famciclovir
fam-sigh-klo-veer
(Famvir)
Do not confuse Famvir with Femhrt.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Synthetic nucleoside. CLINICAL: Antiviral.
ACTION
A synthetic nucleoside that inhibits viral DNA synthesis. Therapeutic Effect: Suppresses replication of herpes simplex virus and varicella-zoster virus.
PHARMACOKINETICS
Rapidly and extensively absorbed after PO administration. Protein binding: 20%U25%. Rapidly metabolized to penciclovir by enzymes in the GI wall, liver, and plasma. Eliminated unchanged in urine. Removed by hemodialysis. Half-life: 2 hr.
USES
Management of acute herpes zoster (shingles), treatment and suppression of recurrent genital herpes, treatment of recurrent mucocutaneous herpes simplex in HIV patients.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to penciclovir cream. CAUTIONS: Renal or hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Increased mammary adenocarcinoma in animals. Unknown if excreted in breast milk. Pregnancy Category B. Children: Safety and efficacy not established. Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Probenecid: May increase the famciclovir plasma concentration. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
TABLETS: 125 mg, 250 mg, 500 mg.
ADMINISTRATION/HANDLING
N Give without regard to meals.
INDICATIONS/ROUTES/DOSAGE
HERPES ZOSTER
GENITAL HERPES, FIRST EPISODE
RECURRENT GENITAL HERPES
SUPPRESSION OF RECURRENT GENITAL HERPES
RECURRENT HERPES SIMPLEX
DOSAGE IN RENAL IMPAIRMENT
Dosage and frequency are modified based on creatinine clearance.
Creatinine Clearance Herpes Zoster Genital Herpes
40U59 ml/min 500 mg q12h 125 mg q12h
20U39 ml/min 500 mg q24h 125 mg q24h
Less than 20 ml/min 250 mg q24h 125 mg q24h
DOSAGE IN HEMODIALYSIS PATIENTS
For adults with herpes zoster, give 250 mg after each dialysis treatment; for adults with genital herpes, give 125 mg after each dialysis treatment.
SIDE EFFECTS
FREQUENT: Headache (23%), nausea (12%). OCCASIONAL (10%U2%): Dizziness, somnolence, numbness of feet, diarrhea, vomiting, constipation, decreased appetite, fatigue, fever, pharyngitis, sinusitis, pruritus. RARE (less than 2%): Insomnia, abdominal pain, dyspepsia, flatulence, back pain, arthralgia.
ADVERSE REACTIONS/TOXIC EFFECTS
Urticaria, hallucinations, and confusion (including delirium, disorientation, confusional state, occurring predominantly in the elderly) have been reported.
NURSING CONSIDERATION
INTERVENTION/EVALUATION
Evaluate cutaneous lesions. Be alert to neurologic effects: headache, dizziness. Provide analgesics, comfort measures; especially exhausting in elderly.
PATIENT/FAMILY TEACHING
N Drink adequate fluids. N Fingernails should be kept short, hands clean. N Do not touch lesions with fingers to avoid spreading infection to new site. N Genital herpes: Continue therapy for full length of treatment. N Space doses evenly. N Avoid contact with lesions during duration of outbreak to prevent cross-contamination. N Notify physician if lesions recur or do not improve.
famotidine
fah-mow-tih-deen
(Novo-Famotidine J Pepcid, Pepcid AC, Ulcidine J)
FIXED-COMBINATION(S)
Pepcid Complete: famotidine/calcium chloride/magnesium hydroxide (antacids): 10 mg/800 mg/165 mg.
G 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 gastric acid secretion when fasting, at night, or when stimulated by food, caffeine, or insulin.
PHARMACOKINETICS
Route Onset Peak Duration
IV 1 hr 0.5U3 hr 10U12 hr
Rapidly, incompletely absorbed from the GI tract. Protein binding: 15%U20%. Partially metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 2.5U3.5 hr (increased with impaired renal function).
USES
Short-term treatment of active duodenal ulcer. Prevention, maintenance of duodenal ulcer recurrence. Treatment of active benign gastric ulcer, pathologic GI hypersecretory conditions. Short-term treatment of gastroesophageal reflux disease (GERD), including erosive esophagitis. OTC formulation for relief of heartburn, acid indigestion, sour stomach. OFF-LABEL: Autism, prevention of aspiration pneumonitis, H. pylori eradication
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Renal or hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category B. Children: No age-related precautions noted. Elderly: Confusion more likely to occur, especially in those with renal or hepatic impairment.
INTERACTIONS
DRUG: Antacids: May decrease the absorption of famotidine. Ketoconazole: May decrease the absorption of ketoconazole. HERBAL: None known. FOOD: None known. LAB VALUES: Interferes with skin tests using allergen extracts. May increase liver enzyme levels.
AVAILABILITY (Rx)
ORAL SUSPENSION (PEPCID): 40 mg/5 ml. TABLETS: 10 mg (Pepcid AC [OTC]), 20 mg (Pepcid, Pepcid AC), 40 mg (Pepcid). TABLETS (CHEWABLE [PEPCID AC]): 10 mg (OTC). CAPSULES (PEPCID AC): 10 mg. INJECTION (PEPCID): 10 mg/ml.
ADMINISTRATION/HANDLING
L IV
Reconstitution N For IV push, dilute 20 mg with 5U10 ml 0.9% NaCl, D5W, D10W, lactated Ringer's, or 5% sodium bicarbonate. N For intermittent IV infusion (piggyback), dilute with 50U100 ml D5W, or 0.9% NaCl.
Rate of administration N IV push given over at least 2 min. N Infuse piggyback over 15U30 min.
Storage N Refrigerate unreconstituted vials. N IV solution appears clear, colorless. N After dilution, IV solution is stable for 48 hr at room temperature.
N Store tablets, suspension at room temperature. N Following reconstitution, oral suspension is stable for 30 days at room temperature. N Give without regard to meals. Best given after meals and/or at bedtime. N Shake suspension well before use.
D IV INCOMPATIBILITIES
Amphotericin B complex (Abelcet, AmBisome, Amphotec), cefepime (Maxipime), furosemide (Lasix), piperacillin/tazobactam (Zosyn).
IV COMPATIBILITIES
Calcium gluconate, dobutamine (Dobutrex), dopamine (Intropin), heparin, hydromorphone (Dilaudid), insulin (regular), lidocaine, lorazepam (Ativan), magnesium sulfate, midazolam (Versed), morphine, nitroglycerin, norepinephrine (Levophed), potassium chloride, potassium phosphate, propofol (Diprivan), total parenteral nutrition (TPN).
INDICATIONS/ROUTES/DOSAGE
ACUTE TREATMENT OF DUODENAL AND GASTRIC ULCERS
DUODENAL ULCER MAINTENANCE
GASTROESOPHAGEAL REFLUX DISEASE
ESOPHAGITIS
HYPERSECRETORY CONDITIONS
ACID INDIGESTION, HEARTBURN (OVER-THE-COUNTER)
USUAL PARENTERAL DOSAGE
IV: ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: 20 mg q12h.
DOSAGE IN RENAL IMPAIRMENT
Dosing frequency is modified based on creatinine clearance.
Creatinine Clearance Dosing Frequency
10U50 ml/min q24h
Less than 10 ml/min q36U48h
SIDE EFFECTS
OCCASIONAL (5%): Headache. RARE (2% or less): Constipation, diarrhea, dizziness.
ADVERSE REACTIONS/TOXIC EFFECTS
None known.
NURSING CONSIDERATION
INTERVENTION/EVALUATION
Assess pattern of daily bowel activity and stool consistency. Monitor for diarrhea and constipation, headache.
PATIENT/FAMILY TEACHING
N May take without regard to meals or antacids. N Report headache. N Avoid excessive amounts of coffee, aspirin. N If symptoms of heartburn, acid indigestion, sour stomach persist with medication, consult physician.
famciclovir
fam-sigh-klo-veer
(Famvir)
Do not confuse Famvir with Femhrt.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Synthetic nucleoside. CLINICAL: Antiviral.
ACTION
A synthetic nucleoside that inhibits viral DNA synthesis. Therapeutic Effect: Suppresses replication of herpes simplex virus and varicella-zoster virus.
PHARMACOKINETICS
Rapidly and extensively absorbed after PO administration. Protein binding: 20%U25%. Rapidly metabolized to penciclovir by enzymes in the GI wall, liver, and plasma. Eliminated unchanged in urine. Removed by hemodialysis. Half-life: 2 hr.
USES
Management of acute herpes zoster (shingles), treatment and suppression of recurrent genital herpes, treatment of recurrent mucocutaneous herpes simplex in HIV patients.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to penciclovir cream. CAUTIONS: Renal or hepatic impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Increased mammary adenocarcinoma in animals. Unknown if excreted in breast milk. Pregnancy Category B. Children: Safety and efficacy not established. Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Probenecid: May increase the famciclovir plasma concentration. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
TABLETS: 125 mg, 250 mg, 500 mg.
ADMINISTRATION/HANDLING
N Give without regard to meals.
INDICATIONS/ROUTES/DOSAGE
HERPES ZOSTER
GENITAL HERPES, FIRST EPISODE
RECURRENT GENITAL HERPES
SUPPRESSION OF RECURRENT GENITAL HERPES
RECURRENT HERPES SIMPLEX
DOSAGE IN RENAL IMPAIRMENT
Dosage and frequency are modified based on creatinine clearance.
Creatinine Clearance Herpes Zoster Genital Herpes
40U59 ml/min 500 mg q12h 125 mg q12h
20U39 ml/min 500 mg q24h 125 mg q24h
Less than 20 ml/min 250 mg q24h 125 mg q24h
DOSAGE IN HEMODIALYSIS PATIENTS
For adults with herpes zoster, give 250 mg after each dialysis treatment; for adults with genital herpes, give 125 mg after each dialysis treatment.
SIDE EFFECTS
FREQUENT: Headache (23%), nausea (12%). OCCASIONAL (10%U2%): Dizziness, somnolence, numbness of feet, diarrhea, vomiting, constipation, decreased appetite, fatigue, fever, pharyngitis, sinusitis, pruritus. RARE (less than 2%): Insomnia, abdominal pain, dyspepsia, flatulence, back pain, arthralgia.
ADVERSE REACTIONS/TOXIC EFFECTS
Urticaria, hallucinations, and confusion (including delirium, disorientation, confusional state, occurring predominantly in the elderly) have been reported.
NURSING CONSIDERATION
INTERVENTION/EVALUATION
Evaluate cutaneous lesions. Be alert to neurologic effects: headache, dizziness. Provide analgesics, comfort measures; especially exhausting in elderly.
PATIENT/FAMILY TEACHING
N Drink adequate fluids. N Fingernails should be kept short, hands clean. N Do not touch lesions with fingers to avoid spreading infection to new site. N Genital herpes: Continue therapy for full length of treatment. N Space doses evenly. N Avoid contact with lesions during duration of outbreak to prevent cross-contamination. N Notify physician if lesions recur or do not improve.
fulvestrant A
full-ves-trant
(Faslodex)
Do not confuse Faslodex with Fosamax.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Estrogen antagonist. CLINICAL: Antineoplasti
ACTION
An estrogen antagonist that competes with endogenous estrogen at estrogen receptor binding sites. Therapeutic Effect: Inhibits tumor growth.
PHARMACOKINETICS
Extensively and rapidly distributed after IM administration. Protein binding: 99%. Metabolized in the liver. Eliminated by hepatobiliary route; excreted in feces. Half-life: 40 days in postmenopausal women. Peak serum levels occur in 7U9 days.
USES
Treatment of hormone receptorUpositive metastatic breast cancer in postmenopausal women with disease progression following antiestrogen therapy. OFF-LABEL: Endometriosis, uterine bleeding.
PRECAUTIONS
CONTRAINDICATIONS: Known or suspected pregnancy. CAUTIONS: Thrombocytopenia, bleeding diathesis, anticoagulant therapy, hepatic disease, reduced hepatic blood flow, estrogen receptorUnegative breast cancer.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Do not administer to pregnant women. Unknown if excreted in breast milk. May cause fetal harm. Pregnancy Category D. Children: Not for use in children. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
PREFILLED SYRINGE: 50 mg/ml in 2.5-ml and 5-ml syringes.
ADMINISTRATION/HANDLING
IM
N Administer slowly into the buttock as a single 5-ml injection or 2 concurrent 2.5-ml injections.
INDICATIONS/ROUTES/DOSAGE
BREAST CANCER
IM: ADULTS, ELDERLY: 250 mg given once monthly.
SIDE EFFECTS
FREQUENT (26%U13%): Nausea, hot flashes, pharyngitis, asthenia, vomiting, vasodilatation, headache. OCCASIONAL (12%U5%): Injection site pain, constipation, diarrhea, abdominal pain, anorexia, dizziness, insomnia, paresthesia, bone or back pain, depression, anxiety, peripheral edema, rash, diaphoresis, fever. RARE (2%U1%): Vertigo, weight gain.
ADVERSE REACTIONS/TOXIC EFFECTS
UTIs, vaginitis, anemia, thromboembolic phenomena, and leukopenia occur rarely.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
An estrogen receptor assay should be done before beginning therapy. Baseline CT
INTERVENTION/EVALUATION
Monitor blood chemistry, plasma lipids. Be alert to increased bone pain, ensure adequate pain relief. Check for edema, especially of dependent areas. Monitor for and assist with ambulation if asthenia or dizziness occurs. Assess for headache. Offer antiemetic for nausea and vomiting.
PATIENT/FAMILY TEACHING
N Notify physician if nausea, asthenia, hot flashes become unmanageable.
felodipine
feh-low-dih-peen
(Plendil, Renedil J)
Do not confuse Plendil with Pletal, or Renedil with Prinivil.
FIXED-COMBINATION(S)
Lexxel: felodipine/enalapril (angiotensin-converting enzyme [ACE] inhibitor): 2.5 mg/5 mg; 5 mg/5 mg.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Calcium channel blocker. CLINICAL: Antihypertensive, antianginal.
ACTION
An antihypertensive and antianginal agent that inhibits calcium movement across cardiac and vascular smooth-muscle cell membranes. Potent peripheral vasodilator (does not depress SA or AV nodes). Therapeutic Effect: Increases myocardial contractility, heart rate, and cardiac output; decreases peripheral vascular resistance and BP.
PHARMACOKINETICS
Route Onset Peak Duration
Rapidly, completely absorbed from the GI tract. Protein binding: greater than 99%. Undergoes first-pass metabolism in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 11U16 hr.
USES
Management of hypertension. May be used alone or with other antihypertensives. OFF-LABEL: Treatment of CHF, chronic angina pectoris, Raynaud's phenomenon.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Severe left ventricular dysfunction, CHF, hepatic or renal impairment, hypertrophic cardiomyopathy, edema, concomitant administration with beta-blockers/digoxin.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: May experience greater hypotension response. Constipation may be more problematic.
INTERACTIONS
DRUG: Beta blockers: May have additive effect. Digoxin: May increase digoxin blood concentration. Erythromycin: May increase felodipine blood concentration and risk of toxicity. Hypokalemia-producing agents (such as furosemide and certain other diuretics): May increase risk of arrhythmias. Procainamide, quinidine: May increase risk of QT-interval prolongation. HERBAL: DHEA: May increase felodipine blood concentration. FOOD: Grapefruit, grapefruit juice: May increase the absorption and blood concentration of felodipine. LAB VALUES: None known.
AVAILABILITY (Rx)
TABLETS (EXTENDED-RELEASE): 2.5 mg, 5 mg, 10 mg.
ADMINISTRATION/HANDLING
N Give without regard to food. N Do not crush or break tablets.
INDICATIONS/ROUTES/DOSAGE
HYPERTENSION
SIDE EFFECTS
FREQUENT (22%U18%): Headache, peripheral edema. OCCASIONAL (6%U4%): Flushing , respiratory infection, dizziness, light-headedness, asthenia (loss of strength, weakness). RARE (less than 3%): Paresthesia, abdominal discomfort, nervousness, muscle cramping, cough, diarrhea, constipation.
ADVERSE REACTIONS/TOXIC EFFECTS
Overdose produces nausea, somnolence, confusion, slurred speech, hypotension, and bradycardia.
BASELINE ASSESSMENT
Assess BP, apical pulse immediately before drug administration (if pulse is 60 or less/min or systolic BP is less than 90 mm Hg, withhold medication, contact physician).
INTERVENTION/EVALUATION
Assist with ambulation if lightheadedness, dizziness occur. Assess for peripheral edema behind media malleolus (sacral area in bedridden patients). Monitor pulse rate for bradycardia. Assess skin for flushing. Monitor hepatic enzyme tests. Question for headache, asthenia.
PATIENT/FAMILY TEACHING
N Do not abruptly discontinue medication. N Compliance with therapy regimen is essential to control hypertension. N To avoid hypotensive effect, rise slowly from lying to sitting position. Wait momentarily before standing. N Avoid tasks that require alertness, motor skills until response to drug is established. N Contact physician or nurse if palpitations, shortness of breath, pronounced dizziness, nausea occurs. N Swallow tablet whole; do not crush or chew. N Avoid grapefruit juice.
ACTION
An enzymatic mineral that is as an essential component in the formation of Hgb, myoglobin, and enzymes. Promotes effective erythropoiesis and transport and utilization of oxygen (O2). Therapeutic Effect: Prevents iron deficiency.
PHARMACOKINETICS
Absorbed in the duodenum and upper jejunum. Ten percent absorbed in patients with normal iron stores; increased to 20%U30% in those with inadequate iron stores. Primarily bound to serum transferrin. Excreted in urine, sweat, and sloughing of intestinal mucosa and by menses. Half-life: 6 hr.
USES
Prevention and treatment of iron deficiency anemia due to inadequate diet, malabsorption, pregnancy, blood loss.
PRECAUTIONS
CONTRAINDICATIONS: Hemochromatosis, hemosiderosis, hemolytic anemias, peptic ulcer disease, regional enteritis, ulcerative colitis. CAUTIONS: Bronchial asthma, iron hypersensitivity, alcoholism, intestinal tract inflammation, hepatic or renal impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Excreted in breast milk. Pregnancy Category A. Children/Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Antacids, calcium supplements, pancreatin, pancrelipase: May decrease the absorption of ferrous fumarate, ferrous gluconate, and ferrous sulfate. Etidronate, quinolones, tetracyclines: May decrease the absorption of etidronate, quinolones, and tetracyclines. HERBAL: None known. FOOD: Eggs, milk: Inhibit ferrous fumarate absorption. LAB VALUES: May increase serum bilirubin and iron levels. May decrease serum calcium level. May obscure occult blood in stools.
AVAILABILITY (OTC)
FERROUS FUMARATE
TABLETS: 63 mg (20 mg elemental iron) (Femiron), 350 mg (115 mg elemental iron) (Nephro-Fer). TABLETS (CHEWABLE [FEOSTAT]): 100 mg (33 mg elemental iron). TABLETS (TIME-RELEASE [FERRO-SEQUELS]): 150 mg (50 mg elemental iron).
FERROUS GLUCONATE
TABLETS: 240 mg (27 mg elemental iron) (Fergon), 325 mg (36 mg elemental iron).
FERROUS SULFATE
TABLETS: 325 mg (65 mg elemental iron). TABLETS (TIMED-RELEASE [SLOW-FE]): 160 mg (50 mg elemental iron). ELIXIR: 220 mg/5 ml (44 mg elemental iron per 5 ml). ORAL DROPS (FER-IN-SOL, FER-IRON): 75 mg/0.6 ml.
ADMINISTRATION/HANDLING
N Store all forms (tablets, capsules, suspension, drops) at room temperature. N Ideally, give between meals with water but may give with meals if GI discomfort occurs. N Transient staining of mucous membranes, teeth occurs with liquid iron preparation. To avoid this, place liquid on back of tongue with dropper or straw. N Avoid simultaneous administration of antacids or tetracycline. N Do not crush sustained-release preparations.
INDICATIONS/ROUTES/DOSAGE
IRON DEFICIENCY ANEMIA
Dosage is expressed in terms of milligrams of elemental iron, degree of anemia, patient weight, and presence of any bleeding. Expect to use periodic hematologic determinations as guide to therapy.
PREVENTION OF IRON DEFICIENCY
SIDE EFFECTS
OCCASIONAL: Mild, transient nausea. RARE: Heartburn, anorexia, constipation, diarrhea.
ADVERSE REACTIONS/TOXIC EFFECTS
Large doses may aggravate existing GI tract disease, such as peptic ulcer disease, regional enteritis, and ulcerative colitis. Severe iron poisoning occurs most often in children and is manifested as vomiting, severe abdominal pain, diarrhea, and dehydration, followed by hyperventilation, pallor or cyanosis, and cardiovascular collapse.
NURSING CONSIDERATION
BASELINE ASSESSMENT
To prevent mucous membrane and teeth staining with liquid preparation, use dropper or straw and allow solution to drop on back of tongue. Eggs, milk inhibit absorption.
INTERVENTION/EVALUATION
Monitor serum iron, total iron-binding capacity, reticulocyte count, Hgb, ferritin. Monitor daily pattern of bowel activity and stool consistency. Assess for clinical improvement, record relief of iron deficiency symptoms (fatigue, irritability, pallor, paresthesia of extremities, headache).
PATIENT/FAMILY TEACHING
N Expect stool color to darken. N If GI discomfort occurs, take after meals or with food. N Do not take within 2 hr of antacids (prevents absorption).
fenofibrate
fen-oh-figh-brate
(Antara, Apo-Fenofibrate J, Lipidil Supra, Lipofen, Lofibra, Tricor, Triglide)
Do not confuse Tricor with Tracleer.
G CLASSIFICATION
CLINICAL: Antihyperlipidemic.
ACTION
An antihyperlipidemic that enhances synthesis of lipoprotein lipase and reduces triglyceride-rich lipoproteins and VLDLs. Therapeutic Effect: Increases VLDL catabolism and reduces total plasma triglyceride levels.
PHARMACOKINETICS
Well absorbed from the GI tract. Absorption increased when given with food. Protein binding: 99%. Rapidly metabolized in the liver to active metabolite. Excreted primarily in urine; lesser amount in feces. Not removed by hemodialysis. Half-life: 20 hr.
USES
Adjunct to diet in treatment of hypertriglyceride levels at risk of pancreatitis. Reduction of low density lipoprotein cholesterol (LDL-C), total cholesterol, triglycerides and apo-lipoprotein B in patients with primary hypercholesterolemia or mixed dyslipidemia.
PRECAUTIONS
CONTRAINDICATIONS: Gallbladder disease, severe renal or hepatic dysfunction (including primary biliary cirrhosis, unexplained persistent liver function abnormality). CAUTIONS: Anticoagulant therapy, history of hepatic disease, substantial alcohol consumption.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Safety in pregnancy not established. Avoid use in breast-feeding mothers. Pregnancy Category C. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Anticoagulants: Potentiates effects of these drugs. Bile acid sequestrants: May impede fenofibrate absorption. Cyclosporine: Increases risk of nephrotoxicity. HMG-CoA reductase inhibitors: Increases risk of severe myopathy, rhabdomyolysis, and acute renal failure. HERBAL: None known. FOOD: All foods: Increase absorption of fenofibrate. LAB VALUES: May increase BUN and serum creatine kinase (CK), AST, and ALT, levels. May decrease blood Hgb and Hct levels, serum uric acid level, and WBC count.
AVAILABILITY (Rx)
CAPSULES: 43 mg (Antara), 50 mg (Lipofen), 67 mg (Lofibra), 87 mg (Antara), 100 mg (Lipofen), 130 mg (Antara), 134 mg (Lofibra), 150 mg (Lipofen), 200 mg (Lipidil Supra, Lofibra). TABLETS: 48 mg (Tricor), 50 mg (Triglide), 54 mg (Lofibra), 145 mg (Tricor), 160 mg (Lofibra, Triglide).
ADMINISTRATION/HANDLING
N Give Lofibra with meals. N Antara , Tricor, and Triglide may be given without regard to food. N Administer fenofibrate preparations 1 hr before or 4U6 hr after giving bile acid sequestrant.
INDICATIONS/ROUTES/DOSAGE
HYPERTRIGLYCERIDEMIA
HYPERCHOLESTEROLEMIA
SIDE EFFECTS
FREQUENT (8%U4%): Pain, rash, headache, asthenia or fatigue, flu symptoms, dyspepsia, nausea or vomiting, rhinitis. OCCASIONAL (3%U2%): Diarrhea, abdominal pain, constipation, flatulence, arthralgia, decreased libido, dizziness, pruritus. RARE (less than 2%): Increased appetite, insomnia, polyuria, cough, blurred vision, eye floaters, earache.
ADVERSE REACTIONS/TOXIC EFFECTS
Fenofibrate may increase excretion of cholesterol into bile, leading to cholelithiasis. Pancreatitis, hepatitis, thrombocytopenia, and agranulocytosis occur rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Obtain serum cholesterol, triglycerides, liver function tests (including ALT), blood counts during initial therapy and periodically during treatment. Treatment should be discontinued if hepatic enzyme levels persist greater than 3 times normal limit.
INTERVENTION/EVALUATION
For patients on concurrent therapy with hydroxamethylglutaryl-CoA (HMG-CoA) reductase inhibitors, monitor for complaints of myopathy (muscle pain, weakness). Monitor serum CK levels. Monitor serum cholesterol, triglyceride concentrations for therapeutic response.
PATIENT/FAMILY TEACHING
N Take with food. N Inform physician if diarrhea, constipation, nausea becomes severe. N Report skin rash or irritation, insomnia, muscle pain, tremors or dizziness.
fenoldopam
phen-ole-doe-pam
(Corlopam)
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Vasodilator (dopamine receptor agonist). CLINICAL: Antihypertensive.
ACTION
A rapid-acting vasodilator. An agonist for D1-like dopamine receptors; also produces vasodilation in coronary, renal, mesenteric, and peripheral arteries. Therapeutic Effect: Reduces systolic and diastolic BP and increases heart rate.
PHARMACOKINETICS
After IV administration, metabolized in the liver. Primarily excreted in urine. Unknown if removed by hemodialysis. Half-life: Approximately 5 min.
USES
Short-term (48 hr or less) management of severe hypertension when rapid, but quickly reversible, emergency reduction of BP is clinically indicated, including malignant hypertension with deteriorating end-organ function. OFF-LABEL: Prevention of contrast media-induced nephrotoxicity.
PRECAUTIONS
CONTRAINDICATIONS: Sensitivity to sulfites. CAUTIONS: Glaucoma, intraocular hypertension, tachycardia, hypotension, hypokalemia, sulfite sensitivity.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if distributed in breast milk. Pregnancy Category B. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Beta blockers: May produce excessive hypotension. HERBAL: None known. FOOD: None known. LAB VALUES: May elevate BUN, blood glucose, serum LDH, and serum transaminase levels. May decrease serum potassium levels.
AVAILABILITY (Rx)
INJECTION: 10 mg/ml.
ADMINISTRATION/HANDLING
O ALERT P Must give by continuous IV infusion, not as a bolus injection.
L IV
Reconstitution N Each 10 mg (1 ml) must be diluted with 250 ml 0.9% NaCl or D5W to provide a concentration of 40 mcg/ml.
Rate of administration N Administer as IV infusion at initial rate of 0.1 mcg/kg/min. N Use infusion pump.
Storage N Store ampules at room temperature. N Diluted solution is stable for 24 hr. Discard any solution not used within 24 hr.
D IV INCOMPATIBILITIES
Do not mix fenoldopam with other medications. Specific IV incompatibilities are not available.
INDICATIONS/ROUTES/DOSAGE
SHORT-TERM MANAGEMENT OF SEVERE HYPERTENSION WHEN RAPID, BUT QUICKLY REVERSIBLE EMERGENCY REDUCTION OF BP IS CLINICALLY INDICATED, INCLUDING MALIGNANT HYPERTENSION WITH DETERIORATING END-ORGAN FUNCTION
IV INFUSION (CONTINUOUS): ADULTS, ELDERLY: Initially, 0.1 mcg/kg/min. May increase in increments of 0.05U0.1 mcg/kg/min until target BP is achieved. Usual length of treatment is 1U6 hours with tapering of dose q15U30min. Average rate: 0.25U0.5 mcg/kg/min. Maximum rate: 1.6 mcg/kg/min. CHILDREN: Initially, 0.2 mcg/kg/min. May increase increments of 0.3U0.5 mcg/kg/min q20U30min. Dosage greater than 0.8 mcg/kg/min have resulted in tachycardia with no additional benefit.
SIDE EFFECTS
EXPECTED: Beta blockers may cause unforeseen hypotension. OCCASIONAL: Headache (7%), flushing (3%), nausea (4%), hypotension (2%). RARE (2% or less): Nervousness or anxiety, vomiting, constipation, nasal congestion, diaphoresis, back pain.
ADVERSE REACTIONS/TOXIC EFFECTS
Excessive hypotension occurs occasionally. Substantial tachycardia may lead to ischemic cardiac events or worsened heart failure. Allergic-type reactions, including anaphylaxis and life-threatening asthmatic exacerbation, may occur in patients with sulfite sensitivity.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Determine initial BP, apical pulse. It is essential to diligently monitor BP, EKG during infusion to avoid hypotension and too rapid decrease of BP. Assess medication history (especially beta-blockers). Obtain baseline serum electrolytes, particularly potassium, and periodically thereafter during infusion. Question asthmatic patients for history of sulfite sensitivity. Check with physician for desired BP range parameters.
INTERVENTION/EVALUATION
Monitor rate of infusion frequently. Monitor EKG for tachycardia (may lead to ischemic heart disease, MI, angina, extrasystoles, worsening heart failure). Monitor closely for symptomatic hypotension.
fentanyl A
fen-ta-nill
(Actiq, Duragesic, Sublimaze)
Do not confuse fentanyl with alfentanil.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Opioid, narcotic agonist (Schedule II). CLINICAL: Analgesic.
ACTION
An opioid agonist that binds to opioid receptors in the CNS, reducing stimuli from sensory nerve endings and inhibiting ascending pain pathways. Therapeutic Effect: Alters pain reception and increases the pain threshold.
PHARMACOKINETICS
Route Onset Peak Duration
IV 1U2 min 3U5 min 0.5U1 hr
IM 7U15 min 20U30 min 1U2 hr
Transdermal 6U8 hr 24 hr 72 hr
Transmucosal 5U15 min 20U30 min 1U2 hr
Well absorbed after IM or topical administration. Transmucosal form absorbed through the buccal mucosa and GI tract. Protein binding: 80%U85%. Metabolized in the liver. Primarily eliminated by biliary system. Half-life: 2U4 hr IV; 17 hr transdermal; 6.6 hr transmucosal.
USES
For sedation, pain relief, preop medication; adjunct to general or regional anesthesia. Management of chronic pain (transdermal). Actig: Treatment breakthrough for pain in chronic cancer or AIDS-related pain.
PRECAUTIONS
CONTRAINDICATIONS: Increased intracranial pressure, severe hepatic or renal impairment, severe respiratory depression. CAUTIONS: Bradycardia; renal, hepatic, respiratory disease; head injuries; altered level of consciousness (LOC); use of MAOI within 14 days; transdermal not recommended in those younger than 12 yr or younger than 18 yr and weighing less than 50 kg.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Readily crosses placenta. Unknown if distributed in breast milk. May prolong labor if administered in latent phase of first stage of labor or before cervical dilation of 4U5 cm has occurred. Respiratory depression may occur in neonate if mother received opiates during labor. Pregnancy Category C (D if used for prolonged periods or at high dosages at term). Children: PATCH: Safety and efficacy not established in those younger than 12 yr. Neonates more susceptible to respiratory depressant effects. Elderly: May be more susceptible to respiratory depressant effects. Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Benzodiazepines, CNS depressants: May increase the risk of hypotension and respiratory depression. Buprenorphine: May decrease the effects of fentanyl. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum amylase and lipase concentrations.
AVAILABILITY (Rx)
INJECTION (SUBLIMAZE): 50 mcg/ml. TRANSDERMAL PATCH (DURAGESIC): 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr. TRANSMUCOSAL LOZENGES (ACTIQ): 200 mcg, 400 mcg, 600 mcg, 800 mcg, 1,200 mcg, 1,600 mcg.
ADMINISTRATION/HANDLING
L IV
Rate of administration N For initial anesthesia induction dosage, give small amount, via tuberculin syringe. N Give by slow IV injection (over 1U2 min). N Too rapid IV increases risk of severe adverse reactions (skeletal, thoracic muscle rigidity resulting in apnea, laryngospasm, bronchospasm, peripheral circulatory collapse, anaphylactoid effects, cardiac arrest). N Opiate antagonist (naloxone) should be readily available.
TRANSDERMAL
N Apply to nonhairy area of intact skin of upper torso. N Use flat, nonirritated site. N Firmly press evenly for 10U20 sec, ensuring adhesion is in full contact with skin and edges are completely sealed. N Use only water to cleanse site before application (soaps, oils, etc., may irritate skin). N Rotate sites of application. N Carefully fold used patches so that system adheres to itself; discard in toilet.
TRANSMUCOSAL
N Suck lozenge vigorously.
Storage N Store parenteral form at room temperature.
D IV INCOMPATIBILITY
Phenytoin (Dilantin).
IV COMPATIBILITIES
Atropine, bupivacaine (Marcaine, Sensorcaine), clonidine (Duraclon), diltiazem (Cardizem), diphenhydramine (Benadryl), dobutamine (Dobutrex), dopamine (Intropin), droperidol (Inapsine), heparin, hydromorphone (Dilaudid), ketorolac (Toradol), lorazepam (Ativan), metoclopramide (Reglan), midazolam (Versed), milrinone (Primacor), morphine, nitroglycerin, norepinephrine (Levophed), ondansetron (Zofran), potassium chloride, propofol (Diprivan).
INDICATIONS/ROUTES/DOSAGE
SEDATION IN MINOR PROCEDURES, ANALGESIA
IV, IM: ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: 0.5U1 mcg/kg/dose; may repeat in 30U60 min. CHILDREN 1U11 YR: 1U2 mcg/kg/dose. CHILDREN YOUNGER THAN 1 YR: 1U4 mcg/kg/dose.
PREOPERATIVE SEDATION, POSTOPERATIVE PAIN, ADJUNCT TO REGIONAL ANESTHESIA
IV, IM: ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: 50U100 mcg/dose.
ADJUNCT TO GENERAL ANESTHESIA
IV: ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: 2U50 mcg/kg.
USUAL TRANSDERMAL DOSE
ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: Initially, 25 mcg/hr. May increase after 3 days.
USUAL TRANSMUCOSAL DOSE
ADULTS, CHILDREN: 200U400 mcg for breakthrough cancer pain.
USUAL EPIDURAL DOSE
ADULTS, ELDERLY: Bolus dose of 100 mcg, followed by continuous infusion of 10 mcg/ml concentration at 4U12 ml/hr.
CONTINUOUS ANALGESIA
IV: ADULTS, ELDERLY, CHILDREN 1U12 YR: Bolus dose of 1U2 mcg/kg, followed by continuous infusion of 1 mcg/kg/hr. Range: 1U5 mcg/kg/hr. CHILDREN YOUNGER THAN 1 YR: Bolus dose of 1U2 mcg/kg, followed by continuous infusion of 0.5U1 mcg/kg/hr.
DOSAGE IN RENAL IMPAIRMENT
Dosage is modified based on creatinine clearance.
Creatinine Clearance Dosage
10U50 ml/min 75% of usual dose
Less than 10 ml/min 50% of usual dose
SIDE EFFECTS
FREQUENT: IV: Postoperative drowsiness, nausea, vomiting. Transdermal (10%U3%): Headache, pruritus, nausea, vomiting, diaphoresis, dyspnea, confusion, dizziness, somnolence, diarrhea, constipation, decreased appetite. OCCASIONAL: IV: Postoperative confusion, blurred vision, chills, orthostatic hypotension, constipation, difficulty urinating. Transdermal (3%U1%): Chest pain, arrhythmias, erythema, pruritus, swelling of skin, syncope, agitation, tingling or burning of skin.
ADVERSE REACTIONS/TOXIC EFFECTS
Overdose or too rapid IV administration may produce severe respiratory depression and skeletal and thoracic muscle rigidity (which may lead to apnea), laryngospasm, bronchospasm, cold and clammy skin, cyanosis, and coma. The patient who uses fentanyl repeatedly may develop a tolerance to the drug's analgesic effect.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Resuscitative equipment, opiate antagonist (naloxone 0.5 mcg/kg) must be available. Establish baseline BP, respirations. Assess type, location, intensity, duration of pain.
INTERVENTION/EVALUATION
Assist with ambulation. Encourage patient to turn, cough, deep breathe q2h. Monitor respiratory rate, BP, heart rate, oxygen saturation. Assess for relief of pain.
PATIENT/FAMILY TEACHING
N Avoid alcohol; do not take other medications without consulting physician. N Do not perform activities requiring alertness, coordination. N Teach patient proper transdermal application. N Use as directed to avoid overdosage; potential for physical dependence with prolonged use. N After long-term use, must be discontinued slowly.
ferrous fumarate
fair-us fume-ah-rate
(Femiron, Feostat, Ferro-Sequels, Nephro-Fer, Palafer J)
ferrous gluconate
fair-us glue-kuh-nate
(Apo-Ferrous Gluconate J, Fergon)
ferrous sulfate
fair-us sul-fate
(Apo-Ferrous Sulfate J, Fer-In-Sol, Fer-Iron, Slow-Fe)
FIXED-COMBINATION(S)
Ferro-Sequels: ferrous fumarate/docusate (stool softener): 150 mg/100 mg.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Enzymatic mineral. CLINICAL: Iron preparation.
ACTION
An enzymatic mineral that is as an essential component in the formation of Hgb, myoglobin, and enzymes. Promotes effective erythropoiesis and transport and utilization of oxygen (O2). Therapeutic Effect: Prevents iron deficiency.
PHARMACOKINETICS
Absorbed in the duodenum and upper jejunum. Ten percent absorbed in patients with normal iron stores; increased to 20%U30% in those with inadequate iron stores. Primarily bound to serum transferrin. Excreted in urine, sweat, and sloughing of intestinal mucosa and by menses. Half-life: 6 hr.
USES
Prevention and treatment of iron deficiency anemia due to inadequate diet, malabsorption, pregnancy, blood loss.
PRECAUTIONS
CONTRAINDICATIONS: Hemochromatosis, hemosiderosis, hemolytic anemias, peptic ulcer disease, regional enteritis, ulcerative colitis. CAUTIONS: Bronchial asthma, iron hypersensitivity, alcoholism, intestinal tract inflammation, hepatic or renal impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Excreted in breast milk. Pregnancy Category A. Children/Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Antacids, calcium supplements, pancreatin, pancrelipase: May decrease the absorption of ferrous fumarate, ferrous gluconate, and ferrous sulfate. Etidronate, quinolones, tetracyclines: May decrease the absorption of etidronate, quinolones, and tetracyclines. HERBAL: None known. FOOD: Eggs, milk: Inhibit ferrous fumarate absorption. LAB VALUES: May increase serum bilirubin and iron levels. May decrease serum calcium level. May obscure occult blood in stools.
AVAILABILITY (OTC)
FERROUS FUMARATE
TABLETS: 63 mg (20 mg elemental iron) (Femiron), 350 mg (115 mg elemental iron) (Nephro-Fer). TABLETS (CHEWABLE [FEOSTAT]): 100 mg (33 mg elemental iron). TABLETS (TIME-RELEASE [FERRO-SEQUELS]): 150 mg (50 mg elemental iron).
FERROUS GLUCONATE
TABLETS: 240 mg (27 mg elemental iron) (Fergon), 325 mg (36 mg elemental iron).
FERROUS SULFATE
TABLETS: 325 mg (65 mg elemental iron). TABLETS (TIMED-RELEASE [SLOW-FE]): 160 mg (50 mg elemental iron). ELIXIR: 220 mg/5 ml (44 mg elemental iron per 5 ml). ORAL DROPS (FER-IN-SOL, FER-IRON): 75 mg/0.6 ml.
ADMINISTRATION/HANDLING
N Store all forms (tablets, capsules, suspension, drops) at room temperature. N Ideally, give between meals with water but may give with meals if GI discomfort occurs. N Transient staining of mucous membranes, teeth occurs with liquid iron preparation. To avoid this, place liquid on back of tongue with dropper or straw. N Avoid simultaneous administration of antacids or tetracycline. N Do not crush sustained-release preparations.
INDICATIONS/ROUTES/DOSAGE
IRON DEFICIENCY ANEMIA
Dosage is expressed in terms of milligrams of elemental iron, degree of anemia, patient weight, and presence of any bleeding. Expect to use periodic hematologic determinations as guide to therapy.
PREVENTION OF IRON DEFICIENCY
SIDE EFFECTS
OCCASIONAL: Mild, transient nausea. RARE: Heartburn, anorexia, constipation, diarrhea.
ADVERSE REACTIONS/TOXIC EFFECTS
Large doses may aggravate existing GI tract disease, such as peptic ulcer disease, regional enteritis, and ulcerative colitis. Severe iron poisoning occurs most often in children and is manifested as vomiting, severe abdominal pain, diarrhea, and dehydration, followed by hyperventilation, pallor or cyanosis, and cardiovascular collapse.
NURSING CONSIDERATION
BASELINE ASSESSMENT
To prevent mucous membrane and teeth staining with liquid preparation, use dropper or straw and allow solution to drop on back of tongue. Eggs, milk inhibit absorption.
INTERVENTION/EVALUATION
Monitor serum iron, total iron-binding capacity, reticulocyte count, Hgb, ferritin. Monitor daily pattern of bowel activity and stool consistency. Assess for clinical improvement, record relief of iron deficiency symptoms (fatigue, irritability, pallor, paresthesia of extremities, headache).
PATIENT/FAMILY TEACHING
N Expect stool color to darken. N If GI discomfort occurs, take after meals or with food. N Do not take within 2 hr of antacids (prevents absorption).
sodium ferric gluconate complex
sew-dee-um fair-ick glue-koe-nate calm-plex
(Ferrlecit)
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Trace element. CLINICAL: Hematinic.
ACTION
A trace element that repletes total iron content in body. Replaces iron found in Hgb, myoglobin, and specific enzymes; allows oxygen transport via Hgb. Therapeutic Effect: Prevents and corrects iron deficiency.
PHARMACOKINETICS
Half-life: 1 hr.
USES
Treatment of iron deficiency anemia in patients undergoing chronic hemodialysis who are receiving supplemental erythropoietin therapy.
PRECAUTIONS
CONTRAINDICATIONS: All anemias not associated with iron deficiency, hypersensitivity to iron products. CAUTIONS: Patients with iron overload, significant allergies, asthma, hepatic impairment, rheumatoid arthritis.
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; lower initial dosages recommended.
INTERACTIONS
DRUG: Aluminum, calcium, magnesium containing drugs: May decrease iron effectiveness. Ibandronate, levodopa, quinolone antibiotics: May decrease the effectiveness of these drugs. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
AMPULES: 12.5 mg/ml elemental iron.
ADMINISTRATION/HANDLING
L IV
Reconstitution N Must be diluted. N Test dose: dilute 25 mg (2 ml) with 50 ml 0.9% NaCl. N Recommended dose: dilute 125 mg (10 ml) with 100 ml 0.9% NaCl.
Rate of administration N Infuse test dose and recommended dose over 1 hr.
Storage N Store at room temperature. N Use immediately after dilution.
D IV INCOMPATIBILITIES
Do not mix with other medications.
INDICATIONS/ROUTES/DOSAGE
IRON DEFICIENCY ANEMIA
IV INFUSION: ADULTS, ELDERLY: 125 mg in 100 ml 0.9% NaCl infused over 1 hr. Minimum cumulative dose 1 g elemental iron given over 8 sessions at sequential dialysis treatments. May be given during dialysis session. CHILDREN 6 YR AND OLDER: 1.5 mg/kg diluted in 25 ml 0.9% NaCl administered over 60 min at sequential dialysis sessions. Maximum: 125 mg/dose.
SIDE EFFECTS
FREQUENT (greater than 3%): Flushing , hypotension, hypersensitivity reaction. OCCASIONAL (3%U1%): Injection site reaction, headache, abdominal pain, chills, flu-like syndrome, dizziness, leg cramps, dyspnea, nausea, vomiting, diarrhea, myalgia, pruritus, edema.
ADVERSE REACTIONS/TOXIC EFFECTS
A potentially fatal hypersensitivity reaction occurs rarely, characterized by cardiovascular collapse, cardiac arrest, dyspnea, bronchospasm, angioedema, and urticaria. Rapid administration may cause hypotension associated with flushing, lightheadedness, fatigue, weakness, or severe pain in the chest, back, or groin.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Do not give concurrently with oral iron form (excessive iron may produce excessive iron storage [hemosiderosis]). Be alert to patients with rheumatoid arthritis or iron deficiency anemia (acute exacerbation of joint pain, swelling may occur).
INTERVENTION/EVALUATION
Monitor vital signs, lab tests, especially CBC, serum iron concentrations (may not be meaningful for 3 wk after administration).
PATIENT/FAMILY TEACHING
N Stools frequently become black with iron therapy; this is harmless unless accompanied by red streaking, sticky consistency of stool, abdominal pain or cramping, which should be reported to physician.
fexofenadine hydrochloride H
fex-oh-fen-eh-deen
(Allegra)
FIXED-COMBINATION(S)
Allegra D 12 Hour: fexofenadine/pseudoephedrine (sympathomimetic): 60 mg/120 mg. Allegra-D 24 Hour: 180 mg/240 mg.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Piperidine. CLINICAL: Antihistamine.
ACTION
A piperidine that competes with histamine for H1-receptor sites on effector cells. Therapeutic Effect: Relieves allergic rhinitis symptoms.
PHARMACOKINETICS
Rapidly absorbed after PO administration. Protein binding: 60%U70%. Does not cross the blood-brain barrier. Minimally metabolized. Eliminated in feces and urine. Not removed by hemodialysis. Half-life: 14.4 hr (increased in renal impairment).
USES
Relief of seasonal allergic rhinitis, chronic idiopathic urticaria.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Severe renal impairment.
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 in those younger than 12 yr. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Antacids: May decrease fexofenadine absorption if given within 15 min of a fexofenadine dose. HERBAL: None known. FOOD: None known. LAB VALUES: May suppress wheal and flare reactions to antigen skin testing unless drug is discontinued at least 4 days before testing.
AVAILABILITY (Rx)
TABLETS: 30 mg, 60 mg, 180 mg.
ADMINISTRATION/HANDLING
N Give without regard to food.
INDICATIONS/ROUTES/DOSAGE
ALLERGIC RHINITIS, URTICARIA
DOSAGE IN RENAL IMPAIRMENT
For adults, elderly, and children 12 yr and older, dosage is reduced to 60 mg once a day. For children 6U11 yr, dosage is reduced to 30 mg once a day.
SIDE EFFECTS
RARE (less than 2%): Somnolence, headache, fatigue, nausea, vomiting, abdominal distress, dysmenorrhea.
ADVERSE REACTIONS/TOXIC EFFECTS
In rare cases, hypersensitivity reactions including rash, urticaria, pruritus, with manifestations characterized as angioedema, chest tightness, dyspnea, flushing, and systemic anaphylaxis have been reported.
NURSING CONSIDERATION
BASELINE ASSESSMENT
If patient is having an allergic reaction, obtain history of recently ingested foods, drugs, environmental exposure, emotional stress. Monitor rate, depth, rhythm, type of respiration; quality, rate of pulse. Assess lung sounds for rhonchi, wheezing, rales.
INTERVENTION/EVALUATION
Assess for therapeutic response; relief from allergy: itching, red, watery eyes, rhinorrhea, sneezing.
PATIENT/FAMILY TEACHING
N Avoid tasks that require alertness, motor skills until response to drug is established. N Avoid alcohol during antihistamine therapy. N Coffee, tea may help reduce drowsiness.
filgrastim
fill-grass-tim
(Neupogen)
Do not confuse Neupogen with Epogen or Nutramigen.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Biologic modifier. CLINICAL: Granulocyte colony-stimulating factor (GCSF).
ACTION
A biologic modifier that stimulates production, maturation, and activation of neutrophils to increase their migration and cytotoxicity. Therapeutic Effect: Decreases incidence of infection.
PHARMACOKINETICS
Readily absorbed after subcutaneous administration. Not removed by hemodialysis. Half-life: 3.5 hr.
USES
Decrease infection incidence in patients with malignancies receiving myelosuppressive therapy associated with severe neutropenia, fever. Reduce neutropenia duration (and sequelae) in patient with nonmyeloid malignancies having myeloablative therapy followed by bone marrow transplant (BMT). Mobilization of hematopoietic progenitor cells into peripheral blood for collection by leukapheresis. Treatment of chronic, severe neutropenia. OFF-LABEL: Treatment of AIDS-related neutropenia, drug-induced neutropenia, myelodysplastic syndrome.
PRECAUTIONS
CONTRAINDICATIONS: Hypersensitivity to Escherichia coliUderived proteins, 24 hr before or after cytotoxic chemotherapy, concurrent use of other drugs that may result in lowered platelet count. CAUTIONS: Malignancy with myeloid characteristics due to a GCSF's potential to act as a growth factor; gout, psoriasis, preexisting cardiac conditions; those taking lithium.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Pregnancy Category C. Children/elderly: No age-related precautions noted.
INTERACTIONS
DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: May increase LDH concentrations, leukocyte alkaline phosphatase (LAP) scores, and serum alkaline phosphatase and uric acid levels.
AVAILABILITY (Rx)
INJECTION: 300 mcg/ml, 480 mcg/0.8 ml, 600 mcg/ml.
ADMINISTRATION/HANDLING
O ALERT P May be given by subcutaneous injection, short IV infusion (15U30 min), or continuous IV infusion.
Reconstitution N Use single-dose vial, do not reenter vial. Do not shake. N Dilute with 10U50 ml D5W to concentration of 15 mcg/ml or greater. For concentration from 5U14 mcg/ml, add 2 ml of 5% albumin to each 50 ml D5W to provide a final concentration of 2 mg/ml. Do not dilute to a final concentration of less than 5 mcg/ml.
Rate of administration N For intermittent infusion (piggyback), infuse over 15U30 min. N For continuous infusion, give single dose over 4U24 hr. N In all situations, flush IV line with D5W before and after administration.
Storage N Refrigerate vials. N Stable for up to 24 hr at room temperature (provided vial contents are clear and contain no particulate matter). Remains stable if accidentally exposed to freezing temperature.
SUBCUTANEOUS
Storage N Store in refrigerator, but remove before use and allow to warm to room temperature. N Aspirate syringe before injection (avoid intra-arterial administration).
D IV INCOMPATIBILITIES
Amphotericin (Fungizone), cefepime (Maxipime), cefotaxime (Claforan), cefoxitin (Mefoxin), ceftizoxime (Cefizox), ceftriaxone (Rocephin), cefuroxime (Zinacef), clindamycin (Cleocin), dactinomycin (Cosmegen), etoposide (VePesid), fluorouracil, furosemide (Lasix), heparin, mannitol, methylprednisolone (Solu-Medrol), mitomycin (Mutamycin), prochlorperazine (Compazine), total parenteral nutrition (TPN).
IV COMPATIBILITIES
Bumetanide (Bumex), calcium gluconate, hydromorphone (Dilaudid), lorazepam (Ativan), morphine, potassium chloride.
INDICATIONS/ROUTES/DOSAGE
MYELOSUPPRESSION
IV OR SUBCUTANEOUS INFUSION, SUBCUTANEOUS INJECTION: ADULTS, ELDERLY: Initially, 5 mcg/kg/day. May increase by 5 mcg/kg for each chemotherapy cycle based on duration or severity of absolute neutrophil count nadir.
BONE MARROW TRANSPLANT
IV OR SUBCUTANEOUS INFUSION: ADULTS, ELDERLY, CHILDREN: 5U10 mcg/kg/day. Adjust dosage daily during period of neutrophil recovery based on neutrophil response.
MOBILIZATION PROGENITOR CELLS
IV OR SUBCUTANEOUS INFUSION: ADULTS: 10 mcg/kg/day beginning at least 4 days before first leukapheresis and continuing until last leukapheresis.
CHRONIC NEUTROPENIA, CONGENITAL NEUTROPENIA
SUBCUTANEOUS: ADULTS, CHILDREN: 6 mcg/kg/dose twice a day.
IDIOPATHIC OR CYCLIC NEUTROPENIA
SUBCUTANEOUS: ADULTS, CHILDREN: 5 mcg/kg/dose once a day.
SIDE EFFECTS
FREQUENT: Nausea or vomiting (57%), mild to severe bone pain (22%) that occurs more frequently with high-dose IV form less frequently with low-dose subcutaneous form; alopecia (18%), diarrhea (14%), fever (12%), fatigue (11%). OCCASIONAL (9%U5%): Anorexia, dyspnea, headache, cough, rash. RARE (less than 5%): Psoriasis, hematuria or proteinuria, osteoporosis.
ADVERSE REACTIONS/TOXIC EFFECTS
Long-term administration occasionally produces chronic neutropenia and splenomegaly. Thrombocytopenia, MI, and arrhythmias occur rarely. Adult respiratory distress syndrome may occur in patients with sepsis.
NIRSING CONSIDERATION
BASELINE ASSESSMENT
CBC, platelet count (differential) should be obtained before therapy initiation and twice weekly thereafter.
INTERVENTION/EVALUATION
In septic patients, be alert to adult respiratory distress syndrome. Closely monitor those with preexisting cardiac conditions. Monitor BP (transient decrease in BP may occur), temperature, CBC with differential, platelet count, Hct, serum uric acid, liver function tests.
PATIENT/FAMILY TEACHING
N Inform physician of fever, chills, severe bone pain, chest pain, palpitations.
finasteride
fin-ah-stir-eyd
(Propecia, Proscar)
Do not confuse Proscar with Posicor, ProSom, Prozac, or Psorcon.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Androgen hormone inhibitor. CLINICAL: Benign prostatic hyperplasia agent.
ACTION
An androgen hormone inhibitor that inhibits 5-alpha reductase, an intracellular enzyme that converts testosterone into dihydrotestosterone (DHT) in the prostate gland, resulting in a decreased serum DHT level. Therapeutic Effect: Reduces size of the prostate gland.
PHARMACOKINETICS
Route Onset Peak Duration
Rapidly absorbed from the GI tract. Protein binding: 90%. Widely distributed. Metabolized in the liver. Half-life: 6U8 hr. Onset of clinical effect: 3U6 mo of continued therapy.
USES
Proscar reduces risk of acute urinary retention, need for surgery in symptomatic benign prostatic hypertrophy (BPH alone or in combination with doxazosin [Cardura]). Most improvement noted in hesitancy, feeling of incomplete bladder emptying, interruption of urinary stream, difficulty initiating flow, dysuria, impaired size and force of urinary stream. Propecia: Treatment for hair loss. OFF-LABEL: Adjuvant monotherapy after radical prostatectomy in treatment of prostate cancer, female hirsutism.
PRECAUTIONS
CONTRAINDICATIONS: Exposure to the patient's semen or handling of finasteride tablets by those who are or may be pregnant. CAUTIONS: Hepatic function abnormalities.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Physical handling of tablet in those who may become or are pregnant. May produce abnormalities of external genitalia of male fetus. Pregnancy Category X. Children: Not indicated in children. Elderly: Efficacy not established.
INTERACTIONS
DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: Decreases the serum prostate-specific antigen (PSA) level, even in patients with prostate cancer.
AVAILABILITY (Rx)
TABLETS: 1 mg (Propecia), 5 mg (Proscar).
ADMINISTRATION/HANDLING
N Do not break or crush film-coated tablets. N Give without regard to meals.
INDICATIONS/ROUTES/DOSAGE
BENIGN PROSTATIC HYPERPLASIA (BPH)
HAIR LOSS
SIDE EFFECTS
RARE (4%U2%): Gynecomastia, sexual dysfunction (impotence, decreased libido, decreased volume of ejaculate).
ADVERSE REACTIONS/TOXIC EFFECTS
Hypersensitivity reactions, including rash, pruritus, urticaria, circumoral swelling, and testicular pain, have been reported.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Digital rectal exam, serum PSA determination should be performed in those with BPH before initiating therapy and periodically thereafter.
INTERVENTION/EVALUATION
Diligent monitoring of I&O, especially in those with large residual urinary volume, severely diminished urinary flow for obstructive uropathy.
PATIENT/FAMILY TEACHING
N Patient should be aware of potential for impotence. N May not notice improved urinary flow even if prostate gland shrinks. N Need to take medication longer than 6 mo, and it is unknown if medication decreases need for surgery. N Because of potential risk to male fetus, women who are or may become pregnant should not handle tablets or be exposed to patient's semen. N Volume of ejaculate may be decreased during treatment.
fluticasone propionate
flew-tih-cah-sewn
(Cutivate, Flonase, Flovent, Flovent Diskus, Flovent HFA)
FIXED-COMBINATION(S)
Advair: fluticasone/salmeterol (bronchodilator): 100 mcg/50 mcg; 250 mcg/50 mcg; 500 mcg/50 mcg.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Corticosteroid. CLINICAL: Anti-inflammatory, antipruritic.
ACTION
A corticosteroid that controls the rate of protein synthesis, depresses migration of polymorphonuclear leukocytes, reverses capillary permeability, and stabilizes lysosomal membranes. Therapeutic Effect: Prevents or controls inflammation.
PHARMACOKINETICS
Inhalation/intranasal: Protein binding: 91%. Undergoes extensive first-pass metabolism in liver. Excreted in urine. Half-life: 3U7.8 hr. Topical: Amount absorbed depends on affected area and skin condition (absorption increased with fever, hydration, inflamed or denuded skin).
USES
Nasal: Relief of seasonal/perennial allergic rhinitis. Topical: Relief of inflammation/pruritus associated with steroid-responsive disorders (e.g., contact dermatitis, eczema). Inhalation: Long-term control of persistent bronchial asthma. Assists in reducing or discontinuing oral corticosteroid therapy.
PRECAUTIONS
CONTRAINDICATIONS: Primary treatment of status asthmaticus or other acute asthma episodes (inhalation); untreated localized infection of nasal mucosa. CAUTIONS: Active or quiescent tuberculosis, untreated fungal, bacterial, or systemic ocular herpes simplex viral infection.
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 in those younger than 4 yr. Children 4 yr and older may experience growth suppression with prolonged or high doses. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Bupropion: May lower the seizure threshold. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
AEROSOL FOR ORAL INHALATION (FLOVENT, FLOVENT HFA): 44 mcg/inhalation, 110 mcg/inhalation, 220 mcg/inhalation. POWDER FOR ORAL INHALATION (FLOVENT DISKUS): 50 mcg, 100 mcg, 250 mcg. INTRANASAL SPRAY (FLONASE): 50 mcg/inhalation. TOPICAL CREAM (CUTIVATE): 0.05%. TOPICAL OINTMENT (CUTIVATE): 0.005%.
ADMINISTRATION/HANDLING
INHALATION
N Shake container well; instruct patient to exhale as completely as possible. N Place mouthpiece fully into mouth; holding inhaler upright. Instruct patient to inhale deeply, slowly while pressing the top of the canister and to hold breath as long as possible before exhaling, then exhale slowly. N Wait 1 min between inhalations when multiple inhalations ordered (allows for deeper bronchial penetration). N Rinse mouth with water immediately after inhalation (prevents mouth/throat dryness).
INTRANASAL
N Clear nasal passages before use (topical nasal decongestants may be needed 5U15 min before use). N Tilt head slightly forward. N Insert spray tip up in 1 nostril, pointing toward inflamed nasal turbinates, away from nasal septum. N Pump medication into 1 nostril while holding other nostril closed, concurrently inspire through nose.
INDICATIONS/ROUTES/DOSAGE
ALLERGIC RHINITIS
INTRANASAL: ADULTS, ELDERLY: Initially, 200 mcg (2 sprays in each nostril once daily or 1 spray in each nostril q12h). Maintenance: 1 spray in each nostril once daily. Maximum: 200 mcg/day. CHILDREN 4 YR AND OLDER: Initially, 100 mcg (1 spray in each nostril once daily). Maximum: 200 mcg/day.
RELIEF OF INFLAMMATION AND PRURITUS ASSOCIATED WITH STEROID-RESPONSIVE DISORDERS, SUCH AS CONTACT DERMATITIS AND ECZEMA
TOPICAL: ADULTS, ELDERLY, CHILDREN 3 MO AND OLDER: Apply sparingly to affected area once or twice a day.
MAINTENANCE TREATMENT FOR ASTHMA FOR THOSE PREVIOUSLY TREATED WITH BRONCHODILATORS
INHALATION POWDER (FLOVENT DISKUS): ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: Initially, 100 mcg q12h. Maximum: 500 mcg/day.
INHALATION (ORAL [FLOVENT]): ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: 88 mcg twice a day. Maximum: 440 mcg twice a day.
MAINTENANCE TREATMENT FOR ASTHMA FOR THOSE PREVIOUSLY TREATED WITH INHALED STEROIDS
INHALATION POWDER (FLOVENT DISKUS): ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: Initially, 100U250 mcg q12h. Maximum: 500 mcg q12h.
INHALATION (ORAL [FLOVENT]): ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: 88U220 mcg twice a day. Maximum: 440 mcg twice a day.
MAINTENANCE TREATMENT FOR ASTHMA FOR THOSE PREVIOUSLY TREATED WITH ORAL STEROIDS
INHALATION POWDER (FLOVENT DISKUS): ADULTS, ELDERLY, CHILDREN 12 YR AND OLDER: 500U1,000 mcg twice a day.
INHALATION (ORAL [FLOVENT]): ADULTS, ELDERLY, CHILDREN 12 YRS AND OLDER: 880 mcg twice a day.
SIDE EFFECTS
FREQUENT: Inhalation: Throat irritation, hoarseness, dry mouth, cough, temporary wheezing, oropharyngeal candidiasis (particularly if mouth is not rinsed with water after each administration). Intranasal: Mild nasopharyngeal irritation; nasal burning, stinging, or dryness; rebound congestion; rhinorrhea; loss of taste. OCCASIONAL: Inhalation: Oral candidiasis. Intranasal: Nasal and pharyngeal candidiasis, headache. Topical: Skin burning, pruritus.
ADVERSE REACTIONS/TOXIC EFFECTS
Deaths due to adrenal insufficiency have occurred in asthma patients during and after transfer from use of long-term systemic corticosteroids to less systemically available inhaled corticosteroids.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Establish baseline history of skin disorder, asthma, rhinitis.
INTERVENTION/EVALUATION
Monitor rate, depth, rhythm, type of respiration; quality/rate of pulse. Assess lung sounds for rhonchi, wheezing, rales. Monitor ABGs. Assess oral mucous membranes for evidence of candidiasis. Monitor growth in pediatric patients. Topical: Assess involved area for therapeutic response to irritation.
PATIENT/FAMILY TEACHING
N Advise patients receiving bronchodilators by inhalation concomitantly with steroid inhalation therapy to use bronchodilator several minutes before corticosteroid aerosol (enhances penetration of steroid into bronchial tree). N Do not change dose schedule or stop taking drug; must taper off gradually under medical supervision. N Maintain careful oral hygiene. N Rinse mouth with water immediately after inhalation (prevents mouth/throat dryness, fungal infection of mouth). N Increase fluid intake (decreases lung secretion viscosity). N Intranasal: Teach proper use of nasal spray. N Clear nasal passages before use. N Contact physician if no improvement in symptoms or sneezing/nasal irritation occurs. N Improvement noted in several days. N Topical: Rub thin film gently into affected area. N Use only for prescribed area and no longer than ordered. N Avoid contact with eyes.
fluconazole H
flu-con-ah-zole
(Apo-Fluconazole J, Diflucan)
Do not confuse Diflucan with diclofenac.
G CLASSIFICATION
CLINICAL: Antifungal.
ACTION
A fungistatic antifungal that interferes with cytochrome P-450, an enzyme necessary for ergosterol formation. Therapeutic Effect: Directly damages fungal membrane, altering its function.
PHARMACOKINETICS
Well absorbed from GI tract. Widely distributed, including to CSF. Protein binding: 11%. Partially metabolized in liver. Excreted unchanged primarily in urine. Partially removed by hemodialysis. Half-life: 20U30 hr (increased in impaired renal function).
USES
Prevention of candidiasis in patients undergoing bone marrow transplant receiving chemotherapy and/or radiation therapy, treatment of esophageal, oropharyngeal, disseminated, vulvovaginal, urinary tract candidiasis, treatment and suppression of cryptococcal meningitis. OFF-LABEL: Treatment of coccidioidomycosis, cryptococcosis, fungal pneumonia, onychomycosis, ringworm of the hand, septicemia.
PRECAUTIONS
CONTRAINDICATIONS: None known. CAUTIONS: Hepatic or renal impairment, hypersensitivity to other triazoles (e.g., itraconazole, terconazole), imidazoles (e.g., butoconazole, ketoconazole).
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown if excreted in breast milk. Pregnancy Category C. Children: No age-related precautions noted. Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Cyclosporine: High fluconazole doses increase cyclosporine blood concentration. Oral antidiabetics: May increase blood concentration and effects of oral antidiabetics. Phenytoin, warfarin: May decrease the metabolism of these drugs. Rifampin: May increase fluconazole metabolism. HERBAL: None known. FOOD: None known. LAB VALUES: May increase serum alkaline phosphatase, serum bilirubin, AST, and ALT levels.
AVAILABILITY (Rx)
TABLETS: 50 mg, 100 mg, 150 mg, 200 mg. POWDER FOR ORAL SUSPENSION: 10 mg/ml, 40 mg/ml. INJECTION: 2 mg/ml (in 100- or 200Uml containers).
ADMINISTRATION/HANDLING
L IV
Rate of administration N Do not exceed maximum flow rate 200 mg/hr.
Storage N Store at room temperature. N Do not remove from outer wrap until ready to use. N Squeeze inner bag to check for leaks. N Do not use parenteral form if solution is cloudy, precipitate forms, seal is not intact, or it is discolored. N Do not add supplementary medication.
N Give without regard to meals. N PO and IV therapy equally effective; IV therapy for patient intolerant of the drug or unable to take orally.
D IV INCOMPATIBILITIES
Amphotericin B (Fungizone), amphotericin B complex (Abelcet, Ambisome, Amphotec), ampicillin (Polycillin), calcium gluconate, cefotaxime (Claforan), ceftazidime (Fortaz), ceftriaxone (Rocephin), cefuroxime (Zinacef), chloramphenicol (Chloromycetin), clindamycin (Cleocin), co-trimoxazole (Bactrim), diazepam (Valium), digoxin (Lanoxin), erythromycin (Erythrocin), furosemide (Lasix), haloperidol (Haldol), hydroxyzine (Vistaril), imipenem and cilastatin (Primaxin), total parenteral nutrition (TPN).
IV COMPATIBILITIES
Diltiazem (Cardizem), dobutamine (Dobutrex), dopamine (Intropin), heparin, lorazepam (Ativan), midazolam (Versed), propofol (Diprivan).
INDICATIONS/ROUTES/DOSAGE
OROPHARYNGEAL CANDIDIASIS
ESOPHAGEAL CANDIDIASIS
PO, IV: ADULTS, ELDERLY: 200 mg once, then 100 mg/day (up to 400 mg/day) for 21 days and at least 14 days following resolution of symptoms. CHILDREN: 6 mg/kg/day once, then 3 mg/kg/day (up to 12 mg/kg/day) for 21 days at at least 14 days following resolution of symptoms.
VAGINAL CANDIDIASIS
PREVENTION OF CANDIDIASIS IN PATIENTS UNDERGOING BONE MARROW TRANSPLANTATION
SYSTEMIC CANDIDIASIS
PO, IV: ADULTS, ELDERLY: 400 mg once, then 200 mg/day (up to 400 mg/day) for at least 28 days and at least 14 days following resolution of symptoms. CHILDREN: 6U12 mg/kg/day.
URINARY CANDIDIASIS
CRYPTOCOCCAL MENINGITIS
ONYCHOMYCOSIS
DOSAGE IN RENAL IMPAIRMENT
After a loading dose of 400 mg, the daily dosage is based on creatinine clearance.
Creatinine Clearance % of Recommended Dose
Greater than 50 ml/min 100
21U50 ml/min 50
11U20 ml/min 25
Dialysis Dose after dialysis
SIDE EFFECTS
OCCASIONAL (4%U1%): Hypersensitivity reaction (including chills, fever, pruritus, and rash), dizziness, drowsiness, headache, constipation, diarrhea, nausea, vomiting, abdominal pain.
ADVERSE REACTIONS/TOXIC EFFECTS
Exfoliative skin disorders, serious hepatic effects, and blood dyscrasias (such as eosinophilia, thrombocytopenia, anemia, and leukopenia) have been reported rarely.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Establish baselines for CBC, serum potassium, liver function studies.
INTERVENTION/EVALUATION
Assess for hypersensitivity reaction (chills, fever). Monitor serum liver and renal function tests, potassium, CBC, platelet count. Report rash, itching promptly. Monitor temperature at least daily. Determine pattern of bowel activity and stool consistency. Assess for dizziness; provide assistance as needed.
PATIENT/FAMILY TEACHING
N Avoid tasks that require alertness, motor skills until response to drug is established (dizziness, drowsiness). N Notify physician of dark urine, pale stool, jaundiced skin or sclera of eyes, rash with or without itching. N Patients with oropharyngeal infections should be taught appropriate oral hygiene. N Consult physician before taking any other medication.
fluorouracil, 5-FU A
phlur-oh-your-ah-sill
(Adrucil, Carac, Efudex, Fluoroplex)
Do not confuse Efudex with Efidac.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Antimetabolite. CLINICAL: Antineoplastic.
ACTION
An antimetabolite that blocks formation of thymidylic acid. Cell cycle-specific for S phase of cell division. Therapeutic Effect: Inhibits DNA and RNA synthesis. Topical form destroys rapidly proliferating cells.
PHARMACOKINETICS
Widely distributed. Crosses the blood-brain barrier. Rapidly metabolized in tissues to active metabolite, which is localized intracellularly. Primarily excreted by lungs as carbon dioxide. Removed by hemodialysis. Half-life: 20 hr.
USES
Parenteral: Treatment of carcinoma of colon, rectum, breast, stomach, pancreas. Used in combination with levamisole after surgical resection in patients with Duke's stage C colon cancer. Topical: Treatment of multiple actinic, solar keratoses, superficial basal cell carcinomas. OFF-LABEL: Parenteral: Treatment of bladder, cervical, endometrial, head and neck, liver, lung, ovarian, or prostate carcinomas; pericardial, peritoneal, or pleural effusions. Topical: Treatment of actinic cheilitis, radiodermatitis.
PRECAUTIONS
CONTRAINDICATIONS: Major surgery within previous month, myelosuppression, poor nutritional status, potentially serious infections. CAUTIONS: History of high-dose pelvic irradiation, metastatic cell infiltration of bone marrow, hepatic or renal impairment.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: If possible, avoid use during pregnancy, especially first trimester. May cause fetal harm. Unknown whether distributed in breast milk. Breast-feeding not recommended. Pregnancy Category D. Children: No age-related precautions noted. Elderly: Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Bone marrow depressants: May increase the risk of myelosuppression. Live virus vaccines: May potentiate virus replication, increase vaccine side effects, and decrease the patient's antibody response to the vaccine. HERBAL: None known. FOOD: None known. LAB VALUES: May decrease serum albumin level. May increase excretion of 5-hydroxyindoleacetic acid (5-HIAA) in urine. Topical form may cause eosinophilia, leukocytosis, thrombocytopenia, and toxic granulation.
AVAILABILITY (Rx)
INJECTION (ADRUCIL): 50 mg/ml. TOPICAL CREAM: 1% (Carac, Fluoroplex), 5% (Efudex). TOPICAL SOLUTION: 1% (Fluoroplex), 2% (Efudex).
ADMINISTRATION/HANDLING
O ALERT P Give by IV injection or IV infusion. Do not add to other IV infusions. Avoid small veins, swollen or edematous extremities, areas overlying joints, tendons. May be carcinogenic, mutagenic, or teratogenic. Handle with extreme care during preparation/administration.
L IV
Reconstitution N IV push does not need to be diluted or reconstituted. N Inject through Y-tube or 3-way stopcock of free-flowing solution. N For IV infusion, further dilute with D5W or 0.9% NaCl.
Rate of administration N Give IV push slowly over 1U2 min. N IV infusion is administered over 30 minU24 hr. N Extravasation produces immediate pain, severe local tissue damage. N Follow protocol.
Storage N Solution appears colorless to faint yellow. Slight discoloration does not adversely affect potency or safety. N If precipitate forms, redissolve by heating, shaking vigorously; allow to cool to body temperature.
D IV INCOMPATIBILITIES
Amphotericin B complex (Abelcet, AmBisome, Amphotec), droperidol (Inapsine), filgrastim (Neupogen), ondansetron (Zofran), vinorelbine (Navelbine).
IV COMPATIBILITIES
Granisetron (Kytril), heparin, hydromorphone (Dilaudid), leucovorin, morphine, potassium chloride, propofol (Diprivan), total parenteral nutrition (TPN).
INDICATIONS/ROUTES/DOSAGE
CARCINOMA OF BREAST, COLON
IV: ADULTS, ELDERLY, CHILDREN: Initially, 12 mg/kg/day for 4U5 days. Maximum: 800 mg/day. Maintenance: 6 mg/kg every other day for 4 doses repeated in 4 wk; or 15 mg/kg as a single bolus dose; or 5U15 mg/kg/wk as a single dose, not to exceed 1 g.
MULTIPLE ACTINIC OR SOLAR KERATOSES
TOPICAL (CARAC): ADULTS, ELDERLY: Apply once a day.
TOPICAL (EFUDEX, FLUOROPLEX): ADULTS, ELDERLY: Apply twice a day.
BASAL CELL CARCINOMA
TOPICAL (EFUDEX): ADULTS, ELDERLY: Apply twice a day for 3U6 wk up to 10U12 wk.
SIDE EFFECTS
OCCASIONAL: Parenteral: Anorexia, diarrhea, minimal alopecia, fever, dry skin, skin fissures, scaling, erythema. Topical: Pain, pruritus, hyperpigmentation, irritation, inflammation, and burning at application site; photosensitivity. RARE: Nausea, vomiting, anemia, esophagitis, proctitis, GI ulcer, confusion, headache, lacrimation, visual disturbances, angina, allergic reactions.
ADVERSE REACTIONS/TOXIC EFFECTS
The earliest sign of toxicity, which may occur 4U8 days after beginning therapy, is stomatitis (as evidenced by dry mouth, burning sensation, mucosal erythema, and ulceration at inner margin of lips). Hematologic toxicity may be manifested as leukopenia (generally within 9U14 days after drug administration, but possibly as late as the 25th day), thrombocytopenia (within 7U17 days after administration), pancytopenia, or agranulocytosis. The most common dermatologic toxicity is a pruritic rash on the extremities or, less frequently, the trunk.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Obtain CBC with differential, platelet count, serum renal and liver function tests.
INTERVENTION/EVALUATION
Monitor for rapidly falling WBC, intractable diarrhea, GI bleeding (bright red or tarry stool). Assess oral mucosa for stomatitis. Drug should be discontinued if intractable diarrhea, stomatitis, GI bleeding occurs. Assess skin for rash.
PATIENT/FAMILY TEACHING
N Maintain fastidious oral hygiene. N Inform physician of signs or symptoms of infection, unusual bruising or bleeding, visual changes, nausea, vomiting, diarrhea, chest pain, palpitations. N Avoid sunlight and artificial light sources; wear protective clothing, sunglasses, sunscreen. N Topical: Apply only to affected area. N Do not use occlusive coverings. N Be careful near eyes, nose, mouth. N Wash hands thoroughly after application. N Treated areas may be unsightly for several weeks after therapy.
fluoxetine hydrochloride H
floo-ox-e-teen
(Novo-Fluoxetine J, Prozac, Prozac Weekly, Rapiflux, Sarafem)
Do not confuse fluoxetine with fluvastatin, Prozac with Prilosec, Proscar, or ProSom; or Sarafem with Serophene.
FIXED-COMBINATION(S)
Symbyax: fluoxetine/olanzapine (an antipsychotic): 25 mg/6 mg, 50 mg/6 mg, 25 mg/12 mg, 50 mg/12 mg.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Psychotherapeutic. CLINICAL: Antidepressant, antiobsessional agent, antibulimic.
ACTION
A psychotherapeutic agent that selectively inhibits serotonin uptake in the CNS, enhancing serotonergic function. Therapeutic Effect: Relieves depression; reduces obsessive-compulsive and bulimic behavior.
PHARMACOKINETICS
Well absorbed from the GI tract. Crosses the blood-brain barrier. Protein binding: 94%. Metabolized in the liver to active metabolite. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 2U3 days; metabolite 7U9 days.
USES
Treatment of clinical depression, obsessive-compulsive disorder (OCD), bulimia nervosa, premenstrual dysphoric disorder (PMDD), panic disorder. OFF-LABEL: Treatment of body dysmorphic disorder, fibromyalgia, hot flashes, post-traumatic stress disorder, Raynaud's phenomena.
PRECAUTIONS
CONTRAINDICATIONS: Use within 14 days of MAOIs. CAUTIONS: Seizure disorder, cardiac dysfunction, diabetes, those at high risk for suicide.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Unknown whether drug crosses placenta or is distributed in breast milk. Pregnancy Category C. Children: May be more sensitive to behavioral side effects (e.g., insomnia, restlessness). Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Alcohol, other CNS depressants: May increase CNS depression. Highly protein-bound medications (including oral anticoagulants): May increase adverse effects. MAOIs: May produce serotonin syndrome and neuroleptic malignant syndrome. Phenytoin: May increase phenytoin blood concentration and risk of toxicity. HERBAL: St. John's
AVAILABILITY (Rx)
CAPSULES: 10 mg (Prozac, Sarafem), 20 mg (Prozac, Sarafem), 40 mg (Prozac). CAPSULES (DELAYED-RELEASE [PROZAC WEEKLY]): 90 mg. ORAL SOLUTION (PROZAC): 20 mg/5 ml. TABLETS (PROZAC, RAPIFLUX): 10 mg, 20 mg.
ADMINISTRATION/HANDLING
N Give with food or milk if GI distress occurs.
INDICATIONS/ROUTES/DOSAGE
DEPRESSION
PANIC DISORDER
BULIMIA NERVOSA
OBSESSIVE-COMPULSIVE DISORDER (OCD)
PREMENSTRUAL DYSPHORIC DISORDER
SIDE EFFECTS
FREQUENT (more than 10%): Headache, asthenia, insomnia, anxiety, nervousness, somnolence, nausea, diarrhea, decreased appetite. OCCASIONAL (9%U2%): Dizziness, tremor, fatigue, vomiting, constipation, dry mouth, abdominal pain, nasal congestion, diaphoresis, rash. RARE (less than 2%): Flushed skin, light-headedness, impaired concentration.
ADVERSE REACTIONS/TOXIC EFFECTS
Overdose may produce seizures, nausea, vomiting, agitation, and restlessness.
NURSING CONSIDERATION
BASELINE ASSESSMENT
For patients on long-term therapy, baseline liver and renal function tests, blood counts should be performed periodically thereafter.
INTERVENTION/EVALUATION
Supervise suicidal-risk patient closely during early therapy (as energy level improves, suicide potential increases). Assess appearance, behavior, speech pattern, level of interest, mood. Monitor pattern of daily bowel activity and stool consistency. Assess skin for appearance of rash. Monitor serum liver function tests, glucose, sodium, weight.
PATIENT/FAMILY TEACHING
N Maximum therapeutic response may require 4 or more wk of therapy. N Do not abruptly discontinue medication. N Avoid tasks that require alertness, motor skills until response to drug is established. N Avoid alcohol. N To avoid insomnia, take last dose of drug before 4 PM.
flutamide A
flew-tah-myd
(Euflex J, Eulexin, Novo-Flutamide J)
Do not confuse flutamide with Flumadine.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Antiandrogen, hormone. CLINICAL: Antineoplastic.
ACTION
An antiandrogen hormone that inhibits androgen uptake and prevents androgen from binding to androgen receptors in target tissue. Used in conjunction with leuprolide to inhibit the stimulant effects of flutamide on serum testosterone levels. Therapeutic Effect: Suppresses testicular androgen production and decreases growth of prostate carcinoma.
PHARMACOKINETICS
Completely absorbed from the GI tract. Protein binding: 94%U96%. Metabolized in the liver to active metabolite. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 6 hr (increased in elderly).
USES
Treatment of metastatic carcinoma of prostate (in combination with luteinizing hormone-releasing hormone [LHRH] analogues, e.g., leuprolide). Management of locally confined stages B2-C, D2 carcinoma. OFF-LABEL: Female hirsutism.
PRECAUTIONS
CONTRAINDICATIONS: Severe hepatic impairment. CAUTIONS: None known.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Not used in this patient population. Pregnancy Category D. Children: Not used in children. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: Warfarin: May increase the risk of bleeding. HERBAL: None known. FOOD: None known. LAB VALUES: May increase blood glucose level and serum estradiol, testosterone, bilirubin, creatinine, AST, and ALT levels.
AVAILABILITY (Rx)
CAPSULES: 125 mg.
ADMINISTRATION/HANDLING
N Give without regard to food.
INDICATIONS/ROUTES/DOSAGE
PROSTATIC CARCINOMA (IN COMBINATION WITH LEUPROLIDE)
SIDE EFFECTS
FREQUENT: Hot flashes (50%); decreased libido, diarrhea (24%); generalized pain (23%); asthenia (17%); constipation (12%); nausea, nocturia (11%). OCCASIONAL (8%U6%): Dizziness, paresthesia, insomnia, impotence, peripheral edema, gynecomastia. RARE (5%U4%): Rash, diaphoresis, hypertension, hematuria, vomiting, urinary incontinence, headache, flu-like syndromes, photosensitivity.
ADVERSE REACTIONS/TOXIC EFFECTS
Hepatoxicity, including hepatic encephalopathy, and hemolytic anemia may be noted.
NURSING CONSIDERATIONS
INTERVENTION/EVALUATION
Periodically monitor liver function tests in long-term therapy.
PATIENT/FAMILY TEACHING
N Do not stop taking medication (both drugs must be continued). N Urine color may change to amber or yellow-green. N Avoid prolonged exposure to sun or tanning beds. Wear clothing to protect from ultraviolet exposure until tolerance is determined.
fluvastatin
flu-vah-stah-tin
(Lescol, Lescol XL)
Do not confuse fluvastatin with fluoxetine.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Hydroxamethylglutaryl-CoA (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, and plasma triglyceride levels. Slightly increases HDL cholesterol concentration.
PHARMACOKINETICS
Well absorbed from the GI tract and is unaffected by food. Does not cross the blood-brain barrier. Protein binding: greater than 98%. Primarily eliminated in feces. Half-life: 1.2 hr.
USES
Adjunct to diet therapy to decrease elevated total, LDL cholesterol concentrations in those with primary hypercholesterolemia (types IIa, IIb), those with combined hypercholesterolemia, hypertriglyceridemia. Treatment of elevated triglycerides, apolipoprotein, secondary prevention of coronary events.
PRECAUTIONS
CONTRAINDICATIONS: Active hepatic disease, lactation, pregnancy, unexplained increased serum transaminase levels. CAUTIONS: Anticoagulant therapy, history of hepatic disease, substantial alcohol consumption, major surgery; severe acute infection; trauma; hypotension; severe metabolic, endocrine, electrolyte disorders; uncontrolled seizures. Withholding or discontinuing fluvastatin may be necessary when patient is at risk for renal failure (secondary to rhabdomyolysis).
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Contraindicated in pregnancy (suppression of cholesterol biosynthesis may cause fetal toxicity), lactation. Unknown whether 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 with these drugs. Cholestyramine: May reduce the effectiveness of fluvastatin. Phenytoin: May increase the maximum plasma concentration of fluvastatin. HERBAL: St. John's
AVAILABILITY (Rx)
CAPSULES (LESCOL): 20 mg, 40 mg. TABLETS (EXTENDED-RELEASE [LESCOL XL]): 80 mg.
ADMINISTRATION/HANDLING
N Give without regard to food.
INDICATIONS/ROUTES/DOSAGE
HYPERLIPOPROTEINEMIA
SIDE EFFECTS
FREQUENT (8%U5%): Headache, dyspepsia, back pain, myalgia, arthralgia, diarrhea, abdominal cramping, rhinitis. OCCASIONAL (4%U2%): Nausea, vomiting, insomnia, constipation, flatulence, rash, pruritus, fatigue, cough, dizziness.
ADVERSE REACTIONS/TOXIC EFFECTS
Myositis (inflammation of voluntary muscle) with or without increased CK, and muscle weakness, occur rarely. These conditions may progress to frank rhabdomyolysis and renal impairment.
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. Check for headache, dizziness. Assess for rash, pruritus. Monitor serum cholesterol, triglyceride lab results for therapeutic response. Be alert for malaise, muscle cramping or weakness.
PATIENT/FAMILY TEACHING
N Follow special diet (important part of treatment). N Periodic lab tests are essential part of therapy. N Report promptly any muscle pain/weakness, especially if accompanied by fever, malaise.
fondaparinux sodium A
fond-dah-pear-in-ux
(Arixtra)
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Factor Xa inhibitor, pentasaccharide. CLINICAL: Antithrombotic.
ACTION
A factor Xa inhibitor and pentasaccharide that selectively binds to antithrombin, and increases its affinity for factor Xa, thereby inhibiting factor Xa and stopping the blood coagulation cascade. Therapeutic Effect: Indirectly prevents formation of thrombin and subsequently the fibrin clot.
PHARMACOKINETICS
Well absorbed after subcutaneous administration. Undergoes minimal, if any, metabolism. Highly bound to antithrombin III. Distributed mainly in blood and to a minor extent in extravascular fluid. Excreted unchanged in urine. Removed by hemodialysis. Half-life: 17U21 hr (prolonged in patients with impaired renal function).
USES
Prevention of venous thromboembolism in patients undergoing total hip replacement, hip fracture surgery, knee replacement surgery. Treatment of acute deep vein thrombosis (DVT), acute pulmonary embolism. Used concurrently with warfarin therapy. Prevention of DVT in patients undergoing abdominal surgery.
PRECAUTIONS
O ALERT P When neuraxial anesthesia (epidural or spinal anesthesia) or spinal puncture is employed, patients anticoagulated or scheduled to be anticoagulated with fondaparinux sodium for prevention of thromboembolic complications are at risk of developing an epidural or spinal hematoma which can result in long-term or permanent paralysis.
CONTRAINDICATIONS: Active major bleeding, bacterial endocarditis, body weight less than 50 kg, severe renal impairment (with creatinine clearance less than 30 ml/min), thrombocytopenia associated with antiplatelet antibody formation in the presence of fondaparinux. CAUTIONS: Conditions with increased risk of hemorrhage (GI ulceration, hemophilia, concurrent use of antiplatelet agents, severe uncontrolled hypertension, history of cerebrovascular accident [CVA]), history of heparin-induced thrombocytopenia, renal impairment, elderly, neuraxial anesthesia, indwelling epidural catheter use.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Use with caution, particularly during last trimester, immediate postpartum period (increased risk of maternal hemorrhage). Unknown if excreted in breast milk. Pregnancy Category B. Children: Safety and efficacy not established. Elderly: Age-related renal impairment may increase risk of bleeding.
INTERACTIONS
DRUG: Anticoagulants, platelet inhibitors: May increase bleeding. HERBAL: None known. FOOD: None known. LAB VALUES: Increases reversible serum creatinine, AST, and ALT levels. May decrease Hgb, Hct, and platelet count.
AVAILABILITY (Rx)
INJECTION: 2.5 mg/0.5 ml prefilled syringe.
ADMINISTRATION/HANDLING
SUBCUTANEOUS
N Parenteral form appears clear, colorless. Discard if discoloration or particulate matter is noted. N Store at room temperature. N Do not expel the air bubble from the prefilled syringe before injection. N Pinch a fold of skin at the injection site between thumb and forefinger. Introduce entire length of subcutaneous needle into skin fold during injection. Inject into fatty tissue between left and right anterolateral or left and right posterolateral abdominal wall. N Rotate injection sites.
INDICATIONS/ROUTES/DOSAGE
PREVENTION OF VENOUS THROMBOEMBOLISM
SUBCUTANEOUS: ADULTS: 2.5 mg once a day for 5U9 days after surgery. Initial dose should be given 6U8 hr after surgery. Dosage should be adjusted in the elderly and in those with renal impairment.
TREATMENT VENOUS THROMBOEMBOLISM, PULMONARY EMBOLISM
SUBCUTANEOUS: ADULTS, ELDERLY WEIGHING GREATER THAN 100 KG: 10 mg once daily. ADULTS, ELDERLY WEIGHING 50U100 KG: 7.5 mg once daily. ADULTS, ELDERLY WEIGHING LESS THAN 50 KG: 5 mg once daily.
SIDE EFFECTS
OCCASIONAL (14%): Fever. RARE (4%U1%): Injection site hematoma, nausea, peripheral edema.
ADVERSE REACTIONS/TOXIC EFFECTS
Accidental overdose may lead to bleeding complications ranging from local ecchymoses to major hemorrhage. Thrombocytopenia occurs rarely.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
Assess CBC, including platelet count, baseline BUN, creatinine clearance.
INTERVENTION/EVALUATION
Periodically monitor CBC, platelet count, stool for occult blood (no need for daily monitoring in patients with normal presurgical coagulation parameters). Assess for any signs of bleeding: bleeding at surgical site, hematuria, blood in stool, bleeding from gums, petechiae, ecchymosis, bleeding from injection sites. Monitor BP and pulse; hypotension and tachycardia may indicate bleeding.
PATIENT/FAMILY TEACHING
N Usual length of therapy is 5U9 days. N Do not take any OTC medication (especially aspirin, NSAIDs). N Consult physician if swelling in hands, feet is noted or unusual back pain, unusual bleeding or bruising, weakness, sudden or severe headache occurs.
fosamprenavir calcium
foss-am-pren-ah-vur
(Lexiva)
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Antiretroviral. CLINICAL: Protease inhibitor.
ACTION
An antiretroviral that is rapidly converted to amprenavir, which inhibits HIV-1 protease by binding to the enzyme's active site, thus preventing the processing of viral precursors and resulting in the formation of immature, noninfectious viral particles. Therapeutic Effect: Impairs HIV replication and proliferation.
PHARMACOKINETICS
Rapidly absorbed after PO administration. Protein binding: 90%. Metabolized in the liver. Excreted in urine and feces. Half-life: 7.7 hr.
USES
Treatment of HIV infection in combination with other antiretroviral agents.
PRECAUTIONS
CONTRAINDICATIONS: Concurrent use of amprenavir, dihydroergotamine, ergonovine, ergotamine, flecainide, methylergonovine, midazolam, pimozide, propafenone, ritonavir, triazolam. EXTREME CAUTION: Hepatic impairment. CAUTIONS: Diabetes mellitus, elderly, renal impairment, known sulfonamide allergy.
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 in children younger than 4 yr. Elderly: Age-related hepatic impairment may require decreased dosage.
INTERACTIONS
DRUG: Amiodarone, bepridil, ergotamine, lidocaine, midazolam, oral contraceptives, quinidine, triazolam, tricyclic antidepressants: May interfere with the metabolism of these drugs. Antacids, didanosine: May decrease the absorption of fosamprenavir. Carbamazepine, phenobarbital, phenytoin, rifampin: May decrease fosamprenavir blood concentration. Clozapine, hydroxamethylglutaryl-CoA (HMG-CoA) reductase inhibitors (statins), warfarin: May increase the blood concentrations of these drugs. HERBAL: St. John's
AVAILABILITY (Rx)
TABLETS: 700 mg (equivalent to 600 mg amprenavir).
ADMINISTRATION/HANDLING
N Give without regard to meals. N Do not crush or break film-coated tablets.
INDICATIONS/ROUTES/DOSAGE
HIV INFECTION IN PATIENTS WHO HAVE NOT HAD PREVIOUS PROTEASE INHIBITOR THERAPY
PO: ADULTS, ELDERLY: 1,400 mg twice daily without ritonavir; or 1,400 mg once daily plus ritonavir 200 mg once daily; or 700 mg twice daily plus ritonavir 100 mg twice daily.
HIV INFECTION IN PATIENTS WHO HAVE HAD PREVIOUS PROTEASE INHIBITOR THERAPY
CONCURRENT THERAPY WITH EFAVIRENZ
SIDE EFFECTS
FREQUENT (39%U35%): Nausea, rash, diarrhea. OCCASIONAL (19%U8%): Headache, vomiting, fatigue, depression. RARE (7%U2%): Pruritus, abdominal pain, perioral paresthesia.
ADVERSE REACTIONS/TOXIC EFFECTS
Severe and possibly life-threatening dermatologic reactions, including Stevens-Johnson syndrome, occur rarely. New onset or exacerbation of diabetes mellitus has been reported.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Obtain baseline lab testing, especially liver function tests, before beginning therapy and at periodic intervals during therapy. Offer emotional support. Obtain medication history.
INTERVENTION/EVALUATION
Closely monitor for evidence of GI discomfort. Monitor pattern of bowel activity and stool consistency. Assess skin for evidence of rash. Monitor serum chemistry tests for marked laboratory abnormalities, particularly hepatic profile. Assess for opportunistic infections: onset of fever, oral mucosa changes, cough, or other respiratory symptoms.
PATIENT/FAMILY TEACHING
N Eat small, frequent meals to offset nausea, vomiting. N Continue therapy for full length of treatment. N Doses should be evenly spaced. N Medication is not a cure for HIV infection, nor does it reduce risk of transmission to others. N Patient may continue to experience illnesses, including opportunistic infections. N Diarrhea can be controlled with OTC medication.
fosinopril
fo-sin-o-pril
(Monopril)
Do not confuse Monopril with Monurol.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Angiotensin-converting enzyme (ACE) inhibitor. CLINICAL: Antihypertensive.
ACTION
An ACE inhibitor that suppresses the renin-angiotensin-aldosterone system and prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor; may also inhibit angiotensin II at local vascular and renal sites. Decreases plasma angiotensin II, increases plasma renin activity, and decreases aldosterone secretion. Therapeutic Effect: Reduces peripheral arterial resistance, pulmonary capillary wedge pressure; improves cardiac output, and exercise tolerance.
PHARMACOKINETICS
Route Onset Peak Duration
Slowly absorbed from the GI tract. Protein binding: 97%U98%. Metabolized in the liver and GI mucosa to active metabolite. Primarily excreted in urine. Minimal removal by hemodialysis. Half-life: 11.5 hr.
USES
Treatment of hypertension. Used alone or in combination with other antihypertensives. Treatment of heart failure. OFF-LABEL: Treatment of diabetic and nondiabetic nephropathy, post-MI left ventricular dysfunction, renal crisis in scleroderma.
PRECAUTIONS
CONTRAINDICATIONS: History of angioedema from previous treatment with ACE inhibitors, pregnancy. CAUTIONS: Renal impairment, those with sodium depletion or on diuretic therapy, dialysis, hypovolemia, coronary or cerebrovascular insufficiency.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Distributed in breast milk. May cause fetal or neonatal mortality or morbidity. Pregnancy Category C (D if used in second or third trimester). Children: Safety and efficacy not established. Neonates, infants may be at increased risk for oliguria, neurologic abnormalities. Elderly: May be more sensitive to hypotensive effects.
INTERACTIONS
DRUG: Alcohol, antihypertensives, diuretics: May increase the effects of fosinopril. Lithium: May increase lithium blood concentration and risk of lithium toxicity. NSAIDs: May decrease the effects of fosinopril. Potassium-sparing diuretics, potassium supplements: May cause hyperkalemia. HERBAL: None known. FOOD: None known. LAB VALUES: May increase BUN, serum alkaline phosphatase, serum bilirubin, serum creatinine, serum potassium, AST, and ALT levels. May decrease serum sodium levels. May cause positive antinuclear antibody titer.
AVAILABILITY (Rx)
TABLETS: 10 mg, 20 mg, 40 mg.
ADMINISTRATION/HANDLING
N Give without regard to food. N Tablets may be crushed.
INDICATIONS/ROUTES/DOSAGE
HYPERTENSION
HEART FAILURE
SIDE EFFECTS
FREQUENT (12%U9%): Dizziness, cough. OCCASIONAL (4%U2%): Hypotension, nausea, vomiting, upper respiratory tract infection.
ADVERSE REACTIONS/TOXIC EFFECTS
Excessive hypotension (“first-dose syncope”) may occur in patients with CHF and in those who are severely salt and volume depleted. Angioedema (swelling of face and lips) and hyperkalemia occur rarely. Agranulocytosis and neutropenia may be noted in those with collagen vascular disease, including scleroderma and systemic lupus erythematosus, and impaired renal function. Nephrotic syndrome may be noted in those with history of renal disease.
NURSING CONSIDERAION
BASELINE ASSESSMENT
Obtain BP immediately before each dose, in addition to regular monitoring (be alert to fluctuations). Renal function tests should be performed before beginning therapy. In patients with renal impairment, autoimmune disease, or taking drugs that affect leukocytes or immune response, CBC, differential count should be performed before therapy begins and q2wk for 3 mo, then periodically thereafter.
INTERVENTION/EVALUATION
If excessive reduction in BP occurs, place patient in supine position with legs elevated. Assist with ambulation if dizziness occurs. Assess for urinary frequency. Auscultate lung sounds for rales, wheezing in those with CHF. Monitor urinalysis for proteinuria. Monitor serum potassium levels in those on concurrent diuretic therapy.
PATIENT/FAMILY TEACHING
N Report any sign of infection (sore throat, fever). N Several weeks may be needed for full therapeutic effect of BP reduction. N Skipping doses or voluntarily discontinuing drug may produce severe, rebound hypertension. N To reduce hypotensive effect, rise slowly from lying to sitting position, permit legs to dangle from bed momentarily before standing. N Inform physician if vomiting, excessive perspiration, persistent cough develops.
fosphenytoin
fos-phen-ih-toyn
(Cerebyx)
Do not confuse Cerebyx with Celebrex or Celexa.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Hydantoin. CLINICAL: Anticonvulsant.
ACTION
A hydantoin anticonvulsant that stabilizes neuronal membranes by decreasing sodium and calcium ion influx into the neurons. Also decreases post-tetanic potentiation and repetitive discharge. Therapeutic Effect: Decreases seizure activity.
PHARMACOKINETICS
Completely absorbed after IM administration. Protein binding: 95%U99%. Rapidly and completely hydrolyzed to phenytoin after IM or IV administration. Time of complete conversion to phenytoin: 4 hr after IM injection; 2 hr after IV infusion. Half-life: 8U15 min (for conversion to phenytoin).
USES
Acute treatment, control of generalized convulsive status epilepticus; prevention, treatment of seizures occurring during neurosurgery; short-term substitution of oral phenytoin.
PRECAUTIONS
CONTRAINDICATIONS: Adams-Stokes syndrome; hypersensitivity to ethotoin, phenytoin, mephenytoin; second- or third-degree AV block; severe bradycardia; SA block. CAUTIONS: Porphyria, hypotension, severe myocardial insufficiency, renal or hepatic disease, hypoalbuminemia.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: May increase frequency of seizures during pregnancy. Increased risk of congenital malformations. Unknown if excreted in breast milk. Pregnancy Category D. Children: Safety not established. Elderly: Lower dosage recommended.
INTERACTIONS
DRUG: Alcohol, other CNS depressants: May increase CNS depression. Amiodarone, anticoagulants, cimetidine, disulfiram, fluoxetine, isoniazid, sulfonamides: May increase fosphenytoin blood concentration, effects, and risk of toxicity. Antacids: May decrease fosphenytoin absorption. Fluconazole, ketoconazole, miconazole: May increase fosphenytoin blood concentration. Glucocorticoids: May decrease the effects of glucocorticoids. Lidocaine, propranolol: May increase cardiac depressant effects. Valproic acid: May increase the blood concentration and decrease the metabolism of fosphenytoin. Xanthines: May increase the metabolism of xanthines. HERBAL: None known. FOOD: None known. LAB VALUES: May increase blood glucose, serum GGT, and serum alkaline phosphatase levels.
AVAILABILITY (Rx)
INJECTION: 75 mg/ml (equivalent to 50 mg/ml phenytoin).
ADMINISTRATION/HANDLING
L IV
Reconstitution N Dilute in D5W or 0.9% NaCl to a concentration ranging from 1.5U25 mg PE/ml.
Rate of administration N Administer at rate of less than 150 mg PE/min (decreases risk of hypotension, arrhythmias).
Storage N Refrigerate. Do not store at room temperature for longer than 48 hr. N After dilution, solution is stable for 8 hr at room temperature or 24 hr if refrigerated.
D IV INCOMPATIBILITY
Midazolam (Versed).
IV COMPATIBILITIES
Lorazepam (Ativan), phenobarbital, potassium chloride.
INDICATIONS/ROUTES/DOSAGE
STATUS EPILEPTICUS
IV: ADULTS: Loading dose: 15U20 mg phenytoin equivalent (PE)/kg infused at rate of 100U150 mg PE/min.
NONEMERGENT SEIZURES
IV, IM: ADULTS: Loading dose: 10U20 mg PE/kg. Maintenance: 4U6 mg PE/kg/day.
SHORT TERM SUBSTITUTION FOR ORAL PHENYTOIN
IV, IM: ADULTS: May substitute for oral phenytoin at same total daily dose.
SIDE EFFECTS
FREQUENT: Dizziness, paresthesia, tinnitus, pruritus, headache, somnolence. OCCASIONAL: Morbilliform rash.
ADVERSE REACTIONS/TOXIC EFFECTS
An elevated fosphenytoin blood concentration may produce ataxia, nystagmus, diplopia, lethargy, slurred speech, nausea, vomiting, and hypotension. As the drug level increases, extreme lethargy may progress to coma.
NURSING CONSIDERATION
BASELINE ASSESSMENT
Review history of seizure disorder (intensity, frequency, duration, level of consciousness [LOC]). Initiate seizure precautions. Obtain vital signs, medication history (especially use of phenytoin, other anticonvulsants). Observe clinically.
INTERVENTION/EVALUATION
Measure cardiac function, EKG, respiratory function, BP during and immediately following infusion (10U20 min). Discontinue if skin rash appears. Interrupt or decrease rate if hypotension, arrhythmias are detected. Assess patient post-infusion (may feel dizzy, ataxic, drowsy). Assess blood levels of fosphenytoin (2 hr post IV infusion or 4 hrs post IM injection).
PATIENT/FAMILY TEACHING
N Teach patients about their seizure condition and role in its management. N If noncompliance is an issue in causing acute seizures, discuss and address reasons for noncompliance. N Avoid tasks that require alertness, motor skills until response to drug is established.
fulvestrant A
full-ves-trant
(Faslodex)
Do not confuse Faslodex with Fosamax.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Estrogen antagonist. CLINICAL: Antineoplastic.
ACTION
An estrogen antagonist that competes with endogenous estrogen at estrogen receptor binding sites. Therapeutic Effect: Inhibits tumor growth.
PHARMACOKINETICS
Extensively and rapidly distributed after IM administration. Protein binding: 99%. Metabolized in the liver. Eliminated by hepatobiliary route; excreted in feces. Half-life: 40 days in postmenopausal women. Peak serum levels occur in 7U9 days.
USES
Treatment of hormone receptorUpositive metastatic breast cancer in postmenopausal women with disease progression following antiestrogen therapy. OFF-LABEL: Endometriosis, uterine bleeding.
PRECAUTIONS
CONTRAINDICATIONS: Known or suspected pregnancy. CAUTIONS: Thrombocytopenia, bleeding diathesis, anticoagulant therapy, hepatic disease, reduced hepatic blood flow, estrogen receptorUnegative breast cancer.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Do not administer to pregnant women. Unknown if excreted in breast milk. May cause fetal harm. Pregnancy Category D. Children: Not for use in children. Elderly: No age-related precautions noted.
INTERACTIONS
DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES: None known.
AVAILABILITY (Rx)
PREFILLED SYRINGE: 50 mg/ml in 2.5-ml and 5-ml syringes.
ADMINISTRATION/HANDLING
IM
N Administer slowly into the buttock as a single 5-ml injection or 2 concurrent 2.5-ml injections.
INDICATIONS/ROUTES/DOSAGE
BREAST CANCER
IM: ADULTS, ELDERLY: 250 mg given once monthly.
SIDE EFFECTS
FREQUENT (26%U13%): Nausea, hot flashes, pharyngitis, asthenia, vomiting, vasodilatation, headache. OCCASIONAL (12%U5%): Injection site pain, constipation, diarrhea, abdominal pain, anorexia, dizziness, insomnia, paresthesia, bone or back pain, depression, anxiety, peripheral edema, rash, diaphoresis, fever. RARE (2%U1%): Vertigo, weight gain.
ADVERSE REACTIONS/TOXIC EFFECTS
UTIs, vaginitis, anemia, thromboembolic phenomena, and leukopenia occur rarely.
NURSING CONSIDERATIONS
BASELINE ASSESSMENT
An estrogen receptor assay should be done before beginning therapy. Baseline CT
INTERVENTION/EVALUATION
Monitor blood chemistry, plasma lipids. Be alert to increased bone pain, ensure adequate pain relief. Check for edema, especially of dependent areas. Monitor for and assist with ambulation if asthenia or dizziness occurs. Assess for headache. Offer antiemetic for nausea and vomiting.
PATIENT/FAMILY TEACHING
N Notify physician if nausea, asthenia, hot flashes become unmanageable.
furosemide H
feur-oh-sah-mide
(Apo-Furosemide J, Lasix)
Do not confuse Lasix with Lidex, Luvox, or Luxiq, or furosemide with Torsemide.
G CLASSIFICATION
PHARMACOTHERAPEUTIC: Loop . CLINICAL: Diuretic.
ACTION
A loop diuretic that enhances excretion of sodium, chloride, and potassium by direct action at the ascending limb of the loop of Henle. Therapeutic Effect: Produces diuresis and lowers BP.
PHARMACOKINETICS
Route Onset Peak Duration
IV 5 min 20U60 min 2 hr
IM 30 min N/A N/A
Well absorbed from the GI tract. Protein binding: 91%U97%. Partially metabolized in the liver. Primarily excreted in urine (nonrenal clearance increases in severe renal impairment). Not removed by hemodialysis. Half-life: 30U90 min (increased in renal or hepatic impairment, and in neonates).
USES
Treatment of edema associated with CHF, chronic renal failure (including nephrotic syndrome), hepatic cirrhosis, acute pulmonary edema. Treatment of hypertension, either alone or in combination with other antihypertensives. OFF-LABEL: Hypercalcemia.
PRECAUTIONS
CONTRAINDICATIONS: Anuria, hepatic coma, severe electrolyte depletion. CAUTIONS: Hepatic cirrhosis.
B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Distributed in breast milk. Pregnancy Category C (D if used in pregnancy-induced hypertension). Children: Half-life increased in neonates; may require increased dosage interval. Elderly: May be more sensitive to hypotensive, electrolyte effects, developing circulatory collapse, thromboembolic effect. Age-related renal impairment may require dosage adjustment.
INTERACTIONS
DRUG: Amphotericin B, nephrotoxic and ototoxic medications: May increase the risk of nephrotoxicity and ototoxicity. Anticoagulants, heparin: May decrease the effects of these drugs. Lithium: May increase the risk of lithium toxicity. Other hypokalemia-causing medications: May increase the risk of hypokalemia. Probenecid: May increase furosemide blood concentration. HERBAL: None known. FOOD: None known. LAB VALUES: May increase blood glucose, BUN, and serum uric acid levels. May decrease serum calcium, chloride, magnesium, potassium, and sodium levels.
AVAILABILITY (Rx)
ORAL SOLUTION: 10 mg/ml, 40 mg/5 ml. TABLETS: 20 mg, 40 mg, 80 mg. INJECTION: 10 mg/ml.
ADMINISTRATION/HANDLING
L IV
Rate of administration N May give undiluted but is compatible with D5W, 0.9% NaCl, or lactated Ringer's solutions. N Administer each 40 mg or fraction by IV push over 1U2 min. Do not exceed administration rate of 4 mg/min in those with renal impairment.
Storage N Solution appears clear, colorless. N Discard yellow solutions.
IM
N Temporary pain at injection site may be noted.
N Give with food to avoid GI upset, preferably with breakfast (may prevent nocturia).
D IV INCOMPATIBILITIES
Ciprofloxacin (Cipro), diltiazem (Cardizem), dobutamine (Dobutrex), dopamine (Intropin), doxorubicin (Adriamycin), droperidol (Inapsine), esmolol (Brevibloc), famotidine (Pepcid), filgrastim (Neupogen), fluconazole (Diflucan), gemcitabine (Gemzar), gentamicin (Garamycin), idarubicin (Idamycin), labetalol (Trandate), meperidine (Demerol), metoclopramide (Reglan), midazolam (Versed), milrinone (Primacor), nicardipine (Cardene), ondansetron (Zofran), quinidine, thiopental (Pentothal), vecuronium (Norcuron), vinblastine (Velban), vincristine (Oncovin), vinorelbine (Navelbine).
IV COMPATIBILITIES
Aminophylline, amiodarone (Cordarone), bumetanide (Bumex), calcium gluconate, cimetidine (Tagamet), heparin, hydromorphone (Dilaudid), lidocaine, morphine, nitroglycerin, norepinephrine (Levophed), potassium chloride, propofol (Diprivan).
INDICATIONS/ROUTES/DOSAGE
EDEMA, HYPERTENSION
IV, IM: ADULTS, ELDERLY: 20U40 mg/dose; may increase by 20 mg/dose q1U2h. CHILDREN: 1U2 mg/kg/dose q6U12h. NEONATES: 1U2 mg/kg/dose q12U24h.
IV INFUSION: ADULTS, ELDERLY: Bolus of 0.1 mg/kg, followed by infusion of 0.1 mg/kg/hr; may double q2h. Maximum: 0.4 mg/kg/hr. CHILDREN: 0.05 mg/kg/hr; titrate to desired effect.
SIDE EFFECTS
EXPECTED: Increased urinary frequency and urine volume. FREQUENT: Nausea, dyspepsia, abdominal cramps, diarrhea or constipation, electrolyte disturbances. OCCASIONAL: Dizziness, light-headedness, headache, blurred vision, paresthesia, photosensitivity, rash, fatigue, bladder spasm, restlessness, diaphoresis. RARE: Flank pain.
ADVERSE REACTIONS/TOXIC EFFECTS
Vigorous diuresis may lead to profound water loss and electrolyte depletion, resulting in hypokalemia, hyponatremia, and dehydration. Sudden volume depletion may result in increased risk of thrombosis, circulatory collapse, and sudden death. Acute hypotensive episodes may occur, sometimes several days after beginning therapy. Ototoxicity—manifested as deafness, vertigo, or tinnitus—may occur, especially in patients with severe renal impairment. Furosemide use can exacerbate diabetes mellitus, systemic lupus erythematosus, gout, and pancreatitis. Blood dyscrasias have been reported.
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