS/TOXIC EFFECTS
Asymptomatic ventricular tachycardia, hyperuricemia not associated with gout, and nephrolithiasis occur rarely.
NURSING CONSIDERATION
INTERVENTION/EVALUATION
Assess for abdominal pain, GI bleeding (overt blood in emesis/stool, tarry stools). Monitor blood tests for elevated AST, ALT, serum alkaline phosphatase (hepatocellular injury).
PATIENT/FAMILY TEACHING
N Avoid tasks that require alertness, motor skills until drug response is established. N Avoid alcohol, aspirin, smoking. N Inform physician if symptoms of heartburn, acid indigestion, sour stomach persist after 2 wk of continuous use of nizatidine.
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